3

Alignment of the Current Food Packages with Dietary Guidance, Special Dietary Needs, and Cultural Eating Practices or Food Preferences

As described in the Statement of Task, recommended revisions to WIC food packages are required to be consistent with the 2015–2020 Dietary Guidelines for Americans (DGA)¹ (for individuals ages 2 years and older), advice from the American Academy of Pediatrics (AAP) or other authoritative groups (for individuals less than 2 years of age), and the Dietary Reference Intakes (DRIs). This chapter provides an evaluation of the alignment of the current food packages with these updated sets of guidance and with special dietary needs, preferences, or practices (e.g., medical conditions, vegetarian or vegan diets, cultural eating practices).

ALIGNMENT OF THE FOOD PACKAGES WITH DIETARY GUIDANCE FOR INDIVIDUALS AGES 2 YEARS AND OLDER

As noted in Chapter 1, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is required to provide foods and services in alignment with the DGA (U.S. Congress, P.L. 101-445, 1990), which are applicable to individuals ages 2 years and older. In this section, the contributions of the food packages to the DGA food patterns are evaluated, including the contribution of WIC-approved foods to intakes of sodium, added sugars, saturated fat, and “calories for other uses” (COU) (see Chapter 2 for a description of COU).

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¹ References to the DGA in this chapter are specific to 2015–2020 unless otherwise noted.

Amounts of Foods in the Current Food Packages Compared to the USDA Food Patterns

Understanding the contribution of the WIC food packages to the U.S. Department of Agriculture (USDA)-recommended food patterns as outlined in the DGA (USDA/HHS, 2016) was required before the committee could consider how the food packages might be adjusted. As shown in Tables 3-1 through 3-4, the proportion of the DGA recommended amounts of food groups provided to women and children in the food packages varies across food groups and across food packages. The packages provide nearly 100 percent of recommendations for dairy in most cases and over 100 percent of recommended amounts of several other food groups and subgroups (i.e., dairy for fully breastfeeding women, juice for children,² peanut butter in most food packages, and legumes in food packages for children). In contrast, amounts of total grains, total protein foods, and total vegetables provided is generally less than 50 percent of recommended amounts. This variation suggested to the committee that there were opportunities for improvement in the alignment of the food packages with the DGA recommendations as well as with providing a more balanced supplement to participants’ diets.

Of note, the WIC food packages serve individuals with a wide range of energy needs.³ The data presented in tables 1 through 4 are therefore only approximations of the contribution of a WIC food package to a specific individual’s energy needs. Additionally, the data in these tables are based on an assumption that all foods in the packages are consumed by the intended beneficiaries.

Alignment of the WIC Food Packages with Dietary Guidance for Intake of Fish

The USDA’s Food and Nutrition Service (USDA-FNS) specifically tasked the committee to evaluate the inclusion of fish across food packages. As is evident in Tables 3-1 through 3-4, fish is provided only in food package VII for breastfeeding women. The DGA encourage consumption of high omega-3, low-mercury fish species (USDA/HHS, 2016), agreeing with the U.S. Food and Drug Administration/Environmental Protection Agency (FDA/EPA) joint federal fish advisory (2014). Intake of fish high in omega-3 fatty acids is recommended not only in the DGA, but also by the American Heart Association (AHA, 2015), AAP (AAP, 2014), and the

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² Based on the lower end of the AAP range of 4 to 6 ounces per day.

³ The food patterns applied in this report were selected based on the Estimated Energy Requirements calculated or assumed for each age and physiological-state subgroup, as outlined in Appendix J.

World Health Organization (PAHO/WHO, 2003). Table 3-5 presents the guidance from each of these groups. Generally, the recommended intake is between approximately 1 ounce and 2 ounces per day, depending on the target population.

These recommendations take into account the risks and benefits of fish intake, given that some fish species contain mercury, specifically methylated (organic) mercury, which can be detrimental to human health. Pregnant women are at the greatest risk. The 2015 Dietary Guidelines Advisory Committee (DGAC) report (USDA/HHS, 2015) reviewed and concurred with the Food and Agriculture Organization/World Health Organization (FAO/WHO) Expert Consultation on the Risks and Benefits of Fish Consumption (FAO/WHO, 2010), which stated that the health benefits of low-mercury fish consumption (whether farm raised or wild) outweigh risks with respect to both offspring development and mortality from cancers and cardiovascular diseases. The fish species for which the FDA advises limiting consumption are not included in the food packages.

Alignment of the WIC Food Packages with Dietary Guidance for Nutrients to Limit

The DGA recommend an upper sodium limit of 2,300 mg per day and upper limits of 10 percent of total calories from saturated fat and 10 percent of total calories from added sugars (USDA/HHS, 2016). Alignment of the WIC food packages with each of these recommendations is discussed below.

Sodium in the WIC Food Packages

The DGA recommendation to limit sodium to 2,300 mg per day aligns with the Tolerable Upper Intake Level (UL, a DRI value) for sodium for adults, ages 19 and older (IOM, 2005). In the WIC food packages, sodium is found primarily in cheese, canned vegetables, and canned fish. Sodium is otherwise limited in most other food categories. Although USDA/FNS (2014) encourages states to offer lower-sodium options, the low-sodium versions of some products cost more than their higher-sodium counterparts which may affect their inclusion on state WIC food lists.⁴ The sodium content of representative allowable WIC foods is presented in Table 3-6.

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⁴ States may implement cost-containment practices in order to reduce the average food cost per WIC participant. This may include limiting food selection by size, form, or price, as well as mandating the use of particular brands.

TABLE 3-1 WIC Maximum Allowance Compared to the 2015–2020 DGA Food Pattern: Food Package V, Pregnant and Partially Breastfeeding Women, Up to 1 Year Postpartum

NOTES: c-eq = cup-equivalents; CVV = cash value voucher; DGA = Dietary Guidelines for Americans; oz-eq = ounce-equivalents.

^a This kcal level most closely matched the calculated Estimated Energy Requirement for pregnant or breastfeeding WIC-participating women in NHANES 2005–2012. In the current WIC food packages, pregnant women and partially breastfeeding women receive the same benefits. Percentages represent the proportion of the recommended food pattern amount in the corresponding row of the DGA food pattern column.

^b The DGA recommend that not more than 50 percent of total fruit intakes come from 100 percent fruit juice (USDA/HHS, 2016).

