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PROCESS USED FOR REVISING THE WIC FOOD PACKAGES

This chapter describes the approach the committee used in revising the WIC food packages. The approach involved evaluating the current food packages in relation to the criteria identified in the first phase of this study (Box 1-1Criteria for a WIC Food Package in Chapter 1Introduction and Background). Criteria 1, 2 and 3 include consideration of the priority nutrients and priority food groups that also were identified in Phase I of the study. The process then proceeded to considering public comments; deciding on the configuration of the packages (possible modifications to the types of packages); identifying food items that could be deleted or reduced in quantity to make room for the inclusion of others without increasing cost; identifying candidate foods and quantities to be added to the revised packages; and engaging in iterative analyses to evaluate potential packages with regard to cost and impact on nutrient content. This chapter addresses the need for flexibility, highlights issues relating to priority nutrients and priority food groups, and discusses each step in the decision making process.

Figure 3-1 illustrates the process the committee used in developing its recommendations.

THE NEED FOR FLEXIBILITY

The six criteria that the committee used are broad and interrelated goals that would be impossible to meet with a rigid prescription for the WIC food packages; thus, greater flexibility became a hallmark of the committee’s recommendations. For example, Criterion 5 suggests that the



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WIC Food Packages: Time for a Change 3 PROCESS USED FOR REVISING THE WIC FOOD PACKAGES This chapter describes the approach the committee used in revising the WIC food packages. The approach involved evaluating the current food packages in relation to the criteria identified in the first phase of this study (Box 1-1—Criteria for a WIC Food Package in Chapter 1—Introduction and Background). Criteria 1, 2 and 3 include consideration of the priority nutrients and priority food groups that also were identified in Phase I of the study. The process then proceeded to considering public comments; deciding on the configuration of the packages (possible modifications to the types of packages); identifying food items that could be deleted or reduced in quantity to make room for the inclusion of others without increasing cost; identifying candidate foods and quantities to be added to the revised packages; and engaging in iterative analyses to evaluate potential packages with regard to cost and impact on nutrient content. This chapter addresses the need for flexibility, highlights issues relating to priority nutrients and priority food groups, and discusses each step in the decision making process. Figure 3-1 illustrates the process the committee used in developing its recommendations. THE NEED FOR FLEXIBILITY The six criteria that the committee used are broad and interrelated goals that would be impossible to meet with a rigid prescription for the WIC food packages; thus, greater flexibility became a hallmark of the committee’s recommendations. For example, Criterion 5 suggests that the

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WIC Food Packages: Time for a Change FIGURE 3-1 Schematic representation of process used for revising the WIC food packages. packages need to take into account cultural food preferences, but preferences vary among states and regions of the United States. Likewise, foods that achieve the nutrient and food guidance goals presented in the first two criteria may not be commonly consumed or readily acceptable in a particular location, as specified by Criterion 5. Foods that might be considered the most desirable (Criterion 5) may require refrigeration or cooking facilities that are not readily available to some low-income families (Criterion 4). To address all the criteria simultaneously, the committee used an approach that would allow more flexibility at the WIC state agency level and more variety and choice at the participant level.

