6
HOW THE REVISED FOOD PACKAGES MEET THE CRITERIA SPECIFIED

The criteria used by the committee in proposing revisions for the food packages appear in Box 6-1. This chapter summarizes specific ways in which the revised food packages address each of the six criteria. During the committee’s deliberations, stakeholders submitted comments regarding concerns about the current food packages. Many of the committee’s recommendations address multiple concerns. In order to avoid text that would be repetitious, this chapter addresses each of the criteria in sequence and makes use of tables to illustrate how the revised food packages address both the criterion and some of the major concerns of stakeholders (Tables 6-4 to 6-6). A small amount of text highlights the major issue(s) for each criterion.

Criterion 1: The package reduces the prevalence of inadequate and excessive nutrient intakes in participants.

The committee designed the revised food packages to provide priority nutrients in amounts that would improve overall nutrient consumption, reducing the prevalence of inadequate or excessive nutrient intakes among the WIC participants.

The impact of the revised food packages on nutrient intakes was evaluated in two ways. First, the nutrient contents of the current and revised packages were compared to determine if the amounts of the priority nutrients (as discussed in Chapter 2Nutrient and Food Priorities) changed in the desired direction (i.e., increased for those with an undesirably high prevalence of inadequacy and decreased for those with an undesirably high prevalence of excessive intakes). The second evaluation examined changes



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WIC Food Packages: Time for a Change 6 HOW THE REVISED FOOD PACKAGES MEET THE CRITERIA SPECIFIED The criteria used by the committee in proposing revisions for the food packages appear in Box 6-1. This chapter summarizes specific ways in which the revised food packages address each of the six criteria. During the committee’s deliberations, stakeholders submitted comments regarding concerns about the current food packages. Many of the committee’s recommendations address multiple concerns. In order to avoid text that would be repetitious, this chapter addresses each of the criteria in sequence and makes use of tables to illustrate how the revised food packages address both the criterion and some of the major concerns of stakeholders (Tables 6-4 to 6-6). A small amount of text highlights the major issue(s) for each criterion. Criterion 1: The package reduces the prevalence of inadequate and excessive nutrient intakes in participants. The committee designed the revised food packages to provide priority nutrients in amounts that would improve overall nutrient consumption, reducing the prevalence of inadequate or excessive nutrient intakes among the WIC participants. The impact of the revised food packages on nutrient intakes was evaluated in two ways. First, the nutrient contents of the current and revised packages were compared to determine if the amounts of the priority nutrients (as discussed in Chapter 2—Nutrient and Food Priorities) changed in the desired direction (i.e., increased for those with an undesirably high prevalence of inadequacy and decreased for those with an undesirably high prevalence of excessive intakes). The second evaluation examined changes

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WIC Food Packages: Time for a Change BOX 6-1 Criteria for a WIC Food Package The package reduces the prevalence of inadequate and excessive nutrient intakes in participants. The package contributes to an overall dietary pattern that is consistent with the Dietary Guidelines for Americans for individuals 2 years of age and older. The package contributes to an overall diet that is consistent with established dietary recommendations for infants and children younger than 2 years of age, including encouragement of and support for breastfeeding. Foods in the package are available in forms suitable for low-income persons who may have limited transportation, storage, and cooking facilities Foods in the package are readily acceptable, widely available, and commonly consumed; take into account cultural food preferences; and provide incentives for families to participate in the WIC program. Foods will be proposed giving consideration to the impacts that changes in the package will have on vendors and WIC agencies. in intakes that might occur as a result of the revised packages, and whether the prevalence of undesirable intakes would decrease, within the context of a risk assessment model (Appendix D—Evaluating Potential Benefits and Risks). Most of the priority nutrients changed in the desired direction in the revised food packages. Priority nutrients that were low in the diets increased for most of the packages, while those that were excessive generally decreased in the packages. Table 6-1 summarizes the direction of changes in the amounts of the priority nutrients in each of the packages. Quantitative estimates of each change are given in the nutrient analyses in Appendix B—Nutrient Profiles of Current and Revised Food Packages. Although the amount of energy content provided by the packages decreased for all but the youngest infants, the changes were minor (averaging approximately 80 kilocalories per day across the packages). The primary focus was on increasing the nutrient density of the packages, not on substantially decreasing their energy content. Compared with the current food packages for children and women, the committee estimates that the revised packages provide greater amounts of nearly all of the nutrients of concern with regard to inadequate intake. The exceptions were potassium for children, calcium and vitamin D for pregnant and partially breastfeeding women, and vitamin C for pregnant and breastfeeding women. The amounts of calcium and vitamin C in most food

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WIC Food Packages: Time for a Change TABLE 6-1 Direction of Changes in the Level of Priority Nutrients in the Revised Food Packages (Criterion 1) Participant Category Priority Nutrients to Increase in the Packages Changes in the Revised Packagesa Priority Nutrients to Decrease in the Packages Changes in the Revised Packagesa Infants, younger than 1 y, non-breastfed   No specific priority nutrients; continue to provide a balanced set of essential nutrients na Zinc:   0–3.9 mo No change 4–5.9 mo – 6–11.9 mo – Vitamin A, preformed: 0–3.9 mo No change 4–5.9 mo + 6–11.9 mo – Food energy: 0–3.9 mo No change 4–5.9 mo – 6–11.9 mo – Infants, 6–11.9 mo, breast-fed (Food Package II-BF)   Iron +       Zinc +     Children, 12–23.9 mo (Food Package IVA)   Iron + Zinc +   Vitamin E ++ Vitamin A, preformed –   Potassium – Sodium –   Fiber ++ Food energy – Children, 2–4.9 y (Food Package IVB)   Iron + Zinc +   Vitamin E ++ Vitamin A, preformed –   Potassium – Sodium –   Fiber ++ Food energy – Pregnant and partially breastfeeding women (Food Package V)   Calcium – Sodium –   Iron + Food energy –   Magnesium + Total fat –   Vitamin E ++ Fat as % of food energy intake –   Potassium +   Fiber ++   Vitamin A +   Vitamin C –   Vitamin D –   Vitamin B6 +   Folate +