^c Assumes that 67 percent of the CVV is used to purchase fruits, based on redemption data from Texas and Wyoming. A weighted composite cost of fruit ($0.55/c-eq) was developed, based on a composite of the most commonly consumed fruits (bananas, apples, oranges, berries, grapes, melon [watermelon was used in this case]) from an average of Massachusetts, Texas, and Wyoming redemption data. Only fresh fruit was included as all states allow fresh forms; ERS 2013 price data were updated with a consumer price index to 2015 values.

^d Assumes that 33 percent of the CVV is used to purchase vegetables, based on redemption data from Texas and Wyoming. A weighted composite cost of vegetables ($0.55/c-eq) was developed, based on a composite of the most commonly consumed vegetables (tomatoes, avocados, potatoes, peppers, lettuce) from an average of Massachusetts, Texas, and Wyoming redemption data. Only fresh vegetables were included as all states allow fresh forms; ERS 2013 price data were updated with a consumer price index to 2015 values. Because potatoes were not yet available in Wyoming, the same proportion of potatoes was assumed for this state as for Texas.

^e Legumes can also be assessed as a protein, but were placed in the vegetable group because a higher proportion of individuals had low intakes of vegetables across WIC participating subgroups compared to protein.

^f In the current food packages, a ratio of 81 percent refined grains and 19 percent whole grains was applied, based on redemption data.

^g To compare the food package contribution to the DGA recommended amounts of whole grains, the whole grain portion of breakfast cereal was added to the whole grain contribution of bread.

SOURCES: USDA/ARS, 2014; USDA/FNS, 2014; USDA/HHS, 2016. State-specific data are available in the public access file for this study (Email: paro@nas.edu).

TABLE 3-2 WIC Maximum Allowance Compared to the 2015–2020 DGA Food Pattern: Food Package VI, Women Up to 6 Months Postpartum

NOTES: c-eq = cup-equivalents; CVV = cash value voucher; DGA = Dietary Guidelines for Americans; oz-eq = ounce-equivalents; PP = postpartum.

^a The 2,300-kcal food pattern level most closely matched the calculated Estimated Energy Requirement for postpartum WIC-participating women in NHANES 2005–2012. Percentages represent the proportion of the recommended food pattern amount in the corresponding row of the DGA food pattern column.

^b The DGA recommend that not more than 50 percent of total fruit intake come from 100 percent fruit juice (USDA/HHS, 2016).

^c Assumes that 67 percent of the CVV is used to purchase fruits, based on redemption data from Texas and Wyoming. A weighted composite cost of fruit ($0.55/c-eq) was developed, based on a composite of the most commonly consumed fruits (bananas, apples, oranges, berries, grapes, melon [watermelon was used in this case]) from an average of Massachusetts, Texas, and Wyoming redemption data. Only fresh fruit was included as all states allow fresh forms; ERS 2013 price data were updated with a consumer price index to 2015 values.

^d Assumes that 33 percent of the CVV is used to purchase vegetables, based on redemption data from Texas and Wyoming. A weighted composite cost of vegetables ($0.55/c-eq) was developed, based on a composite of the most commonly consumed vegetables (tomatoes, avocados, potatoes, peppers, lettuce) from an average of Massachusetts, Texas, and Wyoming redemption data. Only fresh vegetables were included as all states allow fresh forms; ERS 2013 price data were updated with a consumer price index to 2015 values. Because potatoes were not yet available in Wyoming, the same proportion of potatoes was assumed for this state as for Texas.

^e Legumes can also be assessed as a protein, but were placed in the vegetable group because a higher proportion of individuals had low intakes of vegetables across WIC participating subgroups compared to protein.

^f Assumes 50 percent legumes and 50 percent peanut butter. Because these values account for the proportion of the maximum allowance of legumes and peanut butter provided per month, they are lower than those presented in the phase I report (NASEM, 2016).

^g In the current food packages, a ratio of 81 percent refined grains and 19 percent whole grains was applied, based on redemption data.

SOURCES: USDA/ARS, 2014; USDA/FNS, 2014; USDA/HHS, 2016. State-specific data are available in the public access file for this study (Email: paro@nas.edu).

TABLE 3-3 WIC Maximum Allowance Compared to the 2015–2020 DGA Food Pattern: Food Package VII, Fully Breastfeeding Women Up to 1 Year Postpartum

NOTES: c-eq = cup-equivalents; CVV = cash value voucher; DGA = Dietary Guidelines for Americans; oz-eq = ounce-equivalents.

^a The 2,600-kcal food pattern level most closely matched the calculated Estimated Energy Requirement for breastfeeding WIC-participating women in NHANES 2005–2012. Percentages represent the proportion of the recommended food pattern amount in the corresponding row of the DGA food pattern column.

^b The DGA recommend that not more than 50 percent of fruit intakes come from 100 percent fruit juice (USDA/HHS, 2016)

^c Assumes that 67 percent of the CVV is used to purchase fruits, based on redemption data from Texas and Wyoming. A weighted composite cost of fruit ($0.55/c-eq) was developed, based on a composite of the most commonly consumed fruits (bananas, apples, oranges, berries, grapes, melon [watermelon was used in this case]) from an average of Massachusetts, Texas, and Wyoming redemption data. Only fresh fruit was included as all states allow fresh forms; ERS 2013 price data were updated with a consumer price index to 2015 values.

^d Assumes that 33 percent of the CVV is used to purchase vegetables, based on redemption data from Texas and Wyoming. A weighted composite cost of vegetables ($0.55/c-eq) was developed, based on a composite of the most commonly consumed vegetables (tomatoes, avocados, potatoes, peppers, lettuce) from an average of Massachusetts, Texas, and Wyoming redemption data. Only fresh vegetables were included as all states allow fresh forms; ERS 2013 price data were updated with a consumer price index to 2015 values. Because potatoes were not yet available in Wyoming, the same proportion of potatoes was assumed for this state as for Texas.

^e Legumes can also be assessed as a protein, but were placed in the vegetable group because a higher proportion of individuals had low intakes of vegetables across WIC participating subgroups compared to protein.

^f In the current food packages, a ratio of 81 percent refined grains and 19 percent whole grains was applied, based on redemption data.

^g To compare the food package contribution to the DGA recommended amounts of whole grains, the whole grain portion of breakfast cereal was added to the whole grain contribution of bread.

SOURCES: USDA/ARS, 2014; USDA/FNS, 2014; USDA/HHS, 2016. State-specific data are available in the public access file for this study (Email: paro@nas.edu).

