4
REVISED FOOD PACKAGES

The committee recommends changes to each of the current WIC food packages, based on the criteria developed earlier (IOM, 2004b). That is, the proposed changes respond to current dietary guidance for nutrient intakes and dietary patterns, the major diet-related health problems and risks faced by this population, and the characteristics and diversity of the WIC-eligible population. The proposed changes also attempt to avoid undue burden to WIC agencies and retail vendors. The first part of this chapter presents specific proposals for all of the WIC food packages, briefly compares the revised packages to the current ones, and lists specifications for foods in the revised packages. The second part of the chapter provides the basis for changes in the packages or policies related to the food packages. The committee recommends pilot testing and randomized, controlled trials before full-scale implementation of the proposed changes to the food packages. See Chapter 7Recommendations for Evaluation and Implementation—for details.

DESCRIPTION OF THE REVISED FOOD PACKAGES

In addressing proposed changes to the WIC food packages, the committee retained the basic numbering system used for the current food packages. Subparts were added to identify new subcategories based on infant age and breast-fed versus formula-fed status. The numbering systems for infant packages are is shown in Table 4-1 and the numbering systems for children and women are shown in Table 4-2. Table 4-3 presents proposed specifications for allowable foods.



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WIC Food Packages: Time for a Change 4 REVISED FOOD PACKAGES The committee recommends changes to each of the current WIC food packages, based on the criteria developed earlier (IOM, 2004b). That is, the proposed changes respond to current dietary guidance for nutrient intakes and dietary patterns, the major diet-related health problems and risks faced by this population, and the characteristics and diversity of the WIC-eligible population. The proposed changes also attempt to avoid undue burden to WIC agencies and retail vendors. The first part of this chapter presents specific proposals for all of the WIC food packages, briefly compares the revised packages to the current ones, and lists specifications for foods in the revised packages. The second part of the chapter provides the basis for changes in the packages or policies related to the food packages. The committee recommends pilot testing and randomized, controlled trials before full-scale implementation of the proposed changes to the food packages. See Chapter 7—Recommendations for Evaluation and Implementation—for details. DESCRIPTION OF THE REVISED FOOD PACKAGES In addressing proposed changes to the WIC food packages, the committee retained the basic numbering system used for the current food packages. Subparts were added to identify new subcategories based on infant age and breast-fed versus formula-fed status. The numbering systems for infant packages are is shown in Table 4-1 and the numbering systems for children and women are shown in Table 4-2. Table 4-3 presents proposed specifications for allowable foods.

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WIC Food Packages: Time for a Change TABLE 4-1 Revised WIC Food Packages, Maximum Monthly Allowances for Infants [examples of amounts as commonly obtained shown in brackets]   Fully Formula-Fed (FF) Foods/Package Number I-FF I-FF-A: 0–3.9 mo I-FF-B: 4–5.9 mo II-FF 6–11.9 mo Infant formulac [example of commonly available form; reconstituted volume] I-FF-A: 403 fl oz liquid concentrate [31 13-fl oz cans; 806 fl oz]d 312 fl oz liquid concentrate [24 13-fl oz cans; 624 fl oz]d   I-FF-B: 442 fl oz liquid concentrate [34 13-fl oz cans; 884 fl oz]d   Infant cereal   24 oz [3 8-oz boxes] Baby food fruits and vegetables (e.g., strained)   128 oz [32 4-oz jars] Baby food meat (e.g., pureed)     aTo promote the establishment of breastfeeding, the committee recommends that formula not be routinely provided in the first month to breast-fed infants; thus, no mother/infant pairs are classified as partially breastfeeding for the first month postpartum. See discussion in section Promoting and Supporting Breastfeeding and recommendations for studies in Chapter 7—Recommendations for Implementation and Evaluation. bThe committee recommends that infants with special dietary needs receive Food Package III. This means the package would provide the medical foods required by WIC participants of any age if they have special dietary needs. Persons receiving Food Package III also would receive the foods allowed for other participants in the same life stage if those foods were medically and developmentally appropriate for them. cIn most cases, the maximum monthly allowance of infant formula is stated as fl oz of liquid concentrate. Powdered or ready-to-feed formula may be provided as alternative forms at rates that provide the approximate number of fl oz of formula (see note d for additional detail). dThe maximum allowance for infant formula is converted to a practical option using current can sizes commonly obtained, as shown in brackets. For further practical options, see Table B-6—Substitution Rates for Various Volumes of Formula Concentrate (Appendix B). Because of differences in container sizes and yields, the maximum amount of formula provided depends on whether the mother obtains powdered, liquid concentrate, or ready-to-feed formula. When determining the maximum number of cans of each type of formula, the committee recommends rounding to whole cans to approximate the target amount (the maximum monthly allowance shown here in Table 4-1). The results of this method may differ from the rounding currently in use; some rounding methods (e.g., rounding up to whole cans) could result in providing excess formula in some cases. Note that the substitution rate of 8 lb of powdered formula for 403 fl oz of formula concentrate no longer applies; that substitution rate could result in providing excess formula in some cases.

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WIC Food Packages: Time for a Change Partially Breast-Fed (BF/FF) Fully Breast-Fed (BF) Special Dietary Needs I-BF/FF I-BF/FF-A: 1–3.9 moa I-BF/FF-B: 4–5.9 mo II-BF/FF 6–11.9 mo I-BF 0–5.9 mo II-BF 6–11.9 mo I and II or IIIb I-BF/FF-A: 51–60 oz powder [4 12.9-oz cans powder; 384 fl oz]e 156 fl oz liquid concentrate [12 13-fl oz cans; 312 fl oz]d     Same reconstituted volume as othersf I-BF/FF-B: 221 fl oz liquid concentrate [17 13-fl oz cans; 442 fl oz]d           24 oz [3 8-oz boxes]   24 oz [3 8-oz boxes] Same as othersf   128 oz [32 4-oz jars]   256 oz [64 4-oz jars] Same as othersf       77.5 oz [31 2.5-oz jars] Same as othersf eIn this case, the maximum monthly allowance is specified in the powdered form—the form that is recommended for partially breast-fed infants, ages 1–3.9 mo. A range is shown to note the amounts that could be provided at current container sizes for powdered formula. For further detail, see Table B-6—Substitution Rates for Various Volumes of Formula Concentrate (Appendix B). fThe maximum allowance for an infant with special dietary needs is the same as for other infants in the same participant category, if the food is appropriate for the medical, nutritional, and developmental condition of that infant. NOTES (abbreviations in order of appearance in table): FF = fully formula-fed; BF/FF = partially breast-fed (i.e., the infant is breast-fed but also receives some formula through the WIC program); BF = fully breast-fed (i.e., the infant is breast-fed and receives no formula through the WIC program).