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WIC Food Packages: Time for a Change Participant Category Priority Nutrients to Increase in the Packages Changes in the Revised Packagesa Priority Nutrients to Decrease in the Packages Changes in the Revised Packagesa Non-breastfeeding postpartum women (Food Package VI)   Calcium – Sodium –   Iron + Food energy –   Magnesium + Total fat –   Vitamin E ++ Fat as % of food energy intake –   Potassium +   Fiber ++   Vitamin A +   Vitamin C –   Vitamin D –   Vitamin B6 +   Folate + Fully breastfeeding women (Food Package VII)   Calcium + Sodium –   Iron + Food energy –   Magnesium + Total fat –   Vitamin E ++ Fat as % of food energy intake –   Potassium +   Fiber ++   Vitamin A –   Vitamin C –   Vitamin D +   Vitamin B6 +   Folate + a“+” indicates an increase and “–” indicates a decrease; “++” indicates an increase of at least 50 percent. NOTES: na = not applicable. packages are close to or exceed required amounts, according to the Dietary Reference Intakes appropriate in planning for population groups. WIC participants or caregivers could make choices within the options allowed that could increase the amount of specific nutrient(s) in the revised food packages above the committee’s estimates. Indeed, considering various choices among commonly consumed foods (that is, foods used in the nutrient analyses), the committee found examples of choices of food items that provide nutrients in excess of the estimates in the current packages (as for potassium) or, in some cases, to exceed the Adequate Intake or Recommended Dietary Allowance (as for calcium, vitamin D, and vitamin C). The revised food packages generally provide less of nutrients of concern with regard to excessive intakes. Preformed vitamin A was reduced in

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WIC Food Packages: Time for a Change both the infants’ and children’s packages, and sodium1 was reduced in the packages for children and women. Although zinc was identified as a nutrient of concern for excessive intake in the diets of formula-fed infants and children, the committee did not find acceptable ways to revise food packages to reduce the amount of zinc. As noted in Chapter 2—Nutrient and Food Priorities—the committee recognizes that there are only small differences between the amounts of zinc and vitamin A recommended and the Tolerable Upper Intake Levels (ULs) for these two nutrients for infants and children. Because these ULs were extrapolated from limited data, there is controversy regarding whether they are appropriate (for example, Brown et al., 2004a).2 The committee chose to continue to promote adequate zinc intake for the entire group of WIC infants and children, realizing that the zinc intakes of some formula-fed infants and some children would exceed the ULs. Compared to the current packages, in the revised packages: (1) the zinc content is unchanged for fully formula-fed infants 0 through 3 months;3 (2) the zinc content is slightly lower for formula-fed infants 4 through 11 months;4 and (3) the zinc content is higher in the revised package for children ages 1 through 4 years.5 Analyses of potential intakes showed changes that essentially paralleled the changes in the nutrients provided in the packages. Although several assumptions were required, the committee estimated the potential changes 1   The sodium content of the revised packages is lower than the current packages in the nutrient analyses using fresh produce (Tables B-2A through B-2G and Tables B-3A through B-3G). This is not true when the processed option (i.e., canned fruits and vegetables as described in Tables B-4 and E-2) was used in separate nutrient analyses (data not shown). This is one reason the revised Food Packages IV through VII include fresh fruits and vegetable with processed fruits and vegetables as an option. 2   The International Zinc Nutrition Consultative Group (IZiNCG) proposed that the ULs (Tolerable Upper Intake Levels) for zinc (IOM, 2001) be replaced with NOAELs (No Observed Adverse Effect Levels) (Brown et al., 2004a). This proposal was emphasized for children because the IZiNCG found that “insufficient data exist to set an upper limit with confidence” (Brown et al., 2004a; quote from p. S120). Further research is needed to establish NOAELs (Brown et al., 2004b). 3   The revised package for infants 4 through 5 months of age (Food Package I) does not provide infant cereal to correspond better to current recommendations regarding the introduction of complementary foods (AAP, 2005); infant cereals are provided by the current package for infants in this age range (Food Package II). Some infant cereals are zinc fortified (manufacturer labeling, 2004). 4   For infants ages 6 through 11 months, the amount of infant formula was reduced (in the revised package versus the current package—Food Package II) to better correspond with Estimated Energy Requirements (IOM, 2002/2005); infant formulas contain zinc. 5   This is due to the difference in the zinc content of cereals used in the composites for the current and revised packages (see Table B-2A for zinc content of food packages and Table E-2 for description of cereal composites used).

