How the Revised Food Packages Meet the Criteria Specified

National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Food and Nutrition Board; Committee to Review WIC Food Packages

9How the Revised Food Packages Meet the Criteria Specified

This chapter illustrates the committee's approach to revising the food packages in alignment with the criteria that were first described in Chapter 1 (see Box 9-1). Each criterion is presented and discussed in sequence to show how the proposed food package revisions align with the criterion. Several of the proposed food package revisions align with more than one criterion. Consistent with the study task, for each criterion, revisions were made in consideration of the 2015–2020 Dietary Guidelines for Americans (DGA) food groups and subgroups. Throughout the chapter, alignment of the food package revisions with the criteria is evaluated in reference to redeemed amounts (not provided amounts) to reflect the effect of the food packages on meeting participants' needs more accurately. Table 9-1 summarizes how the food packages were revised to meet the seven criteria.

BOX 9-1

Criteria for Inclusion of Foods in the WIC Food Packages.

TABLE 9-1

Overview of How the Revised Food Packages Meet the Criteria.

CRITERION 1

Criterion 1 states: “The packages provide a balanced supplement to the diets of women and children.”

To meet this criterion, the committee reduced food group or subgroup quantities that met or exceeded 100 percent of recommended food group or subgroup intakes. At the same time, it increased food group or subgroup quantities that were either missing or present below an amount that was considered supplemental (and for which intakes were below recommended levels). Together, these two actions reapportioned the food groups and subgroups offered in a way that achieves a more balanced food package. Preferences and cost were also factors in determining the final amounts of foods in the revised packages. To illustrate the concepts of “balanced” and “supplemental,” Figure 9-1 compares the currently offered food groups and subgroups, as redeemed, to the amounts of food groups and subgroups in the revised package, as redeemed, for food package IV-B (children ages 2 to less than 5 years). Food package IV-B is used as an example throughout this chapter, as was done in Chapter 8.^¹ As shown in Figure 9-1, the proportions of food groups or subgroups provided at above-supplemental levels are reduced while the proportions provided at levels below-supplemental are increased. A comparison of all current and revised food packages as the proportion of DGA food groups and subgroups is presented in Appendix T, Figures T-1 through T-5.

FIGURE 9-1

Proportion of the Dietary Guidelines for Americans (DGA) food groups and subgroups provided in the current and revised food package IV-B as redeemed. NOTE: The methodology for calculating redemption rates is detailed in Appendix R.

As a result of the constraint to remain cost neutral, the committee was unable to meet criterion 1 fully. Adding servings of some food groups, particularly of vegetables and fruits, seafood, and whole grain cereals, is expensive relative to the cost of servings from the other food groups or subgroups that were replaced. Inasmuch as each food group contains unique and important nutrients, rebalancing of food groups to align with the DGA necessarily increases some nutrients while decreasing others.

CRITERION 2

Criterion 2 states: “The packages contribute to reduction of the prevalence of inadequate nutrient intakes and of excessive nutrient intakes.”

Nutrient Levels in the Current, Compared to the Revised Food Packages, as Redeemed

The committee's analyses show that the proposed revisions to the food packages provide a better balance of the availability of most of the priority nutrients (see Appendix T). For example, Table T-11b in Appendix T illustrates that, in the current food package IV-B, the proportion of the Estimated Average Requirement (EAR) provided ranges from 63 to 199 percent. In the revised food package IV-B, the proportion of the EAR provided ranges from 57 to 191 percent.^² The level of the higher-priority nutrient potassium increases (as redeemed), and the levels of saturated fat and sodium are reduced in the revised food package IV-B (as redeemed) compared to the current food package IV-B.

Changes to the Prevalence of Nutrient Inadequacy are Anticipated to Be Minimal

The gap analysis presented in Table 9-2 illustrates that revisions to close nutrient gaps for priority nutrients identified for food package IV-B are likely to be too minimal to affect nutrient adequacy. In general, the magnitude of nutrient availability from food group adjustments was limited by the need to remain cost neutral. This allowed the committee to predict similar small increments in nutrient adequacy across other population subgroups. More precise predictions of nutrient adequacy related to the food package revisions would require information on consumption of Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) foods.^³

TABLE 9-2

Effects of the Food Package Revisions on Priority Nutrient Intakes: Gap Analysis for Food Package IV-B Based on Redemption.

Fifty Percent of the Estimated Average Requirement (EAR) or Adequate Intake (AI) Provided for Most Priority Nutrients

Overall, each food package provides at least 50 percent of the EAR/Adequate Intake (AI) for most priority nutrients. Some priority nutrients (as described in Chapter 5) were retained in the revised packages at levels below 50 percent of the EAR or AI, including potassium and fiber (high priority across WIC participant subgroups), choline (high priority, pregnant women), vitamin D (low priority, pregnant women), and copper (low priority, postpartum women). Potassium, vitamin D, vitamin E, and choline are four nutrients for which adequacy goals are not met in almost all DGA food patterns (USDA/HHS, 2016), which indicates that there are some limitations to meeting recommended intakes for these specific nutrients. The same challenges were apparent in the revised food packages. Details of the nutrient composition of the current compared to the revised food packages are provided in Appendix T.

Changes in Sodium, Saturated Fat, and Added Sugars

The revised food packages provide less sodium and saturated fat. Reductions in the amounts of dairy foods were the primary drivers of reducing saturated fat and sodium in all revised food packages (see Appendix T). However, added sugars increase in some packages because of the additional yogurt substitution option.^⁴ Evidence reviewed in the DGA indicates that added sugars in some foods (yogurt is a provided example) can promote consumption of nutrient-dense foods (USDA/HHS, 2016). Thus, additional yogurt was included as a means of promoting intakes of dairy consumption, which was found to be below recommended amounts across WIC population subgroups.