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WIC Food Packages: Time for a Change TABLE 4-2 Revised WIC Food Packages, Maximum Monthly Allowances for Children and Women   Children Foodsa/ Package Number IV-A: 1–1.9 y IV-B: 2–4.9 y Formula (liquid concentrate)d Juice 128 fl oz 128 fl oz Milk,f whole   16 qtg,h Milk,f up to 2% milk fat   16 qth Breakfast cereal (hot or cold) 36 oz 36 oz Cheese — — Eggs 1 doz 1 doz Fruits and vegetables (fresh)l,m $8.00 in cash-value vouchersn (ca. 9.76 lb) $8.00 in cash-value vouchersn (ca. 9.76 lb) Whole wheat breado 2 lb 2 lb Fish (canned) — — Beans (mature legumes), dryp 1 lb dried 1 lb dried and/or or or Peanut butter 18 oz 18 oz aSee Table 4-3 (Proposed Specifications for Foods) and Table B-1 in Appendix B—Nutrient Profiles of Current and Revised Food Packages—for allowed types and forms of foods. bFood Package V is available to two groups: pregnant women and breastfeeding women whose infants participate in the WIC program and receive formula in amounts that do not exceed the maximum allowances for Food Packages I-BF/FF-A, I-BF/FF-B, or II-BF/FF, as appropriate for the age of the infant. cFood Package VII is available to breastfeeding women whose infants do not receive formula from the WIC program and to all breastfeeding women during the first month postpartum. See discussion in section on Promoting and Supporting Breastfeeding and recommendations for studies in Chapter 7—Recommendations for Implementation and Evaluation. Food Package VII is also recommended for women pregnant with two or more fetuses. dThe type of formula depends on the special health need. eSome individuals with special dietary needs require complete nutritional liquids or semisolids with nutrient and caloric content that differ from the formulas designed for infants. Many of these products are sold as powders and the proper reconstitution rates vary. Thus, the calculations used for infant formulas (which are relatively consistent at 1 kcal per cc) may not apply to the formulas for children and women with special dietary needs. fLactose-reduced milk is allowed. See Table B-1 in Appendix B—Nutrient Profiles of Current and Revised Food Packages.

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WIC Food Packages: Time for a Change Women Children and Women V: Pregnant or Partially Breastfeeding (up to 1 y postpartum)b VI: Non-breastfeeding Postpartum (up to 6 mo postpartum) VII: Fully Breastfeeding, Enhanced Package (up to 1 y postpartum)c III: Special Dietary Needs       455 fl oz,e if appropriate 144 fl oz 96 fl oz 144 fl oz Same as othersi Same as othersi 22 qtj,k 16 qtj,k 24 qtj,k Same as othersi 36 oz 36 oz 36 oz Same as othersi — — 1 lb Same as othersi 1 doz 1 doz 2 doz Same as othersi $10.00 in cash-value vouchersn (ca. 12.2 lb) $10.00 in cash-value vouchersn (ca. 12.2 lb) $10.00 in cash-value vouchersn (ca. 12.2 lb) Same as othersi 1 lb — 1 lb Same as othersi — — 30 oz Same as othersi 1 lb dried 1 lb dried 1 lb dried Same as othersi and or and Same as othersi 18 oz 18 oz 18 oz Same as othersi gWhole milk (3.5–4% milk fat) is the only type of milk allowed for 1-y-old children. Exceptions can be made in special circumstances when prescribed in writing by a Recognized Medical Authority (a licensed physician, physician assistant, nurse practitioner, or other health professional specified by the WIC state agency to have this authority). hFor children, cheese or yogurt may be substituted for milk at the rate of 1 lb of cheese per 3 qt of milk (to a maximum of 1 lb of cheese) or 1 qt of yogurt per 1 qt of milk. A maximum of 4 qt of milk can be substituted for in this manner. iIf appropriate for the medical, nutritional, and developmental condition of a participant assigned to Food Package III, the maximum allowance for each food is the same as for the food package to which the participant would be assigned if he or she had no special health need. jCheese, yogurt, or calcium-set tofu (tofu prepared with calcium salts) may be substituted for milk at the rate of 1 lb of cheese per 3 qt of milk (to a maximum of 1 lb of cheese), 1 qt of yogurt per 1 qt of milk, or 1 lb of tofu per 1 qt of milk. A maximum of 4 qt of milk can be substituted for in this manner in Food Packages V and VI. A maximum of 6 qt of milk can be substituted for in this manner in Food Package VII for fully breastfeeding women.