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WIC Food Packages: Time for a Change The process of revising the food packages also called for the committee to be flexible in its approach to the overall set of packages. When considering how to promote breastfeeding (Criterion 3), for example, the committee did not focus on the new mothers only. Instead, the committee considered the relative value of the food packages for breastfeeding mother/infant pairs compared to the value of the food package for non-breastfeeding mother/ infant pairs. PRIORITY FOOD GROUPS AND NUTRIENTS Foods and nutrients of highest priority, either because of inadequate or excessive intake levels, were identified in Phase I of the study. As discussed in Chapter 2—Nutrient and Food Priorities—the committee used three types of evidence in identifying priority foods and nutrients: (1) food choices and dietary patterns of WIC-eligible subgroups relative to the report of the Dietary Guidelines Advisory Committee (DHHS/USDA, 2004) and other dietary guidance; (2) results from an analysis of the nutrient adequacy of the WIC categorical subgroups; and (3) published information on nutrition-related health outcomes. The results of the committee’s analyses of nutrient intakes based on data from the Continuing Survey of Food Intakes by Individuals (CSFII) 1994–1998 were presented in a preliminary report (IOM, 2004b). After the preliminary report was published, the committee undertook additional nutrient analyses to analyze selected nutrients more thoroughly. The set of analyses of nutrient intakes used to support the nutrient priorities are in Appendix B—Nutrient Profiles of Current and Revised Food Packages. Table 2-10 of Chapter 2—Nutrient and Food Priorities—summarizes the nutrient and food group priorities for revising the WIC food packages. The following is a brief summary of the priorities for change highlighted in Table 2-10. Food group priorities—Increase the consumption of fruits and vegetables, whole grains, and fat-reduced milk (for children 2 years and older and women); limit intakes of foods with added sugars, saturated fat, cholesterol, and trans fatty acids1; promote breastfeeding of infants; introduce complementary foods at about six months of age; limit juice intake to recommended amounts; and delay introduction of cow’s milk until 1 year of age. Nutrient priorities because of inadequate intakes—No priority to increase nutrient intakes of formula-fed infants under 1 year of age; increase in- 1   The term trans fatty acids refers to unsaturated fatty acids that contain at least one double bond in the trans configuration (that is, with carbon atoms on opposite sides of the longitudinal axis of the double bond).  

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WIC Food Packages: Time for a Change take of iron and zinc for breast-fed infants 6 through 11 months; increase intake of iron, potassium, vitamin E, and fiber for children 1 through 4 years; increase intake of calcium, iron, magnesium, potassium, vitamin A, vitamin D, vitamin E, vitamin C, vitamin B6, folate, and fiber for adolescent and adult women of reproductive age. Nutrient priorities because of excessive intakes—Decrease intake of zinc and preformed vitamin A for formula-fed infants under 1 year of age and children ages 1 through 4 years; decrease intake of food energy and sodium for children beginning at age 2 years and for women; and decrease intake of total fat for women. Limit saturated fat, cholesterol, trans fat, and added sugars for children beginning at age 2 years and for women. COMPARING CURRENT FOOD PACKAGES WITH DIETARY GUIDANCE The committee examined how the current WIC food packages compare with dietary guidance provided by the Dietary Guidelines for Americans 2005 (DHHS/USDA, 2005) for those 2 years and older and by widely accepted dietary guidance from professional groups for infants and children younger than 2 years. Table 3-1 summarizes the most recent dietary guidance that is related to foods in current WIC food packages. For example, one can see that the inclusion of dried beans and peas in the current food packages is consistent with dietary guidance to consume dried peas and beans. In other cases (e.g., lack of specification of the type of milk, lack of promotion of whole grains), the correspondence with dietary guidance is weaker. In several cases, the maximum number of servings provided by the current WIC food packages exceeds the number of servings recommended. For example, several packages provide more than the recommended amount of milk or milk products, and packages for infants and young children exceed recommendations for juice. Currently, the WIC food packages contribute no vegetables except (1) the option of dried peas and beans rather than peanut butter and (2) carrots for breastfeeding women. The packages provide no whole fruits for any participants. Whole grain cereals are among the choices available to participants, but participants may select refined grains if they prefer. CONSIDERING PUBLIC COMMENTS The committee considered all of the many public comments it received directly and those that had been submitted to USDA (as shown schematically in Figure 3-1). (See also section in Chapter 1—Introduction and Background—Many Stakeholders Are Calling for Change.) Public comments

