In this chapter, the committee’s recommendations for the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food package changes are described. The chapter begins with a review of the committee’s overarching strategy for making food package changes. Then, proposed changes to all food packages for women, infants, and children are reviewed along with the rationale for each change. Women and children are covered first, followed by infants, because the rationale for many of the changes is similar for the foods in packages for women and children. Next, a brief discussion on proposed changes to food package III is presented. Finally, proposed changes to specifications for WIC-eligible foods are reviewed. The revised food packages based on all proposed changes are presented in Tables 6-1 and 6-2,1 and specifications for WIC foods are presented in Table 6-4. The changes proposed herein are evaluated against the committee’s seven criteria in Chapter 9 and recommendations for implementation and research to evaluate the changes proposed are described in Chapter 11. Chapter 10 presents the projected cost effects of the revised food packages over the long term.
1 Unless otherwise indicated, use of the word revised in this chapter refers to the revisions proposed in this report, not revisions that occurred in 2009.
the criteria included in Box 1-4. In particular, the committee sought to fulfill its task to align the WIC food packages with the 2015–2020 Dietary Guidelines for Americans (DGA) by designing packages that were balanced across the food groups and supplemental in amount. Possible revisions to the food packages were identified systematically with the use of the decision tree described in Chapter 5. Within this process, the committee also recognized a number of other factors relevant to the revisions. The factors included the following:
- The value of the food packages to the mother–infant dyad
- The flexibility of the cash value voucher (CVV) and its potential value to participants
- The need for additional seafood in the packages because of the importance of this food subgroup and the nutrients it contains to specific stages of development present in the WIC-participating population
- Participant food preferences (both cultural and personal)
- Constraints to changing foods in the packages related to the foods in the marketplace, the capacity of the vendors who provided foods to participants,2 and administrative issues at the state level
Final adjustments were made in an iterative fashion within the constraints of cost neutrality. Many comments were submitted to and reviewed by the committee, both supporting the foods in the current packages and requesting a change to the amounts or types of foods. These were considered in conjunction with the evidence presented below.
The Concept of Supplemental
The WIC program is designed to supplement participants’ diets without regard to whether these diets contain contributions from other federal (e.g., Supplemental Nutrition Assistance Program [SNAP]) or nonfederal programs (e.g., local food pantries). Determination of what a supplement to the diet should contain requires knowledge of participants’ diets and how well their diets meet both nutrient requirements and intakes of recommended food groups, as described in Chapters 4 and 5. The committee began by considering the meaning of the word supplemental, which is part of the full name of the WIC program, namely the Special Supplemental Food Program for Women, Infants, and Children. Although the U.S. Department of Agriculture’s Food and Nutrition Service (USDA-FNS) adheres to a definition of the term “supplemental,” as described in Chapter 1, additional specificity
2 The term vendor in this document refers to stores or retailers.
was needed to guide the committee’s actions. To provide this specificity, the committee noted that the current food packages provide widely varying proportions of required nutrients (between 5 and 400 percent of the Dietary Reference Intake [DRI]) and recommended food groups (between 0 and 177 percent of recommended intakes). The committee observed that a better balance among these proportions would permit the committee to align the food packages more adequately with the DGA. Given this observation, the committee developed the following guidance for designing food packages that supplement the diet:
- Inasmuch as WIC participants (other than formula-fed infants in the first 6 months of life for whom 100 percent of needs is provided) consume foods and beverages not supplied by the WIC food packages that meet some portion of their nutrient needs or recommended amounts of food groups, the amounts of nutrients and food groups in the WIC packages should provide a moderate proportion of an individual’s requirement for a particular nutrient or recommended amount of a food group.
- The supplementation target (i.e. proportion of requirement or recommended amount in the food package) may differ depending on the prioritization of the nutrient or food group (as described in Chapter 5) and the degree to which foods appropriate for the food packages and available in the marketplace could supply these amounts.
- Some accommodation for food preferences or cultural suitability would be considered acceptable.
Finally, the committee considered that food patterns are intended to be achieved over a period of time, and to serve as a framework from which individuals may choose foods to meet preferences and cultural needs (personal communication, T. E. Schap, USDA Center for Nutrition Policy and Promotion, May 10, 2016). As a result of the constraint to produce a set of cost-neutral food packages and other limitations to this process noted briefly in Chapter 1, the committee was not able to provide a moderate proportion of recommended intakes of all nutrients and food groups and subgroups.
This section summarizes the committee’s proposed changes to the food packages for women and children along with the supporting rationale for each change. The revised food packages based on these changes are presented in Table 6-1 (mother–infant dyad) and Table 6-2 (children and pregnant women). Inasmuch as what new mothers need (or do not need)
TABLE 6-1 The Revised WIC Food Packages: Maximum Monthly Allowancesa Presented as the Benefits to the Mother–Infant Dyad in Food Packages I, II, III, V-B, VI, and VII
|WIC Food Categories||Fully Breastfeeding Dyad||Partially (Mostly) Breastfeeding Dyad||Formula-Feeding Dyad|
|Infants 0 to 5 Months (FP I or IIIb)||Infants 6 to 11 Months (FP II or IIIb)||Infants 0 to 5 Months (FP I or IIIb)||Infants 6 to 11 Months (FP II or IIIb)||Infants 0 to 5 Months (FP I or IIIb)||Infants 6 to 11 Months (FP II or IIIb)|
|Formulac||—||—||0 to 3 months: up to 364 fl ozd,e 4 to 5 months: up to 442 fl ozd,e||Up to 312 fl ozd,e||0 to 3 months: up to 806 fl ozd,e 4 to 5 months: up to 884 fl ozd,e||Up to 624 fl ozd,e|
|Infant cereal||—||16 oz||—||8 oz||—||8 oz|
|Infant food vegetables and fruits||—||128 oz or 64 oz and $10 CVV or 0 oz and $20 CVVf||—||128 oz or 64 oz and $10 CVV or 0 oz and $20 CVVf||—||128 oz or 64 oz and $10 CVV or 0 oz and $20 CVVf|
|Infant food meats||—||40 ozg||—||—||—||—|
|For Women||Fully Breastfeeding Women (FP VII)h,i||Partially (Mostly) Breastfeeding Women (FP V-B)j||Postpartum Women (FP VI)|
|Vegetables and fruitsk||$35 CVV||$25 CVV||$15 CVV||No foods are provided to women after 6 months postpartum|
|Legumesl,m||2 lb every 3 months||2 lb every 3 months||2 lb every 3 months|
|Juice||64 fl ozn||64 fl ozn||—|
|Dairy (milk)||16 qto,p,q,r||16 qto,p,q,r||16 qto,p,q,r|
|Breakfast cereals||36 oz||36 oz||36 oz|
|Whole grainst||16 to 24 oz||16 to 24 oz||—|
|Peanut butterm||16 to 18 oz every 3 months||16 to 18 oz every 3 months||16 to 18 oz every 3 months|
|Eggsu||2 dozen||1 dozen||1 dozen|
|Fish||60 oz every 3 months||30 oz every 3 months||10 oz every 3 months|
NOTES: — = the WIC food category is not authorized in the corresponding food package; CVV = cash value voucher; FP = food package. See Table 6-4 for details related to WIC food specifications.
a Amounts presented are maximum monthly amounts, except where specified and for infant formula. Legumes, peanut butter, and fish are to be provided in a rotation, with states deciding on the best way to program the rotation given the flexibility of their individual Management Information Systems.
b Food package III is issued to participants with qualifying medical conditions. A WIC formula is issued to participants receiving food package III under the direction of a health care provider. Women who are issued food package III may receive up to 455 fl oz of a WIC formula, as deemed appropriate by a health care provider. Women who require jarred vegetables and fruits may be issued the following amounts corresponding to the value of the CVV: 94 oz, 23 4-oz jars, or 27 3.5 oz packages for the $15 CVV; 156 oz, 39 4-oz jars, or 45 3.5 oz packages for the $25 CVV; 219 oz, 55 4-oz jars, or 63 3.5 oz packages for the $35 CVV. If the participant chooses to substitute juice with an additional $3 in CVV, 5 additional 4-oz jars or 3.5-oz packages may be issued.
c WIC formula means infant formula, exempt infant formula, or WIC-eligible nutritionals. Infant formula may be issued for infants in food packages I, II, and III. In food package III, medical documentation is required for issuance of infant formula, exempt infant formula, WIC-eligible nutritionals, and other foods. Numbers indicate the full nutrition benefit, defined as the minimum amount of reconstituted fluid ounces of liquid concentrate infant formula as specified for each infant food package category and feeding variation.
d Amounts represent the full nutrition benefit, defined as the minimum amount of reconstituted fluid ounces of liquid concentrate infant formula as specified for each infant food package category and feeding variation. The corresponding maximum monthly allowance amounts that account for the form of formula are unchanged from those presented in the Final Rule. Infant formula amounts for all infants should be individually tailored to the amounts that meet their nutritional needs.
e Following a detailed assessment of the needs of the dyad by WIC staff, infants may be issued the quantity of formula needed to support any level of breastfeeding, up to the full nutrition benefit.
f Depending upon the amount of infant food vegetables and fruits selected for food package II for infants, $0, $10 or $20 can be substituted. The infant CVV may be used to purchase fresh, canned, or frozen vegetables and fruits, meeting the WIC specifications for these foods.
g Participants may substitute 10 oz of jarred infant food meat with 10 oz of canned fish meeting WIC specifications for this food category.
h Food package VII is issued to three categories of WIC participants: fully breastfeeding women whose infants do not receive formula from the WIC program; women partially (mostly) breastfeeding multiple infants from the same pregnancy; and pregnant women who are also fully or partially (mostly) breastfeeding singleton infants.
i Women fully breastfeeding multiple infants from the same pregnancy are prescribed 1.5 times food package VII.
j Food package V-B is issued to two categories of WIC participants: breastfeeding women participants whose partially (mostly) breastfed infants receive formula from the WIC program in amounts that do not exceed the maximum formula allowances, as appropriate for the age of the infant as described in this table, and women pregnant with two or more fetuses.
k State agencies must authorize fresh and at least one nonfresh (canned fruit, canned vegetables, frozen fruit, frozen vegetables, dried fruit, and/ or dried vegetables) variety each of vegetables and fruits. The CVV may be redeemed for any eligible fruit and vegetable. Vendors are required to stock at least three varieties of vegetables and two varieties of fruits.
l States are required to offer both dry legumes and canned legumes. Two lb of dry legumes or 128 oz (eight 15–16 oz cans) of canned legumes are provided in food packages V-B, VI, and VII once every 3 months.
m Legumes and peanut butter must be provided and are not interchangeable. Participants may be issued legumes in place of peanut butter in the case of a peanut allergy.
n Participants may select a $3 addition to the CVV in place of juice.
o Low-fat (1%) or nonfat milks are the standard milk for issuance to women. Reduced fat (2%) milk is authorized only for participants with certain conditions, including but not limited to, underweight and maternal weight loss during pregnancy. The need for reduced-fat (2%) milk must be based on an individual nutritional assessment as established by state agency policy.
p Evaporated milk may be substituted at the rate of 16 fl oz of evaporated milk per 32 fl oz of fluid milk or a 1:2 fl oz substitution ratio. Dry milk may be substituted at an equal reconstituted rate to fluid milk.
q For women receiving food packages V-B and VI, two substitution options are available for milk: (1) 1 lb of cheese and 1 qt of yogurt (30–32 oz are allowed at the discretion of the state agency) may substitute for 4 qt of milk or (2) 2 qt of yogurt may substitute for 2 qt of milk. Women receiving food package VII also have a third option of 2 lb of cheese substituting for 6 qt of milk. Low-fat or nonfat yogurts are the only types of yogurt authorized for women. Soy-based yogurt or soy-based cheese substitutes are authorized yogurt and cheese options for individuals with a milk allergy, lactose intolerance, or who consume a vegan diet.
r For women, soy-based beverage may be substituted for milk on a quart-for-quart basis up to the total maximum allowance of milk. Tofu may be substituted for milk at the rate of 1 lb of tofu per 1 qt of milk. Additional amounts of tofu may be substituted, up to the maximum allowances for fluid milk, for lactose intolerance or other reasons, as established by state agency policy.
s All breakfast cereals on the state agency’s authorized food list must meet the whole grain-rich criteria as described in Table 6-4.
t Whole wheat bread must be authorized. State agencies have the option to also authorize brown rice, bulgur, oatmeal, whole grain barley, cornmeal (including blue), corn masa flour, whole wheat macaroni (pasta) products, soft corn or whole wheat tortillas, buckwheat, or teff in the range specified.
u A substitution of dry legumes (1 lb) or canned legumes (64 oz or four 15–16 oz cans) for each 1 dozen eggs is permitted for individuals with an egg allergy or who consume a vegan diet.
