Infant Formula Amounts

The committee determined that the current full nutrition benefit amounts approximate the infant's energy needs, and the maximum monthly allowance appropriately accommodates package sizes of powdered formula products. The amounts currently provided were based on the Estimated Energy Requirement (EER) for infants in an Institute of Medicine (IOM) 2006 report. Although EERs calculated for Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participating infants using National Health and Nutrition Examination Survey (NHANES) 2011–2012 data were slightly higher, median EER is too imprecise to support a change to currently offered amounts. In addition, the committee did not receive any feedback either through public comments or from WIC staff in the March 31 workshop suggesting a need for adjustments in formula amounts.

Iron Content of WIC-Approved Infant Formulas

WIC infant formulas are required to provide at least 1.5 milligrams of iron per 100 kcal at standard dilution (USDA/FNS, 2014). The U.S. Food and Drug Administration (FDA)–required range for iron in infant formulas is 0.15–3 mg per 100 kcal.¹ The committee evaluated the iron content of formulas provided through WIC contracts by reviewing products from the three major WIC formula manufacturers. These formulas, considering the full nutrition benefit (FNB) amounts, provide iron in the range of 1.5–2 mg per 100 kcal. This amount of iron falls well within the FDA acceptable range, as would be expected. Infants that consume the full nutrition benefit of WIC-eligible formulas and/or foods would consume more than the Adequate Intake (AI), less than the Tolerable Upper Intake Level (UL), and older infants consuming infant cereals and vegetables and fruits would consume slightly less than the Estimated Average Requirement (EAR).

Recent published evidence comparing health outcomes at different levels of iron in infant formula is limited, as was described in the phase I report (NASEM, 2016). Some inconclusive evidence suggests that iron intake in infants is associated with long-term cognitive, motor, and social-emotional outcomes. Updated data are needed to understand the optimal level of infant formula iron, particularly in cases where the baseline iron status of infants is poor compared to cases where iron status is adequate.

In summary, eligible WIC formulas contain an amount of iron that supports the needs of infants ages 0 to less than 12 months, without exceeding the UL for this age group. Overall, inadequate evidence is available to support changing the concentration of iron that is currently required in WIC-eligible formulas.

Energy Density of WIC-Approved Infant Formulas

Formulas provided through WIC primary contracts must contain 20 kcal per ounce (kcal/oz) prepared at standard dilution with a state option to allow lower-energy formulas in cases of medically documented qualifying conditions (7 C.F.R. § 246.10[c][1][i]; USDA/FNS, 2014). In 2014, a 19 kcal/oz infant formula was introduced to the U.S. market with the rationale that the lower energy formula better reflects the energy density of human milk (Abbott Nutrition, 2015). States having infant formula contracts with companies that subsequently reduced the energy density of their products mid-contract were permitted to continue providing non-primary contract formulas to WIC participating infants with medical documentation (USDA/FNS, 2013).

Total Sugars in Breakfast Cereals

The current specification for WIC-approved ready-to-eat (RTE) cereals was unchanged, and remains 6 grams of sucrose and other sugars per dry ounce (USDA/FNS, 2014). RTE cereals have been reported to contribute between 3 and 8 percent of total added sugars intakes in various subgroups of the U.S. population (Reedy and Krebs-Smith, 2010; Huth et al., 2013; Keast et al., 2013; Drewnowski and Rehm, 2014; USDA/HHS, 2015) and approximately 8 percent of added sugars in the diets of low-income children (Reedy and Krebs-Smith, 2010).³ This is more than the contribution of yogurts, but a relatively small amount compared to soft drinks and sodas (up to 33 percent [Huth et al., 2013]), grain-based desserts (up to 14 percent [Huth et al., 2013]), and other sugary foods and candies (up to 31 percent [USDA/HHS, 2015]).