CRITERION 3

Criterion 3 states: “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 committee met criterion 3 by rebalancing the WIC package food groups and subgroups consistent with its definition of supplemental. As illustrated in Figure 9-1, this process reduced the food groups and subgroups offered at levels greater than that required to meet recommended intakes and increased amounts of food groups and subgroups offered at lower levels. The revised food packages are better aligned with the DGA because:

Fruit is shifted from juice to whole fruit. Although total fruit offered varies depending on the food package, overall, the revisions decrease juice and increase whole fruit in all food packages. These changes align with the DGA, which recommend greater consumption of whole fruit in proportion to fruit juice.
Grains are shifted from refined to whole grains. The proposed revisions increase the proportion of whole grains compared to refined grains in all food packages, consistent with the recommendations of the DGA.
Fish is available in all WIC food packages. The revised food packages provide fish to all WIC participants,^⁵ no longer only to exclusively breastfeeding women.
Total sodium is reduced. Appendix T, Tables T-6a through T-11b illustrate that sodium is reduced in all of the food packages, primarily due to the reductions in dairy.
Contributions to “calories for other uses (COU)” are reduced. Overall, the contribution of the food packages to the total daily limits for COU are reduced or remained relatively stable (see Table 9-3).
Estimates indicate that food group intakes are either unchanged or change slightly. Estimating the effects on intake of food groups is highly dependent on knowing the distribution of both redemption and consumption of WIC foods relative to the food package issued. As noted elsewhere in the report, this information was not uniformly available to the committee. Thus, to generate a rough estimate of effects of the revised packages on intake of food groups, the committee conducted a second “gap analysis” to assess the effect of changes in food groups or subgroups provided in food package IV-B on the gap (i.e., the difference between the food group or subgroup intake at the median [50th percentile]). The results of this analysis are presented in Table 9-4.

TABLE 9-3

Comparison of COUs Based on Redemption in the Current and Revised Food Packages for Children and Women.

TABLE 9-4

Estimated Effect of the Revised Food Packages on DGA Food Group and Subgroup Intakes Based on Redemption: Children Ages 2 to Less Than 5 Years, Food Package IV-B.

As shown in Table 9-4, most of the food package changes are expected to either not affect intake or to reduce the gap in food group or subgroup intake. For dairy and nuts, seeds, and soy, however, the gap is increased. This should be interpreted with attention to the fact that these foods are provided in the current food package in amounts that are nearly, or exceed, 100 percent of that recommended. For this food subgroup, the amount in the revised food package IV-B still exceeds 100 percent of recommended amounts owing to container size limitations.

The Healthy Eating Index–2010 Score May Improve

Estimates indicate that the Healthy Eating Index–2010 (HEI–2010) score may improve slightly. The committee estimated the effects of the revised food package against the HEI–2010 for food package IV-B (see Table 9-5).^⁶ The difference in redeemed amounts of the food groups corresponding to HEI–2010 components between the current and revised food package was calculated, making the assumption that the median intake of participants would increase or decrease by this difference. The new intake values were then used to calculate the HEI–2010 score for the revised food packages. As shown in Table 9-5, the revised food package IV-B is predicted to increase several HEI–2010 subscores (e.g., total vegetables, whole grains, and total protein foods, refined grains, and sodium with increases of at least 0.1 points), while decreasing others (e.g., greens and beans, dairy, seafood, and plant proteins with decreases of at least 0.1 points). The scores for components to consume in moderation (refined grains, sodium, and empty calories) were increased or unchanged. Overall, the total HEI–2010 score is improved, increasing by approximately 1 point, a positive change of approximately 1.4 percent. This small increase may be important because WIC participants generally have poor diets.

TABLE 9-5

Estimated Effect of the Revised Food Packages on the Healthy Eating Index–2010 of Children Ages 2 to Less Than 5 Years: Food Package IV-B Based on Redemption.

The revised food package changes align with select DGA recommendations in other ways as well, as summarized in Table 9-6. Recommendations related to physical activity or alcohol consumption were not considered relevant to this review.

TABLE 9-6

Consistency of the Revised Food Packages with Selected Recommendations from the 2015–2020 Dietary Guidelines for Americans for Individuals Ages 2 Years and Older (Criterion 3).

CRITERION 4

Criterion 4 states: “The packages contribute to an overall diet that is consistent with established dietary recommendations for infants and children less than 2 years of age, including encouragement of and support for breastfeeding.”

The dietary recommendations for infants and children less than 2 years of age that were considered by the committee are summarized in Chapter 3, Table 3-10. The recommendations cover breastfeeding, formula feeding, complementary feeding, and the promotion of healthy eating habits.

Table 9-7 presents a side-by-side comparison of how the revised food packages align with these recommendations. The revised food packages account for the nutritional needs of exclusively breastfed, partially breastfed, and formula-fed infants in the first few months of life, the developmental and nutritional needs during the first 2 years of life, the promotion of healthy eating patterns, and the safety of foods consumed.

TABLE 9-7

Consistency of the Revised Food Packages with Selected Dietary Recommendations for Infants and Children Less Than 2 Years of Age (Criterion 4).

In addition to the comparisons in Table 9-7, the revised food packages are designed to provide incentives for breastfeeding of any intensity with 3 strategies: (1) further increasing the value of the exclusive breastfeeding package by increasing the CVV, (2) increasing the value of the packages for partially breastfeeding women by increasing the CVV and allowing more fish compared to the postpartum package, and by (3) increasing the flexibility of the food packages in the first month so that women may be issued the amount of formula needed based on a professional assessment, instead of having only the choices of no formula, nine cans of formula, or, in states where it is offered, one can of formula.

CRITERION 5

Criterion 5 states: “The foods in the packages are available in forms and amounts suitable for low-income persons who may have limited transportation options, storage, and cooking facilities.”