SOURCE: Modified to reflect the revised food packages from 7 C.F.R. § 246 (USDA/FNS, 2014).
TABLE 6-2 The Revised WIC Food Packages: Maximum Monthly Allowancesa Presented as the Benefits to Children and Pregnant Women in Food Packages IV, V-A, and III
|WIC Food Category||Children 1 to Less Than 2 Years (FP IV-A)||Children 2 to Less Than 5 Years (FP IV-B)||Pregnant Women (FP V-A)b||Special Dietary Needs (FP III)c|
|WIC formula||—||—||—||Up to 455 fl oz of liquid concentrate, if appropriate|
|Vegetables and fruitsd||$12.00 CVV||$12.00 CVV||$15.00 CVV|
|Legumese,f||1 lb every 3 months||1 lb every 3 months||2 lb every 3 months||Other foods in food packages IV and V-A are provided as appropriate|
|Juice||64 fl ozg||64 fl ozg||64 fl ozg|
|Dairy (milk)||12 qth,i,j,k,l||14 qti,k,l,m||16 qtk,m,n,o|
|Breakfast cerealp||36 oz||36 oz||36 oz|
|Whole grainsq||16–24 oz||16–24 oz||16–24 oz|
|Peanut butterf||16–18 oz every 3 months||16–18 oz every 3 months||16–18 oz every 3 months|
|Eggsr||1 dozen||1 dozen||1 dozen|
|Fish||10 oz every 3 months||10 oz every 3 months||10 oz every 3 months|
NOTES: — = the food is not authorized in the corresponding food package; CVV = cash value voucher; FP = food package. See Table 6-4 for details related to WIC food specifications.
a Amounts are monthly except where indicated. Legumes, peanut butter, and fish are to be provided in a rotation, with states deciding on the best way to program the rotation given the flexibility of their individual Management Information Systems.
b Food package V-A is issued to women participants with singleton pregnancies.
c Food package III is issued to participants with qualifying medical conditions. A WIC formula is issued to participants receiving food package III under the direction of a health care provider. Participants that are issued food package III may receive up to 455 fl oz of a WIC formula (liquid concentrate), as deemed appropriate by a health care provider. WIC formula means infant formula, exempt infant formula, or WIC-eligible nutritionals. Powder and ready-to-feed may be substituted at rates that provide comparable nutritive value. The number of fl oz of formula refers to the amount as prepared according to directions on the container. Children or women who require jarred vegetables and fruits may be issued the following amounts
orresponding to the value of the CVV: 75 oz, 19 4-oz jars, or 21 3.5-oz packages for the $12 CVV, or 94 oz, 23 4-oz jars, or 27 3.5-oz packages for he $15 CVV. If the participant chooses to substitute juice with an additional $3 in CVV, 5 additional 4-oz jars or 3.5-oz packages may be issued.
d State agencies must authorize fresh and one nonfresh (canned fruit, canned vegetables, frozen fruit, frozen vegetables, dried fruit, and/or dried egetables) variety each of vegetables and fruits. The CVV may be redeemed for any eligible vegetable and fruit. Vendors are required to stock at east three varieties of vegetables and two varieties of fruits.
e States are required to offer both dry legumes (1-lb) and canned legumes (64 oz or four 15 to 16-oz cans). Legumes are provided once per quarter; lb in food packages IV-A and IV-B and 2 lb in food packages V-A and VI.
f Legumes and peanut butter must be provided and are not interchangeable. Participants may be issued legumes in place of peanut butter in the ase of a peanut allergy.
g Participants may select a $3 addition to the CVV in place of juice.
h Whole milk is the standard milk for issuance to 1-year-old children (12 through 23 months). At state agency option, reduced fat milks may be ssued to 1-year-old children for whom overweight or obesity is a concern. The need for reduced fat milks for 1-year-old children must be based n an individual nutritional assessment and consultation with the child’s health care provider if necessary, as established by state agency policy.
i Children receiving food package IV-A or IV-B may substitute 1 lb of cheese and 1 qt of yogurt (30–32 oz are allowed at the discretion of the tate agency) for 4 qt of milk, or 2 qt of yogurt for 2 qt of milk.
j At state agency option, low-fat or nonfat yogurt may be issued to 1-year-old children for whom overweight and obesity is a concern. The need or low-fat or nonfat yogurt for 1-year-old children must be based on an individual nutritional assessment and consultation with the child’s health are provider if necessary, as established by state agency policy.
k Evaporated milk may be substituted at the rate of 16 fl oz of evaporated milk per 32 fl oz of fluid milk or a 1:2 fl oz substitution ratio. Dry milk ay be substituted at an equal reconstituted rate to fluid milk.
l For children, issuance of tofu and soy-based beverage as substitutes for milk must be based on an individual nutritional assessment and consulation with the participant’s health care provider if necessary, as established by State agency policy. Such determination can be made for situations hat include, but are not limited to, milk allergy, lactose intolerance, and vegan diets. Soy-based beverage may be substituted for milk for children n a quart-for-quart basis up to the total maximum allowance of milk. Tofu may be substituted for milk for children at the rate of 1 lb of tofu per qt of milk.
m Low-fat (1%) or nonfat milks are the standard milk for issuance to children ≥24 months of age and women. Reduced fat (2%) milk is authorized nly for participants with certain conditions including, but not limited to, underweight and maternal weight loss during pregnancy. The need for educed fat (2%) milk must be based on an individual nutritional assessment as established by state agency policy. Soy-based yogurt or soy-based heese substitutes are authorized yogurt and cheese options for individuals with a milk allergy or who consume a vegan diet.
n Women receiving food package V-A, may substitute 1 lb of cheese and 1 qt of yogurt for 4 qt of milk or 2 qt of yogurt for 2 qt of milk.
o For women, soy-based beverage may be substituted for milk on a quart-for-quart basis up to the total maximum allowance of milk. Tofu may be substituted for milk at the rate of 1 lb of tofu per 1 qt of milk. Additional amounts of tofu may be substituted, up to the maximum allowances for fluid milk, for lactose intolerance or other reasons, as established by state agency policy.
p All breakfast cereals on the state agency’s authorized food list must meet the whole grain-rich criteria as described in Table 6-4.
q Whole wheat bread must be authorized. State agencies have the option to also authorize brown rice, bulgur, oatmeal, whole grain barley, cornmeal (including blue), corn masa flour, whole wheat macaroni (pasta) products, soft corn or whole-wheat tortillas, buckwheat, or teff in the range specified.
r A substitution of dry legumes (1 lb) or canned legumes (64 oz or four 15–16 oz cans) for each 1 dozen eggs is permitted for individuals with an egg allergy or who consume a vegan diet.
SOURCE: Modified to reflect the revised food packages from 7 C.F.R. § 246 (USDA/FNS, 2014).
nutritionally depends on how their infants are fed, the committee concluded that it would be most appropriate to consider the mother–infant dyads (breastfeeding mother and her breastfed infant as well as the postpartum mother and her formula-fed infant) together. In designing these dyadic packages, the committee considered nutritional needs (see Chapter 4, and nutrient comparison tables in Appendix T) and costs (see Chapter 7), as prescribed and as redeemed, in the current packages as well as in the revised packages.
Overall, the structure of the revised food packages is essentially the same, except that currently food package V is now divided to provide foods specifically for pregnant (food package V-A) and partially breastfeeding women (food package V-B). Side-by-side comparisons of the current and revised food packages are presented in Appendix N, Tables N-3 through N-7.
The Cash Value Voucher Is Increased as Much as Possible Within Cost-Neutral Constraints
Overall Increases in the CVV
WIC is a source of access to vegetables and fruits for low-income women. Yet, evidence indicates that WIC and SNAP benefits combined may be inadequate for low-income pregnant women to have a steady supply of vegetables and fruits throughout the month (Hromi-Fiedler et al., 2016).3 Given the current CVV of $8 for children and $11 for women, there is substantial room to improve the extent to which the food packages provide supplemental amounts of vegetables and whole fruits. These current amounts permit participants to purchase less than one cup-equivalent of vegetables or fruits per day. Based on the committee’s composite cost for vegetables and fruits most commonly purchased among WIC participants,4 $23, $41, or $45 would be required for individuals who consumed a 1,300-, 2,300-, or 2,600-kcal diet, respectively, to meet half of the recommended intakes of vegetables and fruits. The committee increased the CVV across food packages to the extent possible within cost-neutral restrictions (see Tables 6-1 and 6-2).
The CVV not only provides participants with access to two food groups
3Hromi-Fiedler et al. (2016) reported that of 45 pregnant Latino women surveyed (78 percent and 64 percent of whom benefitted from WIC and SNAP, respectively), some had difficulty maintaining the desired level of vegetables and fruits in the household over the course of the month, considering other food needs, accessibility, and affordability.
4 The fruit and vegetable composite ($0.55 per cup-equivalent) applied in this report considered the vegetables and fruits most commonly purchased by WIC participants in Massachusetts, Texas, and Wyoming.
(vegetables and fruits) for which intakes were below recommended amounts across several population subgroups (see Chapter 5), but it is also the component of the food packages that offers participants the most flexibility to meet their cultural needs. Evidence indicates that preferences for vegetables and fruits vary among WIC participants depending upon race, ethnicity, and geographic region of origin (Di Noia et al., 2016). Additionally, the CVV may help to increase dietary variety, which has been associated with improved diet quality (Arimond and Ruel, 2004).
The committee recognizes that WIC participants have the option to purchase either vegetables, fruits, or a combination of both. Available redemption data (from two states) indicate that the CVV is more commonly used to purchase fruits (67 percent of voucher dollars) than vegetables (33 percent of voucher dollars). Inasmuch as individuals already purchase both vegetables and fruits, the increase in benefit is predicted to enhance the amount of vegetables purchased and may be more effective in doing so with enhanced attention to nutrition education about the selection and preparation of vegetables (see the discussion on nutrition education in Chapter 11).
At Least Two Forms of Vegetables and Fruits Can Be Purchased with the CVV for Women, Infants, or Children
As outlined in the March 2014 Final Rule, states are currently required to authorize fresh vegetables and fruits and may also authorize canned, frozen, or dried forms (USDA/FNS, 2014). At the time of this writing, 10 states offered only fresh forms of vegetables and fruits (USDA/FNS, 2015a). Given the increase in the CVV across food packages in the revised packages, states must authorize at least two forms of vegetables and two forms of fruits: fresh and at least one additional form (frozen, canned, or dried). Limiting participants’ options to fresh-only may compromise available options seasonally and in certain geographic regions. Fresh, frozen, or canned forms of vegetables and fruits offer similar nutritional benefits. In some cases, processing may preserve nutrients that would otherwise be lost (Rickman et al., 2007; USDA/HHS, 2010; HHS, 2011; Miller and Knudsen, 2014; PBHF, 2016). Vegetables and fruits preserved through canning, freezing, or drying are also less perishable, thereby adding convenience. Additionally, in some cases, canned or frozen vegetables and fruits may be more economical than fresh (Miller and Knudsen, 2014; USDA/ERS, 2016), thereby increasing the purchasing power of the CVV. Although the sodium content of canned vegetables may be higher than that of other forms, canned vegetables can be prepared in ways that reduce sodium content (CFA, 2016).
The committee recognizes that state agencies that do not currently
allow canned, frozen, or dried vegetables and fruits will need to ensure that vendors have electronic benefit card (EBT)–linked Universal Product Codes (UPCs) (i.e., for new WIC-eligible canned, frozen, or dried vegetables and fruits). The USDA-FNS effort to develop a more comprehensive national UPC database (USDA/FNS, 2016a) should facilitate state efforts to meet requirements to stock new or additional products.