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WIC Food Packages: Time for a Change in intakes that might occur as a result of offering the revised food packages. Importantly, these analyses assumed that any change in the nutrient profile of the packages would be reflected as a change in actual intake. It is not possible to estimate the precise impact of any changes in the packages on nutrient intakes because the full package is not always prescribed, the full prescription is not always obtained, and all the foods obtained may not be consumed by the WIC participant. Details of the analyses of potential intakes and the resulting changes in the predicted prevalence of inadequate and excessive intakes for the priority nutrients are presented in Appendix D—Evaluating Potential Benefits and Risks. Tables detailing changes in intake of over 30 micro- and macronutrients plus cholesterol and food energy for each of the current and revised WIC food packages are in Appendix B—Nutrient Profiles of Current and Revised Food Packages. Following is a summary of the potential changes in intake for the priority nutrients. Formula-Fed Infants Younger than One Year of Age—The only nutrient with a predicted change in intake in the non-desired direction is preformed vitamin A. The percentage of the population with intakes greater than the UL increases by approximately 10 percentage points for infants 4 through 5 months of age (see Table D-1B in Appendix D—Potential Benefits and Risks) because of a small increase in the amount of formula provided to these infants (see Table B-2B in Appendix B—Nutrient Profiles of Current and Revised Food Packages). Children 1 Year of Age—Children one year of age (12–23 months of age) see improvement in almost all food components. Two priority nutrients have predicted changes in intake in the non-desired direction; mean predicted intake of potassium decreases by 7 percent (see Table D-1A) and the fraction of the population with predicted zinc intakes greater than the UL increases (observed %>UL is 56 percent; predicted %>UL with revised Food Package IV-B is 69 percent ) (see Table D-1B). Children 2 Through 4 Years of Age—The revised food package for children has many predicted benefits including sharp increases in intake of vitamin E and fiber (see Table D-1A) and reductions in consumption of sodium, food energy, saturated fat, and cholesterol (see Tables D-1B and D-1C). Two priority nutrients have predicted changes in intake in the non-desired direction; mean predicted intake of potassium decreases by 6 percent (see Table D-1A) and the fraction of the population with predicted zinc intakes greater than the UL increases (observed %>UL is 58 percent; predicted %>UL with revised Food Package IV-B is 73 percent) (see Table D-1B).

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WIC Food Packages: Time for a Change Pregnant Women and Partially Breastfeeding Women—For most of the priority nutrients, the revised food package (Food Package V) leads to decreases in predicted percentages of the population with inadequate in-takes.6 The benefits are especially large for magnesium, vitamin E, vitamin B6, and folate. Other benefits include predicted increases in intake of fiber and potassium and decreases in sodium, total fat, saturated fat, and cholesterol. Two nutrients have predicted changes in the non-desired direction; the predicted mean intake of calcium decreases by 2 percent (see Table D-1A) because of a reduction in the amount of milk and milk products in the package, and the fraction the population with predicted intakes of vitamin C that are inadequate increases by 11 percentage points (observed %Inadequate is 33 percent; predicted %Inadequate with revised Food Package V is 44 percent ) (see Table D-1A). Non-Breastfeeding Postpartum Women—Other than a predicted decrease in calcium intake (see Table D-1A)and an increase in the percentage with inadequate vitamin C intake (see Table D-1A), the revised package (Food Package VI) makes progress toward addressing the priority nutrients identified by the committee. For example, there is a reduction in the percentage with inadequate intake of iron, magnesium, vitamin E, vitamin A, fiber, potassium, vitamin B6, and folate (see Table D-1A). Predicted intakes of sodium, food energy, total fat, saturated fat, and cholesterol all decrease (see Tables D-1B and D-1C). Fully Breastfeeding Women—The revised package (Food Package VII) addresses very well the priority nutrients for this group, with increased predicted mean intakes of calcium and fiber (see Table D-1A) and predicted decreases in the percentages with inadequate intakes of iron, magnesium, vitamin E, vitamin B6, and folate (see Table D-1A). Again, intake of sodium, food energy, total fat, saturated fat, and cholesterol are all predicted to decrease (see Tables D-1B and D-1C). There is a small increase in the estimated percentage of the population with inadequate intake of vitamin A (see Table D-1A). For vitamin C, the analysis predicts an increase in the percentage of the population with inadequate intake (see Table D-1A). 6   The amount of vitamin D decreases in Food Packages V and VI; however, dietary intake data for vitamin D were not available to allow evaluation of predicted intakes of vitamin D.

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WIC Food Packages: Time for a Change Criterion 2: The package contributes to an overall dietary pattern that is consistent with the Dietary Guidelines for Americans for individuals 2 years of age and older. As outlined in previous chapters, the committee recommends specific changes in the WIC food packages to help make WIC participants’ diets more consistent with the Dietary Guidelines for Americans 2005 (DHHS/ USDA, 2005). The Dietary Guidelines report identifies 41 key recommendations—23 for the general public and 18 for special populations. The recommendations address seven of the nine general topics. The committee considered messages regarding physical activity and alcoholic beverages not to be relevant to WIC food packages. Table 6-2 summarizes characteristics of the revised food packages that relate to selected messages from the Dietary Guidelines. The revised packages also provide greater balance in food group intakes and are more consistent with the food group guidance in the Dietary Guidelines, as shown in Table 6-3. Although not included as a specific recommendation in Dietary Guidelines for Americans 2005 (DHHS/USDA, 2005), the committee maintained consistency with a food safety recommendation of the Dietary Guidelines Advisory Committee (DHHS/USDA, 2004) concerning fish. Table 6-3 compares food group contributions from the current and revised packages with the amounts suggested or recommended in Dietary Guidelines for Americans (DHHS/USDA 2005). This table shows that the revised packages provide greater balance in food groups and are more consistent with the food group guidance in the Dietary Guidelines than the current packages. For fruits and vegetables, the number of servings in the revised package is greater than in the current package, and the emphasis is on whole forms rather than juice. Similarly, the revised food packages for children and women provide whole grains but not refined grains, thus helping participants achieve the recommended three one-ounce-equivalents per day. Although the amounts of milk and equivalents are somewhat smaller in revised packages than in current packages, they are close to the amounts recommended by the Dietary Guidelines. The maximum allowances for eggs, which are counted in the meat and meat alternatives group, were reduced for Food Packages IV–VII. Criterion 3: The package contributes to an overall diet that is consistent with established dietary recommendations for infants and children younger than 2 years of age, including encouragement of and support for breastfeeding. The dietary guidance for infants and for children under the age of 2 years that was considered by the committee is summarized in Table 2-9 (Chapter 2—Nutrient and Food Priorities). This guidance addresses breast-