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WIC Food Packages: Time for a Change TABLE 3-1 Dietary Guidance Related to Foods in Current WIC Food Packages. Foods in Current WIC Food Packages Dietary Guidance for Feeding Infants and Toddlers Guidance from Dietary Guidelines for Americans 2005a Iron-fortified infant formula Breastfeeding recommended NR for at least 1 y (DHHS, 2000b; AAP, 1997, 2004, 2005; Kleinman, 2000); if formula-fed, iron-fortified formula recommended (Kleinman, 2000; AAP, 2004, 2005)   Vitamin C-rich juice (about 3 fl oz/d for infants, >9 fl oz/d for children, 6–11 fl oz/d for women) Limit intake of fruit juice to 4–6 fl oz/d for children ages 1–6 y (Kleinman, 2000; AAP, 2001a, 2004, 2005) Consume whole fruit (fresh, frozen, canned, dried) rather than fruit juice for a majority of the suggested total daily amount to promote adequate fiber intake. Iron-fortified infant cereal Introduce iron-rich complementary foods beginning around age 6 mo (AAP, 2001a, 2004, 2005) NR High-iron, low-sugar cereal,b may be hot or cold, refined or whole grain NR Increase intake of whole grains to at least three servings daily Milk, may be whole milk or fat-reduced typesb No cow’s milk before age 1 y (AAP, 1992a, 2004, 2005) Whole milk for toddlers age 1 y (AAP, 1992b, 1998) Consume 3 c per day of low-fat or fat-free milk or equivalent milk products (2 c for young children)

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WIC Food Packages: Time for a Change Cheese, fat content not specifiedb NR When selecting milk or milk products, make choices that are fat-reduced. Eggsb NR Limit cholesterol intake to less than 300 mg/d Dry beans or peasb and/or NR About 3 c of cooked legumes per week for women, smaller amounts for children Peanut butterb,c Avoid eating peanut butter from a spoon for safety reasons until age 3 y (AAP, 2004) Counted as part of the meat group Tuna (canned)—breastfeeding women only na Counted as part of the meat group. Evidence suggests about two servings of fish per week may reduce the risk of mortality from coronary heart disease. Avoid white tuna (albacore) because of mercury content. Carrots—breastfeeding women only na Increase intake of fruits and vegetables. aFor persons ages 2 years and older (DHHS/USDA, 2004, 2005) bBeginning at age 1 year cPeanut butter is a source of vitamin E, identified as a nutrient of concern with regard to inadequate intake (Table 2-10, Chapter 2—Nutrient and Food Priorities). NOTES: na = not applicable; NR = no recommendation. Bold font highlights topics needing more attention when revising the food packages. DATA SOURCES: Dietary guidance for feeding infants and toddlers is from several sources: American Academy of Pediatrics (AAP, 1992a, 1992b, 1997, 1998, 2001a, 2001b, 2004, 2005; Kleinman, 2000 ); Healthy People 2010 (DHHS, 2000b); 2005 Dietary Guidelines for Americans Advisory Committee Report (DHHS/USDA, 2004); and Dietary Guidelines for Americans 2005 (DHHS/USDA, 2005).

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WIC Food Packages: Time for a Change were received by the committee during three public sessions held during the course of the study; and many other public comments were submitted in letters or via e-mail. Among the public comments were two carefully researched position papers by the National WIC Association (NAWD, 2000; NWA, 2003) and presentations and written comments by food industry representatives and vendors, representatives of public interest groups, former WIC participants, WIC staff from a number of state agencies, academicians, and others. Examples of the points of view that were most prevalent among the public comments are listed here, by type of food package. Women’s food packages Offer fruit and vegetables to partially or fully replace juice. Offer alternative milk products (e.g., yogurt). Offer alternatives to milk and milk products (e.g., soy beverage [“soy milk”], tofu). Offer alternatives to eggs, peanut butter, and dried beans (e.g., canned chicken, canned beans). Decrease the amount of juice, cheese, eggs, and milk. Reduce or eliminate canned tuna because of concerns about methylmercury (e.g., offer canned salmon, chicken, or sardines as options). Allow partial replacement of cereals by other whole grains. Re-examine the policy of allowing partially breastfeeding woman to receive Food Package V while at the same time her infant is eligible to receive the maximum allowance of infant formula. Infants’ food packages Create policies that allow breastfeeding infants to receive a food package consistent with their nutritional needs. Re-examine the policy of providing formula for the infant of a breastfeeding woman, especially in the first few weeks, as this policy may undermine a woman’s commitment to breastfeed successfully. Minimize the allowance of formula for partially breast-fed infants; and provide only powdered formula, which has a longer shelf life than concentrated formula. This would allow the mother to use small quantities as needed. Re-examine the policy of allowing a partially breastfeeding woman to receive Food Package V while at the same time her infant is eligible to receive the maximum allowance of infant formula. Reduce the amount of infant formula provided or eliminate formula except under exceptional medical or social situations. Do not provide juice before 6 months of age.

