RECOMMENDATIONS FOR IMPLEMENTATION AND EVALUATION OF THE REVISED WIC FOOD PACKAGES
The proposed revisions to the WIC food packages described in Chapter 4—Revised Food Packages—involve major changes—by far the most substantial changes in the WIC food packages since the program’s inception in 1974. Additionally, this report is the first application of the Institute of Medicine’s framework for dietary planning for groups (IOM, 2003a) using the Dietary Reference Intakes (IOM, 1997, 1998, 2000b, 2001, 2002/2005, 2005a). Moreover, it is a new effort undertaken to incorporate the Dietary Guidelines for Americans 2005 (DHHS/USDA, 2005). During deliberations of the types and quantities of foods to offer, of incentives for breastfeeding, and of the timing of offering complementary foods to infants, the committee debated several difficult issues and considered various alternatives. The committee’s recommendations for revising the WIC food packages resulted from a thorough and careful deliberation of how best to meet the criteria set out for the food packages while maintaining cost neutrality.
Nonetheless, the committee also recognized that it is impossible to predict a priori the effects of implementing the revised WIC food packages. It is not possible to estimate the precise impact of changes in the food packages on either food consumption or nutrient intakes. The WIC program can control only what is offered to participants, not what participants actually consume. With the revised food packages, consumption patterns may change in intended and in unintended ways, leading to changes in food choices and the distribution of usual nutrient intake. Moreover, the revised food packages could increase or decrease the incentive of different groups to participate in the WIC program, and they could increase or decrease
breastfeeding rates. Implementation procedures and the type of nutrition education (e.g., culturally sensitive) provided will influence the effectiveness of the revised food packages. Ultimately, data collection and analyses conducted after changes in the WIC food packages have been implemented will provide needed information on the impacts of the revised food packages.
This chapter focuses on recommendations relating to studies of the effects of the revised packages, flexibility and variety, workable procedures, breastfeeding promotion and support, nutrition education, and product availability. Following these recommendations would facilitate the gradual adoption of the revised WIC food packages and could lead to improved nutrition of the nation’s mothers, infants, and young children. Recommendations are crafted specifically to address the range of stakeholders whose efforts will be integral to the successful implementation of the revised WIC food packages: the Food and Nutrition Service (FNS) (i.e., federal regulators); administrators in WIC regional, state, and local agencies; Competent Professional Authorities1 (CPAs)at local WIC clinics; retail food vendors; and food manufacturers. All these stakeholders have a role in implementing one or more of these recommendations. It will take cooperation and communication among all these parties to maximize the beneficial impacts of suggested changes in the WIC food packages.
STUDIES RELATED TO IMPLEMENTATION AND ITS EFFECTS
Because of the magnitude of the changes proposed and because it is not possible to determine a priori the impacts of the proposed changes, the committee urges that well-designed pilot testing and randomized, controlled trials of the revised food packages be conducted before full-scale implementation of the revised food packages. Such testing could examine how WIC state and local agencies implement the revised food packages, effects of the revised food packages on participation rates, and the extent to which the food and nutrient goals of the proposed revisions are achieved. Impacts of the revised food packages need to be examined among diverse groups of WIC participants, with documentation of the influence of the mother’s age, ethnicity/race, previous breastfeeding experience, education, employment status, and possibly other characteristics.
Among the broad range of implementation issues and dietary impacts that could be addressed through studies, some recommended changes in policies relating to WIC food packages and their contents are particularly important to examine in pilot tests before full-scale implementation.
Changes to Promote Breastfeeding
The committee recommends a number of changes to the WIC food packages to promote and support breastfeeding. One recommendation, in particular, is likely to be controversial, namely the recommendation that infant formula not routinely be provided during the first month postpartum for infant/mother pairs initiating breastfeeding. The rationale for this recommendation is the empirical evidence that shows early supplementation with formula (i.e., in the first month after birth) is associated with shorter duration of breastfeeding, particularly exclusive breastfeeding (Bergevin et al., 1983; Feinstein et al., 1986; Frank et al., 1987; Snell et al., 1992; Caulfield et al., 1998; Chapman et al., 2004).
