REVIEW OF WIC FOOD PACKAGES
Improving Balance
and Choice
Final Report
Committee to Review WIC Food Packages
Food and Nutrition Board
Health and Medicine Division
A Report of
THE NATIONAL ACADEMIES PRESS
Washington, DC
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This activity was supported by Grant No. AG-3198-D-14-0050_0001-005 from the U.S. Department of Agriculture. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.
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Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2017. Review of WIC food packages: Improving balance and choice: Final report. Washington, DC: The National Academies Press. doi: https://doi.org/10.17226/23655.
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COMMITTEE TO REVIEW WIC FOOD PACKAGES
KATHLEEN M. RASMUSSEN (Chair), Nancy Schlegel Meinig Professor of Maternal and Child Nutrition, Division of Nutritional Sciences, Cornell University
SHANNON E. WHALEY (Vice Chair), Director of Research and Evaluation, Public Health Foundation Enterprises WIC Program
SUSAN S. BAKER, Professor and Co-Chief, Digestive Diseases and Nutrition Center, Department of Pediatrics, Women and Children’s Hospital of Buffalo
MARIANNE P. BITLER, Professor, Department of Economics, University of California, Davis
PATSY M. BRANNON, Professor, Division of Nutritional Sciences, Cornell University
ALICIA L. CARRIQUIRY, Distinguished Professor, Department of Statistics, Iowa State University
DAVID E. DAVIS, Professor, Department of Economics, South Dakota State University
MARY KAY FOX, Senior Fellow, Mathematica Policy Research, Inc.
TAMERA J. HATFIELD, Associate Professor, Obstetrics and Gynecology, Division of Maternal and Fetal Medicine, University of California, Irvine
HELEN H. JENSEN, Professor of Economics and Head, Food and Nutrition Policy Research of the Center for Agricultural and Rural Development, Iowa State University
RACHEL K. JOHNSON, Robert L. Bickford, Jr., Green and Gold Professor of Nutrition, Professor of Medicine, University of Vermont
ANGELA ODOMS-YOUNG, Associate Professor, Department of Kinesiology and Nutrition, University of Illinois at Chicago
RAFAEL PÉREZ-ESCAMILLA, Professor of Epidemiology and Public Health, Director, Office of Public Health Practice, Director, Global Health Concentration, Yale School of Public Health
A. CATHARINE ROSS, Professor of Nutrition, Dorothy Foehr Huck Chair, Department of Nutritional Sciences, Pennsylvania State University
CHARLENE RUSSELL-TUCKER, Chief Operating Officer, Connecticut Department of Education
Consultants
MEI CHUNG, Assistant Professor, Department of Public Health and Community Medicine, School of Medicine, Tufts University
ROSE GLADSTEIN, Consultant, R Gladstein Consulting LLC
HOECHEL JEON, Post-doctoral Research Associate, Center for Agricultural and Rural Development, Iowa State University
JOHN A. KIRLIN, Economist, U.S. Department of Agriculture, Economic Research Service
DAVID LEVIN, Economist, U.S. Department of Agriculture, Economic Research Service
SUZANNE P. MURPHY, Researcher (Professor) Emeritus, University of Hawaii Cancer Center
MIYOUNG OH, Post-doctoral Research Associate, Center for Agricultural and Rural Development, Iowa State University
Health and Medicine Division Staff
MARIE E. LATULIPPE, Study Director
MEGHAN E. QUIRK, Program Officer
BERNICE CHU, Research Associate
ALICE VOROSMARTI, Research Associate
AMBAR SAEED, Senior Program Assistant
ANN L. YAKTINE, Director, Food and Nutrition Board
Reviewers
This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report:
LOREN BELL, Altarum Institute
RONETTE BRIEFEL, Mathematica Policy Research
JULIE A. CASWELL, University of Massachusetts at Amherst
SUSAN J. CROCKETT, University of Minnesota
STEPHEN R. DANIELS, University of Colorado School of Medicine
WILLIAM DIETZ, George Washington University
LUCIA KAISER, University of California, Davis
JACOB A. KLERMAN, Abt Associates, Inc.
