RECOMMENDATIONS FOR IMPLEMENTATION OF THE REVISED FOOD PACKAGES

The Complexities of Implementation

As noted in Chapter 2, administration of the WIC food packages involves stakeholders at many levels: federal, state, local, participant, clinic, vendor, and food manufacturer. At each level, a series of factors ease or pose barriers to redemption of WIC foods by program participants. This was apparent to the committee in their WIC site visits and shopping experiences, from the review of literature conducted in phase I (NASEM, 2016), and from information presented at several workshops and public comment sessions organized for this study. Box 11-1 provides a summary of challenges that affect participant redemption of WIC foods. Once electronic benefit transfer (EBT) systems have been implemented nationwide and adaptation to these systems is complete, some of the barriers noted may be reduced in magnitude or may no longer be present.

BOX 11-1

Challenges That Affect Participant Redemption of WIC Foods.

Additional Considerations for Implementation

In its evaluation of the food packages, the committee reviewed the current federal implementation guidance to states. Several aspects of this guidance were considered particularly important to retain and/or enhance as part of the food package revisions. These are:

• Continue to encourage state agencies to authorize as many food options as feasible within the limits of cost-containment, stocking requirements, and the redemption patterns of WIC participants.
  Rationale: WIC participants appreciate choice in meeting their nutritional needs and accommodating their cultural and personal food preferences. The additional choices being offered in the revised packages also promote redemption of the WIC benefit. Examples of these additional choices include multiple forms of whole grains in addition to whole wheat bread and allowing a range of container sizes for yogurt (i.e., 30–32 ounces to accommodate purchase of multiple 5-ounce containers).
• Continue to encourage state agencies to include lower-sodium options (where available) on state WIC food lists.
  Rationale: The 2015-2020 Dietary Guidelines for Americans (DGA) recommend that individuals limit their sodium intake. As a result, added sodium is not permitted in the specifications for some WIC food categories (e.g., frozen vegetables and fruits). In other food categories (e.g., canned vegetables), lower-sodium products are now widely available but are not always included in state food lists. Including them in such lists would allow WIC participants access to these lower-sodium choices.
• Initiate discussions with national and state Medicaid programs to address barriers to ensuring they are the payer of the full cost of all exempt infant formulas and medical foods issued to WIC participants nationally.
  Rationale: The purpose and scope of WIC does not include providing care to medically fragile infants (7 C.F.R. § 246.1); therefore, Medicaid is the appropriate primary payer (see WIC Policy Memorandum #2015-07). Enhanced collaboration between USDA-FNS and Medicaid at the national and state levels could reduce the complexity of the reimbursement process and remove WIC as the payer.
• Evaluate inclusion of foods and infant formulas containing functional ingredients using the decision tree developed by the committee.
  Rationale: The committee was tasked to consider the current science on functional ingredients¹ added to foods for infants, children, and adults (see the phase I report, NASEM [2016]) to determine how USDA-FNS might approach the inclusion of foods containing these ingredients in the WIC food packages. For this report, the committee outlined an approach that could be applied by USDA-FNS, and, potentially, state agencies, to determine whether foods or formula with these ingredients should be included in food packages (see Figure 11-1).

FIGURE 11-1

Proposed U.S. Department of Agriculture's Food and Nutrition Service (USDA-FNS) decision tree for evaluating inclusion of foods and infant formulas containing functional ingredients. NOTES: This schematic assumes that the safety of infant formulas, foods, (more...)

RESEARCH AND DATA COLLECTION RECOMMENDATIONS FOR EVALUATION OF THE WIC FOOD PACKAGES

Consistent with its task, the committee developed a prioritized list of recommendations for research and data collection. The majority of the research gaps identified also align with the research areas identified in the 2010 workshop, Planning a WIC Research Agenda (IOM, 2011), which indicates that many of the same data needs persist. Three high-priority research gaps were:

1.

How the food packages affect participants' diet quality, food security, program satisfaction, and participation in WIC in combination with other nutrition assistance programs;

2.

The effect of program support and the food packages on the choice to initiate and continue breastfeeding; and

3.

How choices regarding the purchase of vegetables and fruits can be optimized through the enhanced CVV.

Coordination of future WIC research timelines to allow completion by 2024 would ensure availability for the next review of WIC food packages. The specific recommendations that align with these priorities follow.