However, the committee recognizes the potential for some undesirable consequences of the recommended changes in the WIC food packages. A breastfeeding mother—especially one who intends to combine breastfeeding and formula feeding, who needs to return to work, or who faces other personal challenges to breastfeeding—may need some formula to nourish her infant adequately during the first month postpartum. Some mothers who might otherwise try breastfeeding may choose formula feeding to be sure they can obtain formula (a high-cost item) if they run into breastfeeding difficulties. In addition, the reduced amount of formula offered to partially breastfeeding infants, as well as the increase in the maximum allowance of formula for 4- and 5-month-old infants in revised Food Package I-B, might increase the incentive for participants to choose formula feeding, especially if considered apart from other changes in the packages for mother/infant pairs. Thus, the committee recognizes the complexity of the infant-feeding choices faced by the postpartum women of the WIC program.
The committee intends for the revised WIC food packages and policies to be supportive of breastfeeding. Recognizing potential adverse consequences associated with this proposal, the committee urges that before full implementation, well-designed pilot studies be conducted to determine the effect of the recommended changes on the initiation and duration of breastfeeding, as well as on WIC participation rates. Specific questions to address in these pilot studies follow.
What are the effects of the revised food packages and proposed infant-feeding practices on the initiation and duration of full or partial breastfeeding?
How does the recommended approach of having only the fully breastfeeding and fully formula-feeding options for the first month after birth compare with (1) an option that allows the mother to change to partial breastfeeding after a breastfeeding trial period of about two weeks and (2) an option for a partially breastfeeding package from the beginning?
Are breastfeeding initiation and duration affected by enhanced breastfeeding support during the first month after birth and, if deemed necessary, the provision of infant formula to breastfeeding mother during this time?
Delay in Offering Complementary Foods
The committee recommends that the WIC food packages not include complementary foods until the infant is 6 months of age. Several factors were considered in making this recommendation. First, delaying complementary foods until 6 months of age is consistent with the recommendation that infants be exclusively breast-fed until around 6 months of age (AAP, 2005). In addition, dietary recall data presented in Chapter 2—Nutrient and Food Priorities, as well as empirical evidence on the increasing prevalence of overweight, indicate that parents report dietary intakes of infants that provide more food energy than required for healthy growth and development. Finally, the supplemental nature of the WIC program suggests that it is not appropriate to provide complementary foods to infants before 6 months of age, especially if these foods (when fed in addition to breast milk or formula) exceed the energy needs of infants during this age period.
Nonetheless, the committee recognizes the controversy surrounding the timing of the introduction of complementary foods. Some experts contend that infants between the ages of 4 and 6 months may be developmentally ready for complementary foods. Currently, about 70 percent of infants consume complementary foods between the ages of 4 and 6 months (Briefel et al., 2004a), suggesting that parents consider them developmentally ready. In addition, if the omission of appropriate complementary foods (e.g., iron-fortified infant cereals) from the WIC food package leads to the introduction of inappropriate foods, the diets of infants 4 to 6 months of age could worsen.
Despite these considerations, the committee’s interpretation of the evidence provides a sound basis for the WIC program to provide complementary foods beginning at 6 months rather than at 4 months of age. To understand the impacts of delaying the offering of complementary foods in WIC food packages for infants, however, the committee recommends that pilot studies and randomized, controlled trials examine the impact of this proposal on infant-feeding practices, food choices, and nutrient intakes.
Specific Changes to Promote Healthier Eating Patterns and Improved Nutrient Adequacy
The committee made several changes to the food packages that were intended to change the foods consumed by WIC participants, make their
diets more consistent with current dietary guidance and the Dietary Guidelines of Americans, and improve the nutrient adequacy of their diets. In particular, the following changes were proposed for reasons presented in Chapter 4—Revised Food Packages—and Chapter 6—How the Revised Food Packages Meet the Criteria Specified.