BARBARA PETERSEN, Exponent
KAREN E. PETERSON, University of Michigan
LORRENE RITCHIE, University of California Division of Agriculture and Natural Resources
JUDITH S. STERN, University of California, Davis
JANET AUSTIN TOOZE, Wake Forest Baptist Medical Center
KENNETH W. WACHTER, University of California, Berkeley
JAMES P. ZILIAK, University of Kentucky
Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Diane F. Birt, Iowa State University, and Elaine L. Larson, Columbia University Mailman School of Public Health. They were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.
Contents
1 INTRODUCTION AND THE PROCESS FOR REVISING THE WIC FOOD PACKAGES
The Process for Revising the WIC Food Packages
Summary and Organization of This Report
2 THE WIC PROGRAM: CHANGES SINCE THE LAST REVIEW AND CONTINUING CHALLENGES
Adaptation to the WIC Food Package Changes Proposed in 2006
Changes in the WIC-Participating Population
Alignment of the Food Packages with Dietary Guidance for Individuals Ages 2 Years and Older
Alignment of the Food Packages with Dietary Guidance for Individuals Less Than 2 Years of Age
Alignment with the Dietary Reference Intakes
Forms and Composition of Foods Provided in the Food Packages and Alignment with Dietary Guidance
Alignment of the Food Packages with Special Dietary Needs and Preferences
Findings and Conclusions: Potential Areas for Food Package Modifications
4 NUTRIENT AND FOOD GROUP INTAKES OF WIC PARTICIPANTS
Analysis of the National Health and Nutrition Examination Survey Data: Nutrient Adequacy
Quality of WIC Participants’ Diets
Considerations for Interpretation of Findings from the Literature and the Committee’s Analyses
5 NUTRIENT AND FOOD GROUP PRIORITIES FOR THE WIC FOOD PACKAGES
Identifying Nutrient Priorities
Identifying Food Group Priorities
Identifying Potential Actions for Food Package Revisions
The Committee’s Overarching Strategy
The Revised Food Packages for Women and Children
Additional Substitution Options for Vegans or Vegetarians and for Allergies or Intolerances
The Revised Food Packages for Women and Infants
Specifications for WIC-Eligible Foods
Methods Used to Estimate Costs
Results and Discussion: Program Costs
Comparing Cost Incentives for Breastfeeding
8 SENSITIVITY ANALYSIS FOR FOOD PACKAGE NUTRIENT, FOOD GROUP, AND COST MODELS
Purpose, Goals, and Limitations of Sensitivity Testing
Methodological Approach to Sensitivity Analysis
10 THE REGULATORY IMPACT ANALYSIS (ABRIDGED)
11 RECOMMENDATIONS FOR IMPLEMENTATION AND RESEARCH
Recommendations for Implementation of the Revised Food Packages
Research and Data Collection Recommendations for Evaluation of the WIC Food Packages
Priorities for Funding Outside Cost-Neutrality
Multilevel Approaches to Improving Consumption of WIC Foods
Considerations for the Next Review
D Details of the Committee’s Information-Gathering Strategies
E USDA-Funded Studies of the 2009 Food Package Changes
F Changes in the WIC Food Packages and Program Participation
G Barriers to Participation and Redemption
H Kosher and Halal Substitution Options
I Complementary Feeding: Summary of Information Reviewed
J Nutrient and Food Intake of WIC Subgroups: Analytical Methods and Results
M Behavioral Approaches in WIC as a Potential Action
N Comparison of Current and Revised Food Packages
Preface
The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) began 40 years ago as a pilot program and has since grown to serve more than 8 million pregnant women, and mothers and their infants and young children. Today the program serves more than a quarter of the pregnant women and half of the infants in the United States, at an annual cost of about $6.2 billion. Through its contribution to the nutritional needs of pregnant, breastfeeding, and postpartum women; infants; and children under 5 years of age, this federally supported nutrition assistance program is integral to meeting national nutrition policy goals for a significant portion of the U.S. population.
To assure the continued success of WIC, Congress mandated that the Food and Nutrition Service of the U.S. Department of Agriculture (USDA) reevaluate the program’s food packages every 10 years to assure they remain aligned with the goals of the Dietary Guidelines for Americans (DGA). In 2014, USDA asked the Institute of Medicine (IOM) to undertake this reevaluation. This complex task included consideration of whether or not WIC participants should be permitted to purchase white potatoes with the cash value voucher (CVV), a part of the benefit package that provides access to vegetables and fruits. In its first of three reports, published early in 2015, the committee recommended that white potatoes be allowed as a WIC-eligible vegetable for purchase with the CVV. The second report of this series, published in 2016, provided a summary of the work of phase I of the study as well as the analytical underpinnings for phase II. This is the third and final report in this series. It provides further data analyses, a regulatory impact analysis, and the committee’s final recommendations.