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WIC Food Packages: Time for a Change Food package for children ages 1 through 4 years Offer fruits and vegetables to replace juice either partially or fully. Offer alternative milk products (e.g., yogurt). Offer alternatives for children who are allergic to milk, eggs, and peanut butter. Decrease the amounts of juice, cheese, eggs, and milk. Food packages for those with special dietary needs Eliminate Food Package III. Instead, have the other food packages cover those with special dietary needs, allowing substitutions to be prescribed as needed. Include infants with special dietary needs in Food Package III. (Currently Food Package III is provided only for women and children, not infants.) Expand Food Package III to include other WIC-approved foods beyond formula, juice, and cereal. IDENTIFYING FOODS THAT COULD BE DELETED OR REDUCED IN QUANTITY Because cost neutrality was required, new foods could be added to the food packages only if some of the current foods were deleted or reduced in amount. Thus, early in the process, the committee considered ways to pare down the current food packages (as shown schematically in Figure 3-1). Decisions regarding food reductions and deletions and their rationale are summarized in Table 3-2. IDENTIFYING CANDIDATE FOODS FOR ADDITION TO THE PACKAGES The committee considered foods that would be appropriate additions to the current food packages (as shown schematically in Figure 3-1). The following decisions guided the selection of specific foods: Food packages as supplementary foods—The foods provided in the packages are intended to supplement the usual diets of WIC participants. Thus, food groups and nutrients that are lacking in the diet are to be emphasized, rather than staple foods that are already adequate in the diet. Only the package for formula-fed infants from birth through 5 months of age would provide a complete diet for some infants, if the maximum allowance is prescribed.

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WIC Food Packages: Time for a Change TABLE 3-2 Foods in the Current WIC Food Packages to Be Deleted or Reduced in the Revised Food Packagesa Food Change Rationale Infant formula Reduce maximum amounts for partially breast-fed infants The maximum amount provides approximately half the amount provided to fully formula-fed infants to encourage the mother to breastfeed enough to provide at least half of the infant’s nutritional needs and to make possible other improvements in the WIC food packages. Infant formula Reduce maximum amounts for fully formula-fed infants ages 6–11.9 mo of age Since the food package for infants of this age provides greater amounts of nutrients through complementary foods, less formula is needed. Juice Delete juice for infants 4–11.9 mo of age; reduce amount of juice for children 1–4.9 y of age. Meet AAP recommendations: delay introduction of juice for infants until after 6 mo of age; and allow no more than 4–6 fl oz/d for infants above the age of 6 mo (AAP, 2001a, 2005). For infants age 6–11.9 mo, fruit juice has no nutritional benefit over whole fruit (AAP, 2001a, 2004). Milk Decrease maximum amounts allowed for children and adults Amounts provided need not exceed amounts recommended by Dietary Guidelines for Americans 2005 (DHHS/USDA, 2005). Cheese Reduce maximum amount allowed in women’s and children’s packages. Meets recommendation from the Dietary Guidelines (DHHS/USDA, 2005) and recommendation from the IOM to reduce saturated fat and cholesterol intake (IOM, 2002/2005) Eggs Reduce maximum amount allowed Protein is no longer a priority nutrient. Reduction in amount provided is consistent with Dietary Guidelines (DHHS/USDA, 2005) and with recommendation from the IOM to reduce cholesterol intake (IOM, 2002/2005). aAlthough all foods in this table contribute to a healthy diet, it was essential to decrease the quantity of some foods to be able to make improvements in the WIC food packages that meet the committee’s six criteria while maintaining cost neutrality. NOTES: AAP = American Academy of Pediatrics; IOM = Institute of Medicine. Types of food packages—Keep the same seven packages but alter age ranges in some cases. Basic foods—Propose a basic set of foods for each food package. Identify other foods as allowable substitutions. Fruits and vegetables—Add fruits and vegetables to the food packages for older infants, children, and adults, and allow a variety of choices.