• 11-3. USDA-FNS should fund research to evaluate the effects of the recommended revisions to the WIC food packages on participant satisfaction, participation in the program, redemption of WIC foods, and participants' diets and health.
  • 11-3a. USDA-FNS should collect WIC state agency policies on an annual basis and establish a national database of electronic benefit transfer (EBT) expenditures by program participants.
  • 11-3b. USDA-FNS and the U.S. Department of Health and Human Services should collaborate to achieve expansion of nationally representative collection of data on the dietary intakes for pregnant, breastfeeding, and postpartum women and breastfed infants in the National Health and Nutrition Examination Survey. USDA-FNS should request that the data on breastfeeding women include an indicator on the intensity of breastfeeding (i.e., exclusive or partial).

Rationale: Although results from regional and state studies provided the committee with important evidence about the effects of the 2009 food package changes, no nationally representative study evaluated how the new food packages affected participant satisfaction, participation in the program, and use of the new WIC foods.^2,3 In addition, only limited information was available on how participants from different racial, ethnic, and cultural groups selected and used foods in the revised packages.

The EBT system, scheduled for implementation in all states by the year 2020, provides a unique opportunity to collect participant- and state-level data on redemption of issued foods (USDA/ERS, 2014). Under the direction of USDA-FNS, these individual-level data could be collected, anonymized,⁴ and analyzed (or, importantly, left disaggregated and made publicly available) to provide, for example, information about regional and national purchasing patterns, price variations, and how purchasing patterns and price variation interact with state-level regulations about cost containment. To determine whether the food package is meeting the needs of participants, it is essential to link the food redeemed to the specific food package. It is also essential that the timing of implementation nationally is clearly documented. Given that it may only be possible to collect these data in states using EBT, data collected before food package revisions are implemented would ensure that a strong baseline is established. Annual collection of state-level policies, paired with the creation of a national EBT database, would help USDA-FNS and other researchers examine the effect of variations in food package policies on redemption of WIC foods and participation in the program. These data could also be added to other online datasets as part of the current open-data initiative (TWH, 2016) to allow access to information collected via the EBT system.⁵

The committee lacked information on how foods in the WIC packages are used in the context of participants' overall diets, in conjunction with participation in other programs, such as the Supplemental Nutrition Assistance Program (SNAP), and in combination with foods purchased with participants' own funds. Such data would inform how the WIC food packages can be designed to optimize the overall diet and complement other food resources. The recently released Food Acquisition and Purchase Survey (FoodAPS) dataset holds the potential for evaluating food acquisition and purchase in addition to household participation in multiple programs. Although there are limitations in the currently available data,⁶ subsequent rounds of this survey could modify data collection to better address these issues, in addition to having data on low-income nonparticipants.

Research questions that could complement the various data sources mentioned here, applied in studies that use causal techniques, include:

• How do changes to the WIC food packages affect purchasing patterns and redemption of WIC foods?
• How do food purchasing patterns change with WIC participation compared to purchases made in the absence of WIC benefits?
• Do the revised food packages increase participants' satisfaction and improve participation in the program?
• What is the effect of the revised food packages on participants' diets, as measured by Healthy Eating Index–2010 (HEI–2010) score?
• What is the effect of WIC participation on household food security?
• Is there an effect of WIC participation on participant maternal and neonatal health outcomes?

• 11-4. USDA-FNS should fund data collection and analysis of that data toward optimizing support for breastfeeding and increasing the proportion of WIC participants who choose to initiate and continue breastfeeding, and tailoring food package options to best meet the needs and goals of the breastfeeding dyad. USDA-FNS should examine how breastfeeding outcome data are captured in WIC Management Information Systems and work toward a set of universal breastfeeding indicators that can be captured across systems.

Rationale: Achievement of the committee's vision for further improvements in breastfeeding support through the WIC program requires a targeted research initiative. The proposed revisions to the food packages are intended to support a woman's choice to breastfeed by increasing the quantity and variety of foods available to the breastfeeding mother during the infant's first 6 months. The objective is to increase proximal incentives (closer in time) as well as the distal incentive (further in time) of extended food benefits already being provided in the current packages from 6 to 12 months. The “up to” amounts for formula in the revised packages are intended to allow staff to calibrate formula amounts that meet the needs of each dyad. It is not expected that the food package alone will be sufficient incentive to breastfeed because a woman's decision to breastfeed is influenced by numerous complex factors.