Vendors Are Required to Stock at Least Three Varieties of Vegetables and Two Varieties of Fruits
The current regulations require vendors to stock at least two varieties of vegetables and two varieties of fruits. Given the increased value of the CVV, the higher ratio of fruits (67 percent) that are purchased compared to vegetables (33 percent), and the low intakes of vegetables (particularly in contrast to fruits) in all WIC-participating subgroups, the committee decided that weighting the stocking requirements in favor of vegetables is a strategy that may facilitate participant purchase of vegetables over fruits.
Legumes and Peanut Butter Are Reduced to Supplemental Amounts and Are Not Interchangeable
In the current food packages, children and postpartum women may choose between legumes or peanut butter on a monthly basis. For other participants, both are provided on a monthly basis. In the revised food packages, peanut butter and beans are provided to all participants in a 3-month rotation.5 The intention of the rotation is to provide a better balance of food groups within cost-constraints. The committee envisions that states would decide on the best way to program the rotation, given the flexibility of their individual Management Information Systems.
The amount of legumes in the current food packages for children provides 177 percent of recommended amounts of beans and peas, and for women between 44 and 71 percent of recommended amounts (see Chapter 3, Tables 3-1 through 3-4). Legumes are key sources of several nutrients (i.e., potassium, fiber, and folate) for which intakes were found by the committee to be below recommended amounts in several WIC participant subgroups. Therefore, legumes are a valuable component of the WIC food packages. However, to align with the criterion of supplemental, the committee reduced the amounts provided in the revised food packages for
5 Fish is the third component in the rotation, as described later in this chapter.
children and equalized the amounts provided for women. The reduction in legumes (which are not highly redeemed) increases the funds available for the CVV, one of the most highly redeemed “foods” in the packages which may also serve as a source of vegetables. For children and postpartum women who currently choose peanut butter over legumes, the revised package provides both foods on a regular basis (therefore, legumes may actually be increased for some individuals). Legumes are now provided once every 3 months to all children and women (food packages IV, V-A, V-B, VI, and VII). Children are issued 1 pound of dry legumes (or four 15–16 ounce cans) and women are issued 2 pounds of dry legumes (or eight 15–16 ounce cans). The revised food packages for children still provide 120 percent of recommended amounts because package sizes prohibit reasonable further reductions (see Appendix T). For women, the revision brings the amount provided closer to what is considered supplemental: between 47 and 59 percent of the DGA recommended amount.
Offering Options for Both Dried and Canned Legumes
At present, states may authorize either dried and/or canned legumes. Although dried legumes are more commonly used in some cultures, they require significantly more preparation time, which may serve as a barrier to consumption of legumes for some WIC participants. In the revised packages, states are required to offer both dried and canned legumes in all packages as a way to promote both redemption and consumption. Canned legumes are more convenient because they are essentially ready-to-eat. Dry legumes should still be offered for those with a preference (cultural or personal) for this product, and to offer an easier-to-carry option.
According to the 2015 Food Policy Options report, 85 percent of WIC state agencies have already authorized canned legumes (USDA/FNS, 2015a). Therefore, the committee considered this change to be administratively feasible. Although the mandates to provide canned legumes (as well as processed vegetables and fruits) increase the administrative burden related to ensuring that vendors have EBT-linked UPCs, the USDA-FNS national UPC database mentioned previously (USDA/FNS, 2016a) should facilitate state efforts to meet requirements to stock canned legumes.
The amount of peanut butter in the current food packages provides approximately 84 to 168 percent of recommended amounts of nuts, seeds, and soy (a protein food subgroup) to children and women. In the proposed revisions to the food packages, the same quantities of peanut butter currently provided every month will still be provided, but only once every 3
months. This reduces food package provision of nuts, seeds, and soy to between approximately 56 and 111 percent of recommended amounts. Although the latter amount does not meet the committee’s criteria for supplemental, the limited availability of smaller package sizes (at a reasonable cost) prohibited further reduction.
Juice Is Reduced, and a CVV Option Is Allowed
Authoritative Recommendations Related to 100% Fruit Juice
The amount of juice in the current packages for children (food package IV) is equivalent to 107 percent of the lower end of the American Academy of Pediatrics (AAP) recommended range (i.e., 4 ounces per day) (AAP, 2014). The AAP (2014) also states that most fruit intake should be from whole fruit because whole fruit also contributes fiber and other plant-based compounds that are removed during processing. The DGA include a recommendation that at least half of fruit intake should be from whole fruit, and state that most individuals in the United States “would benefit from increasing intakes of fruit, mostly whole fruit” (USDA/HHS, 2016). The food packages for women (with the exception of food package VI) currently provide a disproportionate number of fruit servings from juice compared to fruit servings from whole fruit (see Chapter 3, Tables 3-1 through 3-3).6 As described in Chapter 3, the committee concluded that the amounts of juice in the current food packages are more than supplemental and not aligned with dietary guidance.
Juice in the Revised Food Packages
Based on these considerations, the amount of juice offered in the revised food packages was reduced by approximately half.7 Juice now provides approximately 50 percent of the AAP recommendation for juice intake for children and 27 percent of the DGA limit for fruit intake from juice for women. The funds saved by the reduction in juice were reallocated to the CVV, a priority component of the revised food packages. In addition, participants now have the option to substitute the remaining amount of juice with a further increase in their CVV (described later in this chapter).
Moreover, the amounts of juice in the revised packages are aligned
6 This analysis assumes that 67 percent of the CVV is used to redeem fruit, based on redemption data provided to the committee from Texas and Wyoming. These data are available in the public access file (Email: email@example.com).
7 Juice was also removed from food package VI to achieve cost-neutrality and to increase the relative value of the partially (V-B) and fully (VII) breastfeeding packages.
with sizes available in the marketplace. This provides states and vendors with reasonable stocking options. Results of the small study by Andreyeva et al. (2013) indicated that WIC participants did not compensate for 2009 food package reductions in juice with a comparable increase in purchases of other nonjuice beverages.
Substitution of Juice with the CVV
As mentioned in the previous section about juice, in the revised food packages, participants are permitted to choose an additional $3 CVV in place of the 64 ounces of juice. This option aligns with dietary guidance to encourage intake of whole fruit over juice and is consistent with the committee’s goal of increasing choice.
Additional Milk Substitutions Are Allowed, and the Amounts of Milk Are Reduced in Most Packages
The committee concluded that the milk in the current food packages provides more than a supplemental amount of dairy (between 85 and 119 percent of recommended amounts [see Chapter 3, Tables 3-1 through 3-3]). At the same time, intakes of dairy foods are below recommended amounts in several WIC-participating population subgroups (see Chapter 5). Available data indicate that redemption of whole milk is approximately 75 percent and that redemption of low-fat milk is approximately 71 percent for children and 56 percent for women.8 These data suggest that what is redeemed may not be fully consumed by the intended recipient. The amounts of milk provided in the food packages for both women and children were revised, as described below. Nonfat and low-fat milk were retained as required forms of milk for individuals 2 years of age and older because of the DGA recommendation to consume nonfat or low-fat dairy products (USDA/HHS, 2016). Additional detail on the committee’s consideration of dairy fat can be found in Appendix Q.
Additional Milk Substitutions
Inasmuch as dairy intakes are below recommended amounts across participant subgroups, milk, or the substitution options currently permitted, may not be preferred forms of dairy. The revised food packages allow more substitution options for milk in food packages IV, V-A, V-B, VI, and VII as follows: (1) 1 pound of cheese and 1 quart of yogurt for 4 quarts of milk; or (2) 2 quarts of yogurt for 2 quarts of milk. Women who receive
food package VII have a third option of 2 pounds of cheese for 6 quarts of milk. Soy-based yogurt or soy-based cheese substitutes meeting the specifications outlined later in this chapter are also allowed. The yogurt 1-quart substitution may range from 30 to 32 ounces to allow states the option to accommodate the smaller container sizes (approximately 5 ounces) that are commonly available in the marketplace today. These substitution options are also structured to eliminate the need for a single quart (“dangling quart”) of milk, which may be more difficult to find in stores and is typically more expensive. These additional choices may improve redemption of milk and milk substitutes.
Milk Amounts in the Food Packages for Women
Inasmuch as the Estimated Average Requirement (EAR) for calcium is the same for all subgroups of WIC-participating women (i.e., 800 milligrams),9 it is reasonable to provide the same quantity of the key food group for calcium (i.e., dairy) across food packages for women. The DGA recommendation for the intake of dairy for all subgroups of women is 3 cup-equivalents per day. Yet, the current food packages for women provide widely varying amounts of dairy (again, see Tables 3-1 through 3-3.) With these factors in mind, the amounts of dairy provided in food packages for pregnant (V-A), partially breastfeeding (V-B), and fully breastfeeding (VII) women were reduced to match the amount of dairy provided in food package VI for postpartum women. This change includes removal of the additional 1 pound of cheese for fully breastfeeding women (VII).10 The amount of milk in the revised food packages provides 71 percent of the recommended amount of dairy for women.
Milk Amounts in the Food Packages for Children
The current food package for children ages 2 to less than 5 years (IV-B) provides 85 percent of the DGA recommended amount of dairy. The committee considered this a greater than supplemental amount and reduced the amount of dairy provided in this food package to 75 percent of the DGA recommended amount.
Although the DGA food patterns do not apply to children ages 1 to
9 The EAR for calcium for women ages 14 to 18 years is 1,100 mg per day (IOM, 2011). The most recent (April 2014) data indicate that the proportion of WIC-participating women under the age of 18 is 3.4 percent (USDA/FNS, 2015b). Given this age distribution, changes to the food packages for women target the EAR for women ages 19 to 50 years of 800 mg per day. The revised food packages are considered to still provide more than a supplemental amount of calcium (72 to 78 percent of the EAR) to women ages 14 to 18 years.
10 Fully breastfeeding women may substitute up to 6 qt of milk for 2 lb of cheese.
less than 2 years, the amount of dairy suitable for this group is likely to be lower (in proportion to energy and nutrient needs) than those for children ages 2 to less than 5 years. Therefore, in the revised food packages, the amount of dairy in food package IV-A was reduced to provide 2 quarts less milk per month (the equivalent of 71 percent of the recommended amounts of dairy for a 1,300-kcal diet) compared to food package IV-B (for children ages 2 to less than 5 years).
Implications of the Revised Amounts of Milk
Not only are the revised amounts of milk better aligned with the committee’s concept of supplemental, but the amounts of milk in the revised food packages are closer to the amounts of milk that are currently redeemed (see Appendix T). Therefore, it is anticipated that the volume of milk redeemed in the revised package will be similar to the amount currently redeemed (with the exception of food package VII), or even slightly higher as a result of the additional yogurt option, which may be preferred to fluid milk in some racial and ethnic groups.
Whole Grains Are Expanded to Accommodate a Wider Range of Package Sizes, and Additional Options Are Allowed
Whole Grains Are Expanded to a Range of 16 to 24 Ounces
The committee’s analysis of data from National Health and Nutrition Examination Survey (NHANES) indicated that intakes of whole grains continue to be poor and intakes of refined grains are excessive across the WIC subgroups studied. A recent study found that purchases of whole grain products by WIC households were higher after states introduced the requirement that half of cereals offered meet the Final Rule whole grain requirements (Oh et al., 2016). Increasing the focus on whole grains in the WIC food packages may help to increase whole grain intake and improve acceptability of whole grains for the longer term.11
For women, the current food packages provide between 6 and 17 percent of the recommended amounts of whole grains, but 58 percent of recommended amounts of whole grains for children. Whole grains in the revised food packages provide 16 to 31 percent of recommended amounts of whole grains for women and 61 percent of recommended amounts of whole grains for children (see Appendix T). The total grains (which is the sum of whole and refined grains) provided to children is less than what the
current package provides because allowing the more commonly available 24-ounce bread size, as explained below, removes the need to provide two 1-pound loaves of bread. The ratio of whole grains to refined grains is improved for all food packages.