TABLE 3-4 WIC Maximum Allowance Compared to the 2015–2020 DGA Food Pattern: Food Package IV, Children 2 to Less Than 5 Years of Age*

NOTES: c-eq = cup-equivalents; CVV = cash value voucher; DGA = Dietary Guidelines for Americans; NR = no recommendation; oz-eq = ounce-equivalents.

* Some values in this table are corrected from the original prepublication version.

^a The DGA apply to individuals ages 2 years and older; therefore, although food package IV is issued to younger children, the table is applicable only to those ages 2 to less than 5 years.

^b For children ages 2 to less than 5 years, the median calculated Estimated Energy Requirement was 1,517 kcals. A food pattern of 1,300 kcal was selected for this age group because (1) 1,500 kcal/d may reflect recent increases in body weights for young children and was considered too high for normal weight children in this age group, particularly in light of efforts to reduce and/or contain the prevalence of childhood obesity, and (2) the 1,300-kcal pattern was applied in both the previous WIC food package review (IOM, 2006) and the Child and Adult Care Food Program (CACFP) report (IOM, 2011a) and should similarly be appropriate for current WIC participating children of the same ages. Percentages represent the proportion of the recommended food pattern amount in the corresponding row of the DGA food pattern column.

^c Assumes that 67 percent of the CVV is used to purchase fruits, based on redemption data from Texas and Wyoming. A weighted composite cost of fruit ($0.55/c-eq) was developed, based on a composite of the most commonly consumed fruits (bananas, apples, oranges, berries, grapes, melon [watermelon was used in this case]) from an average of Massachusetts, Texas, and Wyoming redemption data. Only fresh fruit was included as all states allow fresh forms; ERS 2013 price data were updated with a consumer price index to 2015 values.

^d Assumes that 33 percent of the CVV is used to purchase vegetables, based on redemption data from Texas and Wyoming. A weighted composite cost of vegetables ($0.55/c-eq) was developed, based on a composite of the most commonly consumed vegetables (tomatoes, avocados, potatoes, peppers, lettuce) from an average of Texas, Wyoming, and Massachusetts redemption data. Only fresh vegetables were included as all states allow fresh forms; ERS 2013 price data were updated with a consumer price index to 2015 values. Because potatoes were not yet available in Wyoming, the same proportion of potatoes was assumed for this state as for Texas.

^e Legumes can also be assessed as a protein, but were placed in the vegetable group because a higher proportion of individuals had low intakes of vegetables across WIC participating subgroups compared to protein.

^f Assumes 50 percent legumes and 50 percent peanut butter. Because these values account for the proportion of the maximum allowance of legumes and peanut butter provided per month, they are lower than those presented in the phase I report (NASEM, 2016).

^g In the current food packages, a ratio of 81 percent refined grains and 19 percent whole grains was applied, based on redemption data.

^h Equivalent to 4 oz per day, the lower end of AAP guideline of not more than 4–6 ounces per day.

ⁱ To compare the food package contribution to the DGA recommended amounts of whole grains, the whole grain portion of breakfast cereal was added to the whole grain contribution of bread.

SOURCES: USDA/ARS, 2014; USDA/FNS, 2014; USDA/HHS, 2016. State-specific data are available in the public access file for this study (Email: paro@nas.edu)

TABLE 3-5 Authoritative Recommendations for Intake of Fish High in Omega-3 Fatty Acids and Low in Mercury

NOTES: AAP = American Academy of Pediatrics; AHA = American Heart Association; DGA = Dietary Guidelines for Americans; FDA-EPA = Food and Drug Administration-Environmental Protection Agency; WHO = World Health Organization.

SOURCES: PAHO/WHO, 2003; AAP, 2014; FDA-EPA, 2014; AHA, 2015; USDA/HHS, 2016.

Saturated Fat in the Food Packages

Although the DGA do not include an upper limit for total fat intake, as mentioned above and in Chapter 2, they do include an upper limit of 10 percent of total energy from saturated fat. They also include replacing saturated fats with polyunsaturated alternatives and replacing solid animal fats with nontropical vegetable oils and nuts. Additionally, the DGA describe a healthy food pattern as one that includes “fat-free or low-fat dairy, including milk, yogurt, cheese” (USDA/HHS, 2016, p. 15). Aligning with these recommendations, since 2012, the National School Lunch Program has required that all milk served in schools be low-fat or nonfat and, if flavored, nonfat. Although flavored milks are permitted in the National School Lunch Program, the overall food pattern energy levels limit the levels of added sugars in allowable milks (USDA/FNS, 2012). Another federal nutrition assistance program, the Child and Adult Care Food Program, also requires that all milk provided to individuals 2 years of age or older be low-fat or nonfat (USDA/FNS, 2016a). Similarly, the current WIC food packages allow only 1 percent or nonfat milk for individuals ages 2 years and older. Additionally, depending on the food package, quantities of cheese are limited to 1 or 2 pounds per month. The saturated fat content of various WIC-allowable foods is presented in Table 3-7.

TABLE 3-6 Sodium Content of Representative Currently Allowable WIC Foods

NOTES: c-eq = cup-equivalents; DGA = Dietary Guidelines for Americans; oz-eq = ounce-equivalents. Nutrient amounts are from the National Nutrient Database for Standard Reference, release 28 (USDA/ARS, 2016) except where noted. For comparison, limits noted at the top of the table indicate 10 percent of kcal.

^a Cup- and ounce-equivalent servings are per the Food Patterns Equivalents Database 2011–2012: Methodology and User Guide (USDA/ARS, 2014).

^b Values based on the food label of a WIC-approved low-fat vanilla yogurt.

^c Values based on the food label of a WIC-approved soymilk.

SOURCES: USDA/ARS, 2014, 2016; USDA/FNS, 2014; USDA/HHS, 2016; other sources where noted.

TABLE 3-7 Saturated Fat Content of Representative Currently Allowable WIC Foods

NOTES: c-eq = cup-equivalents; DGA = Dietary Guidelines for Americans; oz-eq = ounce-equivalents. Nutrient amounts are from the National Nutrient Database for Standard Reference, release 28 (USDA/ARS, 2016) except where noted. For comparison, limits noted at the top of the table indicate 10 percent of kcal.

^a Cup- and ounce-equivalent servings are per the Food Patterns Equivalents Database 2011–2012: Methodology and User Guide (USDA/ARS, 2014).

^b Values based on the food label of a WIC-approved low fat vanilla yogurt.

^c Values based on the food label of a WIC-approved soymilk.

