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Executive Summary
INTRODUCTION AND BACKGROUND
Started in 1974, the Special Supplemental Nutrition Program for Women, Infants, and
Children (WIC) was designed to meet the special nutritional needs of low-income pregnant,
breastfeeding, or postpartum women; infants; and children up to 5 years of age who have at least
one nutritional risk factor. The WIC Program provides three main benefits: supplemental foods,
nutrition education, and referrals to health and social services. WIC food packages provide
supplemental foods but the proportion of the total diet that is supplied through the package varies
by participant category (see Chapter 1). The food is generally provided through food vouchers or
checks that can be exchanged for specific foods at participating grocery outlets.
Since the inception of the WIC program around 1974, substantial changes have occurred that
make it important to review the WIC food packages.
· Changes have occurred in the WIC population. The size and scope of the WIC Program
have changed. The WIC program has grown substantially and the WIC participants are a very
culturally diverse population.
· Changes have occurred in the food supply and in dietary patterns. Since 1990 the number
of food products in U.S. retail grocery stores has increased by approximately 60 percent.
Women's intake of carbonated soft drinks has more than doubled since 1977-1978.
· Changes have occurred in health concerns. Obesity has emerged as a major public health
concern in both the general population and the population subgroups that participate in the WIC
program. At the same time, a need still exists to ensure adequate nutrition during critical periods
of growth and development. It is important to keep in mind that overweight or obesity can co-
exist with inadequate intakes and even deficiencies of micronutrients. Addressing both the risk of
overweight and obesity and prevention/remediation of undernutrition among vulnerable groups
poses a challenge in terms of optimizing the potential contribution of the WIC food package.
· Changes have occurred in nutrition knowledge and its application through dietary
guidance and recommendations. Knowledge about the effects of diet on health has increased
substantially in the past few decades. New dietary reference standards called Dietary Reference
Intakes (DRIs) are available and may be used to evaluate both nutrient adequacy and nutrient
excess. The number of nutrients included in the new standards and the recommended intakes of
many of the nutrients have changed. The Dietary Guidelines for Americans have been published
ES-1
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ES-2 PROPOSED CRITERIA FOR SELECTING THE WIC FOOD PACKAGES
every five years since 1980; each revision considers the most recent scientific knowledge to
provide guidance on dietary patterns that promote health.
Despite the external changes that have occurred since the inception of the WIC program, the
only recent change in the WIC food packages was a small revision in the package for exclusively
breastfeeding women.
In proposing effective WIC food packages, the Committee is faced with many challenges that
arise from the scientific, market, social, and health changes described above. Challenges also
arise from other considerations such as current food safety concerns; participants' access to
transportation, storage, and cooking facilities; and the impact on WIC administration and
vendors related to modifications to established procedures.
COMMITTEE'S TASK
The U.S. Department of Agriculture's Food and Nutrition Service has charged the
Committee, through the Institute of Medicine's Food and Nutrition Board, to conduct a two-
phase evaluation of the WIC food packages. In Phase I, summarized in this preliminary report,
the Committee's specific tasks are to review nutritional needs of the population subgroups
participating in the WIC program using scientific methods summarized in the Dietary Reference
Intake reports, assess supplemental nutrition needs of these subgroups, and propose priority
nutrients and general nutrition recommendations for the WIC program. In Phase II, the
Committee will apply the findings of this assessment to develop recommendations for specific
changes to the WIC food packages. This preliminary report presents the results of the Phase I
tasks, and proposes the priorities and criteria that will be used to recommend changes to the WIC
food packages during Phase II of the project.