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WIC Food Packages: Time for a Change kFor women, soy beverage (“soy milk”) may be substituted for milk at the rate of 1 qt of calcium- and vitamin D-rich soy beverage for 1 qt of milk up to the total allowance of milk prescribed. lProcessed fruits and vegetables may be substituted for fresh fruits and vegetables using the substitution rates shown in note n. Dried fruits may be included with processed fruits only for adolescent and adult women. mIn the canned options for children, 222 oz of canned fruits and vegetables (e.g., 7 15-oz cans of fruit plus 7 14.5-oz cans of vegetables) would substitute for the $8.00 cash-value vouchers. In the canned options for adolescent and adult women, 280 oz of canned fruits and vegetables (e.g., 9 15-oz cans of fruit plus 9 14.5-cans of vegetables) would substitute for the $10.00 cash-value vouchers. nThe value of the cash voucher is intended to deliver approximately the weight of fresh produce specified and may need to be adjusted upward to account for local prices in some states agencies. oOther whole grain foods could substitute for whole wheat bread on an equal weight basis. Examples and specifications are listed in Table 4-3 (Proposed Specifications for Foods) and Table B-1 in Appendix B—Nutrient Profiles of Current and Revised Food Packages. pLegumes include dry beans, peas, and lentils. Canned legumes may be substituted for dried legumes at the rate of 64 oz of canned beans for 1 lb dried beans. See Table 4-3 (Proposed Specifications for Foods) and Table B-1 in Appendix B—Nutrient Profiles of Current and Revised Food Packages—for additional information. NOTE: ca. = the calculated amount. In the sections that follow, the packages for women are presented immediately after the packages for infants because they are so closely related. WIC Food Packages for Infants Overview of Current Food Packages for Infants Currently, there are two WIC food packages for infants: Food Package I (for infants ages 0–3 mo) provides infant formula only; and Food Package II (for infants 4–11 mo) provides formula, cereal, and juice. When fully breast-fed infants reach the age of 4 months, they receive Food Package II with cereal and juice only. Infants who are partially breast-fed receive either Food Package I or II, depending on their age. Although partially breast-fed infants are eligible to receive the entire allowance of formula, the Competent

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WIC Food Packages: Time for a Change Professional Authority1 (CPA) in the WIC local agency may tailor packages to provide smaller amounts if appropriate.2 Revised Food Packages for Infants Food Package I—The committee recommends that Food Package I serve infants from birth through 5 months of age, as shown in Table 4-1, rather than covering the current period of birth through 3 months of age. For formula-fed infants, formula must be iron fortified as specified in the current packages. Because of differences in container sizes and yields, the maximum amount of formula provided depends on whether the mother obtains powdered, concentrated, or ready-to-feed formula. When determining the maximum number of cans of each type of formula, the committee recommends rounding to whole cans to approximate the target amount (the maximum monthly allowance shown in Table 4-1); the committee’s recommendations are presented in Table B-6—Substitution Rates for Various Volumes of Formula Concentrate—in Appendix B. In some cases the results of this method may be different from the rounding currently in use (e.g., rounding up to whole cans). Otherwise, Food Package I for fully formula-fed infants ages zero through three months is unchanged. For the first month after birth, the committee further recommends only two feeding options initially—full breastfeeding or full formula feeding. Refer to the later section Promoting and Supporting Breastfeeding for a full explanation of the committee’s recommendations concerning infant food package choices during the first month after birth. For ages 1 month through 3 months, the proposed food package for partially breast-fed infants (Food Package I-BF/FF-A in Table 4-1) provides powdered formula as the standard. The maximum allowance is approximately half of the allowance of formula that is provided to fully formula-fed infants (Food Package I-FF-A); in this case it is slightly less than half due to rounding to whole cans in the example used in the Table 4-1. (For further information, see Table B-6 in Appendix B—Nutrient Profiles of Current and Revised Food Packages.) The committee recommends powdered formula for partially breast-fed infants because the amount prepared can be tailored closely to the amount needed. This may help reduce waste, food safety concerns, and/or overfeeding of formula to breast-fed infants. If 1   The term Competent Professional Authorities is used to refer to professionals and paraprofessionals who tailor the food packages and educate and counsel WIC participants. 2   The committee had no data on which to base assumptions regarding the amount of formula currently prescribed for partially breast-fed infants. Thus, in the nutrient and cost analyses, the committee used the assumption that partially breast-fed infants received the maximum monthly allowance for formula in the current food packages.

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WIC Food Packages: Time for a Change the partially breastfeeding mother requests and obtains more than the maximum amount of formula for her partially breast-fed infant, the infant will be considered fully formula-fed and assigned the package for fully formula-fed infants (Food Package I-FF-A in Table 4-1). At 4 months of age, the amount of formula provided for fully formula-fed infants, increases slightly—corresponding closely to the average nutritional needs of infants of this age (see Food Package I-FF-B in Table 4-1). This additional formula is a partial replacement for the juice and cereal that the current Food Package II provides to infants of this age. The maximum amount of formula provided for partially breast-fed infants also increases (see Food Package I-BF/FF-B in Table 4-1). At this age, any of the three types of formula would be acceptable. Due to rounding to whole cans of powdered formula, the amount of formula may not increase at four months of age, depending on the can sizes of formula provided (see Table B-6 in Appendix B—Nutrient Profiles of Current and Revised Food Packages). The maximum allowance for the partially breast-fed infant is calculated as half of the allowance for fully formula-fed infants of the same age; however, rounding to whole cans of powdered formula may result in a slightly lower amount (that is, a reduction of less than two ounces per day) (see Table B-6 in Appendix B). Food Package II—At 6 months of age, infants are assigned to Food Package II. This food package provides semisolid foods for all infants (see Food Packages II-BF, II-BF/FF, and II-FF in Table 4-1) and formula to those who are not fully breast-fed.3 Commercial baby food fruits and vegetables in the revised package replace juice in the current package. To support the continuation of full breastfeeding past 6 months, Food Package II-BF provides more commercial baby food fruits and vegetables than do the other two versions of Food Package II. Because fully breast-fed infants age six months and older need more iron and zinc than breast milk provides (Krebs, 2000; Dewey, 2001; Krebs and Westcott, 2002), Food Package II-BF provides commercial baby food meats. (Infant formulas provide these two minerals in amounts that meet or exceed the needs of most infants [see Table C-2C and IOM, 2004b].) The maximum amount of formula provided for fully formula-fed infants (see Food Package II-FF in Table 4-1) or partially breast-fed infants (see Food Package II-BF/FF in Table 4-1) has been reduced. For formula-fed infants, the combination of foods in the revised Food Package II provides slightly fewer calories than in the current 3   Although semisolid foods are not included in the food packages until 6 months of age, this does not prevent the parents or caregivers from introducing semisolid foods to infants before 6 months of age.