SOURCES: USDA/ARS, 2014, 2016; USDA/FNS, 2014; USDA/HHS, 2016; other sources where noted.

TABLE 3-8 Added Sugars Content of Representative Currently Allowable WIC Foods

NOTES: c-eq = cup-equivalents; DGA = Dietary Guidelines for Americans; oz-eq = ounce-equivalents. Nutrient amounts are from the National Nutrient Database for Standard Reference, release 28 (USDA/ARS, 2016) except where noted. For comparison, limits noted at the top of the table indicate 10 percent of kcal.

^a Cup- and ounce-equivalent servings are per the Food Patterns Equivalents Database 2011–2012: Methodology and User Guide (USDA/ARS, 2014).

^b Added sugars were calculated by subtracting naturally occurring sugar from total sugar in the food option. The USDA Final Rule permits ≤40 grams of total sugar per cup of yogurt and ≤6 grams per ounce of breakfast cereal.

^c Values based on the food label of a WIC-approved low fat vanilla yogurt containing 31.6 grams of total sugars. The plain low fat version of this yogurt contains 15 grams of sugar.

^d Values based on the food label of a WIC-approved soymilk.

^e Based on flavored milks approved for the School Meals Program that are not commercially available.

SOURCES: USDA/ARS, 2014, 2016; USDA/FNS, 2014; USDA/HHS, 2016; other sources where noted.

Added Sugars in the Food Packages

As noted above and in Chapter 2, as with saturated fats, the DGA recommend limiting added sugars to no more than 10 percent of total calories. Added sugars are sweeteners of various types added to foods (e.g., corn syrup, fruit juice concentrate, fructose, maltose) and do not include naturally occurring sugars such as those in 100% fruit juice or lactose in dairy products (USDA/HHS, 2016). The DGA further state that added sugars may have a role in increasing the palatability of nutrient-dense foods and specifically cited whole grain breakfast cereals and nonfat yogurts as examples (USDA/HHS, 2016).

Added sugars are limited in the WIC food packages. Although the FDA has issued a proposed rule on labeling of added sugars, at present, manufacturers are required to include only total sugars on the food label. Thus, specifications for some WIC foods, including ready-to-eat breakfast cereals and yogurt are for total sugars (not added sugars) (USDA/FNS, 2014). At present, USDA does not provide specifications for total sugars for soy beverages or flavored milk in the WIC food packages. The added sugars content of various WIC-allowable foods is presented in Table 3-8.

Alignment of the Current WIC Food Packages with Dietary Guidance for “Calories for Other Uses”

The concept of COU was introduced in the 2015–2020 DGA (replacing the 2010 DGA concept of “discretionary calories”). COU include calories from saturated fats (solid fats), added sugars, added refined starches, and alcohol, as well as additional calories from the food groups beyond amounts recommended. As described in Chapter 2, the limits for COU vary among food patterns, depending on how many “leftover” calories are available after the food group intake recommendations are met. For example, only 100 calories are available to be used as COU in a 1,200-kcal pattern, compared to 390 COU in a 2,600-kcal pattern.

As shown in Table 3-9, based on the committee’s calculations of estimated contributions of the food packages to COU,⁵ assuming full redemp-

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⁵ These estimates are based on several assumptions, as described in detail in Appendix R.

TABLE 3-9 Contributions of the Food Packages to the DGA Daily Limit for “Calories for Other Uses*

NOTES: COU = calories for other uses, defined in the DGA as the combined calories from saturated fats (solid fats), added sugars, refined carbohydrates, and alcohol; DGA = 2015–2020 Dietary Guidelines for Americans; FP = food package. Kcal patterns were selected based on the calculated Estimated Energy Requirement for WIC participants, using NHANES 2011–2012 (children) or 2005–2012 (women). Calculations assume full redemption of the food packages. *Some values in this table are corrected from the original prepublication version.

^a Based on the DGA food pattern indicated.

^b Based on the nutrient profiles of the food packages as developed using the methodology described in Appendix R, and presented in Appendix T.

^c (percent of total daily kcals available for COU) × (total kcal in the food package). To calculate this value, it was considered that the COU provided by the package should be in the same proportion as the COU in the USDA daily food pattern. For example, the USDA food pattern for a 2,600-kcal diet allows 15 percent of calories from COU. Thus, if food package V provides approximately 787 kcal, 15 percent, or 118 kcal, can be proportionally allotted to COU.

^d (saturated fat kcal) + (added sugars kcal).

^e (total COU kcal in the package × 100)/(number of COU kcal for the food pattern [data not shown]).

^f (proportion of the total daily COU limit × 100)/(FP COU daily limit). For example, food package V provides 107 kcal from COU, an amount that is 90 percent of 118 kcal.

SOURCES: USDA/ARS, 2016; USDA/HHS, 2016.

tion, all food packages provide less than the recommended total limit for COU for the diet as a whole. Considering the kcal provided by the package, the COU provided in each package are generally proportional to or slightly exceed the proportional limit for COU. Food packages for children exceed the proportional recommended limit for COU. The primary contributors to COU are dairy foods. Given that the current food packages are relatively limited in added sugars and saturated fat, these results indicate there is little room for additional COU in foods and beverages outside the WIC food packages. These results also suggest that it is a challenge for many WIC participants, especially children, to ensure that their overall diets fall within the recommended limits for COU.

ALIGNMENT OF THE FOOD PACKAGES WITH DIETARY GUIDANCE FOR INDIVIDUALS LESS THAN 2 YEARS OF AGE

The DGA do not currently include dietary guidance for individuals from birth to 24 months of age, although the Agricultural Act of 2014, also known as the Farm Bill, has officially called for future (i.e., 2020) DGA to include infants and toddlers (U.S. Congress, P.L. 113-79, 2014). Meanwhile, without this guidance, it is significantly more difficult to assess the appropriateness of the WIC food packages for children less than 2 years of age. To carry out its task, the committee compiled recommendations from the AAP, the Academy of Nutrition and Dietetics (AND), the World Health Organization (WHO), and other authoritative groups (see Table 3-10) and compared this guidance with the components of the food packages.