The 2009 food package revisions included the addition of several options for tailoring food packages to meet participant needs related to transportation and limited storage and/or cooking facilities. The revised food packages retain these options, and include additional changes that allow for further flexibility in meeting the needs of participants with limited transportation. Table 9-8 summarizes how the WIC food packages (including current policies and recommended changes) address criterion 5.

TABLE 9-8

How the Revised Food Packages Can Be Tailored for Suitability for Individuals with Limited Resources (Criterion 5).

CRITERION 6

Criterion 6 states: “The foods in the packages are readily acceptable, commonly consumed, widely available, take into the account cultural eating patterns and food preferences, and provide incentives for families to participate in the WIC program.”

The 2009 food package changes also included several additional options to improve alignment with cultural eating patterns and food preferences, as reviewed in Chapter 3. In particular, the increase of the CVV with very few restrictions on choice provides participants with the flexibility to choose vegetables and fruits that meet cultural needs (Sucher et al., 2017). Redemption data indicate that the CVV is among the most well-redeemed components of the food packages (see Chapter 2, Table 2-14). The revised food packages increase the value of the CVV further, to the maximum extent possible, while balancing other nutrient and food group priorities and maintaining cost neutrality. Additionally, changes were made that consider participants' personal preferences and cultural needs and/or to incorporate container sizes that are more commonly available (see Table 9-9).

TABLE 9-9

How the Revised Food Packages Were Tailored to Be Readily Acceptable (Criterion 6).

CRITERION 7

Criterion 7 states: “The foods in the packages do not create an undue burden on state agencies or vendors.”

For each proposed change to the food packages, the committee considered the effects on program administration across state and local WIC agencies and vendors. These considerations were informed by public comments from stakeholder groups and the committee members' observations during their WIC shopping experiences. Table 9-10 summarizes the major issues that were considered and how the proposed changes address these concerns.

TABLE 9-10

How the Revised Food Packages Address Selected Concerns for Impact on WIC Agencies and Vendors (Criterion 7).

SUMMARY

As was done in the previous WIC report (IOM, 2006), the committee's proposed revisions to the WIC food packages are based on a set of criteria. As elaborated in this chapter, the revised food packages meet these criteria as closely as possible. However, because of specified cost constraints, meeting the criteria required making trade-offs among food groups and subgroups, as well as considering allowable substitutions within food groups. Generally, the proposed revisions improve the balance of nutrients and food groups provided with respect to the current Dietary Reference Intake and DGA, they are consistent with authoritative dietary guidance for individuals less than 2 years of age, and they increase choice by including additional substitution options and a higher CVV. In addition, women have more flexibility to breastfeed to the extent possible in the first month.

Revising the WIC food packages to satisfy alignment with the DGA may not by itself optimize nutrient adequacy; such optimization also requires that participants actually redeem and consume the foods in the packages. In addition, the likelihood of a change in intakes of nutrients or recommended food groups based on the revised compared to the current food packages depends on both the nutrient or food group (or food subgroup) and also the food package being considered. In some cases, the expected change may be large relative to current consumption (when current consumption is especially low) and, in other cases, it may be modest at best. Overall, the revised packages are not different enough from the current packages to change the likely effect of the food packages on participants' health. It is noteworthy that if participants were to use the CVV to consume a higher proportion of vegetables (relative to fruits) than anticipated in the committee's modeling, this could create a substantial increase in both their fiber intake and their intake of several food groups and subgroups (see Appendix T, Tables T-11 and T-12).

Expanding the container size ranges for some foods relieves the vendor burden to stock uncommon sizes and increases the likelihood of increasing the availability of these foods to participants. Inasmuch as these changes build on the food package changes implemented in 2009, the committee anticipates that administration of these revisions will be less burdensome than those recommended in 2006.

REFERENCES

AAP (American Academy of Pediatrics). Pediatric nutrition. 7th ed. Kleinman RE, Greer FR, editors. Elk Grove Village, IL: American Academy of Pediatrics; 2014.
Fewtrell MS, Morgan JB, Duggan C, Gunnlaugsson G, Hibberd PL, Lucas A, Kleinman RE. Optimal duration of exclusive breastfeeding: What is the evidence to support current recommendations? American Journal of Clinical Nutrition. 2007;85(2):635S–638S. [PubMed: 17284769]
IOM (Institute of Medicine). WIC food packages: Time for a change. Washington, DC: The National Academies Press; 2006.
Sucher K, Kittler PG, Nelms M. Food and culture. 7th ed. Boston, MA: Cengage Learning; 2017.
USDA/ARS (U.S. Department of Agriculture/Agricultural Research Service). What we eat in America, NHANES 2005-2012. 2005-2012. [December 15, 2016]. http://www.cdc.gov/nchs/nhanes/wweia.htm.
USDA/ARS. USDA National Nutrient Database for Standard Reference, release 28. 2016. [September 14, 2016]. http://www.ars.usda.gov/ba/bhnrc/ndl.
USDA/HHS (U.S. Department of Agriculture/U.S. Department of Health and Human Services). 2015-2020 Dietary Guidelines for Americans. 2016. [August 29, 2016]. https://health.gov/dietaryguidelines/2015.

Footnotes

1: As noted in Chapter 8, only food package IV-B is used for assessment of the effects of the revised package on intake. In this chapter, the assessments include the nutrient gap analysis, the food group gap analysis, and the change in Healthy Eating Index–2010 (HEI–2010). Reasons for using only food package IV-B include (1) the Dietary Guidelines for Americans (DGA) food patterns apply only to individuals 2 years of age and older and therefore are not applicable to younger children and infants; (2) the National Health and Nutrition Examination Survey (NHANES) subgroup size for children of these ages yielded more robust intake data due to being much larger compared to other subgroups of women and children; (3) because of small sample sizes, intake data for women were available only for NHANES 2005–2012 combined, which did not allow assessment of the intakes based on the current package; and (4) children make up more than 35 percent of the WIC-participating population, so this analysis represents the estimated effect of the food packages on a large proportion of participants.