A variety of fruits and vegetables would be added to the food packages.
Only whole-grain cereals would be available in the breakfast cereal category and whole-grain bread or a substitute would be included in the food packages for children and many women.
Only fat-reduced milk would be provided for women and children two years and older.
Such changes to the WIC food packages need to be accompanied by creative, effective, and culturally sensitive nutrition education that helps participants understand why the consumption of these foods is healthy for them and their children. Yet, these changes also hold the potential for unintended consequences. If participants will not eat whole-grain cereals or drink fat-reduced milk, then changing the food packages as proposed may reduce grain and milk consumption, leading to even lower intakes of priority nutrients and priority food groups. If the revised food packages (which emphasize fresh fruits and vegetables—somewhat perishable food items) pose more problems for participants than the current food packages (which emphasize 100 percent juice), then intakes of priority nutrients may decline. Because of the uncertainty over the effects of these specific changes, as well as the other numerous changes to the food packages, the committee reiterates the importance of pilot testing and randomized, controlled trials. Important questions to address follow.
How are WIC participation rates, prescription rates, and voucher redemption rates affected by the changes in the food packages?
To what extent do the assumptions regarding the demand for various forms and types of food align with actual food choices (e.g., the percentage of participants choosing canned dry beans)? How does this affect the amount of flexibility, variety, and participant choices that can be allowed while staying within necessary cost constraints?
What are the impacts of the changes on food choices and nutrient adequacy of diets? Do diets conform more closely to the Dietary Guidelines and does the prevalence of inadequate intakes and excessive intakes decline?
What is the feedback from WIC participants regarding the desirability of the revised food packages?
How do the changes in the food packages affect the use of time by CPAs and the amount of time required by vendors to deal with each WIC participant after an initial adjustment period? What new skills and technology do they need to implement the revised food packages effectively?
FLEXIBILITY AND VARIETY
Food and Nutrition Service
A hallmark of the set of revised food packages is the increased flexibility to be offered to the WIC state and local agencies and the increased variety and choice to be offered to WIC participants. Flexibility provides a valuable means of responding to the needs of persons of different cultures and food preferences and/or with limited cooking facilities, skills, or time. The committee urges the Food and Nutrition Service (FNS) to retain, and possibly expand, the flexibility proposed for the revised food packages, so as to allow state and local agencies to adapt the packages to the needs of their WIC populations. Moreover, the committee recommends that FNS allow adjustments in the food packages consistent with newly developed scientific findings related to nutritional requirements, health promotion, and disease prevention. These might include working with food manufacturers to consider addressing the excessive sodium content of selected foods and fortification of selected foods with nutrients that are difficult to obtain in adequate amounts (e.g., fortification of milk products with vitamin D in an amount comparable to that provided by the fluid milk equivalent).
Special recommendation on vitamin D supplementation—Vitamin supplementation is outside the charge of this committee, and supplements are outside the purview of the WIC program. Nonetheless, because routine vitamin D supplementation of breast-fed infants (if ingesting less than 15 fluid ounces of vitamin D-fortified formula per day) is recommended by the American Academy of Pediatrics (AAP, 2005), the committee recommends that FNS find ways that breast-fed infants could be provided with vitamin D supplements. One possibility might be by means of the health referrals routinely provided for WIC participants.
Administrators in WIC State and Local Agencies
The committee recommends that state agencies aim for the maximum variety and choice in allowable food selections by participants, while remaining consistent with foods available in their area and with cost containment. Within the broad categories specified (e.g., breakfast cereals, milk products, whole wheat bread or other whole grains, fresh fruits and veg-
etables, processed fruits and vegetables, and dried peas and beans) allowing a wide range of products helps to accommodate various cultural groups, personal preferences, food allergies or intolerances, home storage, and cooking facilities or abilities. When WIC state agencies are able to implement electronic benefit transactions (EBT), they may be able to increase the variety and choices available to WIC participants even further.