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WIC Food Packages: Time for a Change TABLE 6-2 Consistency of the Revised Food Packagesa with Selected Recommendations from the Dietary Guidelines for Americans 2005 for Individuals Two Years of Age and Older (Criterion 2) Recommendation from the Dietary Guidelines for Americans 2005 How Revised Food Packages Contribute to an Overall Dietary Pattern That Is Consistent with the Dietary Guidelines for Americans 2005 Adequate Nutrients Within Food Energy Needs Consume a variety of nutrient-dense foods within and among the basic food groups while choosing foods that limit the intake of saturated fat, trans fat, cholesterol, added sugars, salt, and alcohol. Nutrient density: the nutrient content of the packages was increased and the energy content was decreased, leading to an increase in nutrient density Food groups: foods included from each food group Variety: choices allowed within the food groups Food energy: reduced-calorie options allowed for some foods Limiting intakes: packages provide much smaller amounts of saturated fat and cholesterol and slightly less salt, and food specifications place certain restrictions on added sugars and added salt. The current and revised food packages contain insignificant amounts of industrial trans fats—the source of trans fat deemed to be of concern by the Dietary Guidelines Advisory Committee (DHHS/ USDA, 2004). Meet recommended intakes within energy needs by adopting a balanced eating pattern Balanced eating pattern: The revised packages are more consistent with food group guidance. Body Weight Management To maintain body weight in a healthy range, balance food energy from foods and beverages with energy expended Full-fat milk productsa and added sugars limited Reduced maximum quantities of foods that previously exceeded recommendations To prevent gradual body weight gain over time, make small decreases in food energy from food and beverages and increase physical activity Small decreases in total food energy provided by the packages Food Groups to Encourage Consume a sufficient amount of fruits and vegetables while staying within energy needs Fruits and vegetables: added to all the food packages beginning with infants age 6 mo and older Choose a variety of fruits and vegetables each day. Variety: choice allowed

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WIC Food Packages: Time for a Change Recommendation from the Dietary Guidelines for Americans 2005 How Revised Food Packages Contribute to an Overall Dietary Pattern That Is Consistent with the Dietary Guidelines for Americans 2005 Consume 3 or more ounceequivalents of whole-grain products per day. Whole grains: whole wheat bread and other whole-grain products added; choices of cereal (cooked and ready-to-eat) specified as whole grain Conesume 3 cups/d of fat-free or low-fat milk or equivalent milk products Fat-reduced milk and milk products: includes recommended amounts or more than two thirds of recommended amounts Fats Consume less than 10% of food energy from saturated fatty acids and less than 300 mg/day of cholesterol For individuals 2 years of age and over, packages provide an average of 8.8% of food energy from saturated fat (range of 7.9 to 10.0% of food energy) and well under 300 mg/day of cholesterol (range of 111 to 227 mg/d). Carbohydrates Choose fiber-rich fruits, vegetables, and whole grains often Whole fruits and vegetables added to the package, replacing part of the juice Whole grains included Choose and prepare foods with little added sugars Added sugars limited Sodium and Potassium Consume less than 2,300 mg/d of sodium. Average sodium content of packages decreased. Options with no added salt or low sodium allowed for processed vegetables (including canned legumes), peanut butter, and canned fish. Food Safety Recommendations focus on prevention of microbial foodborne illness, addressing the messages “clean, separate, cook, chill, and avoid selected raw unpasteurized foods.” Tuna allowed must be light rather than white (no albacore) to limit mercury intake.b Foods that carry high risk for contamination with Listeria were not included in any food package. For foods that have short safe storage times once the container is opened, the costing method allowed for container sizes that could be used within the recommended storage time. aDoes not apply to Food Package III for individuals with special dietary needs. bBased on recommendation from the Dietary Guidelines Advisory Committee; applies only to Food Package VII for fully breastfeeding women. DATA SOURCES: 2005 Dietary Guidelines for Americans Advisory Committee Report (DHHS/USDA, 2004); Dietary Guidelines for Americans 2005 (DHHS/USDA, 2005).