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WIC Food Packages: Time for a Change Whole grains—Replace refined grains with whole grains. Offer other whole grains in addition to fortified breakfast cereals. Milk and milk products—Allow more options for milk (e.g., vegetarian options). Limit the fat content of milk and milk products to a maximum of 2 percent milk fat for children ages 2 years and older, and for adolescent and adult women. Supporting and promoting breastfeeding—Make the food packages for breastfeeding women more attractive than for non-breastfeeding postpartum women who are obtaining infant formula from the WIC program. Improve the food package for fully breast-fed infants ages 6 through 11 months. Candidate foods to add to the revised food packages were identified using several sources. Foods that are commonly consumed and are good sources of nutrients were identified from published information for adults (Krebs-Smith et al., 1997; Smiciklas-Wright et al., 2002; Cotton et al., 2004; NDL, 2004) and children (Briefel et al., 2004a, 2004b). Nutrient profiles for these foods were determined using food composition data from the Nutrient Data System (NDS-R, version 5.0/35) of the University of Minnesota (Schakel et al., 1988, 1997; Schakel, 2001) and the USDA Standard Reference Database (NDL, 2004). In addition to published sources of candidate foods, public comments also guided identification of foods to consider adding to the food packages. In order to model the potential effects of revised food packages on nutrient intakes and on cost when the committee proposed a choice among allowed foods, it was necessary to select specific items. In this case, the committee selected, for analyses, specific commonly consumed foods (see above for sources) or weighted averages of similar foods based on consumption/market share data. The specific composites that were used for the analyses are listed in Appendix E—Cost Calculations. This approach provides a basis for a good approximation of the amounts of nutrients provided by the revised packages and of the costs of the packages. However, the limitations of this approach must be borne in mind, since it necessarily involves assumptions about participant choice and state-agency level decisions that may, in fact, vary rather widely. EVALUATING POSSIBLE FOOD PACKAGES An iterative process was followed to design revised food packages that meet the criteria identified in Box 1-1—Criteria for a WIC Food Package (Chapter 1—Introduction and Background). The committee applied the following general steps to develop each food package. The iterative nature of the process is illustrated by the two-way arrows in Figure 3-1.

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WIC Food Packages: Time for a Change Propose a set of foods that addresses the priorities and is consistent with the basic decisions listed above. Examine nutrient values for foods per unit weight. Determine a specific food combination for the food package. Calculate the nutrient and food group contributions for each specified food combination. Estimate an approximate cost. Make adjustments to the types or amounts of foods to come closer to target recommendations without exceeding cost constraints. Weigh each possible food package against the six criteria. Discuss the relative benefits of the food package as a whole with the entire committee. Repeat the above steps as necessary. Following is a brief discussion of the process that was used to evaluate each candidate food package relative to the six criteria presented in Box 1-1—Criteria for a WIC Food Package (Chapter 1—Introduction and Background). The package reduces the prevalence of inadequate and excessive nutrient intakes in participants. Changes in nutrient content were evaluated for each iteration of the revised food packages. Attempts were made to design food packages that would result in increased intakes of nutrients with a high prevalence of inadequacy and decreased intakes of nutrients with a risk of excessive intakes. In some cases, trying to improve nutrient intake involved including foods of different types that might be more acceptable to participants rather than larger quantities of the foods in the current packages. Ensuring that the WIC food packages did not contribute to excessive energy intake was a particularly important consideration. 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. Foods that improved consistency with the food patterns recommended by the Dietary Guidelines for Americans were considered important for the revised food packages. Fruit, nonstarchy vegetables, whole grains, and fat-reduced milk products were particularly desirable. Other aspects of the Dietary Guidelines that were considered included limiting dietary sources of saturated fat, cholesterol, trans fatty acids,2 and added sugars; and promoting food safety.