2: Exclusive of vitamins E and B₁₂.

3: Owing to lack of detail, the Nutrient-Based Diet Quality index was not a useful tool for evaluation of nutrient adequacy given the revised packages.

4: The food package nutrient profiles were created assuming 70 percent flavored yogurt containing 30 g total sugars per serving, and 30 percent plain yogurt. Participants may choose a flavored yogurt that contains less than 30 g total sugars, if available on state food lists. Details of the assumptions applied can be found in Appendix R.

5: Excluding young infants and older formula-fed or partially breastfed infants.

6: This spreadsheet method was validated by comparing the HEI–2010 value calculated using Excel and intake data to the value calculated using the method described in Appendix J and reported in Chapter 4. The value calculated using the Excel spreadsheet method is 66.26, slightly higher that the value presented in Chapter 4 of 65.02. The committee therefore concluded that the spreadsheet method was adequate for generating a rough estimate of the effects of the revised food package IV-B on the HEI–2010.

Publication Details

Copyright

Publisher

National Academies Press (US), Washington (DC)

NLM Citation

National Academies of Sciences, Engineering, and Medicine; Health and Medicine Division; Food and Nutrition Board; Committee to Review WIC Food Packages. Review of WIC Food Packages: Improving Balance and Choice: Final Report. Washington (DC): National Academies Press (US); 2017 May 1. 9, How the Revised Food Packages Meet the Criteria Specified.

BOX 9-1Criteria for Inclusion of Foods in the WIC Food Packages

1.: The packages provide a balanced supplement to the diets of women and children.

2.: The packages contribute to reduction of the prevalence of inadequate nutrient intakes and of excessive nutrient intakes.

3.: The packages contribute to an overall dietary pattern that is consistent with the Dietary Guidelines for Americans for individuals 2 years of age and older.

4.: The packages contribute to an overall diet that is consistent with established dietary recommendations for infants and children less than 2 years of age, including encouragement of and support for breastfeeding.

5.: The foods in the packages are available in forms and amounts suitable for low-income persons who may have limited transportation options, storage, and cooking facilities.

6.: The foods in the packages are readily acceptable, commonly consumed, widely available, take into account cultural eating patterns and food preferences, and provide incentives for families to participate in the WIC program.

7.: The foods in the packages do not create an undue burden on state agencies or vendors.

TABLE 9-1Overview of How the Revised Food Packages Meet the Criteria

DGA Food Group and Recommended Food Package Change	Criteria
DGA Food Group and Recommended Food Package Change	1. Balanced Supplement to the Diet	2. Reduce Inadequate or Excessive Nutrient Intakes	3. Diet Aligned with DGA	4. Diet Aligned with Guidance for Children <2 y	5. Availability of Suitable Forms and Amounts Suitable for Low-Income Persons	6. Acceptability, Availability, and Cultural Suitability	7. Pose No Undue State Agency or Vendor Burden
Total fruits
Increase CVV	✓	✓	✓	✓	✓	✓
Reduce fruit juice	✓		✓	✓		✓
Reduce jarred infant food fruits	✓
Substitute CVV for juice or jarred infant fruits			✓	✓		✓	✓
Total vegetables
Increase CVV	✓	✓	✓	✓		✓
Reduce legumes	✓		✓
Offer canned beans		✓			✓	✓
Vendors stock three varieties							✓
Reduce jarred infant food vegetables	✓
Substitute CVV for jarred infant foods				✓		✓
Offer a canned, frozen, or dried form (vegetable or fruit)					✓	✓
Allow legumes to substitute for eggs						✓
Total dairy
Reduce amount (except in FP VI)	✓
Increase substitution options	✓	✓				✓
Offer a range of yogurt amounts							✓
Retain only low-fat or fat-free forms for 2 y or older			✓
Remove “dangling quart”^*							✓
Whole grains
Require whole grain-rich breakfast cereals	✓	✓	✓				✓
Retain RTE breakfast cereal form		✓
Offer additional whole grain forms		✓				✓
Offer range of sizes for whole wheat bread and grains		✓				✓	✓
Reduce infant cereal	✓			✓
Total protein
Offer seafood	✓	✓	✓	✓	✓
Reduce peanut butter	✓		✓			✓
Reduce jarred infant food meat	✓			✓
Substitute fish for jarred infant food meat		✓		✓		✓
Calories for other uses
Reduce total sugars limit in yogurt	✓	✓	✓	✓			✓
Limit added sugars in milk alternatives	✓	✓	✓	✓			✓
Reduce saturated fat by reducing dairy	✓	✓	✓

: NOTES: CVV = cash value voucher; DGA = Dietary Guidelines for Americans; FP = food package; RTE = ready-to-eat.

*: The term “dangling quart” refers to the quart of milk that remains in some food packages when cheese is substituted for milk.

FIGURE 9-1Proportion of the Dietary Guidelines for Americans (DGA) food groups and subgroups provided in the current and revised food package IV-B as redeemed

NOTE: The methodology for calculating redemption rates is detailed in Appendix R.

TABLE 9-2Effects of the Food Package Revisions on Priority Nutrient Intakes: Gap Analysis for Food Package IV-B Based on Redemption^*

Priority Nutrients^a	AI or Upper Limit	Median Nutrient Intake	Current Redeemed Amounts^b	Revised Redeemed Amounts^b	Current Daily Gap^c	Revised Daily Gap^d	Change in Gap^e	Evaluation of the Change in the Gap^f
Nutrients to Increase
Potassium (mg)	3,800	2,071	927	940	1,729	1,716	−13	Small narrowing
Fiber (g)	25	12	4.3	4.0	13	13	+0.3	Small widening
Nutrients to Reduce^g		95th Percentile of Intake
Sodium^h (mg)	1,900	2,995	412	367	1,095	1,051	−44	Small narrowing
Saturated fat (g)	14	18	4.5	3.9	15	14	−0.6	Small narrowing
Added sugars (g)	33	60	4.3	4.6	59	59	+0.4	Small widening

: NOTES: Redemption rates for each WIC food category were primarily based on information provided to the committee. The methodology applied to calculate redemption is described in Appendix R. AI = Adequate Intake.