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WIC Food Packages: Time for a Change package, provides nutrients in amounts close to the recommended levels,4 and introduces more variety into the infant’s diet. For fully breast-fed infants, the revised Food Package II provides more calories than before and introduces more variety into the infant’s diet. As is the case for Food Package I, if the partially breastfeeding mother requests and receives more than the maximum amount of formula specified for partially breast-fed infants, the infant will be considered fully formula fed and assigned the package for fully formula-fed infants. WIC Food Packages for Women Overview of Current Food Packages for Women Four packages are currently provided to women as shown in Table 1-1 in Chapter 1—Introduction and Background. Food Package V is designed for pregnant women and partially breastfeeding women (i.e., mothers who combine breastfeeding with formula feeding); Food Package V is available throughout pregnancy and can be available to partially breastfeeding women for up to 12 months postpartum. Food Package VI is for non-breastfeeding postpartum women and is available for 6 months post-partum. Food Package VII, the enhanced breastfeeding package, is for nursing mothers whose infants receive no formula from the WIC program (i.e., fully breastfeeding women); Food Package VII can be available to fully breastfeeding women for up to 12 months postpartum. Food Packages V and VII provide milk, cheese (as a substitute for part of the milk), vitamin C-rich juice, iron-rich breakfast cereal, eggs, and dry beans (plus peanut butter in Food Package VII, with peanut butter as an alternative to dry beans in Food Package V). Food Package VI for non-breastfeeding postpartum women provides most of these foods (except peanut butter and dry beans); however, some maximum allowances are smaller. Food Package VII—the enhanced breastfeeding package for fully breastfeeding women—also provides canned tuna, carrots, cheese (in addition to cheese substituted for milk), and additional juice. Pregnant and breastfeeding women may receive Food Package III if they have special medical problems that preclude prescription of the regular packages. 4   For details on specific nutrients, compare nutrients provided in Tables B-2 and B-3 (Appendix B—Nutrient Profiles of Current and Revised Food Packages) to recommended levels of nutrients in Table F-1 (Appendix F—Supplementary Information).

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WIC Food Packages: Time for a Change Revised Food Packages for Women The committee recommends continuing to provide Food Packages V, VI, and VII to the same groups of women for virtually the same periods of time. However, the committee recommends changing the definitions of breast-fed infants, which would change the classifications of nursing mothers as well.5 Under the proposed system, all women who choose to breastfeed would be encouraged to breastfeed fully in the first month after delivery and therefore would receive the enhanced fully breastfeeding package (Food Package VII) in that first month. A fully breastfeeding woman would receive no formula for her infant from the WIC program, with a few exceptions during the first month postpartum. Generally starting at one month, a partially breastfeeding woman could receive up to half the maximum allowance for a fully formula-fed infant of the same age. If she requests and receives more than this maximum amount of formula, she would no longer be classified as breastfeeding for the purposes of assigning her food package. If the request were made before the end of the sixth postpartum month, she would be reclassified as a postpartum non-breastfeeding woman and switched to Package VI. If the request were made after the sixth postpartum month, the woman no longer would be certified for the WIC program. Food Package VII, for fully breastfeeding women, provides the greatest variety and quantity of food; Food Package VI, for mothers of fully formula-fed infants, provides the least (Table 4-2). Compared with the current food packages (Table 1-1 in Chapter 1—Introduction and Background), all three revised food packages for women provide smaller amounts of milk products, eggs, and juice; the same amount of iron-fortified cereal (now whole grain only); and fruits and vegetables as an addition. Whole grain bread or other whole grains have been added to Food Packages V and VII. The fat content of the milk cannot exceed 2 percent. The revised food packages for women allow several alternatives to cow’s milk for meeting calcium needs. Calcium- and vitamin D-rich soy beverage (“soy milk”) is allowed as an alternative to milk. Cheese, fat-reduced yogurt, and calcium-set tofu (tofu prepared with calcium salts) are allowed as partial substitutions for milk (up to 4 qt of milk in Food Packages V and VI; up to 6 qt of milk in Food Package VII). The current specifications for tuna are not changed. Light tuna, which the Food and Drug Administration and the 5   Currently in the WIC program a woman is classified as breastfeeding if she is providing breast milk on the average of at least once a day. The committee considers this an inappropriate definition of breastfeeding for the purpose of assigning food packages. Thus, the committee proposes classifying a woman as breastfeeding for the purpose of assigning food packages if she requests no more than the maximum amount of formula allowed for partially breast-fed infants (see Table 4-1).

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WIC Food Packages: Time for a Change Environmental Protection Agency determined is sufficiently low in mercury to be safe for breastfeeding women (CFSAN, 2001; EPA/FDA, 2004) is allowed; but white tuna (albacore), which is higher in mercury content, is not. Other low-mercury fish options are included in Table 4-3 for participants preferring to avoid tuna (see Table B-1 in Appendix B—Nutrient Profiles of Current and Revised Food Packages—for details). Based on estimates of increased nutrient and energy needs of women pregnant with more than one fetus,6 the committee recommends that Food Package VII rather than Food Package V be used for such women. Further, the committee recommends that women who are fully breastfeeding twins be prescribed 1.5 times the maximum amounts of Food Package VII to cover their higher needs for energy and nutrients.7 In addition, the committee recommends that women partially breastfeeding twins or higher multiples be assigned to Food Package VII since their milk production would be comparable or perhaps higher than that of mothers breastfeeding one infant. Recommendations for women with special dietary needs (currently covered by Food Package III) are discussed in a later section (Food Package III for Children and Women with Special Dietary Needs). WIC Food Packages for Children Overview of the Current Food Package for Children Currently there is one package for children: Food Package IV for children ages 1 through 4 years. Food Package IV contains milk and cheese, 6   Pregnancy—Nutritional needs of a pregnant women are increased when she is carrying more than one fetus (Luke, 2004). Using a method similar to that used by the Institute of Medicine (IOM, 2002/2005), Brown and Carlson (2000) estimate that, compared with the energy needs of women with singleton pregnancies, women bearing twins need an additional 150 kilocalories per day to support the recommended weight gain. The recommended intakes of most nutrients increase only a small amount (from no increase to about a 10 percent increase) for a singleton pregnancy (IOM, 2005b). The exceptions are iron, zinc, and iodine—for which recommended intakes are 1.4 to 1.5 times higher for pregnant than for nonpregnant women of the same age. 7   Lactation—Based on the composition and expected volume of breast milk produced by a woman breastfeeding twins, she would need about 500 additional kilocalories and higher intake of many vitamins and minerals—a major exception being iron. Considering the nutrient content of proposed Food Package VII for breastfeeding women and the amounts of nutrients needed for milk production, prescribing 1.5 times the maximum amount of Food Package VII would help the woman breastfeeding twins meet her energy and nutrient needs. Moreover, it would help improve comparability of the value of packages for mother/infant combinations, especially considering that each twin is eligible to receive formula if that feeding method is chosen.

