The 2009 revised Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food packages were designed to accommodate a broader array of dietary needs and preferences than in the past. This chapter considers the issuance of food package III for certain medical conditions, the extent to which WIC food packages accommodate the dietary needs of individuals with food allergies and other food-triggered sensitivities, and the availability of WIC package food items to accommodate varying food preferences (i.e., vegetarian and vegan diets) and food-related religious practices (i.e., Kosher and Halal dietary practices). Details of the literature search used to gather this information are provided in Chapter 3.
The revised WIC food packages can accommodate a wide range of medical conditions. This section summarizes the circumstances under which food package III can be issued and the extent to which the WIC food packages (all of the packages, including food package III) accommodate the dietary needs of individuals with food allergies and other food-triggered sensitivities.
The Special Case of Food Package III
At the discretion of a health care provider, individuals may be considered, “medically fragile” and can receive food package III for either themselves or their children. There exists no generally accepted definition
of medical fragility. Examples include an infant with failure to thrive and an adult with a wired jaw. Individual states have policies regarding who may qualify under WIC.
Nutrition plays a pivotal role in the health of medically fragile individuals, especially children, with appropriate nutrition preventing or mitigating significant neurodevelopmental deficiencies and being potentially life-saving. Depending on an individual’s specific medical needs, food package III can be tailored by including non-contract1 infant formulas with unique nutritional composition or WIC-eligible medical foods (see Box 8-1). As detailed in the interim rule and verified in the final rule, individuals receiving food package III may be issued 455 ounces of WIC formula2 per month, but only in addition to (not instead of) the maximum allowance of all other foods in the package appropriate for their life-stage (USDA/FNS, 2014). Exceptions to these food package regulations may be made as necessary and as dictated by the final rule (USDA/FNS, 2014).3
1 Any formula that is non-contract is not subject to rebates. Exempt infant formula is always non-contract. By federal regulation, for WIC participants who are also on Medicaid, the Medicaid program is the primary payer for exempt infant formulas, as well as for WIC-eligible medical foods. WIC is the payer of last resort for the Medicaid beneficiaries and the payer for those not on Medicaid. Some private insurance may also cover exempt formula.
2 WIC formula refers to infant formula, exempt infant formula, or a WIC-eligible medical food.
3 As specified in the final rule, exceptions for food package III include (1) whole milk may be provided to children more than 2 years of age and to women with a qualifying condition; (2) state agencies have the flexibility to provide children and women the option of receiving commercial jarred infant food fruits and vegetables in lieu of the cash value voucher; and (3) infant formula may be provided in lieu of foods at 6 months of age.
There are no publicly available data for estimating how many WIC participants nationwide receive food package III. A report detailing electronic benefit transfer (EBT) redemption patterns in Kentucky, Michigan, and Nevada indicated that, on average, 1.5 percent of WIC families in these states were issued a medical food of some kind, although not necessarily through food package III (Phillips et al., 2014). Only 54 percent of these families redeemed the entire package and 14 percent redeemed none of the package. Non-Hispanic Asian and non-Hispanic white families were more likely to redeem the entire package than non-Hispanic black families, and 72 percent of families in urban areas redeemed the full benefit compared to 53 percent in large rural areas (Phillips et al., 2014). Missouri state data from September 2015 indicate that 2 percent of Missouri WIC participants are receiving food package III (personal communication, R. Arni, Missouri WIC, October 9, 2015). In a recent study of National Health and Nutrition Examination Survey (NHANES) 2003–2010 data, Rossen et al. (2015) found that 6.5 percent of infants living at or below 185 percent of the federal poverty-to-income ratio (PIR) (the qualifying PIR for WIC) consumed “specialty” formulas (those having clear clinical indications for use). Similarly, data from 2004 indicated that 6 percent of infant formulas issued through WIC nationally were exempt (non-contract formula for special medical needs), ranging from 1 to 23 percent by state (USGAO, 2006). This is higher than the proportions of WIC families in the Phillips et al. (2014) study who were reportedly issued medical foods, which is likely to include specialty (exempt) formulas.