*: Some values in this table are corrected from the original prepublication.

a: Priority nutrients were determined using the committee's decision tree, as described in Chapter 5.

b: Application of redemption rates and assumptions applied to develop the food package nutrient profiles are described in Appendix R.

c: See Appendix L for details on calculation of the gap.

d: Based on the difference between redeemed amounts of the current and revised food packages.

e: A negative value for change in gap is favorable, indicating that participants in the subgroup are moved closer to the recommended intake when the food package is consumed as redeemed.

f: A small narrowing or widening in the gap was defined as less than 10 percent of the AI, Tolerable Upper Intake Level (UL), or other upper limit.

g: For nutrients to reduce, the following limits were applied: sodium, the UL; saturated fat, 10 percent of the calculated Estimated Energy Requirement (EER) for the subgroup (33 g); added sugars, 10 percent of the calculated EER for the subgroup (14 g).

h: The gap analysis for sodium was based on the UL for children ages 4 to 8 years. Using the UL of 1,500 for children ages 1 to 3 years also results in a small narrowing.

TABLE 9-3Comparison of COUs Based on Redemption in the Current and Revised Food Packages for Children and Women^*

Food Package and Kcal Pattern Applied	Proportion of the Total Daily Limit (%)^a
Food Package and Kcal Pattern Applied	Current	Revised	Difference
V-A: Women, pregnant (based on a 2,600-kcal pattern)	18	13	−5
V-B: Women, partially breastfeeding (based on a 2,600-kcal pattern)	18	13	−5
VI: Women, postpartum (based on a 2,300-kcal pattern)	15	14	−2
VII: Women, fully breastfeeding (based on a 2,600-kcal pattern)	22	15	−6
IV: Children ages 2 to <5 years (based on a 1,300-kcal pattern)	55	52	−3

: NOTES: COU = calories for other uses, defined in the 2015–2020 Dietary Guidelines for Americans (DGA) as the combined calories from saturated fats (solid fats), added sugars, refined added starches, and alcohol; kcal levels patterns were selected based on the calculated estimated energy requirements for WIC participants, using NHANES 2011–2012 (children) or 2005–2012 (women). The methodology applied to develop the food package nutrient profiles and to calculate redemption is described in Appendix R.

*: Some values in this table are corrected from the original prepublication version.

a: To calculate this value, the COU that are allotted to each kcal level as noted in the DGA food patterns were assumed. The values represent the proportion of those kcals that are contributed by the food packages.

: SOURCES: USDA/ARS, 2005–2012; USDA/ARS, 2016; USDA/HHS, 2016

TABLE 9-4Estimated Effect of the Revised Food Packages on DGA Food Group and Subgroup Intakes Based on Redemption: Children Ages 2 to Less Than 5 Years, Food Package IV-B

USDA Food Pattern Group	DGA Recommendation	Median Food Group Intake	Current Redeemed Amounts	Revised Redeemed Amounts	Current Daily Gap	Revised Daily Gap	Change in Gap^c	Evaluation of Change in Gap^d
Total fruit	1.25	1.4	0.63	0.57	0	0	NA	No effect
Fruit, whole (CVV)^a	0.63	0.71	0.25	0.37	0	0	NA	No effect
Total vegetables	1.50	0.6	0.19	0.22	0.89	0.86	−0.04	Small narrowing
Vegetables (CVV)^b	1.50	0.6	0.12	0.18	0.89	0.84	−0.06	Small narrowing
Legumes (beans and peas)	0.07	0.05	0.06	0.04	0.02	0.04	+0.02	Moderate widening
Total dairy	2.50	1.9	1.51	1.48	0.56	0.59	+0.03	Small widening
Total grains	4.50	4.7	1.29	1.13	0	0	NA	No effect
Whole grains	2.25	0.6	0.70	0.81	1.67	1.56	−0.11	Small narrowing
Total protein foods	3.50	2.9	0.62	0.86	0.57	0.34	−0.23	Small narrowing
Nuts, seeds, and soy	0.36	0.2	0.31	0.21	0.16	0.25	+0.09	Moderate widening
Meat, poultry, eggs	2.36	2.5	0.32	0.32	0	0	NA	No effect
Seafood	0.57	0.1	0.00	0.08	0.47	0.39	−0.08	Moderate narrowing

: NOTES: CVV = cash value voucher; DGA = Dietary Guidelines for Americans; NA = not applicable. The 2015–2020 DGA do not include recommendations for intake of fruit juice or refined grains; therefore these food subgroups were not considered in this analysis. The methodology applied to estimate redemption is described in Appendix R.

a: Includes estimated intake from whole fruit purchased with the CVV.

b: Includes estimated intake from legumes and vegetables purchased with the CVV.

c: A reduction in the gap indicates a change that moves food group intakes closer to the DGA recommended amounts.

d: The evaluation categorizes a change in the gap of less than 10 percent of recommended amounts as “small,” and categorizes a change of less than 50 percent of recommended amounts as “moderate.” A narrowing of the gap (i.e., a negative value) indicates an improvement in dietary intake.