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WIC Food Packages: Time for a Change feeding, formula-feeding, feeding other foods to infants and young children, developing healthy eating patterns, and promoting food safety. Most of the recommendations derive from dietary guidance provided by the Committee on Nutrition of the American Academy of Pediatrics or by the American Dietetic Association. Table 6-4 provides a side-by-side comparison of how the revised food packages for infants and young children meet the established recommendations. The major revisions center on changes to the infants’ food packages to help meet the developmental needs of infants (e.g., delaying the provision of complementary foods until 6 months of age; inclusion of commercial baby food for infants 6 months of age and older to introduce older infants to a wider variety of foods in appropriate forms). A major revision of the children’s food package is the specification that whole milk with 3.5 to 4 percent milk fat be the type of milk provided for only one WIC subpopulation—children ages 12 through 23 months. The committee recognizes that it will not be convenient to obtain whole milk for a 1-year-old child and obtain other types of milk for other WIC participants in the household. However, the committee has a strong basis for the proposed change: (1) clear recommendations recently re-published by the American Academy of Pediatrics (AAP, 2004) and (2) the findings that a sizeable percentage of young children have fat intakes below the lower boundary of the Acceptable Macronutrient Distribution Range (AMDR) (IOM, 2002/2005; see Table 2-5, Chapter 2—Nutrient and Food Priorities). Nutrition education can help the parents or guardians learn about the importance of providing adequate fat intake for young children and the importance of separating certain items for use by one or more specific household members. Criterion 4: Foods in the package are available in forms suitable for low-income persons who may have limited transportation, storage, and cooking facilities. If adopted at the state agency level, the committee’s recommendations allow local agencies a wide range of options for tailoring the food packages to meet specific participant needs and preferences. Table 6-5 summarizes how the changes recommended address Criterion 4, highlighting some of the major concerns expressed to the committee by various stakeholders. Criterion 5: Foods in the package are readily acceptable, widely available, and commonly consumed; take into account cultural food preferences; and provide incentives for families to participate in the WIC program. This criterion guided many of the committee’s decisions with regard to recommendations for the revised food packages. The major revision that allows the food packages to address the issue of cultural suitability is the

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WIC Food Packages: Time for a Change TABLE 6-3 Amounts Provided by Current and Revised Food Packages Compared with Amounts Suggested for Caloric Level, by Major Food Group and Participant Category Food Group and Participant Category (Food Package No.) Estimated Amounts, Current Food Package Fruits and Vegetables, expressed in cups per day Children, 2-4.9 y (IV-B) ~1.2 c† Pregnant or partially breastfeeding women (V) ~1.2 c† Non-breastfeeding postpartum women (VI) ~0.8 c† Fully breastfeeding women (VII) ~1.5 c Milk and Alternatives, expressed in 1-cup equivalentsc per day Children, 2-4.9 y (IV-B) 3.2 Pregnant or partially breastfeeding women (V) 3.7 Non-breastfeeding postpartum women (VI) 3.2 Fully Breastfeeding Women (VII) 3.7 Grains, expressed in 1-ounce equivalentsd per day Children, 2-4.9 y (IV-B) 1.2 Pregnant or partially breastfeeding women (V) 1.2 Non-breastfeeding postpartum women (VI) 1.2 Fully breastfeeding women (VII) 1.2 Meat and Alternatives, expressed in 1-ounce equivalentse per day Children, 2-4.9 y (IV-B) 2.9 Pregnant or partially breastfeeding women (V) 1.9 Non-breastfeeding postpartum women (VI) 0.9 Fully breastfeeding women (VII) 3.8 aSuggested amounts are from Dietary Guidelines for Americans 2005 (DHHS/USDA, 2005, App A-2, p 53). bRanges of caloric levels used: children, 1,000–1,400 kilocalories; pregnant or partially breastfeeding women, 2,200–2,400 kilocalories; non-breastfeeding postpartum women, 1,600–2,000 kilocalories; and fully breastfeeding women, 2,400–2,600 kilocalories. cA 1-cup equivalent equals 1 cup of milk or yogurt, 1.5 oz natural cheese, or 2 oz processed cheese. dA 1-ounce equivalent equals 1 slice bread, 1 oz dry rice, or 1 oz dry breakfast cereal. inclusion of fruits and vegetables with very few restrictions on choice.7 The committee urges administrators in the WIC program at various levels to 7   The committee recommendation not to allow potatoes (with the exception of yams and sweet potatoes) is based on the data that these starchy vegetables already are very widely consumed. The WIC program would provide no additional nutritional benefit by promoting the intake of potatoes. In certain local populations, WIC agencies may wish to restrict the purchase of other starchy vegetables for similar reasons.

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WIC Food Packages: Time for a Change Estimated Amounts, Revised Food Package Suggested Amounts, Dietary Guidelinesa,b ~1.3 c 2–3 c ~1.7 c 5 c ~1.5 c 3.5–4.5 c ~1.7 c 5–5.5 c 2.1 2 2.9 3 2.1 3 3.5 3 2.3 (whole grain only) 3–5 (aim toward 3 oz equiv whole grain) 1.7 (whole grain only) 7–8 (≥ 3 oz equiv whole grain) 1.2 (whole grain only) 6–7 (≥ 3 oz equiv whole grain) 1.7 (whole grain only) 8–9 (≥ 3 oz equiv whole grain) 2.4 2–4 2.4 6–6.5 1.4 5–5.5 3.4 6.5 eThe number of meat and alternatives servings shown counts dry beans and peanut butter as meat alternatives. Examples of 1-ounce equivalents are 1 oz fish; 1 egg; 1/4 cup cooked dry beans, peas, or lentils; and 1/2 oz peanut butter. If dry beans were counted in the vegetable category, as is done usually, the serving size would be 1/2 cup cooked dry beans. One lb of dried beans per mo (or the equivalent of canned dry beans) provides less than 1/4 cup of cooked dry beans per day (that is, less than one 1-ounce equivalent per day as a meat alternative). NOTES: † = all servings are from juice; c = cups; oz equiv = ounce equivalent. ~ indicates approximate amounts. Amounts are rounded, and amounts from the revised food package are based on yields of specified foods. allow the maximum variety of choices for participants to obtain fruits and vegetables. By including a wide variety of fruits and vegetables, the food packages become much more responsive to the preferences of different cultures (ADA, 1994, 1995, 1998a-d, 1999a, 1999b, 2000; Kittler and Sucher, 2004) and are likely to offer more incentives to participate in the WIC program (Herman, 2004; Runnings, 2004). Table 6-6 summarizes how the recommended changes in food packages address Criterion 5, fo-