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WIC Food Packages: Time for a Change and timing of availability of complementary foods, and the requirement for whole milk for 1-year-old children. Amounts of Infant Formula Provided Fully Formula-Fed Infants—For fully formula-fed infants birth through 3 months of age (Food Package I-FF-A), the amount of formula provided is not changed from the current Food Package I. The maximum allowance of 403 fluid ounces of formula concentrate (26 fl oz of formula per day)15 provides approximately 530 kilocalories per day, which is nearly the same as the mean Estimated Energy Requirement (EER) of 555 kilocalories per day for formula-fed WIC infants birth through 3 months of age (see Appendix B—Nutrient Profiles of Current and Revised Food Packages for detailed information). For fully formula-fed infants 4 through 5 months of age (Food Package I-FF-B), the committee recommends increasing the maximum amount of formula to 442 fluid ounces of formula concentrate per month. The slightly increased amount provides an additional 2.5 fluid ounces of formula per day and brings the total food energy to 581 kilocalories per day. This amount of food energy equals 93 percent of the mean EER for infants 4 through 5 months of age (623 kilocalories per day) and 88 percent of the maximum food energy provided by the current Food Package II (for infants 4–11 mo of age).16 (See Appendix B for detailed information.) Thus, compared with the current Food Package II, the revised Food Package I-FF-B provides slightly less energy to infants 4 through 5 months of age. The seeming contradiction (fewer calories despite more formula) is explained by the exclusion of juice and cereal from the revised food package for infants 4 through 5 months of age. In the current Food Package II, the juice and cereal provide about 134 kilocalories per day (see Appendix B for detailed information). The revised infant food packages provide essential nutrients without providing excess food energy and reinforce the nutrition education message to initiate the routine feeding of complementary foods beginning around six months of age (AAP, 2004, 2005). For fully formula-fed infants ages 6 through 11 months (Food Package II-FF), the proposed amount of 15   Factor for days per month—In keeping with the apparent assumptions used in various FNS documents, the committee used the factor of 31 days per month for calculations involving nutrients provided for infants. For all other participants, the committee used the factor of 30 days per month. For standard use, formula concentrate is diluted with an equal amount of water. Thus, 13 fluid ounces of formula concentrate reconstitutes to 26 fluid ounces of formula. A 13-fluid ounce can of infant formula concentrate is a common unit for purchase. 16   Substitution for powdered formula—See Table B-6 in Appendix B—Nutrient Profiles—for the amounts of powdered formula that would be allowed.

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WIC Food Packages: Time for a Change formula is reduced to 312 fluid ounces of formula concentrate per month; the rationale is to provide an increasing amount of nutrients through complementary foods while reducing intake of formula. Partially Breast-Fed Infants—The amounts of formula provided for partially breast-fed infants mirrors the amounts provided for fully formula-fed infants with the following important differences: (1) the partially breastfed option in not available in the first month postpartum—in order to promote breastfeeding as explained elsewhere; (2) the maximum amount provided approximates half of the amount provided to fully formula-fed infants—to provide about half of the infant’s nutritional needs to encourage the mother to breastfeed enough to provide at least half of the infant’s nutritional needs; and (3) powdered formula is recommended during ages 1 through 3.9 months—to promote food safety and discourage waste as explained elsewhere. The revised infant food packages provide essential nutrients, limit food energy, and reinforce the nutrition education message to initiate the routine feeding of complementary foods beginning around 6 months of age (AAP, 2005). Changes in the Types and Timing of Availability of Complementary Foods The committee recommends that the WIC program not provide complementary foods until the infant is 6 months of age. This is the age at which most healthy infants are developmentally ready to handle complementary foods (Hammer, 1992; Morris and Klein, 2000; Naylor and Morrow, 2001). Infants ordinarily do not need complementary foods for nutritional reasons at younger ages—either breast milk or iron-fortified infant formula would entirely meet the nutritional needs of most infants (Brown et al., 1998; Dewey, 2001; Domellöf et al., 2001; Griffin and Abrams, 2001; Butte et al., 2002; WHO, 2001a, 2001c, 2002; Habicht, 2004). There are some exceptions in which nutrient supplementation is recommended.17 The committee’s intent is to design food packages that address the nutritional 17   Infants who will be fully breast-fed should receive vitamin K supplementation within the first six hours after birth (AAP, 2004, 2005). Infants who have inadequate iron stores (e.g., were born preterm, had low birth weight, have hematological disorders) generally require iron supplementation before 6 months of age (AAP, 2004, 2005). Vitamin D supplementation is recommended for fully breast-fed infants (and partially breast-fed infants if receiving less than 17 fluid ounces of iron-fortified formula per day) (AAP, 2004, 2005). Additional supplementation may be required for infants born preterm (see Schanler, 2001) or in underdeveloped countries (Greer, 2001).