TABLE 9-5Estimated Effect of the Revised Food Packages on the Healthy Eating Index–2010 of Children Ages 2 to Less Than 5 Years: Food Package IV-B Based on Redemption

HEI–2010 Component	Serving-Equivalents per Day^a		Current Food Group Density^b	New Food Group Density^b	HEI–2010 Max Score^c	Density for Min Score	Density for Max Score	Estimated Current Food Group Score	Estimated New Food Group Score
HEI–2010 Component	Median Food Group Intake	Change in Food Group Intake	Current Food Group Density^b	New Food Group Density^b	HEI–2010 Max Score^c	Density for Min Score	Density for Max Score	Estimated Current Food Group Score	Estimated New Food Group Score
Adequacy
Total fruit	1.4	−0.05	0.91	0.88	5.00	0.00	0.80	5.00	5.00
Fruit, whole	0.7	0.11	0.47	0.55	5.00	0.00	0.40	5.00	5.00
Total vegetables	0.6	0.05	0.41	0.44	5.00	0.00	1.10	1.84	1.98
Greens and beans^d	0.1	−0.01	0.04	0.04	5.00	0.00	0.20	1.10	0.92
Whole grains	0.6	0.11	0.39	0.46	10.00	0.00	1.50	2.59	3.06
Total dairy	1.9	−0.03	1.29	1.27	10.00	0.00	1.30	9.95	9.79
Total protein foods	2.9	0.19	1.95	2.08	5.00	0.00	2.50	3.90	4.16
Seafood and plant proteins	0.3	−0.06	0.20	0.16	5.00	0.00	0.80	1.25	1.00
Fatty acids (ratio to SFA)^e	34.7	−1.26	1.95	1.90	10.00	<1.2	>2.5	5.79	5.41
Moderation
Refined grains	3.9	−0.26	2.61	2.44	10.00	>4.30	<1.80	6.76	7.45
Sodium	2,182	−44.9	1,455	1,425	10.00	>2000	<1,100	6.06	6.39
Empty calories (kcal)^f	354	−0.20	23.60	23.59	20.00	>50	<19	17.0	17.0
Total HEI–2010 % Change								66.26	67.21 1.4

: NOTES: HEI–2010 = Healthy Eating Index–2010; SFA = saturated fatty acid. It was assumed that changes in the food groups offered in the WIC packages, as redeemed, will alter the median intake of the recipients by the same amount (either increase or decrease). The methodology applied to estimate redemption is described in Appendix R.

a: Fatty acids are expressed in g; sodium is expressed in mg; empty calories are expressed in kcal.

b: Food group density expressed per 1,000 kcal; intake of 1,500 kcal per day was assumed for this example, based on the median reported energy intake for this subgroup. Because the energy in the current and revised food packages differ by only 8 kcal as redeemed, 1,500 kcals is used for all density calculations.

c: The minimum score for each HEI–2010 component is always zero.

d: No change in greens intake is assumed, because intake of these vegetables was seldom reported, and is unlikely to increase substantially even with an increased value of the CVV. The intake of legumes is included in the greens and beans component because protein foods were close to recommended intakes.

e: Because the monounsaturated fatty acid (MUFA) and polyunsaturated fatty acid (PUFA) content of the food packages was not determined, MUFA + PUFA as estimated and total fat minus saturated fat. Although this calculation will overestimate MUFA + PUFA, it should have little effect on the magnitude of the change in the ratio.

f: Although the HEI–2010 typically applies solid fats in the calculation of empty calories, saturated fat was used for this calculation because data for the solid fat composition of foods in the food packages was not available.

TABLE 9-6Consistency of the Revised Food Packages with Selected Recommendations from the 2015–2020 Dietary Guidelines for Americans for Individuals Ages 2 Years and Older (Criterion 3)

Recommendation from the DGA	How the Revised Food Packages Contribute to an Overall Dietary Pattern That Is Consistent with the DGA
To meet nutrient needs within calorie limits, choose a variety of nutrient-dense foods across and within all food groups in recommended amounts	Emphasize nutrient-dense foods such as seafood, vegetables and fruits, whole grains, dairy Allow additional dairy and whole grains options to improve acceptability Reduce contribution to COU Reduce contribution to the proportional limit for COU for food packages V-A, V-B, VI, VII, and IV-B, as redeemed Allow additional yogurt substitution option, which provides some additional added sugars, but may increase dairy intake
Consume a variety of vegetables from all of the subgroups	Increase CVV, which allows participants to redeem more/wider variety of vegetables Require a frozen, canned, or dried option for vegetables, which may improve the variety available to participants across seasons
Intake of fruit should be at least 50 percent whole fruit and not more than 50 percent 100% fruit juice	Increase ratio of whole fruit to juice
At least half of grains should be whole grains	Add more whole grain alternatives and expand the allowable size for whole grains from 16 to 24 oz to encourage redemption Require 100% whole wheat bread Require cereal (cooked and ready-to-eat) to meet “whole grain-rich” criteria Increase ratio of whole grains to refined grains
Consume fat-free or low-fat dairy products	Retain nonfat or low-fat milk for participants aged 2 years and older (current policy is unchanged)^*
Consume less than 10% of energy from saturated fats	Reduce dairy, which reduces saturated fat
Consume less than 10% of energy from added sugars	Reduce total sugars limits specifications for yogurt Propose total sugars limit for soy beverages Retained total sugars limit for cereals
Stay within the limits for “calories for other uses” for specific food-pattern energy levels	Revised packages V-A, V-B and VII fall within the limits of COUs relative to the energy content of the food packages and the appropriate food pattern
Limit sodium intake to less than 2,300 mg per day for individuals ages 14 years and older, less than 1,900 for children age 4 years, and less than 1,500 for children ages 1 to 3 years	Reduce sodium in all packages by reducing dairy
The general population should consume 8 oz of seafood a week that are high in EPA/DHA. Pregnant and breastfeeding women should consume 8 to 12 oz of seafood a week from choices that are high in EPA/DHA and lower in methyl mercury	Add currently authorized canned fish options high in omega-3 fatty acids and low in mercury to additional packages
Women should consume between 320 and 520 µg DFE per day, depending on life stage	Increase CVV and added options for fortified corn masa flour Encourage states to authorize tortillas made with fortified corn masa flour when available

: NOTES: CVV = cash value voucher; DFE = dietary folate equivalents; DGA = Dietary Guidelines for Americans; EPA/DHA = eicosapentaenoic acid/docosapentaenoic acid; COU = calories for other uses.