The committee found that the food packages are generally aligned with dietary guidance for infants and children ages 0 to less than 2 years, with the exception of juice, infant cereal, and jarred infant meat. Specifically, although the amount of juice provided in food package IV (which is provided to children 1 to 2 years of age) falls within the AAP recommended range of 4 to 6 ounces per day, this range is an upper limit. Moreover, the AAP guidelines emphasize whole fruit over 100% juice. Additionally, the AAP recommends a maximum of 4 tablespoons of infant cereal per day and a maximum of 1 to 2 ounces of jarred infant meat per day. The current infant food packages (food package II) provide 6 tablespoons of infant cereal per day (150 percent of the recommended amount) to all infants ages 6 to less than 12 months of age and 2.6 ounces of jarred infant meat (130 percent of the recommended amount) to fully breastfed infants of the same ages.

ALIGNMENT WITH THE DIETARY REFERENCE INTAKES

The committee also evaluated the alignment of the food packages with the DRI values appropriate for each age and physiological-state subgroup

(see Appendix J, Tables J-1a to J-1c for a compilation of DRIs). For women and children, most nutrients have an associated Estimated Average Requirement (EAR), which is the intake level at which 50 percent of individuals in a population will meet their needs. Nutrient contributions of the food packages as percentages of EARs are presented in Tables 3-11 through 3-13 (EARs are specific to each target population). For nutrients with only an Adequate Intake (AI), the proportion of the AI offered in the packages is also presented, but interpretation should take into account that, in contrast to the EAR, mean intakes should fall at or above the AI. For infants, most of the DRIs are expressed as AIs. A detailed description of the methodology applied to create the food package nutrient profiles is provided in Appendix R.⁶

Highlights of the nutrient profiles presented in Tables 3-11 through 3-13 are summarized here, with a focus on the provision of shortfall nutrients. As discussed in Chapter 2, the DGA identified 10 shortfall nutrients: vitamin A, vitamin D, vitamin E, vitamin C, folate, calcium, magnesium, fiber, iron, and potassium. Of these, four were identified further as nutrients of public health concern: calcium, vitamin D, fiber, and potassium, as well as iron for adolescent and premenopausal females. All of the food packages provide relatively small amounts of vitamin E, choline, and potassium. Similarly, the majority of the USDA food patterns do not assure adequacy of these nutrients, or of vitamin D (USDA/HHS, 2016), a factor that was considered when determining options for improving nutrient composition of the food packages. None of the food packages exceeded the UL for any nutrient.

Food Packages for Women

Food Package V for Pregnant and Partially Breastfeeding Women

For pregnant women, food package V contributes more than 100 percent of the EAR for calcium, vitamin C, vitamin A, phosphorus, riboflavin, and vitamin B12; close to 100 percent of the EAR for folate; and between approximately 60 and 80 percent of the EAR for iron, magnesium, zinc, selenium, vitamin B6, thiamin, niacin, and vitamin D. Food package V provides approximately 8 g per day of fiber and 1,800 mg per day of potassium, or about one-third of the AI for these nutrients (see Table 3-11).

The DRI for breastfeeding women assumes exclusive breastfeeding. Therefore, it was not possible to estimate the contribution of the food packages to the needs of partially breastfeeding women in reference to a DRI value as no appropriate DRI is available.

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⁶ To develop the food package nutrient profiles, the nutrient contribution of each WIC food category (i.e., “milk” or “bread”) was determined. The category may include the nutrient contributions of substitution options (i.e., cheese for milk) as described in Appendix R.

TABLE 3-10 Dietary Guidance for Breastfeeding Mothers and Infants and Children Less Than 2 Years of Age

^a There is some controversy regarding whether exclusive breastfeeding meets energy requirements of infants at 6 months of age in developed countries. Fewtrell et al. (2007, p. 637S) states, “A reasonable interpretation of the available scientific data is that there are currently insufficient grounds to confidently recommend an optimal duration of exclusive breastfeeding of 6 as opposed to 4–6 months for infants in developed countries.”

^b This level of maternal fish intake has been associated with improved neurobehavioral development in infants. Concern regarding the possible risk from intake of excessive mercury or other contaminants is offset by the neurobehavioral benefits of an adequate DHA intake and can be minimized by avoiding the intake of predatory fish (e.g., pike, marlin, mackerel, tilefish, swordfish) (AAP, 2014).

SOURCES: As noted in the Reference column.

TABLE 3-11 Nutrients Provided per Day in the Current Food Packages Compared to Dietary Reference Intakes: Pregnant, Breastfeeding, and Postpartum Women

NOTES: AI = adequate intake; DGA = Dietary Guidelines for Americans; EAR = Estimated Average Requirement; FP = food package; RAE = retinol activity equivalents; RDA = Recommended Dietary Allowance; Nutrient profiles were developed by applying the assumptions outlined in Appendix R.

* Some values in these columns are corrected from the original prepublication version.

^a Value is the median estimated energy requirement (EER) calculated by the committee. Values differ slightly from those in Chapter 4 because EER values for that chapter were re-calculated in a different statistical program to generate percentiles. The means are equivalent for the two analyses.

^b Values represent an RDA. The RDA is used for evaluation of the food package protein content because the EAR for protein is in units of g per kg body weight and therefore must be calculated for an individual.

^c Indicates an AI. Other values are an EAR unless otherwise noted.

^d Magnesium has two values: 19-30y/31-50y;

^e Based the DGA recommended limit of 10 percent of kcal.

SOURCES: IOM, 1997, 1998, 2000, 2001, 2002/2005, 2005, 2011a; USDA/ARS, 2016; USDA/HHS, 2016.

TABLE 3-12 Nutrients Provided per Day in the Current Food Packages for Infants Less Than 12 Months of Age*

NOTES: AI unless otherwise noted; AI = adequate intake; BF = breastfed; BF/FF = partially breastfed; DFE = dietary folate equivalents; DGA = Dietary Guidelines for Americans; EAR = Estimated Average Requirement; FF = formula fed; RAE = retinol activity equivalents; RDA = Recommended Dietary Allowance. Nutrient profiles were developed by applying the assumptions outlined in Appendix R. *Some values in this table are corrected from the original prepublication version.

^a Value is the median estimated energy requirement (EER) calculated by the committee.

^b Value represents an RDA. The RDA is used for evaluation of the food package protein content because the EAR for protein is in units of g per kg body weight and therefore must be calculated for an individual.

^c Value represents an EAR.

SOURCES: IOM, 1997, 1998, 2000, 2001, 2002/2005, 2005, 2011a; USDA/ARS, 2016; USDA/FNS, 2016b.