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WIC Food Packages: Time for a Change TABLE 6-4 Consistency of the Revised Food Packages for Infants and Children Under 2 Years of Age with Established Dietary Recommendations (Criterion 3) Established Recommendation (derived from Table 2-9) How Revised Food Packages Meet the Established Recommendation Breastfeeding Breastfeeding is the preferred method of infant feeding because of the nutritional value and health benefits of human milk. New policies, for which pilot testing and randomized, controlled trials are recommended, encourage full breastfeeding: Delay the provision of formula for breast-fed infants during the crucial first month postpartum as mother/infants pairs initiate breastfeeding;a For fully breastfeeding mother/infant pairs, the value of the revised food packages is increased substantially over the value of the current food packages; and, Compared with formula-using pairs, and the relative value of food packages for fully breastfeeding mother/infant pairs is increased substantially. Encourage breastfeeding with exclusion of other foods until infants are around 6 months of age. Food Package II, which provides complementary foods, is now limited to infants ages 6–11.9 mo so that no complementary foods are provided for the first 6 mo after birth. Recent studies verify that foods introduced before the age of 6 mo serve to dilute the nutritional benefits of breast milk (Briefel et al., 2004a; Skinner et al., 2004). Continue breastfeeding for first year after birth. Food Package II-BF for fully breast-fed infantsb provides commercial baby food meats to support their need for iron and zinc (in forms with good bioavailability) from complementary foods during age 6–11.9 mo and to provide an incentive for continued breastfeeding. Continue breastfeeding into second year after birth if mutually desired by the mother and child. No specific changes in the food package address this recommendation. (Current policy is unchanged.) Formula Feeding For infants who are not currently breastfeeding, use infant formula throughout the first year after birth. Infant formula is provided throughout the first year. (Current policy is unchanged.) Maximum formula allowances for infants 4–5.9 mo of age (Food Packages I-FF-B and

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WIC Food Packages: Time for a Change Established Recommendation (derived from Table 2-9) How Revised Food Packages Meet the Established Recommendation   I-BF/FF-B) were increased to correspond to higher nutritional needs at this age. Infant formula used during the first year after birth should be iron-fortified. Only iron-fortified formula is provided throughout the first year after birth. (Current policy is unchanged.) Infants with specific medical conditions may require medical formula and this should be readily available through nutrition assistance programs such as the WIC program. Medical formula is available to infants, with a doctor’s prescription. (Current policy is unchanged.) Feeding Other Foods to Infants and Young Children Introduce semisolid complementary foods gradually beginning around 6 mo of age. for infants beginning at age 6 mo (Food Semisolid foods are provided in the food package Package II).c Infants 4–5.9 mo of age were moved to Food Package I so that only breast milk or iron-fortified formula are provided for the first 6 mo. Recent studies verify that foods introduced before the age of 6 mo serve to dilute the nutritional benefits of breast milk or formula (Briefel et al., 2004a; Skinner et al., 2004). Introduce single-ingredient complementary foods, one at a time for a several day trial. All of the allowed complementary foods (infant cereals; baby food fruits, vegetables, and meats) are commonly available in single-ingredient forms. See Table 4-3—Proposed Specifications for Foods (see Table B-1 for additional detail). Since some allowable fruits, vegetables, and cereals are not single-ingredient foods, nutrition education will need to address this recommendation. Introduce a variety of semisolid complementary foods throughout ages 6–12 mo. Starting at 6 mo of age, all infants receive infant cereal and baby food fruits and vegetables.d Fully breast-fed infantsb also receive baby food meatse starting at 6 mo of age. All of these infants foods are available commercially in a variety of allowed choices. Encourage consumption of ironrich complementary foods during ages 6–12 mo. Iron-fortified infant cereal is provided to all infants, starting at 6 mo of age. Fully breast-fed infantsb also receive commercial baby food meatse starting at 6 mo of age. See Table 4-3—Proposed Specifications for Foods (see Table B-1 for additional detail).