Food-Triggered Immune-Mediated Sensitivities
All of the food packages, including food package III, can support the nutritional needs of several different types of food-triggered immune-mediated sensitivities, including food allergies, celiac disease, non-celiac gluten sensitivity (NCGS), and lactose intolerance. This section summarizes evidence from the literature on the nutritional needs of individuals with these medical conditions, and ways that the 2009 revised food packages accommodate individuals with these conditions.
Allergy has been defined as a hypersensitivity disorder of the immune system where the immune system reacts to substances in the environment normally considered harmless (CDC, 2013). When allergy manifests as disease, those diseases, such as dermatitis, asthma, and rhinitis, are commonly referred to as “atopic” diseases. Researchers still do not understand the underlying factors that cause atopic disease, although several theories
have been put forth. Prominent among these is dysbiosis of the microbiome (Brown et al., 2013), which at one time was known as the “hygiene hypothesis” (Strachan, 1989). It has also been suggested that how and when foods are introduced into the diet of infants influences the risk of food allergy in particular (NIAID, 2010).
Food allergy has been defined as an adverse health effect arising from a specific immune response that occurs reproducibly on exposure to a given food; the specific food component eliciting the immune response and causing symptoms is the allergen (NIAID, 2010). Proper diagnosis of allergy is important because, in 50 to 90 percent of cases, symptoms presumed to be associated with food allergy are not related (NIAID, 2010).
Food allergies can be either IgE-mediated or non-IgE-mediated. The symptoms of IgE-mediated food allergy include cutaneous, ocular, respiratory, gastrointestinal, cardiovascular, and other miscellaneous effects. Diagnoses of IgE-mediated allergies are made using food elimination diets and oral food challenges (i.e., symptoms resolve when the causative food is removed from the diet and recur following an oral challenge). Non-IgE-mediated immunologic reactions to food include food protein-induced enteropathy, eosinophilic gastrointestinal diseases, allergic contact dermatitis, and systemic contact dermatitis. Some, but not all, non-IgE-mediated allergies can be diagnosed using food elimination diet and oral food challenges.
Several expert groups have made still-evolving recommendations for prevention of food allergy. In 2000, the American Academy of Pediatrics (AAP) recommended delaying the introduction of allergenic foods in infants at higher risk of allergy development (AAP, 2000). However, subsequently, the AAP reported insufficient data to document a protective effect of any dietary intervention beyond 4 to 6 months of age (Greer et al., 2008). Likewise, a committee convened by the National Institute of Health’s (NIH’s) National Institute of Allergy and Infectious Diseases recommended that infants be breastfed for 4 to 6 months to prevent food allergy but that the introduction of solid foods not be delayed beyond 4 to 6 months, regardless of whether they are potentially allergenic (NIAID, 2010). Based on accumulating evidence (Osborn and Sinn, 2006; see also Alexander et al., 2010), the NIH committee further recommended hydrolyzed4 (and not soy) formula for the prevention of allergy in non-breastfed or supplemented breastfed at-risk infants (NIAID, 2010). In accordance with these earlier recommendations, in 2013 the American Academy of Allergy recommended breastfeeding for 4 to 6 months, use of a hydrolyzed protein infant formula
4 Hydrolyzed refers to formulas containing cow’s milk proteins that have been extensively broken down so they are unlikely to cause an allergic reaction.
In addition to recommending the delayed introduction of allergenic foods, AAP (2000) recommended avoidance of some foods by breastfeeding mothers. However, authors of a recent systematic review of maternal intake during pregnancy or lactation did not find any conclusive evidence of an effect of maternal diet on atopy in infants (Netting et al., 2014). Similarly, the NIH committee referenced above recommended against maternal restriction of allergenic foods during pregnancy and lactation as a means of reducing the likelihood of allergy development in infants (NIAID, 2010).
Despite these ever-evolving recommendations, the prevalence of reported food allergy has continued to rise. Centers for Disease Control and Prevention (CDC) data indicate that, among children ages 0 to 17 years, reports of food allergies increased approximately 50 percent between 1997 and 2011 (CDC, 2013). The prevalence of food allergies appears to be higher in non-Hispanics and in families with higher household incomes (CDC, 2013). The most common food allergies are allergies to peanuts, tree nuts, seafood, milk, and hen’s egg (NIAID, 2010), although wheat, fish, and soy allergies are also relevant to the WIC food packages. There is some evidence that early introduction of peanut protein reduces the likelihood of peanut allergy (Du Toit et al., 2008, 2015; Gruchalla and Sampson, 2015). Based on this evidence, in September 2015 AAP issued interim guidance for the early (between 4 and 11 months of age) introduction of peanut protein to high-risk infants under care of a health care provider (Fleischer et al., 2015).