In Phase I of the project, the Committee considered evidence of three major types: analyses
of the nutrient intake of WIC-eligible populations (described in Chapter 3); analyses of the food
intake of WIC-eligible populations (described in Chapter 4); and nutrition-related health risks
and outcomes of WIC-eligible populations (described in Chapter 5). By utilizing and integrating
all three of these approaches, when possible, the Committee attempted to overcome the
limitations of any one approach applied individually. It was not feasible to include all categories
of WIC participants in every type of analyses because the appropriate data set was not always
available. For example, sufficient dietary intake data for breastfed infants were not available for
the nutrient analyses described in Chapter 3; however, breastfed infants were considered in the
analyses of nutrition-related health risks and outcomes described in Chapter 5. It was not feasible
to include all nutrients in every type of analyses because the appropriate data were not available.
For example, intake data for vitamin D and folate were not available for the nutrient analyses
described in Chapter 3; however, vitamin D and folate were considered in the analyses of
nutrition-related health risks and outcomes described in Chapter 5.
NUTRIENT INTAKE OF WIC-ELIGIBLE POPULATIONS
Because published evaluations comparing the nutrient intakes of WIC-income-eligible
populations to the new DRIs were not available, the Committee conducted analyses of the
nutrient adequacy of the diets of WIC-income-eligible subgroups--infants under one year of age,
children ages 1 through 4 years, and women of reproductive age--from households with incomes
in the range that is eligible for the WIC program. Although many of these households are already
receiving WIC benefits, the intent of the analyses was to identify nutrients of concern to guide
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EXECUTIVE SUMMARY ES-3
the Committee in recommending specific changes in the food packages during phase II of the
project. The term "nutrient of concern" signifies that, if feasible, the revised food packages will
improve intake of that nutrient. The analyses conducted for this report utilized 24-hour dietary
recall data from the 1994-1996 and 1998 Continuing Survey of Food Intakes by Individuals
(CSFII) and methods recently published by the Institute of Medicine to assess the nutrient
adequacy of diets. Nutrient adequacy was examined by determining the estimated prevalence of
inadequate intakes for eight micronutrients (calcium, iron, zinc, magnesium and vitamins A, C,
E, and B6), potassium, dietary fiber, and protein. Possible excessive intakes were examined for
food energy (the caloric content of the diet), percentage of food energy from fat, and intakes of
sodium, added sugar,1 and several micronutrients (calcium, iron, zinc and vitamins A, C, and B6).
Although intake data are biased to some extent by under-reporting in data for adults and
over-reporting in data for children, these data permit a ranking of nutrients likely to be
inadequate or excessive within each of the WIC target populations. For example, although there
are limitations to intake estimates for vitamin E, the very high prevalence of inadequate intakes
cannot be ignored. Additionally, although the application of the DRIs has not been thoroughly
tested and enhanced in the iterative process envisioned, it provides the Committee with the best
documented approach to identifying nutrients of concern.
Based on the Committee's analyses of available data, priority nutrients of concern because of
inadequate intake are:
· Infants, non-breastfeeding: none
· Children 1 through 4 years of age: vitamin E, potassium, and fiber
· Adolescents and adult women of reproductive age:
Highest priority--calcium, magnesium, vitamin E, potassium, and fiber
Next in priority--vitamins A, C, and B6
Based on the Committee's analyses of available data, nutrients that may be excessive in diets
are:
· Infants, non-breastfeeding: zinc and preformed vitamin A. Food energy intake may exceed
energy needs.
· Children 1 through 4 years of age: zinc, preformed vitamin A, and sodium. Food energy
intake may exceed energy needs.
· Adolescent and adult women of reproductive age: sodium, food energy, and total fat intake
as a percentage of food energy.
FOOD INTAKE OF WIC-ELIGIBLE POPULATIONS
The Dietary Guidelines for Americans provide science-based advice to promote health and to
reduce risk for major chronic diseases through diet and physical activity. They are targeted to
healthy people two years of age and older. According to Public Law No. 101-445 (U.S.
Congress, 1990), the Dietary Guidelines form the basis of federal food assistance, nutrition
education, and information programs, including the WIC program. The USDA food pattern
recommendations that accompany the Food Guide Pyramid, issued in 1992, were designed to
reflect the Dietary Guidelines.