RTE cereals are a dietary staple and a popular food, they are significant contributors to micronutrient intakes in the U.S. population (see Fulgoni and Buckley, 2015), are a source of whole-grains, and may promote the consumption of milk (Hill et al., 2012; Michels et al., 2016) and the associated vitamins D (Hill et al., 2012) or A (Affenito et al., 2013). The committee's analysis of NHANES 2011–2012 data indicated a high prevalence of low intake of a number of micronutrients as well as whole-grains among WIC participants, both of which may be provided in fortified RTE cereals. Because fortified cereals are significant contributors to the overall micronutrient content of WIC food package grain foods, it is likely important to ensure the continuing palatability of RTE breakfast cereals. The 2015–2020 Dietary Guidelines for Americans (DGA) note that the inclusion of some added sugars in foods, including whole grain foods, is one way to maintain palatability (USDA/HHS, 2016).

Retaining Fortified RTE Breakfast Cereals

The committee received several comments that RTE cereals are not consumed in some cultures. Fortified RTE cereals offer higher concentrations of nearly all nutrients compared to other whole grain products, so were retained as a separate food category (see Table Q-1). Of particular importance to the WIC population are folate and iron, which are not required fortificants in whole grain products, but are typically added to RTE breakfast cereals. Therefore, the retention of fortified RTE cereals was considered important to support intake of these priority nutrients.

TABLE Q-1

Contribution to Amounts of Selected Nutrients per Day, Considering Specific Selection Scenarios for Grains per Month (0.53 oz/d).

Requiring Lower-Sodium Options

Although sodium intakes exceed upper limits in all WIC population subgroups, lower-sodium options remain encouraged but not required. Lower-sodium options may be more expensive than their regular counterparts. In addition, availability of lower-sodium options may be limited in some areas, and may be difficult for smaller vendors to stock. Given these possibilities and the lack of evidence to support a low administrative burden of adding a sodium restriction, a requirement for lower-sodium products is not recommended.

Allowing 2% Milk for Women and Children

The committee received many comments related to the change in the Final Rule that disallowed issuance of 2% milk to children and women (see Appendix D). Emerging evidence suggest that dairy fat intake is not associated with obesity or body weight (Kratz et al., 2013; Keast et al., 2015), body mass index (Scharft et al., 2013), or metabolic health (Kratz et al., 2013) (see the phase I report [NASEM, 2016] for additional details). In the phase I report, the committee noted that the 2015 Dietary Guidelines Advisory Committee (DGAC) did not review this topic because studies evaluating the differential effects of dairy fat were just appearing in the published literature at the close of DGAC deliberations (personal communication, A. Lichtenstein, Tufts University, to the committee in their workshop held on March 12, 2015). The specifications for the fat content of milk in food packages IV through VII are unchanged for two reasons: (1) because the DGA continue to advise consumption of low-fat dairy products, and (2) because the committee was tasked by U.S. Department of Agriculture's Food and Nutrition Service (USDA-FNS) to align the WIC food packages with the DGA, which recommend fat-free or low-fat dairy for individuals 2 years of age and older. Furthermore, fat-free and low-fat dairy are the standard for other federal feeding programs including the Child and Adult Care Feeding Program (CACFP) (USDA/FNS, 2011) and the National School Nutrition Program (USDA/FNS, 2016), which includes school breakfast and lunch. The committee considered it important to provide a consistent message to children and families about the recommendations for fat in milk.

Individuals who commented had a preference for 2% milk, did not believe it was detrimental to health, and/or were concerned that the change was resulting in lower milk redemption and consumption by WIC participants. Data from Texas milk sales indicated that by 2015, there was a 17 percent drop in milk redemption compared to when 2% milk was allowed. This decrease was more than four times higher than the decline in WIC participation over the same time period (3 percent) (C. Frye, International Dairy Foods Association, as commented to the committee in their workshop held on March 31, 2016). National data were not available to permit the committee to evaluate changes in milk redemption before and after the October 1, 2014, change from up-to-2% milks to lower-fat milks. Should future DGA change the recommendation on fat levels of milk, or should conclusive evidence on the differential health effects of dairy fat compared to other types of saturated fats become available, USDA-FNS or a future committee may reconsider the requirement that fluid milk be fat free or low fat for children and women.