WIC food package options for individuals with food allergies In sum, with respect to food allergy, the committee’s review of the literature indicated that most experts recommend breastfeeding for approximately 6 months and the provision of hydrolyzed protein formula for non-breastfed infants who are at risk of developing allergy. In accordance with these recommendations, hydrolyzed protein infant formulas for allergy at-risk infants are available to formula-fed WIC infants with a physician’s prescription. Because it is not fully understood how introduction of solid foods in the first year of life might influence the development of allergy, there is no currently defined role for WIC-provided infant foods in allergy prevention.
For children and adults, the current WIC packages include substitutions for allergenic foods so individuals with most major food allergies can be accommodated (see Table 8-1). However, as noted in the table, there is no current substitution in the case of an egg or a fish allergy. Importantly, WIC
TABLE 8-1 Options in WIC Food Package Categories Potentially Unsuitable for Special Diets and Major Allergies
|WIC Food Category||Special Diet|
|Whole wheat bread|
NOTES: Indicates that the primary food in the category is not likely to be suitable for the particular diet or allergy unless a suitable substitution is made available. The major allergens shellfish and tree nuts were excluded from the table because no WIC foods are provided in these categories. Soy is excluded because the baseline food packages do not contain soy products. The WIC food categories “mature legumes” and “juice” were excluded from the table because they are suitable for all cases covered in this table.
offers participants with food allergies a number of educational resources to support adherence to dietary restrictions (USDA/FNS, 2015a).
Approximately 1 in 200 individuals living in the United States have celiac disease, an immune-mediated inflammation of the small bowel caused by sensitivity to dietary gluten (a protein found in wheat and other grains) and related proteins (Guandalini and Assiri, 2014; Mooney et al., 2014). The disorder is neither IgE- nor IgG-mediated. A diagnosis is based on histology of a small bowel biopsy. A recent meta-analysis that included data from more than 4 million women indicated that women with celiac disease have an increased risk of obstetrical complications (Saccone et al., 2015). These included preeclampsia and preterm birth, intrauterine growth
|Major Allergen||Substitutions Allowed (% of State Agencies Allowing Substitution)|
|Corn, rice, or oat certified gluten-free cereala: 78%|
|Brown rice: 90%; Tortillas: 82%; Oats: 34%|
|Soy beverage: 71%; Tofu: 40%; Lactosefree milk: 73%|
|Canned beans: 72%; Dry beans: 70%|
a States may offer several gluten-free options. Seventy-eight percent of states allow the most commonly offered gluten-free rice cereal.
b Lactose-free milk is also permitted for individuals with lactose intolerance. Milk substitutions such as soy beverage and tofu are unsuitable for people with soybean allergies.
restriction, stillbirth, low birthweight, or a small for gestational age infant (Saccone et al., 2015). An Academy of Nutrition and Dietetics (AND) systematic review indicated that women with undiagnosed celiac disease who follow a gluten-free diet have an increased risk of adverse pregnancy outcomes (evidence graded as fair) (AND, 2006).
Delayed introduction of wheat proteins to the diet was once thought to prevent or delay the onset of the disease (Norris et al., 2005). However, results from a recent study and meta-analysis suggest that the time to first introduction of gluten into the diets of infants is not an independent risk factor for developing celiac disease by 5 years of age (Aronsson et al., 2015; Szajewska et al., 2015). Additional research may be needed on the optimal timing and amount of introduced foods containing gluten (Lebwohl et al., 2015).
Treatment for celiac disease includes lifelong avoidance of wheat, bar-
ley, and rye. Individuals with symptoms for celiac disease should be tested and, if positive, receive detailed nutritional counseling on gluten avoidance, because even milligram levels in the diet can have severe long-term health consequences (Rubio-Tapia et al., 2013). Because gluten-free grains (e.g., rice, potato flour, tapioca flour, corn) are not typically fortified, gluten-free diets may be low in iron and folate, as well as dietary fiber (Thompson, 2000). Nutrients of particular concern for pregnant women who follow a gluten-free diet include carbohydrates, iron, folic acid, niacin, calcium, phosphorus, zinc, and fiber (AND, 2014).