The Committee compared food group intakes with recommendations from the Food Guide
Pyramid to assess food patterns of low-income children and women of childbearing age. In
1 Added sugars have been defined by USDA as sugars and syrups that are added to foods during processing or
preparation. See Chapter 3 for a description of the term "added sugars."
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ES-4 PROPOSED CRITERIA FOR SELECTING THE WIC FOOD PACKAGES
general, for four of the food groups (grains, vegetables, fruits, and dairy) fewer than 50 percent
of children, adolescents, and women met the recommended minimum. Also, fewer than 50
percent of the adolescents and women met the recommended minimum for the meat and meat
alternatives group. For children 2 to 5 years of age, percentages meeting the recommended
minimum were lowest for the vegetable group. For women of childbearing age, percentages
meeting the recommended minimum were lowest for the fruit and dairy groups. Compared to
Food Guide Pyramid allowances, intakes of added sugars were high for all groups for which data
were available.
Since children under the age of two years are not generally included in dietary guidance for
the general population, different sets of guidance were considered. A major finding for infants
was that breastfeeding rates for WIC mothers have increased--more than 50 percent of WIC
women now initiate breastfeeding--but the duration of breastfeeding was much shorter than the
American Academy of Pediatrics recommendation of one year (see Chapter 4). Another finding
that impacts children ages 12 to 24 months is that their diets lack variety and the mechanisms
that promote acceptance of a variety of foods are lacking. For example, juice is by far the major
form of food ingested from the fruit group but only a few select juices are consumed on a regular
basis.
Priorities for the revised WIC food packages include improving the contribution of the
package to an overall dietary pattern that is consistent with the Dietary Guidelines (emphasizing
the vegetable group for children, emphasizing the fruit and dairy groups for women, limiting the
amount of added sugars, saturated fat, cholesterol, and trans fatty acids), further promoting
breastfeeding of infants, and keeping juice allowances within recommendations.
NUTRITION-RELATED HEALTH RISKS AND OUTCOMES OF
WIC-ELIGIBLE POPULATIONS
Nutrients of concern in the WIC-eligible populations also were identified by examining
health risks that are specific to infants, young children, and women of reproductive age. Growing
rates of overweight and obesity among low-income adolescent and adult women are of particular
concern. Although the cause of obesity has many facets, the common denominator is positive
energy balance. In order to promote a healthy body weight at each life stage, the overall energy
balance between physical activity and food energy intake must be considered in prescribing an
appropriate food package for each individual. Thus, flexibility to promote food energy intakes
over a healthy range should be considered in formulating the food package allowances from
which an individual's prescription will be drawn.
Although intakes of folate and vitamin D could not be evaluated using data from the CSFII,
information from other sources indicates that these should be priority nutrients in the WIC food
package. Adequate dietary folate prior to and early in pregnancy is crucial for reducing the risk
of neural tube defects, yet many women fail to obtain recommended intakes. Vitamin D is
needed for bone health in women, yet evidence suggests that intakes are low. Although dietary
iron inadequacy was not identified as a significant problem in WIC-income-eligible children,
there is biochemical evidence from clinical laboratory data that iron deficiency remains above
the goal for reduction of iron deficiency in children as outlined it the Healthy People 2010
initiative (see Chapter 5). Although dietary iron inadequacy was identified at a low level of
concern for low-income women of reproductive age, biochemical evidence from clinical
laboratory data that iron deficiency remains a problem with women in this life stage raises iron to
a nutrient of concern (see Chapter 5).
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EXECUTIVE SUMMARY ES-5
Health risks related to environmental exposures are also a concern for the WIC food package.
Recent recommendations to reduce exposure to dioxin and dioxin-like compounds suggest that
low-fat and non-fat dairy products should replace higher-fat alternatives, particularly for girls
and women throughout the pre-reproductive and reproductive years. Exposure to methylmercury
can be reduced by limiting intakes of certain types of fish that accumulate these compounds. The
adverse effects of lead exposure may be somewhat mitigated by a diet that contains at least the
recommended intake of calcium.