TABLE 3-13 Nutrients Provided per Day in the Current Food Packages Compared to Dietary Reference Intakes: Children Ages 1 to Less Than 5 Years of Age*

NOTES: AI = adequate intake; DFE = dietary folate equivalents; DGA = Dietary Guidelines for Americans; EAR = Estimated Average Requirement; NA = not applicable; RAE = retinol activity equivalents. Nutrient profiles were developed by applying the assumptions outlined in Appendix R.*Some values in this table are corrected from the original prepublication version.

^a Value is the median estimated energy requirement (EER) calculated by the committee.

^b Values represent a Recommended Dietary Allowance (RDA). The RDA is used for evaluation of the food package protein content because the EAR for protein is in units of g per kg body weight and therefore must be calculated for an individual.

^c Indicates an AI. Other values are an EAR unless otherwise noted.

^d For added sugars and saturated fat, value is the percent of the Dietary Guidelines for Americans (DGA) limit.

SOURCES: IOM, 1997, 1998, 2000, 2001, 2002/2005, 2005, 2011a; USDA/ARS, 2016; USDA/HHS, 2016.

Food Package VI for Postpartum Women

Food package VI for women who are postpartum (up to 6 months) provides more than 100 percent of the EAR for iron, folate, phosphorus, riboflavin, vitamin B12, and vitamin A, and nearly 100 percent of calcium, vitamin B6, and vitamin C EARs are provided in the food package. The package also provides between 70 and 80 percent of the EAR for zinc and niacin and approximately 50 percent of the EAR for vitamin D. This food package provides 6 g per day of fiber and approximately 1,300 mg per day of potassium, well below the AIs for these nutrients (see Table 3-11).

Food Package VII for Fully Breastfeeding Women

Food package VII for women who are fully breastfeeding (up to 12 months) provides more than 100 percent of the EAR for calcium, phosphorus, selenium, vitamin C, riboflavin, vitamin B12, and iron. Between 70 and 100 percent of the EAR for protein, zinc, thiamin, niacin, vitamin B6, folate, and vitamin D is provided. This food package provides 8 g of fiber per day and approximately 1,900 mg per day of potassium. As for other food packages, these amounts are below the AI for these nutrients (see Table 3-11).

Food Packages for Infants

Assessment of the contributions of the infant food packages to nutrient requirements was made more challenging by the lack of EAR values for these age groups. Although a full analysis of the food package nutrients was conducted, the committee focused on iron and zinc, which are commonly considered nutrients of concern for infants, particularly if breastfed (AAP, 2014), and for which EAR values have been determined. The results of this analysis are presented in Table 3-12.

For infants ages 6 to less than 12 months, food package II provides between 14 and 21 mg per day of iron depending on the feeding mode (formula fed, partially breastfed, or fully breastfed), compared to an EAR of 6.9 mg per day. The same food package provides between approximately 3 and 6 mg per day of zinc, compared to an EAR of 2.5 mg, again depending on feeding mode.

Food Package IV for Children Ages 1 to Less Than 5 Years

The nutrient contributions of the food package are different between children ages 1 to less than 2 years compared to children ages 2 to less than 5 years because the former are required to be issued whole milk products (see

Table 3-13). Overall, provision of most nutrients is well over 100 percent of the EAR, with some as high as approximately 400 percent (iron and vitamin C). For children ages 2 to less than 5 years, the food package provides over 100 percent of the EAR for calcium, iron, vitamins C and A, and folate among other nutrients. The package provides approximately 50 percent of the average vitamin D requirements for children of all qualifying ages.

FORMS AND COMPOSITION OF FOODS PROVIDED IN THE FOOD PACKAGES AND ALIGNMENT WITH DIETARY GUIDANCE

In addition to evaluating the quantities of nutrients and food groups provided by the food packages, the committee evaluated the appropriateness of the types of food for the intended recipients. Table 3-14 lists the current WIC foods that are authorized across food packages and the dietary guidance related to food types and food composition. In nearly all cases, the foods provided are consistent with this guidance. For example, only whole milk is provided to children 1 to less than 2 years of age, and milk provided to individuals ages 2 years and older is low-fat or nonfat. In only two cases are the foods provided not well aligned with dietary guidance. First, juice provided to children meets 100 percent of the lower end of the AAP limit. Yet whole fruit is the preferred form of fruit (see Table 3-10). Second, although intake of fish, particularly varieties high in omega-3 and low in mercury, is recommended for children and women (see Table 3-5), fish is currently provided only to fully breastfeeding women in food package VII.

ALIGNMENT OF THE FOOD PACKAGES WITH SPECIAL DIETARY NEEDS AND PREFERENCES

In Chapters 8 and 9 of the phase I report for this study, the ability of the food packages to meet the needs of WIC participants with particular medical conditions, cultural eating patterns, or food preferences was reviewed (NASEM, 2016). In this section, key components of that review that affected the committee’s decisions on food package changes are summarized along with additional relevant information collected in phase II.

Foods to Address Medical Conditions

The current WIC food packages can accommodate a wide range of medical conditions. This section summarizes, first, the circumstances under which food package III can be issued and, second, the extent to which the WIC food packages accommodate the dietary needs of individuals with food allergies and other food-triggered sensitivities.

TABLE 3-14 Dietary Guidance Related to Types or Composition of Foods in Current WIC Food Packages

NOTES: DGA = Dietary Guidelines for Americans; NA = not applicable; NR = no recommendation; T = tablespoon.

* Sources of guidance as cited in parentheses.

The Special Case of Food Package III

At the discretion of a health care provider, participants 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. Approximately 3 percent of WIC participants are recipients of this package, 75 percent of whom are infants, 25 percent children, and less than 1 percent adults (USDA/FNS, 2016b).

Depending on a participant’s specific medical needs, food package III is tailored to include either infant formula, noncontract⁷ infant formulas with unique nutritional composition, or WIC-eligible nutritionals (a “WIC formula”⁸). Most WIC participants who are issued food package III receive non-contract formulas (USDA/FNS, 2016b). The WIC definition for WIC-eligible nutritionals (see Box 3-1) is similar to the FDA definition of a medical food (Section 5(b)(3) of the Orphan Drug Act (21 U.S.C. 360ee(b)(3)), except that the WIC definition does not include “administered under the supervision of a physician” and does not acknowledge “distinctive nutritional requirements, based on recognized scientific principles … established by medical evaluation.” However, a medical professional prescription or recommendation is still needed for a participant to receive food package III, therefore in practice, the definitions are essentially the same and the WIC definition was considered by the committee to be appropriate.