In the current food packages, a 1-pound (16-ounce) loaf of bread is permitted, which may be substituted with oatmeal, brown rice, barley, corn tortillas, whole wheat tortillas, or whole wheat pasta of the same weight. As reviewed in the phase I interim report (NASEM, 2016) and in Chapter 2 of this report, the 1-pound size of bread was uncommon in the marketplace when the current food packages were introduced and posed a challenge for vendors and manufacturers. The price per ounce of the more commonly available size of whole grain bread ($0.10 per ounce for a 24-ounce size) is lower than for the 1-pound loaf size ($0.14). Thus, a more economical way to provide whole grains to participants is to increase the size of the whole grain bread to one that is more commonly available. The committee therefore changed the whole grain category to a range of 16 to 24 ounces. This range allows for the purchase of bread in 22- to 24-ounce sizes, thereby reducing the burden for vendors to stock the uncommon 1-pound size. Second, it eliminates the need for manufacturers to create WIC-specific product sizes, reducing overall program costs. Third, additional options for package size may increase availability and promote intake of whole grains, for which intake is inadequate in 100 percent of WIC-participating women and more than 90 percent of WIC-participating children. The lower price per ounce allows for delivery of 50 percent more whole grains to participants at an increased cost of only $0.17 per loaf.12
Additional Whole Grain Options Are Allowed
A greater degree of flexibility in size, as described above, is one way that the revised packages will allow states to offer a greater number of grain options. The committee further recommends that the WIC food category of whole grains also include fortified corn masa flour (which is not a whole grain, see further description below), cornmeal, teff, and buckwheat, and that states authorize as many of these options as cost constraints allow. Some options may be more or less suitable to a state’s particular WIC-participating population. Of note, with the exception of fortified corn masa flour, these products are generally not fortified and, thus, their primary contribution to the diet is provision of whole grains (see Appendix Q, Table Q-1).
In accordance with the Final Rule, in the current food packages state
12 Price data in this section obtained from the Information Resources, Inc. (IRI) store scanner dataset.
agencies are encouraged to offer corn tortillas with whole grain corn listed as the primary ingredient (USDA/FNS, 2014). The revised food packages include the additional option of ground corn masa flour, even though this option is not whole grain. The committee concluded that this option should be permitted because (1) tortillas made with corn masa flour are currently permitted to improve the cultural suitability of the packages and, (2) early in 2016, the U.S. Food and Drug Administration (FDA) approved corn masa flour for fortification with folic acid (FDA, 2016a). Data from the Centers for Disease Control and Prevention indicate that only 17 percent of Hispanic women report intake of 400 µg or more of folic acid daily through fortified foods or supplements, compared with 30 percent of non-Hispanic white women (Williams et al., 2015). States are therefore encouraged to offer fortified corn masa flour and tortillas made with fortified corn masa flour once such products become available in the marketplace. The other expanded options must be whole grain.
Fortified Ready-to-Eat Breakfast Cereals Are Retained
Fortified ready-to-eat (RTE) cereals offer higher concentrations of nearly all nutrients compared to other whole grain products, so they were retained as a separate food category, in part to address nutrients of concern. Folate and iron are particularly important to the WIC-participating population and are not required fortificants in whole grain products, but are typically added to ready-to-eat breakfast cereals. Therefore, the committee considered that retention of fortified ready-to-eat cereals would support intake of these nutrients. The committee also recognized that RTE cereals may be important to retain as a delivery mechanism for fluid milk (Song et al., 2006). Additional details related to the folic acid content of RTE cereals can be found in the section on food specifications, and additional data supporting this conclusion are available in Appendix Q.
Fish Is Added to Nearly All Food Packages Within Cost-Neutral Constraints
USDA-FNS tasked the committee with evaluating whether fish should be included in additional food packages. As described in Chapter 3, authoritative groups recommend consumption of 1.0 to 1.7 ounces of lower-mercury fish per day by children ages 1 to 4 years (AAP, 2014; AHA, 2015; USDA/HHS, 2016) and pregnant and breastfeeding women (FDA/EPA, 2004; AHA, 2015; USDA/HHS, 2016). Yet, seafood intake is either low or too uncommon to assess in most subgroups of WIC participants. Only food package VII for fully breastfeeding women currently includes fish (USDA/FNS, 2014). In alignment with dietary guidance, the committee considered it appropriate to include fish in additional food packages. However, due
to cost constraints, the amount of fish added to the revised food packages varies, providing between 8 and 47 percent of the recommended intakes of seafood. In alignment with the overall strategy to promote any intensity of breastfeeding (discussed later in the chapter), fish was reduced from 30 to 20 ounces per month in the revised food package VII for fully breastfeeding women to allow partially breastfeeding women to receive 10 ounces per month. The other revised food packages contain a smaller amount (10 ounces, or two 5-ounce cans every 3 months). Although this amount provides only 8 percent of the DGA recommended amount of seafood for postpartum women and 19 percent for children, the committee considered it important to provide some amount of this food group in each package to improve balance across the food groups and consistency with the DGA, and introduce this underconsumed food into the diets of WIC participants. Fish is also now permitted as a partial substitute for infant food meat, as described later in this chapter.
Canned Fish May Be Packed in Water and May Include Sauces and Flavorings
In the current food packages, fish may be packed in water or oil and may include added sauces and flavorings. In the revised food packages, fish may be water-packed (not oil-packed), but may include the same sauces and flavorings that are currently allowed. Water-packed varieties are higher in nutrient density because water-packed fish is lower in energy but contains the same levels of key nutrients per serving (see Appendix O, Table O-3). Currently, approximately 43 percent of WIC participants are allowed to purchase oil-packed varieties (based on state WIC food lists [USDA/FNS, 2015a]). Therefore this specification change will affect less than half of the WIC participating population.
Rotating Fish, Legumes, and Peanut Butter
In the revised food packages, legumes and peanut butter are rotated on a quarterly basis to provide more supplemental amounts, and amounts that better align with participant preferences.13 In most packages (IV, V-A, and VI), fish is added to the quarterly rotation. For food packages V-B and VII, states may decide how best to provide fish based on the capabilities of their individual Management Information Systems (i.e., quarterly or monthly). Although this may appear to add administrative burden, it is similar to the current rotation allowed between legumes and peanut butter. Although
13 Data provided to the committee indicate that redemption of legumes and peanut butter is approximately 50 percent.
legumes, peanut butter, and fish are not nutritionally interchangeable, the revised amounts of legumes and peanut butter not only improve their alignment with recommended dietary intake but also help to allow for the cost-neutral inclusion of fish. It is anticipated that states will create food packages that rotate the issuance of legumes, peanut butter, and fish over each 3-month period, eliminating the burden of asking for the participants’ preference between legumes and peanut butter and optimizing nutrients available to participants through these nonperishable foods.
The revised food packages include several additional options for vegans, vegetarians, and individuals with specific types of food-triggered immune-mediated sensitivities (e.g., lactose intolerance, milk allergy, celiac disease). The soy-based cheese and soy-based yogurt products allowed in the revised food packages are suitable substitutes for dairy products for both vegans and individuals with lactose intolerance or a milk allergy. Vegans who wish to substitute for 1 dozen eggs may do so with 1 pound of dry legumes or four 15- to 16-ounce cans of legumes; these options provide the same number of ounce-equivalent servings for their respective food groups and are both nutrient-dense. Several of the new grain options may be available in certified gluten-free forms that would be suitable for individuals with celiac disease (the expansion of whole grain options is discussed earlier this chapter).
As discussed in Chapter 3, individuals with lactose intolerance may be able to tolerate yogurt. The revised food packages allow states to authorize a substitution of 2 quarts of yogurt for 2 quarts of milk (a one to one substitution). Participants with a preference for yogurt over milk may also take advantage of this option. Although yogurt is already offered in most states, it is a recent addition to state agency WIC-approved food lists. As a result, adequate data are not yet available to assess redemption of yogurt by WIC participants. In a study of WIC participants in California, Fung et al. (2010) found that that the majority of respondents wanted to substitute some of their milk with yogurt. This preference for yogurt over milk, coupled with low intakes of calcium in some WIC subgroups (see Chapter 5), suggests that offering yogurt may improve dairy redemption and consumption.
Although peanut butter and legumes are no longer considered interchangeable in the revised food packages, participants with a peanut allergy may be issued 1 pound of dry legumes or four 15- to 16-ounce cans of legumes in place of peanut butter.
SUMMARY OF RECOMMENDED CHANGES TO THE AMOUNTS AND TYPES OF FOOD AND SUBSTITUTION OPTIONS IN THE WIC FOOD PACKAGES FOR WOMEN AND CHILDREN
In the previous sections, the committee provides the rationale for a number of changes to the WIC food packages for women and children in alignment with the statement of task. The overarching recommendations and specific changes are summarized below.
6-1. The U.S. Department of Agriculture’s Food and Nutrition Service (USDA-FNS) should increase the dollar amount of the cash value voucher, add fish, and reduce the amounts of juice, milk, legumes, and peanut butter in all food packages for women and children (IV, V-A, V-B, and VII), to improve the balance of food groups in alignment with the 2015–2020 Dietary Guidelines for Americans. These changes also apply to food package VI, except that the amounts of milk are unchanged and the amounts of legumes are increased.
The specific changes recommended include
- Increase the CVV to at least $12, $15, $25, and $35 in food packages IV (children), V-A (pregnant women) and VI (postpartum women), V-B (partially breastfeeding women), and VII (fully breastfeeding women), respectively, to align with the DGA for increased intakes of vegetables and fruits.
- Add 10 ounces of fish to food packages IV, V-A, and VI once per quarter (once every 3 months), 10 ounces of fish every month in food package V-B, and modify the amount of fish in food package VII to 20 ounces per month.
- Provide 64 ounces of juice in food packages IV, V-A, V-B, and VII, and remove juice from food package VI.
- Provide 12 quarts of milk in IV-A (children ages 1 to less than 2 years), 14 quarts in food package IV-B (children ages 2 to less than 5 years) and 16 quarts in food packages V-A, V-B, VI, and VII.
- Provide legumes once per quarter (once every 3 months): 1 pound (16 ounces of dry or 64 ounces canned [four 15- to 16-ounce cans]) in food package IV and 2 pounds in food packages V-A, V-B, VI, and VII.
- Provide 16 to 18 ounces of peanut butter to women and children on a quarterly basis (once every 3 months).
In addition, the committee recommends substitution options for individuals with special dietary needs or preferences, and to promote intake of foods that are currently underconsumed:
6-2. USDA-FNS should support the cultural food preferences and special dietary needs of WIC participants by requiring states to offer additional options for the WIC food categories, including substitution of a CVV in place of juice, additional forms and varieties of vegetables and fruits, both canned and dried legumes, and a range of options and sizes for grains and yogurt. A substitution of legumes for peanut butter or for eggs should be allowed for individuals who have a peanut allergy, or who are following a vegan diet, respectively.
The specific substitution options recommended include
- Allow participants the choice to select a CVV option for all remaining juice ($3 may be added to the CVV in place of juice for each participant who chooses this option).
- Require states to offer fresh and one additional form (frozen, canned, or dried) each of vegetables and fruits.
- Require vendors to offer at least three varieties of vegetables and two varieties of fruits.
- Allow states to authorize teff, buckwheat, and cornmeal (including blue) as substitutions for whole-wheat bread. Corn masa flour should also be permitted in alignment with the current FNS allowance of corn tortillas, which may be made from corn masa flour.
- Allow participants a range of 16 to 24 ounces of grains to fulfill the maximum allowance for whole grains and a range of 30 to 32 ounces of yogurt to substitute for 1 quart of milk.
- Require states to offer a choice of 1 pound of dry legumes or 64 ounces (four 15- to 16-ounce cans) of canned legumes in all food packages offering legumes.
- Allow WIC participants to substitute 1 pound of soy-based cheese substitute for 3 quarts of milk, or 2 quarts of yogurt or soy-based yogurt substitute for 2 quarts of milk.
- Allow vegan participants to substitute 1 pound of dry legumes or 64 ounces (four 15- to 16-ounce cans) of canned legumes for 1 dozen eggs.