WIC food package options for individuals with celiac disease As of 2009, the majority of states (96 percent) offered a non-wheat option for the “whole wheat bread” food category that is suitable for gluten-free diets (USDA/FNS, 2011). The final rule for the WIC food packages does not require that states provide a gluten-free option for cereals, although the provision allows state agencies to offer corn or rice-based cereals which may be appropriate for participants who must avoid gluten (USDA/FNS, 2014). Such cereals are not necessarily certified as gluten-free, however, and gluten content may not fall under the U.S. Food and Drug Administration (FDA) limit of 20 parts per million of gluten that is tolerated by most individuals with celiac disease (21 C.F.R. § 101). Individuals with non-celiac gluten sensitivity (NCGS) may also benefit from these non-wheat options (see section on NCGS that follows). Table 8-1 indicates the currently available WIC foods and substitutions that meet the dietary needs of individuals who must or choose to avoid gluten.
Non-Celiac Gluten Sensitivity
NCGS is defined as the occurrence of gastrointestinal symptoms after the ingestion of wheat-containing foods in the absence of celiac disease or wheat allergy. Because there is no biomarker for gluten sensitivity, NCGS is not clinically diagnosable and is generally self-diagnosed (Branchi et al., 2015; Elli et al., 2015; Lebwohl et al., 2015). DiGiacomo et al. (2013) reported a 0.55 percent prevalence of NCGS in NHANES 2009–2010, although gluten-free diets may have become more prevalent since then. Additional studies are needed to understand the etiology and underlying physiology of NCGS (Husby and Murray, 2015).
The AND has not issued guidance for dietary practices related to the mitigation of NCGS. WIC nutritionists may counsel individuals self-diagnosing with NCGS to clinically test for possible celiac disease and to ensure dietary adequacy of micronutrients (also see Rubio-Tapia et al., 2013).
WIC food package options for individuals with NCGS As mentioned above, Table 8-1 indicates the currently available WIC foods and substitutions that meet the dietary needs of individuals who choose to avoid gluten.
Lactose intolerance is a set of symptoms caused by lactase deficiency. Its prevalence varies greatly by racial and ethnic background, with primary lactase deficiency being nearly 100 percent in Asian and American Indian, 60 to 80 percent in black and Ashkenazi Jewish, and 50 to 80 percent in Hispanic subgroups. Lactose intolerance is rare in individuals of generally northern European descent. In Hispanic, Asian, and black children, evidence of lactase deficiency can appear before the age of 5; in white children, symptoms often appear after age 5 (Heyman et al., 2006). The condition can be diagnosed by a lactose challenge and breath test.
Individuals with lactose intolerance may be able to consume small amounts of dairy products (up to 8 ounces of milk or yogurt at one time) (Suarez et al., 1995, 1997; Lomer et al., 2007) or specific forms of dairy products (e.g., natural cheddar cheese contains 0.18 percent lactose, whereas skim milk contains 5.09 percent lactose [USDA/ARS, 2014]), although nutrition education might be necessary to ensure adequate calcium intake.
Food package options for individuals with lactose intolerance Table 8-1 also indicates the currently available WIC foods and substitutions that meet the dietary needs of individuals who choose to avoid lactose. Of note, there is no substitution for cheese for participants unable to tolerate that quantity of lactose.
The committee considered how WIC food packages accommodate preferences for vegetarian and vegan diets and food-related religious practices (e.g., Kosher and Halal diets). This section summarizes the committee’s evaluation of evidence supporting inclusion of foods in the packages that adhere to these practices.
Vegetarian or Vegan Diets
Several authoritative bodies hold the position that, when carefully planned, plant-based diets can be nutritionally adequate for infants, children, and adults. A vegetarian diet does not include animal flesh foods (i.e.,
meat, fish, seafood), but does include other animal products (e.g., eggs, milk, cheese, yogurt), whereas a vegan diet excludes all animal foods and products. In 2015, the Dietary Guidelines Advisory Committee developed and evaluated a healthy vegetarian food pattern and found that it can meet nutrient intake needs for individuals ages 2 years and older (USDA/HHS, 2014). Individuals who consume a vegan diet should pay particular attention to their intakes of vitamins B12 and calcium, but their requirement for these nutrients can be met by consuming fortified foods (AND, 2014). If no eggs are consumed (as in a vegan diet), intake of eicosapentaneoic (EPA) and docosahexaenoic acids (DHAs) may be low (AND, 2015). The position of AND is that both vegetarian and vegan diets are not only adequate, but may promote the prevention or aid in the treatment of certain health conditions (AND, 2009).