The types and quantities of WIC formula and supplemental foods must be determined by the medical professional with appropriate documentation provided to the state agency. State agencies may allow the health care provider to refer to the WIC registered dietitian and/or qualified nutritionist for identifying appropriate supplemental foods (excluding WIC formula) and their prescribed amounts, as well as the length of time the participant requires the supplemental foods. Participants receiving food package III may be issued 455 ounces of WIC formula per month in addition to the maximum allowance of all other foods in the package appropriate for their life stage. Exceptions to these food package

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⁷ Any formula that is noncontract is not subject to rebates. Exempt infant formula is always noncontract. 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 nutritionals. WIC is not the primary payer for Medicaid beneficiaries but may be the payer for those not on Medicaid. Some private insurance may also cover exempt formula.

⁸ WIC formula refers to infant formula, exempt infant formula, or a WIC-eligible nutritional.

regulations may be made as necessary and as dictated by the Final Rule (USDA/FNS, 2014).⁹

In some cases, participants under the care of a health care provider may be prescribed foods atypical for the participant’s age category, such as when jarred infant foods are issued to individuals over 1 year of age. Under current regulations, participants must be prescribed a WIC formula to be issued food package III, whether or not it is included in the health care provider prescription and whether or not this required issuance suits the participant’s condition (i.e., a participant 2 years of age or older who is prescribed whole milk is unlikely to also be in need of a WIC formula).¹⁰

Food-Triggered Immune-Mediated Sensitivities

All of the food packages 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. Chapter 8 of the phase I report included a summary

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⁹ As specified in the Final Rule, exceptions to the maximum monthly allowance of all other foods may be made for recipients of food package III, including (1) whole milk may be provided to children over 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) WIC formula may be provided in lieu of foods at 6 months of age.

¹⁰ Text in this paragraph is updated from the original prepublication version.

of evidence from the literature on the nutritional needs of individuals with these medical conditions (NASEM, 2016). Here, the ways that the current food packages accommodate individuals with these conditions and potential gaps are highlighted.

Food allergies 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). The most common food allergies are allergies to peanut, tree nuts, seafood, milk, hen’s eggs, wheat, fish, and soy (Chafen et al., 2010), all of which were considered relevant to this review.

The committee’s review of the literature indicated that, for infants at risk of developing allergy, most experts recommend breastfeeding for approximately 6 months and the provision of hydrolyzed¹¹ protein formula for nonbreastfed infants (Greer et al., 2008; Chafen et al., 2010; Fleischer et al., 2013). Historically, the AAP Committee on Nutrition (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 the development of allergy in infants (Netting et al., 2014). 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.

There is no currently defined role for WIC-provided infant foods in allergy prevention because it is not fully understood how introduction of solid foods in the first year of life might influence the development of allergy. However, 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, the AAP issued interim guidance in September 2015 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). In the fall of 2016, the National Institute of Allergy and Infectious Disease is set to release a policy to formally recommend the introduction of peanut to high-risk children at between 4 to 6 months of age (Greenhawt, 2016).

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 3-15). However, as noted in the table, there is no current substitution for individuals with egg or fish allergies or those allergic to both cow’s milk and soy. The committee considered the latter

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¹¹ Hydrolyzed refers to formulas containing cow’s milk proteins that have been extensively broken down so they are unlikely to cause an allergic reaction.

TABLE 3-15 Options in WIC Food Package Categories Potentially Unsuitable for Special Diets and Major Allergies

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 as a major allergen because the baseline food packages do not contain soy products. The WIC food categories mature legumes, juice, and the CVV were excluded from the table because they are suitable for all cases covered in this table.

SOURCES: USDA/FNS, 2014, 2015a.

to be a medical condition for which food package III should be prescribed by the health care provider. Importantly, WIC offers participants with food allergies a number of educational resources to support adherence to dietary restrictions (USDA/FNS, 2015b).

Celiac disease Approximately 1 in 200 individuals living in the United States has 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). Women with celiac disease may have an increased risk of obstetrical complications and adverse birth outcomes (AND, 2006; Saccone et al., 2016). An Academy of Nutrition and Dietetics (AND) systematic review indicated that women with undiagnosed or untreated celiac disease have an increased risk of several adverse pregnancy outcomes (evidence graded as fair) (AND, 2006).

Treatment for celiac disease includes lifelong avoidance of wheat, barley, 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).

All state agencies now offer a nonwheat option for the “whole grain bread” food category (USDA/FNS, 2016b). These are suitable for gluten-free diets if the state-approved products are certified gluten-free. 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 oat, corn, or rice-based cereals that may be appropriate for participants who must avoid gluten (USDA/FNS, 2014). However, such cereals are not necessarily certified as gluten-free and, thus, the gluten content of state-approved products may not fall under the FDA limit of 20 parts per million of gluten (an amount tolerated by most individuals with celiac disease) (21 C.F.R. § 101). Individuals with non-celiac gluten sensitivity (NCGS)¹² may

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¹² 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).

also benefit from these non-wheat options. Table 3-15 indicates the currently available WIC foods and substitutions that meet the dietary needs of individuals who must or choose to avoid gluten.

Lactose intolerance Lactose intolerance is a set of symptoms caused by lactase deficiency. 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., 2008) or dairy products in specific forms. For example, natural cheddar cheese contains 0.18 percent lactose, whereas nonfat milk contains 5.09 percent lactose (USDA/ARS, 2016). For lactose-intolerant individuals, nutrition education might be necessary to ensure adequate calcium intake. A 2013 consensus statement issued by the National Medical Association and the National Hispanic Medical Association indicates that dairy intake may be low among African Americans and Hispanic Americans because of either perceived or actual lactose intolerance. In these cases, consumption of yogurt containing live and active cultures was suggested as a strategy for including dairy in the diet (Bailey et al., 2013).

Table 3-15 also indicates the currently available WIC foods and substitutions that meet the dietary needs of individuals who choose to avoid lactose. Soy products (soy beverages and tofu) are available as substitution options for cow’s milk. Although there is no substitution for cheese for fully breastfeeding women, most individuals with lactose intolerance are able to consume cheese in small quantities.

Alignment of Foods with Specific Preferences and Dietary Practices

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 comply with these practices.