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WIC Food Packages: Time for a Change needs of most rather than all infants. The committee’s recommendation to provide complementary foods beginning at age 6 months is consistent with the most recent dietary guidance on complementary feeding (AAP, 2005; WHO, 2002; Kramer and Kakuma, 2002, 2004) and common guidelines for clinical practice in the field of pediatrics (Hendricks et al., 2001; Morris and Klein, 2000; AAP, 2001c; Rudolph and Rudolph, 2003).18 To make possible the gradual introduction of a variety of fruits and vegetables, the committee recommends the deletion of fruit juice and the addition of commercial baby food fruits and vegetables and fresh bananas to Food Package II for infants ages 6 months and older. The allowed foods span the range of textures appropriate for infants at different stages of development. To provide iron and zinc in forms with high bioavailability to meet the needs of fully breast-fed infants, the committee recommends the addition of commercial baby food meats for fully breast-fed infants beginning at age 6 months (Food Package II-BF). The package for fully breast-fed infants also provides additional baby food fruits and vegetables; the rationale is to provide additional nutritional value to improve the parity with other infant packages, to provide sufficient fruits and vegetables to mix with baby food meats to increase the palatability of strained meats for older infants, and to encourage prolonged breastfeeding by adding to the convenience and monetary value of the food packages of the fully breastfeeding mother/infant pair. The recommendations for the milk fat content are consistent with AAP recommendations of whole milk for children who are one year of age and fat-reduced milk for older children (AAP, 2004). The exclusion of dried fruit from the processed fruit and vegetable options for children (see Table 4-3) is intended to reduce the risk of choking posed by that form of fruit (AAP, 2004). Addressing Obesity Concerns Overweight and obesity in children and adults largely outranks undernutrition as a significant public health concern (DHHS/PHS, 1988; NRC, 1989a; IOM, 1991, 2004a; Kessler, 1995; Koplan and Dietz, 1999; Mokdad et al., 1999, 2000, 2004, 2005; DHHS, 2001). Moreover, prevalences of overweight and obesity are especially high in subpopulations that are overrepresented in the WIC population (Flegal et al., 2002, Kumanyika et al., 1999; Paeratakul et al., 2002; Wardle et al., 2002). 18   Some parents may choose to feed their infants complementary foods before the age of 6 months, but the committee did not find a developmental or nutritional rationale to provide complementary foods in the WIC food package before age 6 months.

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WIC Food Packages: Time for a Change Thus, the committee considered ways that redesign of the WIC food packages could help promote healthy body weight for WIC participants. In doing so, the committee kept in mind a number of key points: Although many factors contribute to overweight and obesity, the ultimate cause is positive energy balance (Koplan and Dietz, 1999; IOM, 2004a). If maintained over time, small changes in energy intake can lead to substantial gain in body weight. For example, it is estimated that most of the U.S. population could maintain a healthy body weight by a change in energy balance of 100 kilocalories per day (Hill et al., 2003)—that is, by decreasing daily intake by 100 kilocalories, increasing daily energy output by 100 kilocalories, or some combination. Infancy may be a critical period for preventing the development of overweight during childhood (Whitaker et al., 1997; Ong et al., 2000; Law et al., 2002; Stettler et al., 2002) and its long-term consequences (Whitaker et al., 1997; Law et al., 2002). Some evidence suggests that reducing the consumption of sweet drinks, including fruit juice, may be helpful in managing the body weight of preschool children (Welsh et al., 2005). The committee’s recommended changes to the WIC food packages support small reductions in total food energy and improvements in nutrient density. The emphasis is on nutrient-dense foods and beverages and limitations on added sugars for all, and an increase in fiber and decrease in saturated fat content of the packages for children and women. Compared with the current food packages, the revised food packages for infants provide less food energy after the age of four months (except for fully breastfed infants). The food packages for children and women provide somewhat less milk, cheese, eggs, and juice; and, for those age two years and older, milk cannot exceed 2 percent milk fat. The addition of fruits and vegetables and the emphasis on whole grains are consistent with recommendations for food patterns that may contribute to a healthy body weight. Together with nutrition education, the proposed WIC food packages can play an important role in promoting optimal pregnancy weight gain, postpartum weight status, and healthy growth of children. The revised food packages are designed to encourage breastfeeding and thus may contribute to a reduced risk of overweight in children. In a recent review, Dewey examined 11 studies and found that 8 of the studies demonstrated a moderate but significant protective effect of breastfeeding against overweight in childhood and adolescence (Dewey, 2003). Moreover, a recent prospective study of mother/infant pairs found that the combined effects of short duration of breastfeeding and early introduction

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WIC Food Packages: Time for a Change of solid foods are associated with significantly greater infant weight gain, from birth to one year, especially among infants born to overweight mothers (Baker et al., 2004). Based on this evidence, extending the duration of breastfeeding and delaying the introduction of solid foods would appear to be appropriate strategies for early prevention of overweight in young children. In summary, the subpopulations served by the WIC program are at risk for the development of overweight and obesity. It is important to address issues of a healthy body weight during the life stages of WIC participants. The proposed WIC food packages provide a variety of nutrient-dense foods in moderate amounts and can contribute to developing healthy eating patterns, reinforcing nutrition education, and promoting positive changes in dietary behaviors. Providing More Flexibility for WIC States Agencies and More Variety and Choice for WIC Participants The cultural diversity and heterogeneity of the WIC participant population pose special challenges for a supplemental nutrition program. Many public comments called for more options among allowed foods—both to improve incentives for participation in the WIC program and to increase consumption of the foods provided. In proposing revisions, therefore, the committee recommends increases in the types and total number of allowed foods. Table 4-3 lists proposed specifications that give the state agencies more flexibility in determining which food items they will allow. The committee urges WIC state agencies to allow the participants as much variety and choice of foods from Table 4-3 as is feasible considering cost constraints and availability of foods in grocery outlets common to the region. Providing more variety and choice will facilitate the tailoring of food packages to specific situations, especially for different ethnic or cultural groups. Two food categories merit special attention in this regard: fruits and vegetables and milk and milk products. Other areas of increased choice include the form of dry beans and peas (either dry-packaged or canned), more types of fish (see Table 4-3), and whole grain options. Fruits and Vegetables The committee recommends a great deal of flexibility for state agencies and the opportunity for variety and choice for participants within the proposed fruit and vegetable category of the food packages. This recommendation is based on three considerations. The availability, cost, and quality of different forms of fruits and vegetables vary substantially among states, territories, and tribal agencies.