*: Low-fat cheese may be offered by states, but is not required. Low-fat cheese may be less available across WIC-approved vendors and if not commonly carried, it is likely to be offered at a higher price.

TABLE 9-7Consistency of the Revised Food Packages with Selected Dietary Recommendations for Infants and Children Less Than 2 Years of Age (Criterion 4)

Recommendation^a	How the Revised Food Packages Meet the Recommendation
Breastfeeding
All infants should be exclusively breastfed for about 6 months, followed by continued breastfeeding as complementary foods are introduced, with continuation of breastfeeding for 1 year or longer as mutually desired by mother and infant.^b	Increase the CVV from $11 to $35 to enhance the value of the fully breastfeeding package
To improve the intake of omega-3 long-chain fatty acids by breastfed infants, it is recommended that their mothers consume 1–2 servings of “ocean-going” fish per week to achieve a maternal intake of 200–300 mg of omega-3 long-chain fatty acids.^c	Provide 10 oz of fish per month in food package V-B Provide 20 oz of fish per month in food package VII
Formula Feeding
For infants who are not breastfeeding, iron-fortified infant formula is the recommended alternative for feeding the baby during the first year of life.	Provide only iron-fortified infant formula throughout the first year after birth (current policy is unchanged)^d
Therapeutic (noncontract) formula should be made available through physician prescription for specific medical conditions.	Provide therapeutic (noncontract) formula to infants with a doctor's prescription (current policy is unchanged)
Complementary Feeding
Complementary foods should be gradually introduced to infants at approximately 6 months of life.	Provide only infant formula in food packages for infants under 6 months of age (current policy unchanged)
Complementary foods rich in iron and zinc (fortified cereals and meats) should be introduced to exclusively breastfed infants at about 6 months of age depending on developmental readiness. Recommended amounts are 2 servings per day of cereal (2 tablespoons/serving) or 1 to 2 oz of meat per day.	Provide iron-fortified infant cereals to all infants and infant food meats to fully breastfed infants starting at 6 months of age Reduce amounts to align better with AAP (2014) recommendations
Introduce single-ingredient new foods, one at a time, observing for adverse reactions or intolerance.	Provide complementary foods in the food package for older infants (current policy is unchanged)
Avoid cow's milk until age 1 year. Whole milk may be provided at age 1 year. During the second year of life, low-fat milk may be considered if weight gain is appropriate, if weight gain is excessive, or family history is positive for obesity, dyslipidemia, or cardiovascular disease. Recommended total daily milk intake is 16 to 24 oz. Intakes above 25 oz/day may contribute to iron deficiency.	Do not provide cow's milk to infants (current policy is unchanged) Provide whole milk to children ages 1 to less than 2 years (current policy is unchanged)
Introduce a variety of foods. By 7 to 8 months, infants should be consuming foods from all food groups. Provide foods of varying textures (e.g., pureed, blended, mashed, finely chopped, and soft lumps). Gradually increase table foods. Avoid mixed textures, such as broth with vegetables.	Include jarred infant food vegetables and fruits to support introduction of a variety of foods Allow caretakers to select a variety of vegetables and fruits, and prepare with varying textures using a CVV in place of jarred infant food vegetables and fruits
Promoting Healthy Eating Patterns
Allow lower fat milks for children age 1 year and older for whom obesity or overweight is a concern.	Issue, at state agency option, fat-reduced milks to children under 2 years of age for whom overweight or obesity is a concern, as determined by individual nutrition assessment and consultation with the child's health care provider (current policy is unchanged)
Total daily juice intake should be limited to 4 to 6 oz per day from 1 to 6 years of age. Encourage whole fruit intake over juice.	Reduce juice amounts for children to provide a supplemental amount of the recommended limit
Avoid added sugar and added salt.	Limit the amount of added sugars and salt (sodium) in foods (current policy is unchanged) Introduce new total sugars limits for yogurt and soy beverages. Retain total sugars limit for RTE cereals
Repeat exposure to new foods and flavors may be required to optimize acceptance. Early exposure may promote the selection of a varied diet later in life.	Provide a CVV option for all infants ages 6 to less than 12 months in place of jarred infant food vegetables and fruits, which expands the variety of possible flavors and textures to which infants may be exposed Retain all of the foods currently provided in the food packages, adjusting amounts to obtain improved balance across food groups

: NOTES: AAP = American Academy of Pediatrics; CVV = cash value voucher; RTE = ready-to-eat. Guidance related to supplementation is not addressed in this table as it falls outside of the constraints of the food packages.

a: References for each recommendation are presented in Table 3-10.

b: There is some controversy regarding whether exclusive breastfeeding meets energy requirements of infants at 6 months of age in developed countries (Fewtrell et al., 2007). Fewtrell et al. (2007, p. 637S) states, “A reasonable interpretation of the available scientific data is that there are currently insufficient grounds to confidently recommend an optimal duration of exclusive breastfeeding of 6 as opposed to 4–6 months for infants in developed countries.”

c: Concern regarding the possible risk from intake of excessive mercury or other contaminants is offset by the neurobehavioral benefits of an adequate DHA intake and can be minimized by avoiding the intake of predatory fish (e.g., pike, marlin, mackerel, tilefish, swordfish) (AAP, 2014).

d: “Current policy is unchanged” indicates, both in this table and in Tables 9-8 and 9-9, that the current food package(s) is already aligned with a specific recommendation and that no changes were proposed.