The committee recommends that the package size specifications be consistent with safe food practices and consider a household’s storage capabilities and the amount of the food suggested for daily consumption. Careful consideration of package sizes could help to ensure that the foods are eaten only by the participant (or participants in the case of family vouchers) and that food spoilage is minimized.
When CPAs are tailoring food packages, the committee recommends that they continue the practice of offering WIC participants choices that are allowed by the state agency. Examples of new choices include the substitution of yogurt for part of the milk and the form of fruits and vegetables (i.e., fresh, processed, or a combination).
Vouchers or Other Food Instruments
The design and ease of use of food instruments (cash-value vouchers and other food instruments) will be critical to effective implementation of the revised WIC food packages. The committee recommends that WIC state agencies obtain input from local agencies, CPAs, vendors, and participants regarding the design of new food vouchers, including food instruments that cover all WIC participants in the same family or household. The development and use of specialized computer software may facilitate the printing of customized food instruments. Similarly, software could be developed to facilitate checkout at the stores, given the increased variety and choice of foods.
The committee carefully considered feasible mechanisms for providing fresh fruits and vegetables as part of the WIC food packages. At present, the only relevant activity that has been published is related to the experience of the Farmers Market Nutrition Program in which cash-value vouchers are issued for WIC participants to obtain fresh produce at specified farmers markets (NAFMNP, 1996–2003). Employing several open sessions, the committee sought (1) the input of experienced grocery vendors (Gradziel et al., 2004) and (2) the experience gained from several pilot studies that issued cash-value vouchers for participants to obtain fresh produce at WIC grocery vendors (Herman, 2004; Runnings, 2004). Details of workshops are presented in Appendix H—Open Sessions. Together, this information
indicated that providing fresh produce to WIC participants using cash-value vouchers: (1) results in increases in the intake of fruits and vegetable; (2) adds variety to the diets of WIC participants; (3) is highly acceptable to WIC participants of various ethnic/cultural backgrounds; (4) appears to be a workable system for many grocery vendors; and (5) abuse of such vouchers is minimal. From this compelling information, albeit primarily unpublished at the present time, the committee concluded that cash-value vouchers are a feasible mechanism.
Thus, the committee recommends that all WIC states agencies allowing the fresh produce option develop cash-value vouchers (i.e., cash-value food instruments), to be issued in small denominations to redeem for fresh produce at WIC grocery vendors. These cash-value vouchers are to be issued in addition to the standard WIC food instruments used to prescribe specific quantities of other foods. (For clarification of definitions of WIC food instruments, see Box 4-1 in Chapter 4—Revised Food Packages.) In consideration of the perishable nature of fresh fruits and vegetables, small denominations are needed so the participant can obtain small amounts of fresh produce at various times during the month. Requiring the redemption of a large cash-value voucher at one time would tend to encourage participants to obtain more than they could eat in a short time, thus increasing the chance of food spoilage and waste (Kantor et al., 1997).
The committee recommends specific values for the cash-value vouchers in the revised food packages for children and women. Because an increase in the cost of fresh produce would lead to a reduced amount of fruits and vegetables that could be obtained with the cash-value voucher and this, in turn, would reduce the nutrient content of the packages, the committee recommends review and revision of the total value of the cash-value vouchers for fresh fruits and vegetables every 1 to 3 years.
The committee recommends that WIC state and local agencies work with vendors to ease the transition to the use of cash-value vouchers for fresh produce. Useful measures could include the following.
Making scales readily available in the produce department and monitoring their accuracy so that customers can estimate the costs of the produce relatively accurately. Scales that allow entry of price per pound and compute total cost could be especially helpful if assistance is available for customers to learn how to use them.