- Allow participants with a peanut allergy to substitute 1 pound of dry legumes or 64 ounces (four 15- to 16-ounce cans) of canned legumes for 16 to 18 ounces of peanut butter.
Currently, there are three WIC food packages available to infants: (1) food package I provides only infant formula (no foods) for infants ages 0 to less than 6 months; (2) food package II provides infant formula and foods for infants ages 6 to 11 months; and (3) food package III provides infant formula and foods that meet special dietary needs for infants of all ages with medically documented, qualifying conditions (proposed revisions to food package III are described later in this chapter). As stated earlier, formula-fed infants in the first 6 months of life were considered an exception to the concept of supplemental. The only proposed change to infant formula is a change in provision during the first 30 days, as described in the below recommendation.
6-3. USDA-FNS, as a means of supporting breastfeeding of any duration and intensity, should allow individual tailoring of the infant food packages to best meet the needs of the mother–infant dyad.
The Committee’s Vision for Breastfeeding Support in WIC
The first Institute of Medicine (IOM) committee to review the WIC food packages made an important recommendation that attempted to bolster support of breastfeeding in the first 30 days postpartum by limiting the issuance of formula to breastfeeding women (IOM, 2006). This committee fully supports the intent of the previous committee. It shares the vision for WIC in the future that all women receive adequate counseling and support prenatally through the first month postpartum, and the issuance of formula is individually tailored to the needs of every mother–infant dyad, without routine issuance of formula in the first 30 days after the infant’s birth as this practice increases the risk of breastfeeding failure (Walker, 2015).
The evidence reviewed in Chapter 2 indicated that providing no formula to breastfeeding mothers in the first month did not lead to the expected gains in initiation and duration of breastfeeding (with the exception of California [Whaley et al., 2012]). Therefore, the committee recommends that, following a detailed assessment of the needs of the dyad by WIC staff, women should be permitted to receive the quantity of formula that they need to support their desired level of breastfeeding. Consistent with USDA Breastfeeding Policy and Guidance (USDA/FNS, 2016b), exclusive breastfeeding remains the goal for those women able to do so. Tailored issuance of formula in the first month, through adequate counseling and support from WIC staff, is recommended not only to maximize the potential for women to achieve exclusive breastfeeding goals, but also to achieve successful partial breastfeeding when exclusive breastfeeding is not possible or
desired. This recommendation is in alignment with the USDA Breastfeeding Policy and Guidance Report with only one exception: In the first 30 days, states may opt to create food packages allowing issuance of formula up to 364 fluid ounces (instead of the current 104 ounces).
Allowing states to increase package diversity in the first month to allow smaller amounts of formula and avoid issuance of the full formula package is intended to increase flexibility in food package options and support more women to breastfeed. This is further supported by the creation of food package V-B for postpartum partially (mostly) breastfeeding women. As shown in Table 6-1, each infant package is aligned with a food package for the mother that supports the level of breastfeeding, allowing three choices for the dyad starting at birth: (1) the fully breastfeeding dyad with no formula provided and food package VII provided for the mother; (2) the partially (mostly) breastfeeding dyad, with a tailored amount of formula up to 364 ounces per month and food package V-B for the mother; and (3) the fully formula feeding dyad with up to 806 fluid ounces/month and food package VI for the mother. These revisions allow more opportunities to tailor the food packages for both the infant and the mother, including during the first 30 days. In addition, they are intended to shift some women from receiving the fully formula-feeding dyadic packages to receiving the partially (mostly) breastfeeding dyadic packages. Furthermore, the three revised packages are more similar in monetary value than the comparable current packages. This creates incentives that are more proximal to the infant’s birth and, thus, have greater likelihood of supporting the mother’s interest in breastfeeding.
“Up to” Amounts of Formula
Although formula amounts to infants are largely unchanged from the current packages, the committee found it important to include language clarifying that, across all infant food packages, formula amounts should be considered up to amounts to emphasize the importance of assessing the actual need for formula and reducing the possibility of interfering with the successful establishment of the mother’s desired breastfeeding behavior. This language is well aligned with the USDA-FNS guidance for issuance of formula through the WIC program (USDA/FNS, 2016b),14 and is intended to offer breastfeeding women in need of infant formula more options in the first month in contrast to the current policy, which requires choosing either
14 The 2016 USDA-FNS document WIC Breastfeeding Policy and Guidance specifies that “WIC staff are expected to individually tailor the amount of infant formula based on the assessed needs of breastfed infants and provide the minimal amount of formula that meets but does not exceed infants’ nutritional needs” (USDA/FNS, 2016b, pages 16–17).
the fully breastfeeding or the formula-feeding package in the first 30 days (see Chapter 2 for a discussion of the current policy).
Consistent with the modification allowing up to amounts in all infant packages that include infant formula, the revised food package for partially breastfed infants 0 to less than 1 month of age (food package I-A) allows up to the full nutrition benefit of 364 fluid ounces of formula per month (the same allowance in the current food package I for partially breastfed infants,15 and a change from the 104 fluid ounces allowed in the current package). Issuance continues to be based upon an assessment by WIC staff of what is needed to support the breastfeeding mother–infant dyad. This recommendation is not intended to undermine the success of states or local agencies that have identified the resources needed to support breastfeeding through the provision of up to 104 fluid ounces of formula. Rather, it is meant to bolster the importance of the support and counseling needed to support breastfeeding in the immediate postpartum period. Without this support, based on available evidence, the 2009 limitations on choice in the first month have not had the intended effect of supporting breastfeeding. Given the paucity of data on alignment of infant food packages with actual feeding behavior, this committee recommends that WIC staff assess the formula needs of all infants and offer amounts up to the full nutrition benefit.
As noted in Chapter 11, USDA-FNS should identify resources to increase breastfeeding support, both within the WIC program (e.g., increases in funds for peer counseling) and outside of WIC (e.g., hospital policies, legislation on family leave, and workplace support of breastfeeding). It is the hope of this committee that these supports can be put into place and evaluated by 2024 so the next committee charged to examine the WIC food packages will have substantial evidence on which to base future changes in policies on issuance of WIC formula.
Aligning the Amounts of Infant Foods with American Academy of Pediatrics Recommendations
The Amounts of Infant Cereals Are Reduced
The current food package II (for infants ages 6 to 11 months) provides approximately 6 tablespoons of infant cereal per day, which is 150 percent of the maximum amount recommended by the AAP (4 tablespoons per day) (AAP, 2014). Although iron-fortified infant cereals are a favored first food and are good sources of iron and zinc, this amount is substantially
15 The full nutrition benefit of 364 fl oz corresponds to the maximum monthly allowance of 388 fl oz reconstituted liquid concentrate, 384 fl oz ready-to-feed, or 435 fl oz reconstituted powder.
greater than supplemental. Infants who receive formula generally exceed their iron and zinc intake recommendations, so the provision of these nutrients through cereal is not critical for them. Therefore, the committee recommends that the amount of infant cereal provided in food package II to formula-fed or partially breastfed infants be reduced to 8 ounces per month, which provides 50 percent of the AAP-recommended amount of iron-fortified infant cereal (AAP, 2014). Iron and zinc are critical nutrients for fully breastfed infants because human milk contains low levels of these nutrients. Therefore, the revised food package II provides more infant cereal to fully breastfed infants per month: 16 ounces, which is 100 percent of the AAP-recommended amount. As described below, fully breastfed infants also receive jarred infant food meats, which are another good source of iron and zinc.
The Amount of Jarred Infant Food Vegetables and Fruits for Fully Breastfed Infants Is Reduced
The current package II (for infants ages 6 to 11 months) provides fully breastfed infants with 256 ounces of jarred infant food vegetables and fruits. This is more than 1 cup-equivalent per day, which may be appropriate for older infants but is likely to be difficult for younger infants to consume. AAP does not recommend specific intake amounts of vegetables and fruits for infants. Instead, these foods are considered useful as a transition to solid foods (AAP, 2014). The IOM (2006) report also did not provide a nutrient-based rationale for the recommended quantities of these infant foods. Rather, it stated, “To encourage or promote full breastfeeding, the recommended amounts of [infant] food vegetables and fruits are more generous for fully breast-fed infants than other infants” (p. 103). Given that there appears to be no nutritional rationale for providing more vegetables and fruits to fully breastfed infants compared to other infants and that the food packages for formula-fed or partially breastfed infants are distinguished in other ways in this revision, the committee recommends providing the same amount of jarred infant food vegetables and fruits to all infants receiving food package II: 128 ounces per month. The revised amounts provide approximately 0.5 cup-equivalents of vegetables and fruits per day to all infants who receive food package II. This decision allowed the committee to provide further support to the breastfeeding dyad by moving the savings from the jarred infant vegetables and fruits to a significantly enhanced CVV for both partially and fully breastfeeding women. Behavioral economics evidence suggests that shifting the benefit closer in time (to a higher CVV when the infant is born, compared to more jarred infant food vegetables and fruits in 6–12 months in the future), may enhance the probability that women choose the fully breastfeeding package (Loewenstein, 1988).
Infant Food Vegetables and Fruits May Be Substituted with the CVV
In the current food packages, infants ages 9 to 11 months may receive either a $4 (partially breastfed) or $8 (fully breastfed) CVV in place of half of the jarred infant food vegetables and fruits. In the revised food packages, the proposed CVV substitution is $10 plus half of the jarred infant foods or $20 and no jarred infant foods for all infants ages 6 to 11 months. The committee compared the nutrient content of infant fruit and vegetable products to noninfant products and found that nutrients provided to infants with the jarred foods were similar to those provided with a CVV of the same value (see Appendix O, Tables O-1 and O-2). Additionally, the committee compared the cost of 4 ounces of infant jarred fruits or vegetables ($0.64) to the composite average cost of the most popular vegetables and fruits purchased by WIC participants ($0.55 per cup-equivalent serving).16 Not only are the amounts of the proposed CVV substitution cost-neutral options, but participants may be able to buy more servings (of vegetables or fruits) using the CVV. This option also allows caregivers to prepare foods with developmentally appropriate textures for older infants.
In All Food Packages, the CVV Can Be Used to Purchase All Authorized Forms of Vegetables and Fruits
In the current food packages, the infant CVV may only be used to purchase fresh vegetables or fruits. Limiting the infant CVV to only fresh vegetables and fruits creates a significant burden for participants and local agencies in states whose EBT systems already authorize a voucher allowing multiple forms of vegetables and fruits for women and children (personal communication, public comment submitted by Texas WIC, July 30, 2015). In the revised packages, all forms of vegetables and fruits authorized for purchase with the CVV for women and children must be authorized for the infant CVV.17 As noted previously, the nutritional value of canned or frozen vegetables and fruits can be comparable to that of fresh forms (see Appendix O). Moreover, this expansion of forms offers the opportunity to create foods of varying textures that are suitable to an infant’s developmental stage and meet cultural needs. The AAP’s (2014) and USDA’s (2016e) guidance for home preparation of infant foods is shown in Box 6-1.
16 Some of the most commonly purchased types may not be suitable for infants (e.g., lettuce), but the price was considered an adequate estimate given that the preferred vegetables and fruits purchased with the infant CVV is not known.
17 Except dried.
The Amount of Jarred Infant Food Meat for Fully Breastfed Infants Is Reduced
The committee agrees with the IOM (2006) recommendation to provide jarred infant food meat as a key source of iron and zinc for fully breastfed infants. The AAP (2014) recommends 1 to 2 ounces of meat per day (30 to 60 ounces per month). The current WIC food packages provide 130 percent of the maximum of this range, which may be one factor in the low redemption of jarred infant food meat (generally 40 percent or less). Jarred infant food meat is not a common complementary food. In the 2008 Feeding Infants and Toddlers Study (FITS 2008) study, infant food meat was consumed by only 4.6 percent of infants ages 6 to less than 9 months and 1.2 percent of infants ages 9 to less than 12 months (Siega-Riz et al., 2010). In the committee’s independent analysis of breastfed infants ages 6 to less than 12 months participating in WIC (NHANES 2009–2012), 10 percent consumed any amount of jarred infant food meat. Although noninfant food meat was consumed by 33 percent of older infants (ages 9 to less than 12 months) in the FITS 2008 study (Siega-Riz et al., 2010), provision of noninfant food meat in the WIC food packages, in amounts and forms appropriate for infants as young as age 6 months, was considered and ruled out as administratively unfeasible. The committee considered potential nutritionally equivalent but preferred alternatives to jarred infant food meat, but was unable to identify any options suitable to the WIC food packages in the marketplace.