Continued improvements in the coverage and quality of breastfeeding counseling available to WIC participants are necessary to achieve national breastfeeding goals. Adequate support by state and local agencies is important to determine the level of breastfeeding support provided through nutrition services administration funds as well as through peer-counseling funding and other sources. Piloting of various approaches to formula distribution by state and local WIC agencies, particularly in the first 30 days postpartum, would provide a strong evidence base to determine whether providing breastfeeding counseling in conjunction with customizing infant formula helps women to achieve their breastfeeding goals. Behavioral economics research may help elucidate how breastfeeding can be promoted through further revisions to the food packages and/or increased investments in sound breastfeeding protection, promotion, and support efforts.

Specific research questions could include

• From birth to age 1 year, what are the patterns of breastfeeding exhibited by mother–infant dyads on WIC? How well are these patterns aligned with the food packages issued? How is breastfeeding affected by the food package change?
• Paired with support, how does tailoring the food package to provide an amount of formula that supports the needs of the dyad in the first 30 days affect the duration and intensity of breastfeeding? • What incentives motivate WIC participants to choose to breastfeed as well as to continue to breastfeed beyond 4 to 6 weeks postpartum? Did the package changes affect these outcomes?
• Outside of the food package for mother–infant dyads, what level and type of support (peer counseling, lactation consultation, etc., for what duration/periodicity) is optimal to promote and support breastfeeding?

To investigate these research questions, it will be necessary to collect and evaluate state-level data on the efficacy of various breastfeeding promotion and support practices and policies, including the number of peer counselors available at local agency sites, the ratio of peer counselors to women participants, the state agency formula issuance policy, and demographic characteristics (including race and ethnicity) of WIC participants at the state level. These data could be collected on a routine basis (e.g., once annually), linked to participant outcome data, and disseminated to researchers. If possible, it would be ideal to test different approaches for the promotion of breastfeeding through randomized controlled trials. USDA-FNS could provide funding (and waivers if needed) to allow states to explore how varying policies and resources affect breastfeeding initiation, exclusive breastfeeding duration, and overall duration. This evidence could help ensure that cost-effective approaches are used.⁷

• 11-5. USDA-FNS should fund research to assess how inclusion of the cash value voucher as a component of WIC food packages affects: food package redemption rates; participant choice ofvegetable and fruit varieties; overall diet quality; and vendor stocking practices.

Rationale: There is a lack of comprehensive national data on WIC food package redemption rates; participant choice of vegetable and fruit varieties; overall diet quality; and vendor stocking practices. EBT redemption data should be used to the fullest extent to capture data on use of the CVV to elucidate redemption rates and vegetable and fruit choices made with the revised CVV. For the next WIC program review, it is also important to understand the extent to which the recommended increased CVV assists WIC participants in meeting their nutritional goals.

Future evaluations of the WIC food packages would also benefit from information on vendor stocking practices for vegetables and fruits as an outcome of increasing the CVV. It would be valuable to understand the feasibility of stocking the new WIC food options as well as the effects of vendor stocking practices on participant purchasing patterns.

Specific research questions could include

• What are the CVV redemption rates, and what factors (CVV amount, region in the United States, participant characteristics, etc.) are associated with higher and lower rates of redemption?
• What do participants purchase with the CVV, and how do participants apportion their purchases of vegetables and fruits, including the variety of vegetables and fruits and selection of vegetables versus fruits?
• Does the revised CVV assist participants to consume a nutritionally adequate diet and meet the recommendations for consumption of vegetables and fruits of the DGA?
• What are the changes in the availability of vegetables and fruits at WIC authorized vendors and in vendor stocking practices before and after changes in the CVV amount? Do vendors increase the diversity of their vegetable and fruit offerings? Do vendors change their WIC authorization status in response to the package changes? How does vendor size relate to stocking requirements and participant options?

• 11-6. USDA-FNS should fund research to evaluate the feasibility of adjusting the value of the cash value voucher (CVV) in high-cost states and territories (Alaska, Guam, Hawaii, and the U.S. Virgin Islands).