Training produce personnel in ways to assist their customers to estimate the total cost of their random-weight produce purchases.
Identifying to participants and vendors items that are in the pro-
duce departments of retail stores but are not allowed through the local WIC program.
Packaging or pricing produce so costs are easily understood.
If the cost of the fresh produce brought to the checkout stand at a retail grocery outlet exceeds the value of the voucher(s) presented, the committee recommends that the WIC participant be allowed to pay for the excess cost if she chooses to do so. This could facilitate the checkout process, minimize the amount of fresh produce that stores will have to return to the produce department (or discard), minimize waste, and reduce embarrassment.
BREASTFEEDING PROMOTION AND SUPPORT
Many of the proposed package changes were intended to encourage breastfeeding. In support of the proposed package changes, the committee strongly recommends intensive support for breastfeeding mothers, particularly in the first few weeks postpartum, and further support to extend the duration of breastfeeding. Breastfeeding advice and support are important for all new mothers, regardless of their participation in the WIC program. An analysis of data from the 1988 National Maternal and Infant Health Survey found that, compared with the breastfeeding initiation rates of income-eligible nonparticipants, the initiation rates of WIC participants were lower only among those who did not receive breastfeeding advice (Schwartz et al., 1995). A more recent study, based on the Fragile Families and Child Well-Being Study from 1999–2000, also found a positive association of WIC participation on breastfeeding initiation by low-income women but no effect of WIC participation on the duration of breastfeeding (Chatterji and Brooks-Gunn, 2004).
A complex set of demographic, psychosocial, clinical, and breastfeeding management factors appears to influence breastfeeding duration. Regardless of socioeconomic status, breastfeeding problems requiring individualized counseling and support are common (Dewey et al., 2003). Family support, positive maternal attitudes towards breastfeeding, and appropriate suckling techniques are among the factors positively related to longer duration of breastfeeding (Rogers et al., 1997; Ceriani Cernadas et al., 2003) that may be influenced by breastfeeding support services. Lack of self-confidence in ability to breastfeed and the belief that a baby prefers formula have been negatively related to duration of breastfeeding in WIC participants (Ertem et al., 2001). One randomized, controlled trial, carried out in a WIC setting, found that peer counseling, compared to the usual WIC nutrition education, significantly increases the duration of breastfeeding among women whose infants received supplemental formula on the first day postpartum (Chapman et al., 2004). In sum, to continue nursing, WIC
participants need at least as much, if not more, breastfeeding advice and support than higher-income women.
While very few data are available to determine whether or not the WIC food packages can be designed to provide an incentive for breastfeeding, the committee has received public comments (written and oral testimony) that the current enhanced Food Package VII is not attractive enough, compared to WIC food packages for the partially breastfeeding mother and infant. Therefore, in addition to intensive breastfeeding education to promote breastfeeding, the committee recommends a comprehensive approach that involves:
enhanced food packages for both the fully breastfeeding mother and infant, ages 6 months and older;
reduced maximum amount of formula that is provided to all partially breast-fed infants and to the formula-fed infants ages 6 months and older;
policy change of not routinely providing formula in the first month postpartum to breast-fed infants;
policy change of not providing juice in the first year after birth;
policy change of not providing complementary foods before 6 months of age; and
provision of breastfeeding counseling to breastfeeding mothers who request formula in the first month postpartum.
Thus, the committee recommends that FNS and WIC state and local agencies continue or expand their efforts to increase the initiation and duration of breastfeeding. For example, the incentive value of the food packages for fully breastfeeding mother/infant pairs could be supported by new educational efforts that address the package changes, providing breast pumps, and guidance on initiating and sustaining full breastfeeding, such as peer counseling.