Vegetarian or Vegan Diets

Plant-based diets can be nutritionally adequate for infants, children, and adults (AND, 2009; AAP, 2014; USDA/HHS, 2016). A vegetarian diet does not include animal flesh foods (i.e., meat, fish, seafood), but it does include other animal products (e.g., eggs, milk, cheese, yogurt), whereas a vegan diet excludes all animal foods and products. Individuals who consume a vegan diet should pay particular attention to their intakes of vitamins B12, calcium (AND, 2009), and vitamin D (AND, 2009; Craig, 2009), but their requirement for these nutrients can be met by consuming fortified

foods (AND, 2009). An additional concern exists for intakes of choline by pregnant women consuming vegan diets, but no research to date has assessed the intakes of choline by vegans. Individuals following a vegan diet may also have low intakes of eicosapentaenoic (EPA) and docosahexaenoic acids (DHA) (AND, 2009). The position of AND is that both vegetarian and vegan diets are not only adequate, but they may promote the prevention or aid in the treatment of certain health conditions (AND, 2009).

In cases where an infant’s caretaker prefers to provide a vegetarian or vegan diet (as well as in cases where an infant does not tolerate cow’s milk formula), the AAP supports the provision of soy protein–based formulas (Bhatia et al., 2008; AAP, 2014). A nutrition-related health challenge for breastfed infants adhering to a vegetarian or vegan diet is ensuring adequate iron intake. The introduction of complementary foods to infants at approximately 6 months of age is recommended, in part, to ensure adequate iron intake, and the AAP (2014) encourages early introduction of red meats and other foods rich in iron. AAP (2014) further indicates that oral iron supplementation may be needed for infants 6 to 12 months of age who are not consuming the recommended amount of iron from formula and complementary foods.

Soy formula is an option in all WIC packages for formula-fed infants. The WIC food packages include 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 3-2). A vegetarian or vegan substitution for infant meat is not permitted in the current WIC food packages.

Kosher or Halal Diets

Although federal regulations do not require foods that meet the needs of individuals who follow Kosher or Halal diets (in accordance with Jewish and Islamic dietary laws, respectively),¹³ states have the option to accommodate these individuals (USDA/FNS, 2014). At least 53 percent of WIC participants are served by WIC agencies that allow either Kosher or Halal, or both Kosher and Halal substitutions (USDA/FNS, 2011; personal communication, N. Cole, Mathematica, March 17, 2015) (see Appendix H, Table H-1). A 2015 update of state options indicated that 7 percent of

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¹³Eliasi 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.

state agencies allowed Kosher milk, no state agencies specified 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, 2016b).

Only limited data are available to assess the proportion of WIC participants who observe Kosher or Halal practices, and these data indicate that such individuals are rare in the WIC-participating population. In a nationally representative study in which 2,649 WIC-participating mothers were interviewed, less than 1 percent were found to observe Kosher or Halal feeding practices (see Appendix H, Table H-2). In the same study, 0.4 percent of mothers were found to be vegetarian, and less than 0.1 percent reported following a vegan diet (personal communication, K. Castellanos-Brown, USDA/FNS, April 27, 2016).

Alignment with Other Cultural Needs, Preferences, and Practices

Given the culturally diverse populations served by WIC, it is important to consider the appropriateness of WIC foods in meeting the food preferences of its varied racial and ethnic subgroups. The AAP acknowledges the strong influence of culture on parental behaviors related to food choice, preparation, and consumption (AAP, 2014). However, cultural eating practices, and feeding styles of WIC participants in particular have been examined in only a few studies. What studies do exist have reported cultural differences in breastfeeding initiation and duration, foods available and accessible to young children in the home, parent modeling, parent encouragement, and family rules (Bonuck et al., 2005; Kasemsup and Reicks, 2006; Hurley et al., 2008; Mistry et al., 2008; Arthur, 2010; Evans et al., 2011; Skala et al., 2012; Marshall et al., 2013; Odoms-Young et al., 2014; St. Fleur and Petrova, 2014). In addition, one study indicated that vegetable and fruit consumption differs depending upon the race/ethnicity of WIC participants (Di Noia et al., 2016).

These varying parental styles and practices for infant and child feeding may shape early food preferences and eating patterns that, in turn, have been associated with the risk of overweight or obesity (Adair, 2008; Weng et al. 2012), although no connection has been established with specific foods or food groups (Grote and Theurich, 2014).

Cultural variations in infant and child feeding practices may also affect the use of specific WIC foods. Kim et al. (2013) reported that satisfaction with jarred baby foods varied across ethnic groups, with about half of whites and African Americans preferring cash value vouchers (CVVs) for fruits and vegetables over jarred baby foods compared to more than two-thirds of Latinos and those identifying as “Other” preferring CVVs for

vegetables and fruits. However, redemption of jarred infant foods declined at similar rates with increasing infant age across all ethnic groups. Redemption data reviewed by the committee indicate that overall use of jarred infant vegetables and fruits may be poor. The committee also received many public comments requesting that the CVV replace jarred infant foods. This information suggests that in general, the CVV would allow the infant food packages to meet cultural needs and preferences for vegetables and fruits.

Other foods currently in the WIC food packages may also be more or less preferred by certain cultural groups. In the March 31, 2016, workshop convened by the committee,¹⁴ panelists who were asked to speak about cultural preferences of WIC participants shared the following:

• There is variation within broader cultural groups. For example, Latin American diets vary by region. In Mexico, corn and beans are core foods; in South America, potato, rice, and corn are staples; and in the Caribbean, preferences are for starchy root vegetables in addition to rice and beans.
• Dairy, legumes, and peanut butter are not part of most traditional Asian diets.
• WIC staff should avoid making assumptions about the stage of clients in the acculturation process, but instead should ask clients what foods are acceptable to them.
• Several whole grain options offered by WIC, such as whole wheat pasta, brown rice, and whole wheat bread, are not widely accepted by many cultural groups.
• Dry breakfast cereals are popular and often seen as status symbols, but people from porridge-based cultures may prefer hot cereals or boiled root vegetables.

FINDINGS AND CONCLUSIONS: POTENTIAL AREAS FOR FOOD PACKAGE MODIFICATIONS

In this chapter, the alignment of the current food packages with the most recent dietary guidance and the suitability of WIC foods for particular medical conditions and to meet dietary preferences and practices are reviewed. Table 3-16 summarizes the committee’s findings on key aspects of the food package as well as the conclusions the committee drew from these findings.

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¹⁴ See Appendix D for workshop agendas.

TABLE 3-16 Alignment of the Current Food Packages with Dietary Guidance, Special Dietary Needs, and Cultural Eating Practices or Food Preferences

NOTES: COU = calories for other uses; CVV = cash value voucher; DRI = Dietary Reference Intake.

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