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WIC Food Packages: Time for a Change Established Recommendation (derived from Table 2-9) How Revised Food Packages Meet the Established Recommendation Avoid introducing fruit juice before 6 mo of age. No juice is provided in Food Package I (for infants under 6 mo of age). Limit intake of fruit juice to 4–6 fl oz/d for children ages 1–6 y. The maximum fruit juice allowance does not exceed 4 fl oz/d for children ages 1–4.9 y. Encourage children to eat whole fruits to meet their recommended daily fruit intake. Food packages for children include cash-value voucher(s) to obtain up to $8.00 of fresh produce per month. Some vitamin C-rich juice is retained in the children’s packages to ensure an adequate source of vitamin C. Additionally, commercial baby food fruits and vegetables (with an option for fresh banana) are provided in the food package for older infants so that children are introduced to a variety of fruits and vegetables at an early age. Delay the introduction of cow’s milk until the second year after birth. Cow’s milk is not provided to infants. (Current policy is unchanged.) Cow’s milk fed during the second year should be whole milk. Whole milk is provided to children in the second year after birth (ages 1–1.9 y). Developing Healthy Eating Patterns Provide children with repeated exposure to new foods to optimize acceptance and encourage development of eating habits that promote selection of a varied diet. Commercial baby food fruit and vegetables are provided in the food package for older infants so that children are introduced to a variety of fruits and vegetables at an early age. All of the foods in the current packages for children—cereal, milk, eggs, peanut butter, legumes, cheese, and juice—remain in the revised packages at adjusted amounts to achieve a more balanced set of foods. Packages provide more food types, such as fruits and vegetables and whole grains, and more choices among allowed foods. Prepare complementary foods without added sugars or salt. Specification for allowed foods limit added sugars and include sodium-reduced options. Nutrition education may be used to address the preparation of foods without added sugars and salt.

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WIC Food Packages: Time for a Change Established Recommendation (derived from Table 2-9) How Revised Food Packages Meet the Established Recommendation Promote healthy eating early in life. The packages provide more fiber, vitamin E, and iron through a greater variety of foods. The revised food packages for participants 2 y of age and older provide moderate amounts of saturated fat, cholesterol, and total fat. Fat-reduced and sodium-reduced (i.e., reduced salt) options are allowed. Promoting Food Safety Avoid feeding hard, small, particulate foods up to age 2–3 y to reduce risk of choking. The revised food packages for infants provide only strained, pureed, or diced commercial baby food or fresh bananas (intended to be mashed) to reduce the risk of choking. The processed fruit options exclude dried forms for children. aThe committee considered the potential benefits and consequences of the recommendation not to provide formula during the first month of breastfeeding. On balance, the empirical evidence on the relationship between early use of formula and reduced breastfeeding was considered paramount (Bergevin et al., 1983; Feinstein et al., 1986; Frank et al., 1987; Snell et al., 1992; Caulfield et al., 1998; Chapman et al., 2004). bFully breast-fed infants do not receive any formula from the WIC program. cAlthough semisolid foods are not included in the food packages until 6 mo of age, this does not prevent the parents or caregivers from introducing semisolid foods to infants before 6 mo of age. dCommercial baby food in Food Package II is the form of fruits and vegetables most consistent with the committee’s criteria as applied to older infants, but this does not prevent the family from introducing other forms of fruits and vegetables (e.g., mashed foods from the family table). eCommercial baby food meats provide iron and zinc with good bioavailability in the form that is most consistent with the committee’s criteria. DATA SOURCES: Established recommendations are from the American Academy of Pediatrics (AAP, 1992a, 1992b, 1997, 2001a, 2001b, 2004, 2005; Kleinman, 2000); the American Dietetic Associations (ADA, 1999c, 2004); and the World Health Organization (WHO, 2001a, 2002). (See Table 2-9, Chapter 2—Nutrient and Food Priorities.)

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WIC Food Packages: Time for a Change TABLE 6-5 How the Revised Food Packages Can Be Tailored for Suitability for Persons with Limited Resources (Criterion 4) Suitability Requirements of Criterion 4 How the Revised Food Packages Correspond with the Suitability Requirements of Criterion 4 Food forms available are convenient to participants’ transportation options Food specifications allow for dried, powdered, or concentrated forms of a number of foods. See Appendix B, Table B-1—Proposed Specifications for Foods. Cost evaluation allowed for some small container sizes. See detail in Tables E-1 and E-2 (Appendix E—Cost Calculations). Small-denomination cash-value vouchers could ease transportation burdens. Food forms available for different storage options Food specifications allow for forms of foods that do not require refrigeration and are less perishable. See Table B-1. Cost evaluation allowed for some small package sizes allowing the entire contents to be consumed by the participant within a safe period without freezing. See detail in Tables E-1 and E-2. Small-denomination cash-value vouchers could ease storage burden for fresh fruits and vegetables. Food specifications allow for fruits, vegetables, and legumes in forms (fresh, canned, frozen, and/or dried) suitable for various storage conditions. See Table B-1. Food available in forms for diverse cooking and food preparation facilities Food specifications allow for ready-to-feed infant formulas, full-strength juices, and commercial baby foods. See Table B-1. Fruit and vegetable selection includes both fresh and processed options. See Table B-1. Dry beans and peas are allowed in dried and canned forms. Food specifications allow whole-grain selection to include ready-to-eat items (e.g., a loaf of bread), quick-cooking choices (e.g., parboiled brown rice), and slow-cooking grains (e.g., regular-cooking brown rice). See Table B-1. cusing on some of the major concerns expressed to the committee by various stakeholders. Criterion 6: Foods will be proposed giving consideration to the impacts that changes in the package will have on vendors and WIC agencies. The committee considered the administrative and logistical impact of each of the revised changes in the WIC food packages for program staff at state and local levels and for retail food vendors serving the WIC population. The committee received numerous public comments from these stake-