The revised food packages provide new possibilities for nutrition education because the packages are more consistent with the Dietary Guidelines for Americans. Action is needed at many levels—demonstration projects funded by FNS, coordination of nutrition education efforts, CPA training by WIC regional and state agencies, and implementation of innovative culturally sensitive teaching methods by local WIC clinics. Changes in the food packages may trigger the need for nutrition education to address topics such as the following:
Adapting to fat-reduced milk and milk products, becoming familiar with nutrient-dense fruits and vegetables;
Adapting to whole-grain cereals and other whole-grain products, becoming familiar with labeling of whole-grain products;
Honoring the cultural backgrounds of WIC participants by adapting traditional ways of preparing foods in the WIC food packages to fit within current dietary guidance (e.g., reducing fat and salt content of foods prepared by traditional methods); and
Using new food packages to support body weight control or other aspects of the Dietary Guidelines.
Feeding Infants and Young Children
Breastfeeding, in particular full breastfeeding, provides benefits for both infant and mother; food packages for mother/infant pairs are designed to encourage breastfeeding, in particular full breastfeeding;
When and how to introduce semisolid foods into the infant’s diet;
Guidance on appropriate types and amounts of foods and fluids for infants and young children, including foods to offer beyond those provided by the WIC program and the importance of quenching thirst with water; and
Encouragement to make appropriate choices among the variety of allowed fruits and vegetables to introduce infants and children to a varied diet that includes both fruits and vegetables.
Characteristics of good quality fresh fruits and vegetables;
How to use cash-value vouchers for fresh produce—determining how much they can obtain with the cash-value vouchers they have and identifying best buys; and
How to identify allowed processed fruits, vegetables, and other new food choices when shopping.
Handling Food in the Home
Transporting, storing, preparing, and using fruits, vegetables, whole-grain products, and other new food choices for best taste and shelf life; and
Following good food safety practices, especially with perishable foods.
However, in a recent report from the General Accounting Office (GAO, 2004), the WIC program is described by WIC administrators as having “limited ability to provide frequent and ongoing nutrition education because of competing program requirements.”2 For example, because of competing demands, the average WIC participant receives less than 20 minutes of nutrition education twice every six months. To realize fully the potential of the revised food packages to improve the nutritional status of the WIC population, a revised system for providing nutrition education may be needed that includes greater frequency and intensity of nutrition education efforts.
The committee also recommends that the FNS support demonstration projects to foster the development of educational approaches and materials to promote effective use of the revised food packages by WIC participants.
The food specifications in Table B-1 (Appendix B—Nutrient Profiles of Current and Revised Food Packages) cover more items than have been allowed previously and, in some cases, limit the use of foods that contain added sugars, fat, or salt (i.e., sodium). The committee encourages food manufacturers to consider changes in some of their products to meet the nutritional needs of WIC participants. These changes might take the following forms:
more product choices with reduced-sodium content;
fortification of selected foods with nutrients that are difficult to obtain in adequate amounts (e.g., fortification of yogurt and other milk products with vitamin D to amounts equivalent to milk);
ready-to-eat or quick-cooking whole grain products that meet the proposed specifications; and
economical packaging that is re-sealable or in sizes sufficiently small to aid in keeping food safe over the time frame for a single participant to consume the contents.
By staying abreast of innovations in the food industry and keeping open the lines of communication with industry leaders, WIC administrators at the national, regional, state, and local levels could maintain a vibrant and
flexible WIC program that will continue to serve the nutritional needs of WIC recipients and improve the health of women, infants, and children in the United States.
The set of revised WIC food packages holds potential to benefit the nutrition and health of the nation’s low-income women, infants, and children. However, effective implementation and nationwide adoption of the changes need to be preceded not only by administrative adjustments of the WIC program but also by a series of pilot studies and randomized, controlled trials to test and, if necessary, to improve the revisions. In addition, careful planning is needed to develop workable implementation procedures among all parties (Box 7-1), improve breastfeeding promotion and support, and effectively relate nutrition education to the revised food packages. Adoption of the plan to increase flexibility, variety, and participant choices described in this report is integral to meeting the criteria used by this committee in the redesign of the WIC food packages.