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WIC Food Packages: Time for a Change 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 food packages for infants and women were specifically evaluated for their potential impact on both the initiation and duration of breastfeeding. Support for lactating mothers was considered particularly important, so as to encourage breastfeeding over time. Food packages for older infants were redesigned to encourage full breastfeeding and meet current recommendations not to introduce complementary foods before 6 months of age. Food packages for older infants and children younger than age 2 years were redesigned to encourage the development of healthy eating patterns (e.g., juice was eliminated or reduced according to current recommendations). Foods in the package are available in forms suitable for low-income persons who may have limited transportation, storage, and cooking facilities. Forms of foods that are appropriate for persons with limited transportation, storage, and cooking facilities were included in food specifications for the packages. This includes foods that do not require refrigeration and foods that require a minimum amount of cooking. Availability of foods in neighborhood stores, as well as in large supermarkets, was considered important. 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. Candidate foods were initially identified by examining which foods were good sources of the priority nutrients (NDL, 2004; DHHS/USDA, 2004). Since foods are good sources of a nutrient only if they are consumed, both acceptability and frequency of consumption were considered from the beginning of the selection process. Foods commonly consumed were identified (Krebs-Smith et al., 1997; Smiciklas-Wright et al., 2002; Cotton et al., 2004). Cultural food preferences, based on both published references (Kittler and Sucher, 2004; ADA, 1994, 1995, 1998a, 1998b, 1998c, 1998d, 1999a, 1999b, 2000) and public comments, were given high priority, par- 2   Reliable data were not available to assess intakes of trans fatty acids; however, the amount of trans fatty acids in the current and proposed food packages were estimated and are included in Tables B-2E in Appendix B—Nutrient Profiles. The current and revised WIC 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).

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WIC Food Packages: Time for a Change ticularly in identifying substitutions to be allowed. Throughout the process of selecting the food packages, the value of the packages to participants (in terms of both dollar value and desirability) was considered. Increased flexibility at the level of the state agency and increased choice by participants were considered desirable attributes of the revised food packages. Foods will be proposed giving consideration to the impacts that changes in the package will have on vendors and WIC agencies. The committee heard from numerous vendors and WIC agencies during the process of revising the food packages. Changes were evaluated to ensure that they did not impose an undue burden at either the vendor or the agency level. EVALUATING THE COST OF THE REVISED PACKAGES In addition to considering the criteria listed above, the committee considered the constraint of cost neutrality in recommending changes to the WIC food packages. At each iteration of food choices, the relative costs of the proposed foods were considered. Some foods that would not fit or were found not to fit in a cost-neutral set of food packages were considered as possible alternatives that could be allowed by individual WIC state agencies, perhaps on a limited basis. As shown in Chapter 5—Evaluation of Cost—for each revised food package, the committee estimated the average cost per participant per month based on the quantities of component foods in each package, the weighted average price of those foods, and the number of participants in the relevant participant category. The average price of component foods were calculated using data from various sources, as appropriate and available to the committee, as described in that chapter. SUMMARY Redesigning the WIC food packages was an iterative effort involving identification of foods to omit from the packages or to provide in reduced amounts, the selection of candidate foods to add to each package, and the evaluation of the resulting revised packages using the previously established criteria. Many iterations were undertaken in the revision of the food packages. The results of these evaluations are the revised food packages described in the next chapter (Chapter 4—Revised Food Packages).