Vitamin D Fortification of Yogurts

Vitamin D is a DGA nutrient of public health concern, and vitamin D status was poor among women participating in WIC. Although some yogurts available in the marketplace are fortified with vitamin D, moving to near universal voluntary fortification (as is the case for milk) may improve vitamin D status of WIC participants (and the U.S. population broadly). When market data indicate an increased availability of vitamin D-fortified yogurts that meet other WIC product specifications and cost requirements, it may be prudent to consider requiring that WIC-approved yogurts be fortified with vitamin D.

Allowing 100% Whole Grain Options Other Than Whole Wheat Bread

Although 100 percent whole grain breads other than wheat are available in the marketplace, identification of these products is complicated by the fact that some products labeled as “whole grain,” may contain some proportion of whole grain or may be 100 percent whole grain (Oldways Whole Grain Council, 2017). Clear guidance and further investigation of the ability of WIC staff and participants to identify 100 percent whole grain products other than 100 percent whole wheat bread would facilitate the decision to expand the options for this WIC food category.

Further Reductions in Legumes and Peanut Butter

As noted in the report, available package sizes limited the degree to which these WIC foods could be further reduced without increasing cost because of turning to uncommonly available sizes. Further reductions in these items (mainly for children) may be possible with increasing availability of smaller package sizes with a proportional price reduction. Evaluation of the response of WIC participants to the initial reduction proposed in this review would also inform further changes.

Additional Fish Species and Wild Salmon

In addition to considering the inclusion of fish in additional food packages, USDA-FNS requested that the committee consider the inclusion of additional fish species, and the inclusion of wild salmon. Fish species currently allowed by the Final Rule in food package VII may be light tuna, salmon, sardines, and mackerel, and states are required to make at least two options available to participants (USDA/FNS, 2014).

The committee's requirements for expanding this list of approved species included: availability in a shelf-stable form (i.e., canned), nationwide availability, appropriate nutrient contribution (considering sodium and provision of omega-3 fatty acids), low in contaminants of particular relevance to growth and development, in a price range that permits cost-neutral adjustments to the food packages, and a likelihood of redemption and consumption. Considering these requirements, the committee did not identify fish species appropriate for addition to food packages other than those already permitted. Therefore, fish options continue to be at least two of light tuna, salmon, sardines, and mackerel.

Although a small amount of farmed salmon is marketed as canned, most canned salmon is wild,⁴ removing the option to easily distinguish the two. Additionally, there is currently no requirement to label canned salmon as wild or farmed, so it may not be possible for state agencies to differentiate.⁵ Finally, the committee did not find a substantial difference in risk–benefit for consumption of farmed compared to wild salmon (EPA/TERA, 1999; Foran et al., 2005; Health Canada, 2007; IOM, 2007; FAO/WHO, 2010; Loring et al., 2010; Sirot et al., 2012; FDA, 2014; USDA/HHS, 2015).

Substitutions: Cases Without Nutritionally Comparable Options

Food Package III: Substitutions for Restricted Diets or Cases in Which Human Milk Fortifier Is Needed

The committee received several comments about situations in which participants have medical conditions with very specific nutritional implications, such as in cases where an infant or child is required to follow a very-low protein diet and an exempt formula is needed, but other foods in the WIC packages are not suitable. While participants may feel short-changed on the quantity of items provided, the value of the special formulas is generally much higher than that of the food in the packages. It is also reiterated in this report that as for the current food packages, the revised food packages do not require issuance of foods that are not in alignment with the participant's prescribed diet. The committee received several comments related to the issuance of human milk fortifier (HMF) through WIC; however, there is no universal agreement on the use of this product (see, e.g., Zachariassen et al., 2011; Kreissl et al., 2013; Lafeber, 2013; Teller et al., 2016). HMF is needed only in very rare cases, and often human milk can be fortified with powdered infant formula for these medically fragile infants.