Given this evidence and in line with providing supplemental amounts
of foods in the WIC food packages, the committee reduced the amount of jarred infant food meat provided to fully breastfed infants to 40 ounces per month (approximately 65 percent of the AAP recommended maximum amount). It is noteworthy that, despite reductions in both jarred infant food meats and infant cereals (see above), the revised food package for fully breastfed infants still provides 130 percent of the EAR for iron and 72 percent of the EAR for zinc.
Fish May Be Substituted for a Portion of Jarred Infant Food Meat
Given that redemption of jarred infant food meat is poor and jarred infant food meat is not a preferred infant food, coupled with the importance of providing a bioavailable source of iron as infants begin complementary feeding (AAP, 2014), the committee considered possible substitutions. Global authorities recommend that infants consume flesh foods, including fish, as early as possible (PAHO/WHO, 2003). Canned fish can provide an amount of iron comparable to that of jarred infant food meats (with similar amounts of highly bioavailable heme iron), some (but less) zinc per ounce, and costs approximately half as much per ounce (see Appendix O, Table O-3). Inasmuch as jarred infants food meats are often sold in packages that contain 12 2.5-ounce jars (30 ounces), substitution of two cans of fish (10 ounces) for four jars of infant food meat (10 ounces) is feasible and well suited to package sizes commonly available in the marketplace.
Given this summary of evidence, the committee recommends the following adjustments to the food packages for infants to (1) improve alignment of the food packages with dietary guidance for individuals less than 2 years of age, (2) better reflect typical eating patterns of infants who are consuming complementary foods, and (3) increase flexibility to align with cultural eating patterns, preferences, and developmental needs:
6-4. USDA-FNS should reduce the amounts of infant cereal across food package II for all infants, and reduce the amounts of jarred infant food vegetables and fruits and jarred infant food meats provided in food package II for fully breastfed infants. Caregivers should be permitted to substitute all or part of the jarred infant food vegetables and fruits with a cash value voucher, and a portion of jarred infant food meat with canned fish.
Specific changes recommended are
- Provide 8 ounces of infant cereals to formula-fed and partially breastfed infants, and 16 ounces to fully breastfed infants in food package II.
- Provide 128 ounces per month of jarred infant food vegetables and fruits to all infants in food package II.
- Allow participants to substitute half or all jarred infant food vegetables and fruits with a CVV of comparable value. Caregivers of infants ages 6 to 11 months should have the option to choose a $10 CVV plus 64 ounces of jarred infant food vegetables and fruits or a $20 CVV in place of all jarred infant food vegetables and fruits.
- Allow the purchase of fresh, frozen, or canned vegetables and fruits that meet other current specifications for these forms with CVVs issued to any participant, including infants.
- Provide 40 ounces per month of jarred infant food meats in food package II for fully breastfed infants.
- Allow caregivers to substitute 10 ounces of jarred infant food meat with 10 ounces of canned fish. Fish options should adhere to the revised WIC specifications for canned fish.
As described in Chapter 2, food package III is issued to WIC participants with particular medical needs. The guidance for issuance of foods in this package may vary by state. Most recipients of this package are infants. The committee agrees with the intent of the previous IOM committee that food package III recipients should be provided with “the foods that they would receive from the package to which they would be assigned if they did not have special dietary needs, to the extent that is appropriate” (emphasis added) (IOM, 2006, p. 8). Currently, every participant who receives this package is required to be prescribed a WIC formula (i.e., infant formula, exempt infant formula, and WIC-eligible nutritionals) even if these products do not suit the participant’s specific medical need. For example, in the current food packages, a participant who is issued food package III because of a need for jarred infant food vegetables and fruits although the participant is over 1 year of age is also required to be issued a WIC formula. In the revised food package III, if a health care practitioner does not specifically prescribe a WIC formula, but prescribes a conventional food for medical reasons, there is no requirement to provide these products.18
The committee made no specific changes to the quantities of WIC formulas or WIC-eligible nutritionals that may be provided in food package III. The way in which special products are issued (by reconstituted fluid ounce amount, protein needs, kilocalories, or other) depends on the particular medical condition. No data were identified to suggest that the types of WIC formulas currently permitted at the federal level, the quantities
18 Text in this paragraph is updated from the original prepublication version.
provided, or the issuance basis were inadequate for participant needs. In addition to specifically prescribing WIC formula, it is also the health care practitioner’s responsibility to determine the amounts and issuance methods (reconstituted fluid ounce amount, protein needs, or kilocalories). As stated in Chapter 11, it is important to note that WIC is not the primary payer for therapeutic formulas (USDA/FNS, 2015c). Collaborations with Medicaid are essential to both lessen the cost burden on WIC and increase support of the WIC participant from the medical professional.
The committee recommends one change to the amounts of jarred infant food fruits and vegetables provided to children and women in food package III. In the current packages, children may receive 128 ounces and women may receive 160 ounces jarred infant food vegetables and fruits in place of the CVV. The rationale for these amounts was not outlined in the Final Rule. The committee translated the value of the CVV into an amount of jarred infant food fruit vegetables and fruits to determine the appropriate amounts to provide in these situations, as indicated in Table 6-3.
Given this evidence, the committee recommends the following change to food package III:
6-5. USDA-FNS should no longer require provision of a WIC formula to all participants that are issued food package III. Participants should be permitted access to the foods in the package appropriate for their age, physiological state, and medical condition. The health care provider may refer to the WIC registered dietitian and/or qualified nutritionist for identifying appropriate foods (excluding WIC formula) and their prescribed amounts as well as the length of time the participant requires the foods.
TABLE 6-3 Recommended Substitution of Jarred Infant Food Vegetables and Fruits in Place of the CVV in Food Package III
|Food Package(s) Corresponding to the Participant’s Age and Physiological State||CVV ($)||Equivalent Amount of Infant Food Veg/Fr (oz)*||Round Number of 4 oz Jars||Round Number of 3.5-oz Packages|
NOTES: CVV = cash value voucher; veg/fr = vegetables and fruits.
* Based on the composite cost of jarred infant veg/fr of $0.16 per oz. Participants that opt to replace juice with a $3 CVV may be issued an additional 5 jars or 3.5-ounce packages.
Women who are fully breastfeeding multiple infants, pregnant with multiple fetuses, or both pregnant and breastfeeding have higher nutrient and caloric needs than women with singletons. In the absence of any evidence on the additional energy needs for the women fully breastfeeding multiple infants, the committee estimated the additional energy need would be approximately 400 kcal per day for the additional milk produced and assumed no further maternal fat mobilization. This represents approximately 50 percent more energy than is supplied by the fully breastfeeding package, indicating that the current regulation to provide 1.5 times food package VII to these women is appropriate.
Similarly, there is a lack of evidence available to estimate the energy needs for women who are pregnant with multiple fetuses or who are partially breastfeeding multiple infants. Providing food package V-B to women pregnant with multiple fetuses increases the CVV by $10 per month and adds more fish compared to food package V-A for pregnant women with singletons. Issuance of food package VII to women partially breastfeeding multiples provides an additional 1 dozen eggs, $10 in CVV, and 10 ounces of fish per month compared to the revised food package V-B for women who are partially breastfeeding singletons.
Therefore, to meet the additional nutrient needs and provide packages that minimize the burden to state agencies, the committee recommends the following in these special cases:
6-6. USDA-FNS should issue food package V-B to women who are pregnant with multiple fetuses and food package VII to women who are partially breastfeeding multiple infants.
In addition, the following regulations are retained:
- Issue food package VII to women who are breastfeeding and also pregnant.
- Issue 1.5 times food package VII to women who are fully breastfeeding multiple infants.
The previous sections of this chapter reviewed the recommended changes across all food packages. The committee also examined current food specifications and considered modifications to improve the potential for food packages to meet the nutritional needs of participants or improve alignment with dietary guidance while still ensuring availability. Foods for
which specifications have been changed are presented in Table 6-4 and this section provides the rationale for each change. (Specifications for canned fish are covered earlier in this chapter). A side-by-side comparison of the current and revised specifications for all foods is presented in Appendix P.
Vegetables and Fruits Authorized for Purchase with the CVV
As stated in the Final Rule, vendors are currently required to offer at least two varieties of fruits and two varieties of vegetables in a fresh, frozen, canned, or dried form depending on forms authorized by the state (USDA/FNS, 2014). The revised packages require that vendors offer at least three vegetable and two fruit varieties. When possible, states could consider increasing vendor stocking requirements further, particularly in light of the increased CVV value across food packages. Published guidance related to optimum stocking for promotion of healthy choices is available (see HER, 2016; USDA/FNS, 2016c). Other specifications for canned, frozen, or dried forms of vegetables and fruits remain unchanged. States are encouraged to authorize low- or reduced-sodium forms of all canned foods.
Limiting Added Sugars in the Food Packages
The 2015–2020 DGA are the first of the DGA to recommend that an individual’s intake of added sugars not exceed 10 percent of total calories. The contribution of WIC food packages to the intake of nutrients to limit, including added sugars, was of particular concern to the committee because of this guidance and also because of excessive intakes of added sugars across subgroups of WIC participants (see Chapter 5). The current food packages provide close to or above the limit for “calories for other uses” (COU) recommended in the DGA (see Table 3-9).19 As a result, it was appropriate to decrease the contribution of the food packages to intakes of added sugars in participants’ diets while maintaining the acceptability and palatability of the nutrient-dense foods that are provided by WIC. WIC foods that were targeted for reductions in total sugars are described below. The new food labels20 will allow WIC staff that make decisions about state food lists to identify qualifying foods by using added sugars amounts. Table 6-5 presents the suggested added sugars limits for WIC foods discussed in this section. The committee reviewed current
19 The DGA food patterns recommend different limits for “calories for other uses” (calories from saturated fat and added sugars) depending on energy level. As explained in Chapter 2, with some food patterns it is not possible to consume 10 percent of energy from added sugars and simultaneously meet nutrient needs (USDA/HHS, 2016).