PROPOSED PRIORITY NUTRIENTS AND FOOD GROUPS FOR
THE WIC FOOD PACKAGES
The Committee considered the results from each type of analysis (analyses of nutrient intakes
of WIC-eligible populations, analyses of food intake of WIC-eligible populations, and
consideration of nutrition-related health risks and outcomes in the WIC population). After
evaluating the strengths and weaknesses of each approach, the proposed priority nutrients and
food groups were selected, and are summarized in Table ES-1.
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ES-6 PROPOSED CRITERIA FOR SELECTING THE WIC FOOD PACKAGES
TABLE ES-1 Proposed Priorities for the WIC Food Packages
Nutrients of
Participant Proposed Priority Proposed Priority Concern with Nutrients to Limit
Category Nutrients Food Groups Regard to in the Diet
Excessive Intake
Infants, less than 1 year of age, non-breastfed
N/A Zinc
Vitamin A,
preformed 1
Food energy
Infants, 6 through 11 months of age, breastfed
Iron N/A
Zinc
Children, 12 through 23 months of age
Iron Vegetables Zinc
Vitamin E Vitamin A,
Potassium Fiber preformed 1
Sodium
Food energy
Children, 2 through 4 years of age
Iron Vegetables Zinc Saturated fat
Vitamin E Vitamin A, Cholesterol
Fiber preformed 1
Potassium Sodium
Food energy
Adolescent and adult women of reproductive age
Highest priority: Fruit Sodium Saturated fat
Calcium Dairy products, Food energy Cholesterol
Iron low-fat or Total fat Trans fatty acids 2
Magnesium nonfat
Vitamin E
Fiber
Potassium
Also consider:
Vitamin A
Vitamin C
Vitamin D
Vitamin B6
Folate
NOTE: N/A = not applicable from available data.
1The UL applies only to preformed vitamin A (i.e., retinol) ingested from the combined sources of animal-
derived foods, fortified foods, and dietary supplements.
2Trans fatty acids have not specifically been identified as a hazard for infants and children, and thus are
shown in the table as nutrients to limit only in the diets of adolescents and adults. However, the recommendation
to limit trans fatty acids from processed foods in the diet is presumed to apply to all individuals regardless of
age.
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EXECUTIVE SUMMARY ES-7
PROPOSED APPROACH FOR SELECTING
THE WIC FOOD PACKAGES
The criteria shown in Box ES-1 are proposed for use in selecting the revised WIC food
packages. Both a cost evaluation and an evaluation of benefits and risks will be performed for
the proposed revisions to the WIC food packages. The goal is to propose food packages that
improve the health of the WIC population with minimal impact on costs, vendors, and WIC
agencies.
The identification of these proposed priority nutrients and food groups and these proposed
criteria represents the first phase in the Committee's two phase task of recommending specific
changes to the food packages.
BOX ES-1 Proposed Criteria for a WIC Food Package,
if Consumed as Specified
1. The package reduces the prevalence of inadequate nutrient intakes and of excessive nutrient
intakes.
2. The package contributes to an overall dietary pattern that is consistent with the Dietary
Guidelines for Americans for individuals two years of age and older.
3. The package contributes to an overall diet that is consistent with established dietary
recommendations for infants and children less than two years of age, including encouragement
and support for breastfeeding.
4. The foods in the package are available in forms suitable for low-income persons who may have
limited transportation options, storage, and cooking facilities.
5. The foods in the package are readily acceptable, commonly consumed, are widely available,
take into account cultural food preferences, and maintain the incentive value of the food
packages for families to participate in the WIC Program.
6. The foods will be proposed giving consideration to the impact of changes in the package on
vendors and WIC agencies.
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Representative terms from entire chapter:
wic food