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WIC Food Packages: Time for a Change These characteristics range from (a) markets with a wide variety of fresh produce that is abundant year-round with little seasonal variation to (b) markets with a very limited selection of fresh produce, possibly only seasonally, but with some variety (e.g., the most popular selections) of fruits and vegetables available in canned or frozen forms. WIC state agencies would determine if and when the fresh produce option would be available (e.g., certain months of the year). The committee encourages the WIC state agencies to allow participants to select from a wide variety of processed fruits and vegetables for the processed option. The Dietary Guidelines for Americans 2005 recommends the consumption of a variety of nutrient-dense foods within and among the basic food groups and staying within energy needs (DHHS/USDA, 2005). The recommendation is based on evidence that dietary variety within food groups is related to dietary adequacy for both adults and children (Krebs-Smith et al., 1987; Cox et al., 1997; Foote et al., 2004). Variety and choice at the participant level directly addresses recommendations in the Dietary Guidelines (DHHS/USDA, 2005). Although there is some evidence that participation in the WIC program is associated with greater dietary variety than is nonparticipation among low-income children, dietary variety generally is low among children in low-income families (Knol et al., 2004). Choice at the participant level also responds to this IOM committee’s Criterion 4 (which addresses the suitability of forms of food) and Criterion 6 (which addresses the acceptability of the foods for people of different cultural backgrounds). The committee recognizes that nutrient content varies widely across individual items within the fruit and vegetable groups. Allowing choice at the participant level makes it impossible to ensure that the selections made will provide a specified amount of nutrients. This is especially applicable to the fresh produce option. However, the limited available evidence from pilot studies shows that, when provided with a fresh fruit and vegetable supplement to the WIC food package, participants chose a wide variety of different items (Herman, 2004; Runnings, 2004). Allowing choice increases the likelihood that a food will be consumed. The committee identified individual participant choice and variety as priorities, especially within this proposed food category. Choice holds potential to provide incentives for participation, improve acceptability of foods offered across a diverse set of cultural backgrounds, and promote long-term healthy eating patterns. The only restriction the committee placed on the choice of fruits and vegetables is not to allow white potatoes (that is, disallow potatoes other than orange yams and sweet potatoes). The committee based this restriction on the amounts suggested in the USDA Food Guide for consumption of starchy vegetables (DHHS/USDA, 2005), food intake data indicating that consumption of

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WIC Food Packages: Time for a Change starchy vegetables meets or exceeds these suggested amounts (Krebs-Smith et al., 1997; FSRG, 1999; Smiciklas-Wright et al., 2002; Briefel et al., 2004b), and food intake data showing that white potatoes are the most widely used type of vegetable (Krebs-Smith et al., 1997; FSRG, 1999; Cavadini et al., 2000, Smiciklas-Wright et al., 2002; Briefel et al., 2004b). Milk Products Although milk and milk products provide the most concentrated source of calcium in the U.S. diet, a high prevalence of lactose maldigestion and low cultural acceptability have been widely cited as reasons for the low consumption of dairy products among people of color (Pobocik et al., 2003; Auld et al., 2002; Jackson and Savaiano, 2001; Horswill and Yap, 1999; Story and Harris, 1989; Fishman et al., 1988). Studies show that women of color of childbearing age, particularly Asians and African Americans, are especially at risk for low intakes of dietary calcium (Siega-Riz and Popkin, 2001; Klesges et al., 1999; Wu-Tso et al., 1995). Milk and cheese are not a part of traditional food patterns of many cultural groups (NAWD, 2000; NWA, 2003; Kittler and Sucher, 2004). In public comments, yogurt, soy beverage (“soy milk”), and tofu were frequently requested calcium-rich options (NWA, 2003). For a variety of reasons, individuals with lactose maldigestion are able to tolerate yogurt better than milk (Kolars et al., 1984; Savaiano et al., 1984; Smith et al., 1985; Lerebours et al., 1989; Martini et al., 1991; Wynckel et al., 1991; Kotz et al., 1994, Galvão et al., 1995, 1996). In the U.S. diet, fluid milk is an important source of vitamin D, a fatsoluble vitamin. The U.S. supply of fluid milk is fortified with vitamin D to prevent rickets on a population-wide basis. However, most other milk products are not fortified with vitamin D. If milk is replaced by milk products or other alternatives that are not vitamin D fortified, vitamin D intakes may be inadequate. Thus, replacements for milk are to be approached with caution even if they are rich in calcium. For the reasons discussed in the two preceding paragraphs, proposed allowed foods include fat-reduced yogurt as a partial substitute for fluid milk for children and women, calcium-set tofu (tofu prepared with calcium salts) as a partial substitute for milk for women, and calcium- and vitamin D-rich soy beverage (“soy milk”) as an alternative for all or part of the fluid milk for adult women.19 These new choices may be viewed by some 19   Soy products (i.e., tofu, soy beverage [“soy milk”]) are not allowed as substitutions for milk in the children’s package except when prescribed in writing by an RMA. Through nutrition education, parents or guardians should learn that children are at nutritional risk when milk is replaced by other foods.