The revised food packages were constrained to be cost neutral with the current food packages, which means that any increases in the costs of components of the packages or allowed substitutions had to be balanced by corresponding decreases in costs elsewhere. This required the committee to be creative in responding to its charge to align the packages with the DGA. When making these revisions, the committee considered the supplemental nature of the WIC program and used a systematic approach. The committee was able to make changes to the packages that improve their alignment with the DGA and, thus, the dietary balance of the packages. The committee was able to improve the number of substitution options included in the packages and, thus, the choices available to participants to meet their cultural and personal preferences. The revised packages increase the cash value voucher for all participants, although the amounts differ by food package, and include fish in nearly all food packages. In addition, the committee provided enhanced support for breastfeeding, both exclusive and partial breastfeeding, along with greater flexibility for breastfeeding in the first 30 days after delivery.
This report is the first review of the WIC food packages to contain a regulatory impact analysis. This may permit USDA to move more rapidly to implement the changes proposed. These changes build on administrative actions taken in response to the IOM’s 2006 Time for a Change report for further ease of implementation. It is noteworthy that the regulatory impact analysis not only shows that the revisions to the food packages should be cost neutral when implemented but also that they are projected to provide substantial cost savings over time, savings that could be used to make further nutritional improvements to the food packages.
The work of the committee was greatly enhanced by the contributions of many individuals who participated in the study’s public activities. The committee is grateful to the speakers in its data-gathering workshops who gave valuable insights as well as their time to assist the committee with its task. The committee also thanks the members of the public who provided comments in open sessions or through the committee’s website. Lastly, the committee is indebted to the many WIC staff members who gave their time and expertise to help committee members better understand administration of and participation in the WIC program.
The size of this report is testimony to the magnitude of the committee’s task. It exists thanks to the hard work of many individuals. Committee members volunteered many hours of their time to this work. Their collaborative spirit as well as careful thinking and writing are to be commended. The committee was supported in its work by several consultants. Suzanne Murphy provided critical insights based on her experience in leading the committee that produced the first major reevaluation of the WIC food packages, published in 2006. Her sage advice is much appreciated. Mei Chung
led the development and execution of all of the committee’s literature reviews. Rose Gladstein assisted with the regulatory impact analysis.
The committee would like to thank the staff of the Center for Agricultural and Rural Development (CARD) and the Department of Statistics at Iowa State University for their analysis of the data from the National Health and Nutrition Examination Survey (NHANES) and National Household Food Acquisition and Purchase Survey. Committee members Helen Jensen and Alicia Carriquiry guided the CARD’s work, which was carried out by David Osthus, Miyoung Oh, and Hocheol Jeon. John A. Kirlin and David Levin of USDA’s Economic Research Service reviewed the committee’s application of the FoodAPS and IRI datasets to the study, and Kevin Dodd and Susan Krebs-Smith of the National Cancer Institute provided helpful guidance on analyses of NHANES.
To accomplish this task numerous staff members at the National Academies of Sciences, Engineering, and Medicine supported the work of the committee. Marie Latulippe served as the project’s study director and provided leadership, creative ideas, and an optimistic and calm spirit against tight deadlines. She was assisted by Meghan Quirk after March 2015, who led the regulatory impact analysis. Bernice Chu assisted with literature reviews and data management, and Ambar Saeed dealt with administrative logistics. Leslie Pray assisted with report organization and editing, and Rebecca Morgan of the National Academies Library/Research Center with fact checking. Alice Vorosmarti assisted with literature reviews and other data-oriented tasks. Naisi Zhao assisted the committee from January to April 2016 as a Mirzayan Fellow. Ann Yaktine, director of the Food and Nutrition Board, supervised the work of the staff and provided useful insights at many points in the committee’s deliberation. The committee owes them all a debt of gratitude for their hard work and professionalism.
Kathleen M. Rasmussen, Chair
Committee to Review WIC Food Packages