20 The earliest compliance date for implementation of new food labels is July 26, 2018.
TABLE 6-4 Proposed Changes to Specifications for Foods in the Revised WIC Food Packagesa
|Category/Food||Food Package and Affected Participant Group, Considering the Proposed Food Package Revisions||Selected Current Specifications||Proposed Change to the Specificationsb||Rationale|
|Vegetables and Fruits Purchased with CVV||II Infants||Any variety of fresh, whole, or cut vegetable, without added sugars, starches, or salt Any variety of fresh, whole, or cut fruit without added sugars||Fresh, frozen, or canned forms of vegetables and fruits meeting other specifications may be purchased||Fresh, frozen, and canned vegetables and fruits are suitable for infants and meet developmental needs when prepared appropriately|
|Milk and Milk Alternatives||(as defined in 21 C.F.R. 101.95)|
|Cow’s milk||IV, V-A, V-B, VI, VII Women and children||Must conform to FDA standard of identity for whole, reduced-fat, low-fat, or nonfat milks (21 C.F.R. 131.110). Must be pasteurized and contain at least 400 IU of vitamin D per quart (100 IU per cup) and 2,000 IU of vitamin A per quart (500 IU per cup) May be flavored or unflavored. May be fluid, shelf stable, evaporated (21 C.F.R. 131.130), or dried (i.e., powder) (21 C.F.R. 131.147)||Only unflavored milk is permitted||Low-fat forms (for children 2 years of age and older, and women) align with CACFP provision of milk and with the DGA; requiring unflavored forms reduces inclusion of added sugars in the WIC food packages|
|Cultured milks must conform to FDA standard of identity for cultured milk (21 C.F.R. 131.112—cultured buttermilk, kefir cultured milk, acidophilus cultured milk)|
|Soy-based beverage||IV, V-A, V-B, VI, VII Women and children||Must be fortified to meet the following nutrient levels: 276 mg calcium per cup, 8 g protein per cup, 500 IU vitamin A per cup, 100 IU vitamin D per cup, 24 mg magnesium per cup, 222 mg phosphorus per cup, 349 mg potassium per cup, 0.44 mg riboflavin per cup, and 1.1 µg vitamin B12 per cup, in accordance with fortification guidelines issued by FDA||In addition, the total sugar content of soy-based beverages should be as low as possible, not to exceed 12 g per 8 oz serving||Soy-based beverages are available in the marketplace that contain 12 g or less of total sugars per serving; sugars in soy-based beverages are 100 percent added; intakes of added sugars are excessive in the WIC population, therefore it is appropriate to apply a limit that considers nationwide availability of these products|
|Tofu||IV, V-A, V-B, VI, VII Women and children||Calcium-set tofu prepared with calcium salts (e.g., calcium sulfate); may not contain added fats, sugars, oils, or sodium||Must contain a minimum of 200 mg of calcium per 100 g of tofu (calcium-set is no longer part of the specification); retain the specification that tofu may not contain added fats, sugars, oils, or sodium||Tofu in the food packages serves as a milk substitution; as such, the revised specification ensures that tofu in the food packages provides an amount of calcium as close to that in a serving of milk as reasonable, considering marketplace options|
|Category/Food||Food Package and Affected Participant Group, Considering the Proposed Food Package Revisions||Selected Current Specifications||Proposed Change to the Specificationsb||Rationale|
|Yogurt||IV, V-A, V-B, VI, VII Women and children||Must be pasteurized and conform to standards of identity for yogurt as listed in Table 4 of 7 C.F.R. 246.10(e) (12); may be plain or flavored with ≤40 grams of total sugars per 1 cup of yogurt||Must contain no more than 30 g total sugars per 8 oz serving (≤3.75 g total sugars per oz); soy-based yogurt substitute must contain at least 250 mg of calcium and 6.5 g of protein per 8 oz servingc||The availability of yogurts that contain 30 g or less of total sugars per 8 oz serving has expanded substantially; this amount is more closely aligned with the DGA; soy products meet the needs of individuals with a milk allergy or who consume a vegan diet|
|Cheese||IV, V-A, V-B, VI, VII Women and children||Domestic cheese made from 100 percent pasteurized milk. Must conform to FDA standard of identity (21 C.F.R. Part 133); Monterey Jack, Colby, natural Cheddar, Swiss, Brick, Muenster, Provolone, part skim or whole Mozzarella, pasteurized processed American, or blends of any of these cheeses are authorized Cheeses that are labeled low, free, reduced, less, or light in the nutrients of sodium, fat or cholesterol are WIC eligible||In addition, soy-based cheese substitute (not soy curd cheese) is permitted and must contain at least 250 mg of calcium and 6.5 g of protein per 1.5 ounce serving||Soy products meet the needs of individuals with a milk allergy or who consume a vegan diet|
|Breakfast cereal||IV, V-A, V-B, VI, VII Women and children||Must contain a minimum of 28 mg iron per 100 g dry cereal Must contain ≤21.2 g sucrose and other sugars per 100 g dry cereal (≤6 g per dry oz) At least half of the cereals authorized on a state agency’s food list must have whole grain as the primary ingredient by weight and meet labeling requirements for making a health claim as a “whole grain food with moderate fat content”:
(1) contain a minimum of 51% whole grains (using dietary fiber as the indicator);
(2) meet the regulatory definitions for “low saturated fat” at 21 C.F.R. 101.62 (≤1 g saturated fat per RACC) and “low cholesterol” (≤20 mg cholesterol per RACC);
(3) bear quantitative trans-fat labeling; and (4) contain ≤6.5 g total fat per RACC and ≤0.5 g trans-fat per RACC
|All ready-to-eat cereals on a state agency’s authorized food list must adhere to the whole grain-rich criteriad and conform to other current specifications (e.g., must be iron-fortified, must not exceed added sugars limitations)||Intake of whole grains is low in the WIC population; whole grain cereal options have expanded substantially since the last review; the same products should qualify while aligning with USDA guidance for CACFP, the National School Lunch Program, and the National Breakfast Program (USDA/FNS, 2016d)|
|Category/Food||Food Package and Affected Participant Group, Considering the Proposed Food Package Revisions||Selected Current Specifications||Proposed Change to the Specificationsb||Rationale|
|Whole grain options||IV, V-A, V-B, VI, VII Women and children|
|Whole grain bread||Whole grain bread must conform to FDA standard of identity (21 C.F.R. 136.110) and meet labeling requirements for making a health claim as a “whole grain food with moderate fat content,” as outlined above||Whole grain bread is no longer permitted; only 100 percent whole wheat bread is permitted||Very few states offer whole grain bread options other than 100 percent whole wheat; identification of suitable wholegrain breads (>50% whole grain) is challenging; restricting to 100 percent whole wheat bread aligns with most current state WIC authorized food lists and promotes intake of whole grains by WIC participants|
|Other whole grain options||Other whole unprocessed grains: Brown rice, bulgur (cracked wheat), oats, whole grain barley, and whole wheat macaroni (pasta) without added sugars, fats, oils, or salt (i.e., sodium)||In addition, teff or buckwheat may be offered; cornmeal (including blue); and corn masa flour meeting specifications outlined below are allowed||Additional options provide culturally suitable alternatives; participants and WIC staff expressed an interest in addition of these grains|
|Tortillas||Soft corn or whole wheat tortillas may be allowed at the state agency’s option. Soft corn tortillas made from ground masa flour (corn flour) using traditional processing methods are WIC eligible, and include whole corn, corn (masa), whole ground corn, corn masa flour, masa harina, and white corn flour. For whole wheat tortillas, ‘‘whole wheat flour’’ must be the only flour listed in the ingredient list||In addition, once available in the marketplace, states are encouraged to offer tortillas made with folic acid–fortified corn masa flour||Folic acid is a nutrient of concern for premenopausal women; consumption of folic acid is lower among Hispanic compared to non-Hispanic women (Williams et al., 2015)|
|Cornmeal||Not yet permitted||Add whole corn meal (including blue) meeting the FDA standard of identity (21 C.F.R. 137.260) and that is in alignment with USDA specifications for corn meal in School Meal Programs (USDA-CNP-01-2008) to current options||Provides a culturally suitable option; similar in nutritive value to some types of permitted corn tortillas|
|Corn masa flour||Not yet permitted||Add corn masa flour. Once available in the marketplace, states are encouraged to offer folic acid–fortified corn masa flour||Allowing this flour aligns with the allowance of tortillas made with corn masa flour; participants expressed an interest|
|Category/Food||Food Package and Affected Participant Group, Considering the Proposed Food Package Revisions||Selected Current Specifications||Proposed Change to the Specificationsb||Rationale|
|Fish||IV, V-A, V-B, VI, VII Women and children||May be packed in water or oil. Pack may include bones or skin. Added sauces and flavorings, such as tomato sauce, mustard, or lemon, are authorized at the state agency’s option. May be regular or lower in sodium content||Canned fish may be water-packed (not oil packed) and may contain added sauces and flavorings. All other specifications remain unchanged||Few states currently offer oil-packed fish so there is minimal effect on participant choice; water-packed varieties are higher in nutrient-density because water-packed fish is lower in energy but contains the same levels of key nutrients per serving|
NOTES: CACFP = Child and Adult Care Food Program; C.F.R. = Code of Federal Regulations; CVV = cash value voucher; FDA = U.S. Food and Drug Administration; IU = International Unit; NA = not applicable; RACC = reference amounts customarily consumed; RTE = ready-to-eat; USDA = U.S. Department of Agriculture.
a The table covers only cases in which a change to a food specification was made. See Appendix P, Table P-1, for a more comprehensive list of food specifications and proposed changes.
b Details are provided only for the proposed change. Other components of the specification remain the same.
c The committee’s rationale for not requiring vitamin D fortification of yogurt is available in Appendix Q.
d It is anticipated that changes to the whole grain-rich criteria in alignment with the FDA proposed changes to the RACCs used for food labeling would be applied to the WIC food packages.
SOURCE: For current specifications, see USDA/FNS, 2014.
TABLE 6-5 Suggested Added Sugars Limits for WIC-Authorized Foods
|WIC Food||g per Serving*|
|Naturally Occurring Sugars||Revised Total Sugars Specification||Suggested Added Sugars Specification (Upper Limit)|
|Yogurt, whole milk||11.4||30||18|
|Yogurt, low fat||17.3||30||13|
NOTES: — = naturally occurring sugars are negligible.
* Based on 8 oz for yogurt and soy beverage, and 1 oz for cereals.
SOURCE: Based on data available in USDA/ARS, 2016.
specifications in light of not only the contribution of the current food packages to the DGA limit on COU, but also products now available in the marketplace, the role of added sugars in improving the palatability of nutritious foods, and the preferences of WIC participants. Specifications for total sugars21 are outlined for yogurt, ready-to-eat cereals, and soy beverages. When the FDA regulation to include added sugars on food labels is implemented (FDA, 2016b), WIC food specifications could be changed from total sugars to added sugars. The rationale for maintaining the current total sugars limit for breakfast cereals is provided in Appendix Q. The rationales for revising the added sugar limits for yogurt and soy beverages are summarized below.
Total Sugars in Yogurt
The committee proposes reducing sugars in yogurt to 30 grams or less of total sugars per 8 ounces. The current limit for total sugars in yogurt (40 grams per 8 ounces) was set by the IOM (2006) committee and was based on amounts of total sugars in yogurts available in the marketplace at that time (personal communication, S. Murphy, July 6, 2016). Over the past decade, yogurt formulations have changed dramatically. In 2015, 55
21 Although the FDA has issued a Final Rule, at present manufacturers are not required to include the amount of added sugars on food labels until as late as 2019. For this reason, a total sugars specification is required to limit the amount of added sugars in WIC-approved foods.
percent22 of name-brand yogurt products sold in the United States that met all other WIC specifications contained 30 grams or less of total sugars per 8 ounces (personal communication, National Yogurt Association, March 3, 2016). These data indicate that yogurts containing less total sugars than the current WIC specification permits are widely available. Because private-label products typically follow the formulation changes of name-brand products (personal communication, National Yogurt Association, March 3, 2016), the availability of private-label yogurts with lower amounts of added sugar will probably expand in coming years.
Not only is the added sugars content of yogurts in the marketplace declining, but the committee’s proposed reduction of added sugars in yogurt is aligned with the USDA-FNS Final Rule that requires all yogurt provided in the Child and Adult Care Food Program (CACFP) to contain no more than 23 grams of total sugars per 6 ounces (or 30 grams per 8 ounces) (USDA/FNS, 2016d). Market research conducted by USDA-FNS in support of this rule also indicated that yogurts with this amount of total sugars were widely available (USDA/FNS, 2016d).
At the time of this writing, yogurt had been added to WIC-approved food lists in only a few states. As a result, acceptance of this option by WIC participants could not be determined.
Total Sugars in Soy Beverages
At present, there are no specifications for total sugars in WIC-approved soy beverages. Although most states authorize soy beverages that contain 10 grams or less of total sugars, the committee considered it advisable to provide states with guidance about how to identify appropriate soy beverage choices as the market expands. Soy beverages currently available in the marketplace may contain as much as 20 grams of total sugars per 8-ounce serving (USDA/ARS, 2016). The committee proposes that the limit for total sugars in soy beverages selected by states be as low as possible, but not higher than 12 grams per 8 ounce serving. The level of 12 grams was selected because it is equivalent to the amount of total sugars from naturally occurring lactose in 8 ounces of unsweetened cow’s milk.
22 Data were extracted from Information Resources, Inc. (IRI) Total Multi-Outlet (MULO), including the latest 52 weeks, ending December 27, 2015. The percentage represents the proportion of the volume of yogurts sold, excluding private-label brands and yogurts containing artificial sweeteners, but includes all available package sizes.