The WIC food package includes several foods that by nature are compliant with vegetarian and vegan diets, including fruits, vegetables, legumes, peanut butter, and grains. However, there are currently no vegetarian/vegan substitutions for fish and no vegan substitutions for eggs or cheese (see Table 8-1). The proportion of the WIC population that prefers these types of diets is unknown, but 2012 estimates indicated that approximately 5 percent of Americans considered themselves vegetarian and 2 percent vegan (Newport, 2012).
With respect to infant feeding practices, AAP supports the provision of soy protein-based formulas in cases where an infant’s caretaker prefers to provide a vegetarian diet (as well as in cases where an infant does not tolerate cow’s milk formula) (Bhatia et al., 2008; AAP, 2014). A potential nutrition-related health challenge for these infants is ensuring adequate iron intake. As described in Chapter 6, the introduction of complementary foods to infants at approximately 6 months of age is recommended, in part, to ensure adequate iron intake, with AAP (2014) encouraging early introduction of red meats and other foods rich in iron. A vegetarian or vegan substitution for infant meat is not currently permitted in the WIC food packages. AAP (2014) further recommends that oral iron supplementation is appropriate for infants 6 to 12 months of age who are not consuming the recommended amount of iron from formula and complementary foods.
Kosher or Halal Diets
Regarding the extent to which the 2009 revised food packages accommodate food-related religious practices, some states offer options for Kosher or Halal foods prepared in accordance with Jewish and Islamic dietary laws, respectively. Eliasi and Dwyer (2002) provide a detailed description of Kosher and Halal diets. Very generally, for Kosher diets, meats must be
prepared a certain way, animal products must come from Kosher-prepared animals, and packaged foods must be Kosher-certified. Fruits and vegetables are considered inherently Kosher. To be considered Halal, meats must be prepared in a particular way and milk and foods prepared from milk must come from Halal animals. With respect to the WIC food packages, although federal regulations do not specify any requirement for availability of food that meet the needs of individuals who follow either of these diets, states have the option to accommodate these individuals. In 2009, 34 percent of WIC participants nationwide had the option to purchase Kosher items, 19 percent had the option to purchase Kosher or Halal foods, and 27 percent were allowed no substitution (see Table 8-2) (USDA/FNS, 2011; personal communication, N. Cole, Mathematica, March 17, 2015). A 2015 update of state options indicated that 7 percent of state agencies allowed Kosher milk, 100 percent of state agencies did not specify whether they allowed Kosher eggs, 92 percent did not specify whether Kosher juice was allowed, and 8 percent did not allow Kosher juice. No additional data were available for other Kosher options, and an update of the national availability of Halal options was not presented (USDA/FNS, 2015b). There were no available data on requests for Kosher or Halal foods either among WIC participants in general or in states in which these foods are available.
TABLE 8-2 Authorization of Kosher and Halal Substitutions
|Substitutions Offered for WIC Foods||WIC State Agencies Authorizing Substitutions (%)||Nationwide WIC Participants Covered by the Option (%)*|
|Kosher and Halal||6||19|
NOTES: Results were obtained from a database of WIC food lists for all 90 state agencies as of October 2009, as well as foods that were approved in the period immediately preceding implementation of the interim rule. WIC state plans, vendor manuals, and grocery shopping guides were also reviewed. The most recent WIC Food Packages Policy Options Study (USDA/FNS, 2015b) did not quantify the number of state agencies allowing Kosher and Halal options nationally. The report indicated that 7 percent of state agencies covering 21.3 percent of WIC participants allowed Kosher milk.
* Percentages represent the number of WIC participants linked to the state agencies offering the option.
SOURCE: USDA/FNS, 2011. WIC Food Packages Policy Options Study, with update from personal communication with N. Cole, Mathematica, March 17, 2015.
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