: SOURCES: As indicated in Chapter 3, Table 3-10, of this report.

TABLE 9-8How the Revised Food Packages Can Be Tailored for Suitability for Individuals with Limited Resources (Criterion 5)

Suitability Requirements of Criterion 5	How the Revised Food Packages Correspond with the Suitability Requirements of Criterion 5
Food forms and amounts available are convenient to participants' transportation options	Allow dried, powdered, or concentrated forms of a number of foods, including dried fruit, powdered milk, and concentrated juice (current policy is unchanged) Permit 30 to 32 oz of yogurt to allow authorization of smaller (5 oz) containers Include some small packages (e.g., 5 oz cans of fish) in the cost evaluation, which eases transportation and storage
Food forms and amounts available for different storage options	Allow forms of foods that do not require refrigeration and that are less perishable (current policy is unchanged) Include some small sizes (e.g. 5 oz cans of fish) in cost evaluation, allowing consumption of the full container at one time Allow fruits, vegetables, and legumes in a form (fresh, canned, frozen, dried) suitable for various storage conditions (current policy is unchanged) Require at least one form of canned, frozen, or dried fruit and one form of canned, frozen, or dried vegetable, which may be in nonperishable forms
Food forms and amounts available for diverse cooking facilities	Allow for ready-to-feed infant formulas, full-strength juices, and jarred infant foods (current policy is unchanged) Allow whole grain selections to include ready-to-eat items (e.g., bread), quick-cooking choices (e.g., parboiled brown rice), and slow-cooking grains (e.g., regular-cooking brown rice) (current policy is unchanged) Require at least one form of canned, frozen, or dried fruit and one form of canned, frozen, or dried vegetable Require provision of legumes in dried and canned forms

TABLE 9-9How the Revised Food Packages Were Tailored to Be Readily Acceptable (Criterion 6)

Suitability Requirements for Criterion 6	How the Revised Food Packages Correspond with the Suitability Requirements of Criterion 6
Commonly consumed foods	Modify foods and options based on identification of more or less preferred foods using redemption data Allow fish as a substitution for a portion of infant food meat based on redemption and other data indicating that jarred infant food meat is not commonly redeemed or consumed
Widely available foods	Retain current WIC foods that are widely available Change some allowable sizes to better reflect availability in the marketplace (e.g. ranges are allowed for grains [16 to 24 oz] and for yogurt [30 to 32 oz]) Require states to offer one canned, frozen, or dried form of fruit and one canned, frozen, or dried form of vegetable which may improve the availability of a variety of vegetables and fruits across seasons Set limit on total sugars in yogurt and soy beverages and retain limit for whole grain cereal options. Market research reviewed by the committee indicate that yogurts containing 30 g of total sugars or less and the number of whole grain cereals are likely to be widely available to meet participant preferences
Culturally suitable foods and foods and preferred foods	Include additional options for grains to align with cultural eating patterns Increase CVV and option to substitute a CVV for fruit juice and/or jarred infant food vegetables and fruits provides participants with increased flexibility Retain yogurt, tofu, and soy beverage as culturally suitable options (current policy is unchanged) Add a yogurt substitution option to suit individuals who prefer this product over fluid milk Add soy-based cheese and soy-based yogurt substitute options Allow participants following a vegan diet to select legumes in place of eggs
Foods that provide incentive for participation in the WIC program	Enhance the food packages for fully and partially breastfeeding women Increase the value of the CVV in all food packages; mandate for canned, frozen, or dried options may increase the purchasing power of the CVV; additional options to substitute a CVV for juice and jarred infant food vegetables and fruits provide additional flexibility Add canned fish to nearly all food packages

: NOTES: CVV = cash value voucher.

TABLE 9-10How the Revised Food Packages Address Selected Concerns for Impact on WIC Agencies and Vendors (Criterion 7)

Concerns About Potential Administrative Burden for WIC Staff and Retail Vendors	How the Revised Food Packages Address the Concern
WIC state agencies
The restriction to one can of infant formula in the first month does not allow the CPA/lactation trained staff to assign a food package based on the nutritional needs of the infant.	Allow an amount of infant formula up to that suitable for a partially breastfed infant in the first month
Allowing only fresh vegetables and fruits to be purchased with the infant CVV is not compatible with some state EBT systems.	Allow the purchase of frozen or canned vegetables and fruits with any CVV
WIC local agencies
With nutrition education that follows the DGA, staff instruct participants to limit intake of juice in favor of whole fruit; this is in conflict with the provision of juice in the food packages.	Reduce amounts of juice; offer participant option to substitute a CVV for juice
The FNS Infant Nutrition and Feeding Guide indicates that around 9 months of age most infants are developmentally ready to consume foods of increased texture and consistency.	Allow a CVV in place of jarred infant food vegetables and fruits
Additional culturally-suitable options are needed.	See “culturally suitable foods” in Table 9-7
Vendorsa
Concern that 16 oz size of bread and 16 oz whole wheat pasta are difficult to obtain.	Expand the range of grains to 16 to 24 oz to accommodate more commonly available bread and grain sizes
Vegetable juices are not available in 48 oz sizes.	Provide 64 oz of juice in all packages
Substitution options result in the issuance of less available sizes (e.g. the “dangling quart”^b of milk).	Substitution options for milk that no longer result in a “dangling quart”

: NOTES: CPA = competent professional authority; CVV = cash value voucher; DGA = Dietary Guidelines for Americans; EBT = electronic benefit transfer; FNS = USDA's Food and Nutrition Service.

a: The committee did not receive many comments from vendors; however, several comments submitted by other stakeholders relate to vendor administrative burden.

b: In the current food packages, when participants choose a particular set of milk substitutions, a quart of milk may remain. This quart size is generally less available and may also be more expensive.