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WIC Food Packages: Time for a Change participants as more acceptable sources of calcium (and vitamin D in some cases) for WIC participants with milk allergies and lactose maldigestion and for those who avoid milk for cultural, religious, or other reasons. To maintain the nutritional content and cost neutrality of the food packages, some substitutions for milk (i.e., yogurt, calcium-set tofu) are allowed in limited amounts. These limitations can be waived in cases of lactose intolerance or other medical conditions when prescribed in writing by an RMA. SUMMARY The IOM Committee to Review the WIC Food Packages proposed changes in the amounts and kinds of foods in all seven food packages. In doing so, the committee gave special attention to revising the food packages to: Include fruits and vegetables for all participants 6 months of age and older; Include more whole-grain products; Reduce the amount of saturated fat for participants 2 years of age and older; Promote and support breastfeeding, especially full breastfeeding; Address the developmental needs of infants and young children; Address obesity concerns; and Provide more flexibility for the WIC states agencies and more variety and choice for the WIC participants. Additionally, the committee recommends that the revised food packages be provided in full, except to the extent that the packages are tailored to the needs of individual WIC participants. The proposed changes consider current recommendations for nutrient intakes and dietary patterns, the major diet-related health problems and risks faced by this population, the characteristics of the WIC program, and the diversity of the WIC-eligible population. The proposed changes will serve to make the WIC food packages more consistent with national and professional dietary guidance and more consistent with nutrition education messages that promote healthful diets for the WIC population. The revised WIC food packages have the potential to address current nutrient inadequacies and excesses, to address current discrepancies between dietary intake and dietary guidance described by food groups, and to address current and future diet-related health problems in the nation’s population.

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WIC Food Packages: Time for a Change TABLE 4-3 Proposed Specifications for Foods in the Revised Food Packagesa Category/Food Participant Group Allowed Foods and Minimum Requirements Infant Foods Infant formula Infants, 0–11.9 mo Iron-fortified infant formula. (No change from current specifications.) Infant cereal Infants, 6–11.9 mo Iron-fortified infant cereal, instant. (No change from current specifications.) Baby food fruits and vegetables Infants, 6–11.9 mo Commercial baby food fruits and vegetables without added sugars, starches, or salt (i.e., sodium)—Texture may range from strained through diced. Fresh banana may replace up to 16 oz of baby food fruit at a rate of 1 lb of bananas per 8 oz of baby food fruit. Baby food meats Fully breast-fed infants only, age 6–11.9 mo Single major ingredient, commercial baby food meat; without added sugars, starches, vegetables, or salt (i.e., sodium)—Texture may range from strained through diced. Fruits and Vegetables Juice Children and women No change from current specifications. Fresh fruits and vegetables Children and women Any variety of fresh whole or cut fruits, without added sugars Any variety of fresh whole or cut vegetables except white potatoes (orange sweet potatoes and yams are allowed), without added sugars, fats, or oils Variety in choices should be encouraged through nutrition education. Processed fruits and vegetables Children and women Any variety of canned fruits, juice pack or water pack, without added sugars—Any variety of frozen fruits, without added sugars Any variety of canned or frozen vegetables except white potatoes (orange sweet potatoes and yams are allowed), without added sugars, fats, or oils—Soups and condiments such as catsup, pickles, and olives are excluded. Variety in choices should be encouraged through nutrition education.

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WIC Food Packages: Time for a Change Category/Food Participant Group Allowed Foods and Minimum Requirements   Women only Any variety of dried fruits, without added sugars, fats, oils, or salt (i.e., sodium). Milk and Alternatives Milk, whole Children (age 1–1.9 y) Only whole milk is allowed for 1-y-old children. Milk, fat-reduced Children (age ≥ 2 y) and women No more than 2% milk fat allowed. Cheese Children and women No change from current specifications. The committee does not recommend any substitutions for cheese in Food Package VII. Yogurt, fat-reduced Children and women Plain or flavored; 17 g of total sugars per 100 g yogurt—Yogurt for those age 2 y and older may not contain more than 2% milk fat. Soy beverage Women Soy beverage (“soy milk”) must be fortified to contain nutrients in amounts similar to cow’s milk. Tofu Women Calcium-set tofu (prepared with only calcium salts [e.g., calcium sulfate]). May not contain added fats, oils, or sodium. Grains Cereal Children and women Ready-to-eat cereals and hot cereals (instant, quick- and regular-cooking) must be whole grain (e.g., a minimum of 51% of the grain in the product must be whole grains) and conform to other current specifications (e.g., must be iron-fortified, must not exceed added sugars limitations). Whole-grain bread Children and women except non-breastfeeding postpartum women Bread must conform to FDA standard of identity for whole wheat bread (i.e., a minimum of 51% of the grain in the product must be whole grains). or Bread must meet labeling requirements for making a health claim as a “whole-grain food with moderate fat content” (i.e., a minimum of 51% of the grain in the product must be whole grains).

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WIC Food Packages: Time for a Change Category/Food Participant Group Allowed Foods and Minimum Requirements Other whole grains   Brown rice, bulgur, oatmeal, barley; without added sugars, fats, oils, or salt (i.e., sodium)—May be instant-, quick-, or regular-cooking. Soft corn or whole wheat tortillas without added fats or oils could be allowed. Meat and Alternatives Eggs Children and women No change from current specifications. Hard boiled eggs, where readily available in small quantities, may be provided for participants with limited cooking facilities. The committee does not recommend any substitutions for eggs. Fish, canned Woman, fully breastfeeding (VII) New options include canned salmon and other canned fish that do not pose a mercury hazard as identified by advisories from the FDA or EPA. Pack may include bones and skin as indicated by FDA standard of identity or USDA commercial item description. Legumes Children and women Any variety of mature dry beans, peas, or lentils in dry-packaged (i.e., dried) or canned forms; without added sugars, starches, or fats—Canned legumes may be regular or lower in sodium content. Baked beans may be provided for participants with limited cooking facilities. Peanut butter Children and women No change from current specifications. aSee Table B-1 (Appendix-B—Nutrient Profiles of Current and Revised Food Packages) for detailed specifications. Any processed foods for children and adults may be regular or reduced in sodium content unless otherwise specified. For the purposes of this specifications table, the term canned refers to processed food items in cans or other shelf-stable containers. NOTES: EPA = U.S. Environmental Protection Agency; FDA = Food and Drug Administration; USDA = U.S. Department of Agriculture.