Rationale: Higher amounts of WIC program funds are allotted per-participant to states and territories with a high cost of living, including Alaska, Guam, Hawaii, and the U.S. Virgin Islands. The average food package costs in these areas are 21, 18, 81, and 82 percent higher, respectively, than the average for all U.S. states and territories (USDA/FNS, 2016a). For most foods in the WIC package, participants receive a specific quantity of the WIC-approved food, an amount that does not vary with the price of the food. However, as a cash benefit, the amount of food available to the participant through the CVV reflects the regional price difference and thus, it is likely that fewer vegetables and fruits can be purchased with the CVV in those high-cost areas. For example, the U.S. Department of Agriculture's Economic Research Service (USDA-ERS) (2011) reported that commonly purchased vegetables and fruits may cost up to 70 percent more in the most expensive markets, compared to the least expensive markets. Therefore, the available benefit varies at the participant level if participants nationwide receive a flat purchase value with the CVV. In the proposed revised food packages, the CVV makes up a larger proportion of the food package benefit than the current packages; thus vegetable and fruit intake may be influenced to a greater degree by geographic variations in their price.

A first step to address the inequity in high-cost areas is to adjust the CVV using the SNAP cost adjustments assigned to these four high-cost regions (see USDA/FNS, 2016b).⁸ If adjusted in this manner, on average, the CVV would be 49 percent higher (unweighted; 60 percent when weighted by the state population) for WIC participants in these areas. Inasmuch as WIC participants in these areas make up 1 percent of the total WIC population (USDA/FNS, 2016a), the effect on overall program costs will be minor. A second step would be to consider adjustments that account for higher costs of vegetables and fruits in additional states.

PRIORITIES FOR FUNDING OUTSIDE COST-NEUTRALITY

USDA-FNS asked that the committee identify changes to the food packages that should be made if funding for the WIC food packages is either 10 percent higher or 10 percent lower than cost neutrality. The committee's priority in case of additional funding is enhancement of food package IV (for children).

• 11-7. The committee recommends that in the case that USDA-FNS has funding above cost neutrality, the value of the CVV should be increased for all children on the program.

Rationale: A CVV of $23 (approximately 10 percent above cost-neutral) would allow children adhering to a 1,300-kcal food pattern to meet half of their recommendations for consumption of vegetables and fruits. Retention of children in the WIC program is a concern. Inasmuch as this food package represents approximately 53 percent of all food packages issued, changes to food package IV have a significant effect on overall program costs for food. As a result, the degree to which the committee could enhance this food package within cost-neutral constraints was severely limited, and any changes in this food package likewise limited the degree to which other food packages could be enhanced. The reasons for the decline in WIC participation at 1 year of age and beyond are unknown and likely multifaceted. In the absence of additional information, one strategy to improve child retention may be to enhance food package IV for children ages 1 to less than 5 years.

• 11-8. The committee recommends that in the case that USDA-FNS has funding below cost neutrality, provision of juice should be further reduced or eliminated across food packages.

Rationale: Elimination of juice would reduce the food package costs by approximately 4 percent. Both the DGA and authoritative guidance for children less than 2 years of age indicate that fruit juice is a less preferred way to meet fruit intake recommendations, compared to whole fruit. Moreover, these sources suggest upper limits for juice intake rather than recommended amounts. The nutrients in juice are also present in many other foods, specifically, whole vegetables and fruits, dairy foods, legumes, and ready-to-eat breakfast cereals.

Should further reductions be needed, the committee recommends targeting the following foods in priority order:

1.

Eliminate peanut butter from the food packages. Because of the availability and price of smaller container sizes, it is difficult to provide a supplemental quantity of peanut butter. This is a relatively inexpensive food with a long shelf-life. WIC dollars may be better allocated to foods that provide nutrients more critical to the WIC population than those provided by peanut butter.

2.

Further reduce the amount of milk in food package IV-B to 12 quarts. Milk in the proposed revised food package IV-B, although reduced, still provides 75 percent of the recommended dairy intake. Inadequate calcium intake in children of this age group was found to be less than 5 percent.

3.

Reduce the quantity of fish that has been added to the revised food packages. Participant acceptability of fish in the revised food packages is not known. An alternate option would be to add fish only to food packages for women and then assess participant acceptability before revising the food packages for children.