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WIC Food Packages: Time for a Change TABLE 6-6 How the Revised Food Packages Were Tailored to Be Readily Acceptable (Criterion 5) Suitability Requirements of Criterion 5 How the Revised Food Packages Correspond with the Suitability Requirements of Criterion 5 Commonly consumed foods Widely accepted reference sources were consulted regarding foods commonly consumed in the U.S. (Smiciklas-Wright et al., 2002, 2003; Krebs-Smith et al., 1997; Cotton et al., 2004) and used to identify fruits and vegetables to include in the composites used in the nutrient and cost analyses. Widely available foods Availability was considered at state and regional levels as well as across the U.S. and territories. Current WIC foods are widely available and retained in packages. The options for fresh produce obtained with cash-value voucher(s), processed fruits and vegetables, or a combination of the two allow states to be responsive to availability in the local area. Culturally appropriate foods Reference sources from widely known sources were consulted regarding cultural suitability of foods by subpopulations in the U.S. (ADA, 1994, 1995, 1998a–d, 1999a, 1999b, 2000; Kittler and Sucher, 2004;). Information in these resources supports the importance of allowing milk substitutes and the value of allowing participants a broad selection of fruits and vegetables Participant choice is allowed for whole grains and for fruits and vegetables. Yogurt and tofu are allowed substitutes for a portion of fluid milk. For women, calcium- and vitamin D-rich soy beverage (“soy milk”) is an allowed alternative for milk. Salmon and other canned fish are allowed as substitutions for tuna. Foods that provide incentive for participation in the WIC program More choices are allowed at the state and participant levels. Food packages for the fully breastfeeding mother/infant pair are enhanced. Commercial baby foods are provided for infants 6 mo of age and older, with higher amounts for fully breast-fed infants than for formula-fed infants. Except for Food Package I for infants ages birth to 5.9 mo, the array of foods in the food packages is greater.

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WIC Food Packages: Time for a Change TABLE 6-7 Concerns about Current Food Packages and the Potential Impact of Revised Food Packages on WIC Agencies and Retail Vendors (Criterion 6) Impacts and Concerns Expressed by WIC Personnel and Retail Vendors How the Revised Food Packages Address the Administrative Impact or Concern WIC State Agencies It is difficult to obtain approval for changes in food package to address state or local needs. Recommendations allow a greater number of substitutions, decreasing the need for special approvals. See Table 4-3—Proposed Specifications for Foods (see Table B-1 for additional detail). Changes require retraining of administrators, staff, and vendors and education of participants; but if they address concerns effectively, the changes will be welcome. Revised packages include many of the recommendations requested by state agencies. WIC Local Agencies Current food packages aren’t consistent with dietary guidance, making nutrition education difficult Revised packages are more consistent with the Dietary Guidelines, with current dietary guidance for infants and young children, and with current information on nutritional deficits and needs. Few options are available for addressing cultural diversity. Increased variety and choice in several types of foods provided will provide flexibility in prescribing culturally appropriate packages for diverse groups. Vendors Handling random-weight fresh produce at checkout would pose serious problems using the current food instruments. Cash-value voucher(s) for fresh fruit and vegetable option could be seen as a benefit by many vendors. Handling of random-weight items will be simplified by allowing WIC participants to pay the difference when the amounts of fresh fruits and vegetables selected cost more than the value of the WIC cash-value voucher(s). Obtaining fresh produce with WIC cash-value voucher(s) could be simplified if vendors choose to price produce in $1 or $2 units (e.g. four oranges or one bunch of broccoli for $1).

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WIC Food Packages: Time for a Change holder groups. The recommended changes address their major concerns, appear manageable for both WIC agency staff and vendors, and provide a number of benefits. Table 6-7 summarizes how the proposed changes address Criterion 6, highlighting some of the major concerns expressed to the committee by various stakeholders. In general, the committee’s final recommendations reflect the kinds of changes that were proposed by WIC administrators (Knolhoff and Dallavalle, 2004; Sallack, 2004; Tate, 2004; Jenks, 2004; Hoger, 2004) and vendor representatives (Gradziel et al., 2004) who communicated with the committee. Vendors have indicated that WIC vouchers for fresh produce, prescribed as a dollar amount, need to be on a separate food instrument from the food instruments that itemize specific quantities of specific foods. This is because, to a large extent, fresh produce is sold by random weight rather than with consistent package weights and standard bar codes. Thus, to a large extent, produce cannot be tracked precisely like grocery items that are scanned at the checkout counter. Having both cash-value vouchers for fresh produce and quantity-denominated vouchers (that is, the current type of food instrument with an itemized list of specific grocery items) will facilitate transactions at the checkout stand, save embarrassment, and accommodate the accounting and billing systems currently used between the WIC state agencies and the grocery outlets. SUMMARY Recommendations for the revision of the current WIC food packages were based on a set of specified criteria. The committee also took into consideration the major concerns that were submitted to the committee by various stakeholder groups. This chapter illustrates how the recommended changes address the criteria and selected concerns of stakeholders. Overall, the revised packages meet the six criteria while remaining cost-neutral. Most nutrient intakes are expected to improve. The proposed changes would result in packages that are consistent with the Dietary Guidelines for Americans 2005 for those ages 2 years and older and packages that are consistent with widely accepted dietary guidance for infants and children younger than 2 years of age. Since new food specifications expand offerings, more forms and types of foods are suitable for culturally diverse groups with limited transportation, food storage, and cooking facilities. WIC state and local agencies will have more flexibility in developing prescriptions, and the food packages can reinforce the WIC nutrition education efforts, and vice versa. Finally, allowing two types of food instruments—a cash-value voucher for fresh produce and the standard (itemized) food instrument for other foods—is expected to address some vendor concerns about adding fresh fruits and vegetables to the food packages.