Only Unflavored Milk Is Permitted
The Final Rule permits provision of flavored milk in the current WIC food packages. However, the CACFP allows only low-fat, unflavored milk and does not permit flavored milk to children up to age 5 (USDA/FNS, 2016d). To align the WIC food packages with CACFP regulations and to limit added sugars in the food packages, only unflavored milk is authorized in the revised WIC food packages. Although nonfat, flavored milk is permitted in the school meals programs (USDA/FNS, 2012), the nonfat, low-added-sugars flavored milk provided to schools is not widely commercially available (personal communication, C. Patey, National Dairy Council, July 16, 2016). The committee considered it appropriate for WIC to not only provide children with an easy transition into CACFP, but also to avoid contributing to early establishment of a preference for sweet taste (Beauchamp and Menella, 2009; Ventura and Worobey, 2013; personal communication, S. Johnson, University of Colorado, shared with the committee at the March 20, 2016 workshop).
At present, flavored milk is offered in 6 percent of states and 40 percent of Indian Tribal Organizations (ITOs), which together cover 3 percent of WIC participants (USDA/FNS, 2015a). At least one ITO is removing flavored milk from its food list to align with CACFP policy (personal communication, D. Tipton, Chickasaw Nation WIC, July 2016). Therefore, the recommendation is not expected to cause a significant disruption in administration of food packages nationally.
Changes to Whole Grain Requirements for WIC Foods
All Breakfast Cereals Must Meet “Whole Grain-Rich” Criteria
The current specifications for WIC-approved breakfast cereals (ready-to-eat and instant and regular hot cereals) require that half of such cereals made available by WIC vendors include whole grain as the primary ingredient by weight and meet the FDA labeling requirement for a “health claim notification for whole grain foods with moderate fat content” (i.e., these foods must also contain ≥51 percent whole grain ingredients by weight, but using dietary fiber as a marker [≥1.6 grams fiber per 28.35 grams of cereal]) (USDA/FNS, 2014). In the revised packages, this specification is changed in two ways: (1) “whole grain” breakfast cereals must meet the “whole grain-rich” criteria that is applied in CACFP,23 the National School
23 “Foods that qualify as whole grain-rich are foods that contain a blend of whole grain meal and/or whole grain flour and enriched meal and/or enriched flour of which at least 50 percent is whole grain and the remaining grains in the food, if any, are enriched; or foods that contain 100 percent whole grain.” Most of the cereals that qualify as whole grain under the current WIC criteria would also qualify under the “whole grain-rich” criteria.
Lunch Program, and the National Breakfast Program (USDA/FNS, 2016d); and (2) all breakfast cereals offered by the WIC program must meet these criteria. All cereals must still meet current WIC requirements for iron (i.e., 28 milligrams of iron per 100 grams of cereal) and added sugars (not more than 6 grams per ounce serving).
Although the DGA have consistently specified that at least half of grain intake should be from whole grains since 2005, the 2015–2020 DGA additionally state that intake of refined grains should be limited but that individuals (particularly women capable of becoming pregnant) who consume all grains as whole should include in their diets at least some sources that are fortified with folic acid as a means of preventing neural tube defects (USDA/HHS, 2016). Table 6-6 illustrates the folic acid content of commonly redeemed ready-to-eat WIC cereals, including some fortified whole grain cereals. Although there is some variability, the popular whole grain cereals presented in the table provide an average of 160 percent of the EAR for folate for children ages 1 to 4 years and 47, 56, and 70 percent of the EAR for pregnant, breastfeeding, and postpartum women, respectively. These data indicate that whole grain and refined grain breakfast cereals are generally fortified with comparable amounts of folic acid.
TABLE 6-6 Folate Content of Commonly Redeemed Selected Cereals in WIC Food Packages
|Categorization on Example State WIC Food Lists||Ready-to-Eat Cereal Type||Folate in 1 oz-eq (µg DFE)*|
|Whole grain||Honey and oat cereal, WG varieties||168|
|Oat O’s cereal||340|
|Wheat squares with frosting (name brand)||175|
|Wheat squares with frosting (store brand)||345|
|Corn puffs cereal||375|
|Nonwhole grain||Honey and oat cereal, non-WG varieties||297–318|
|Corn puffs cereal, with cartoon theme||353|
|Corn flakes cereal||165|
|Crisped rice cereal||293|
NOTES: DFE = dietary folate equivalent; oz-eq = ounce-equivalents; WG = whole grain; µg = microgram.
* Based on the Food Patterns Equivalent Database value of 28.35 g cereal per serving equivalent.
SOURCES: USDA/ARS, 2016; redemption data provided to the committee from Texas and Wyoming WIC agencies (2015), available in the public access file for this study (Email: firstname.lastname@example.org).
Although there are no specific regulations about fortification of ready-to-eat breakfast cereals other than enrichment of the refined grain portion with 140 micrograms of folic acid per 100 grams grain, both refined and whole grain cereals are generally fortified with at least 25 percent of micronutrient needs for a 2,000-kcal diet (the current basis for Daily Values on the food label24) (USDA/ARS, 2016). Therefore, there is no substantive difference in micronutrient content of refined grain cereals compared to whole grain cereals that meet the revised WIC “whole grain-rich” criteria.
Evaluation of Breakfast Cereal Redemption and Current Marketplace Options
To ensure that a variety of breakfast cereal products that meet the new specifications will be available to WIC state agencies, the committee reviewed product information provided by two large national manufacturers of ready-to-eat breakfast cereals.25 Together, these manufacturers produce at least 14 different types of ready-to-eat cereals that meet the current WIC whole grain criteria, including 4 gluten-free whole grain varieties. Launches of whole grain products, including cereal (wheat and other grains), doubled between 2006 and 2011 (Oldways, 2015). This information suggests that an adequate number of products are now available to meet state needs for WIC-approved choices for “whole grain-rich” breakfast cereals.
All Breads Are 100 Percent Whole Wheat
At present, WIC-authorized breads include both 100 percent whole wheat bread (i.e., whole grain wheat is the primary ingredient by weight) and whole grain breads that meet the FDA requirement for a “health claim notification for whole grain foods with moderate fat content” (again, these foods must also contain at least 51 percent whole grain ingredients by weight, but using dietary fiber as a marker [at least 1.6 grams fiber per 28.35 grams]) (USDA/FNS, 2014). The committee proposes that this specification be revised such that all bread in the WIC food packages be 100 percent whole wheat and that whole grain bread no longer be permitted. Currently, very few states offer a whole grain bread option, possibly
24 The committee is aware that the FDA has issued a proposed Final Rule for food label revisions (FDA, 2016b) that may affect ready-to-eat cereal fortification levels for some nutrients. This is not anticipated to adversely affect provision of key nutrients (specifically, iron and folate) to WIC participants consuming these cereals.
25 This information is available in the public access file for this study (Email: email@example.com). One manufacturer collated and provided data on the whole-grain options produced by the “top four RTE cereal manufacturers.”
as a result of the expansive selection of bread products in the marketplace that include the words whole grain but that contain various proportions of whole grain and refined grain. Manufacturers are permitted to make factual statements about the amounts of whole grains on the labels of their products (e.g., “this product contains 5 grams of whole grains per serving”), but products for which the labels include the words “whole grain” are not required to contain a minimum amount of this ingredient (FDA, 2006). The committee concluded that WIC-approved breads should be restricted to those that contain 100 percent whole wheat to reduce confusion, align WIC-authorized breads with most current state offerings, and improve WIC participants’ overall dietary balance of whole to refined grains. For individuals with celiac disease or gluten intolerance, other grain options are available.
Specifications for Tofu
Tofu is included in the current food packages as a substitute for milk and is required to be calcium-set.26 To ensure that tofu provides an amount of calcium equivalent to the amount in milk it is intended to replace, the proposed new specification requires that tofu contain at least 200 milligrams of calcium per 100 grams of tofu. Products matching this requirement are anticipated to be readily available in the marketplace. The specification that tofu may not contain added fats, sugars, oils, or sodium is retained.
Specifications for New Substitution Options
Specifications for New Grain Options
The revised food packages offer additional grain options to accommodate cultural eating patterns and other food preferences. Cornmeal (including blue), buckwheat, and teff must be 100 percent whole grain. Cornmeals should align with the USDA-FNS specifications for cornmeal in USDA-FNS child nutrition programs (e.g., CACFP), that is, products must be labeled as “whole corn” (or be labeled with other “whole” corn designations, such as whole grain corn, whole ground corn, whole cornmeal [including blue], and whole corn flour) (USDA-CNP-01-2008). To align with USDA-FNS allowances for tortillas (USDA/FNS, 2014), corn masa flour that is not 100 percent whole grain is permitted. States should be encouraged to offer corn masa flour and tortillas made with corn masa flour that is fortified with folic acid when these products become available.
26 Calcium-set tofu is prepared using calcium salts as a coagulant.
Specifications for New Soy Options
To expand options for WIC participants who are lactose-intolerant or who follow a vegan diet, soy-based cheese and soy-based yogurt substitute products are added to the revised packages as substitutions for milk. These products are required to contain 250 milligram of calcium and 6.5 grams of protein per serving equivalent (1.5 ounces of soy-based cheese substitute or 8 ounces of soy-based yogurt substitute). These specifications ensure that these substitutes supplement the diets of WIC participants with key nutrients that the WIC food packages are intended to provide.
Other Specifications for WIC-Approved Foods
The committee reviewed in detail all food specifications outlined in the Final Rule (USDA/FNS, 2014). Any specifications not addressed in this section remain as currently stated in the Final Rule (see Appendix P for details on additional WIC food specifications). Given the evidence presented, the committee recommends the following changes related to specifications for WIC-approved foods in the food packages:
6-7. USDA-FNS should modify required specifications for some WIC foods to improve their alignment with dietary guidance.
The specific specification changes recommended for WIC foods are
- Yogurt may contain no more than 30 grams of total sugars per 8 ounces (3.75 grams of total sugars per ounce).
- Soy beverages may contain no more than 12 grams of total sugars per 8 ounces.
- Only unflavored milk is permitted.
- All breakfast cereals provided through WIC meet the “whole grain-rich” criterion, as outlined for the USDA-FNS Child and Adult Food Care Program. Other specifications, such as 6 grams or less of total sugars per 28.35 grams (1 cup-equivalent) serving and 28 milligrams iron per 100 grams of dry of cereal, are retained.
- Bread should be 100 percent whole wheat bread.
- Tofu should contain at least 200 milligrams of calcium per 100 grams of tofu.
- Each 1.5 ounces of soy-based cheese substitute or 8 ounces of soy-based yogurt substitute should contain 250 milligrams of calcium and 6.5 grams of protein.
- Fish may be packed in water or the currently allowed sauces and flavorings.
Foods and Food Specifications That Were Reviewed, But Not Changed
The committee deliberated over several possible decisions that did not result in a change to the food packages. In particular, USDA-FNS asked that the committee evaluate currently provided amounts of infant formula and specifications for iron and energy density of infant formulas, and inclusion of additional fish species in the food packages. Following a comprehensive review of available evidence, no changes were recommended in these, and other cases. A description of these topics and the rationale for retaining the status quo is presented in Appendix Q.
The recommended revisions to the WIC food packages outlined in this chapter are based on the committee’s considerations of the health of the WIC-participating population, food safety risks relevant to the WIC-participating population, current dietary guidance (i.e., the DGA and dietary guidance for individuals less than 2 years of age), nationwide availability of foods, and state agency and vendor administrative burden. These recommended changes build upon the successes of the 2009 food package changes by further increasing participant access to vegetables and fruits, increasing the flexibility of options to better meet participant cultural eating patterns and food preferences, and increasing the latitude of participants to make the choice to breastfeed. The revised food packages were designed with the benefit of redemption information that was not available to the 2006 committee as well as firsthand experience through committee site visits and shopping experiences. Although the cost-neutral requirement restricted the committee’s ability to make all of the changes they would have preferred to make across all food groups, application of the “supplemental” criterion allowed savings that resulted from reduction in some food groups to support increases in other food groups. Overall, the committee was able to improve the balance of food groups and subgroups to better meet the DGA recommendations. In Chapter 11, recommendations for implementation of these revised food packages, as well as recommendations for evaluation of the revised food packages are provided.
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