MULTILEVEL APPROACHES TO IMPROVING CONSUMPTION OF WIC FOODS

CONSIDERATIONS FOR THE NEXT REVIEW

The committee evaluated a number of potential revisions to the food packages that ultimately were rejected. The committee's key ideas are shown in Appendix Q. In many cases, revisiting these ideas at the time of the next review of the WIC food packages may be helpful as a result of changes in the landscape of food availability, nutritional needs, and participant preferences. Among the potential revisions considered, support for breastfeeding emerged as a priority concern and therefore is discussed below.

CONCLUDING REMARKS

Although the committee completed its task, much work remains. Three major issues emerged as priorities for future consideration: support for breastfeeding, encouraging consumption of vegetables, and availability and use of WIC data.

Historically, the WIC program has given priority to exclusive breastfeeding by optimizing the food package for women who exclusively breastfeed. This committee continued that practice. However, given the barriers to breastfeeding faced by low-income women in the United States, it is possible that WIC may be reaching nearly all those who are willing and able to breastfeed exclusively. To promote and encourage any breastfeeding, the committee also chose to enhance the food package for partially breastfeeding women and allow issuance of this package in the first month postpartum. As stated above, the committee's vision is that all women should receive adequate counseling and support for breastfeeding prenatally through the first month postpartum. This is especially the case for women who find exclusive breastfeeding incompatible with other constraints in their lives, but are nonetheless interested in breastfeeding and can be successful with partial breastfeeding. WIC can enhance its stated commitment to breastfeeding (USDA/FNS, 2016d) by reaching and supporting these women. However, achieving the committee's vision will require the expansion and full coordination of the several WIC resources that promote and support breastfeeding. The committee strongly encourages USDA-FNS to meet this challenge.

Although the committee was able to respond to its primary task by increasing the variety and balance of foods in the WIC food packages, providing some priority nutrients in adequate amounts (i.e., potassium, vitamin D, and choline) is limited even in the DGA food patterns. In addition, finding ways to encourage redemption of vegetables with the CVV remained a challenge. This is because of WIC participants' preference for fruits. Participants who receive the largest increase in the CVV in the revised food packages should be able to satisfy their preference for fruits and begin to purchase more vegetables. However, to increase vegetable redemption, the CVV may have to be substantially increased for all participants and accompanied by appropriate nutrition education and perhaps further incentives as well. In a cost-neutral environment, this may require reductions in the amount of other high-cost items such as dairy products and infant formula, which are provided in amounts at the high end of “supplemental” in the recommended revised packages. To assist USDA-FNS in identifying ways to accomplish this goal, the committee's recommendations include specific ideas for data collection and analyses.

This committee had access to a limited amount of data on redemption and also the distribution of redemption of WIC foods. This information was crucial for understanding how participants use the program, but more such data as well as many other kinds of data that would have assisted the committee were unavailable, so the committee has provided recommendations to address these data needs for future decision making. Moreover, the committee views it as essential that WIC identify ways to increase the availability of program data so interested researchers can contribute their expertise to determine which aspects of the program work and how and which aspects are cost effective and scalable.

The committee's strategy for revisions included several noteworthy innovations that are anticipated to lead to improvements to the WIC food packages. Highlights of these innovations include development of the concept of “supplemental” and its use as a criterion for the revision of the food packages (the concept of supplemental is discussed in Chapter 6); use of data on redemption and the distribution of redemption to inform estimates of actual use of the food packages (an explanation of how redemption data were used is provided in Chapter 7); and consideration of the dyadic nature of infant feeding related to the contents of the food packages (the committee's consideration of the mother–infant dyad is discussed in Chapters 6 and 7). These innovations permitted the committee to make important revisions to the food packages within the constraint of cost neutrality. In particular, the committee was able to balance the food packages to increase the variety of foods included, increase participants' choices within food categories, and develop a more thoughtful and comprehensive approach to the use of the packages to support breastfeeding of all durations and intensities. To be fully effective, the committee's recommended revisions to the food package should be accompanied by the recommendations for implementation presented in this chapter. As the committee's experience indicated, it is necessary for USDA-FNS to invest in data collection and research that can inform the next revision of these packages. These revisions to the food packages, when accompanied by their successful implementation, should improve both the attractiveness of the program to participants and success in meeting the WIC program's goals to promote and support breastfeeding and to safeguard the health of low-income women, infants, and children through the provision of foods that provide key nutrients.

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