Alignment of the Current Food Packages with Dietary Guidance, Special Dietary Needs, and Cultural Eating Practices or Food Preferences

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

3Alignment of the Current Food Packages with Dietary Guidance, Special Dietary Needs, and Cultural Eating Practices or Food Preferences

As described in the Statement of Task, recommended revisions to WIC food packages are required to be consistent with the 2015–2020 Dietary Guidelines for Americans (DGA)^¹ (for individuals ages 2 years and older), advice from the American Academy of Pediatrics (AAP) or other authoritative groups (for individuals less than 2 years of age), and the Dietary Reference Intakes (DRIs). This chapter provides an evaluation of the alignment of the current food packages with these updated sets of guidance and with special dietary needs, preferences, or practices (e.g., medical conditions, vegetarian or vegan diets, cultural eating practices).

ALIGNMENT OF THE FOOD PACKAGES WITH DIETARY GUIDANCE FOR INDIVIDUALS AGES 2 YEARS AND OLDER

As noted in Chapter 1, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is required to provide foods and services in alignment with the DGA (U.S. Congress, P.L. 101-445, 1990), which are applicable to individuals ages 2 years and older. In this section, the contributions of the food packages to the DGA food patterns are evaluated, including the contribution of WIC-approved foods to intakes of sodium, added sugars, saturated fat, and “calories for other uses” (COU) (see Chapter 2 for a description of COU).

Amounts of Foods in the Current Food Packages Compared to the USDA Food Patterns

Understanding the contribution of the WIC food packages to the U.S. Department of Agriculture (USDA)-recommended food patterns as outlined in the DGA (USDA/HHS, 2016) was required before the committee could consider how the food packages might be adjusted. As shown in Tables 3-1 through 3-4, the proportion of the DGA recommended amounts of food groups provided to women and children in the food packages varies across food groups and across food packages. The packages provide nearly 100 percent of recommendations for dairy in most cases and over 100 percent of recommended amounts of several other food groups and subgroups (i.e., dairy for fully breastfeeding women, juice for children,^² peanut butter in most food packages, and legumes in food packages for children). In contrast, amounts of total grains, total protein foods, and total vegetables provided is generally less than 50 percent of recommended amounts. This variation suggested to the committee that there were opportunities for improvement in the alignment of the food packages with the DGA recommendations as well as with providing a more balanced supplement to participants' diets.

TABLE 3-1

WIC Maximum Allowance Compared to the 2015–2020 DGA Food Pattern: Food Package V, Pregnant and Partially Breastfeeding Women, Up to 1 Year Postpartum.

TABLE 3-4

WIC Maximum Allowance Compared to the 2015–2020 DGA Food Pattern: Food Package IV, Children 2 to Less Than 5 Years of Age.

Of note, the WIC food packages serve individuals with a wide range of energy needs.^³ The data presented in tables 1 through 4 are therefore only approximations of the contribution of a WIC food package to a specific individual's energy needs. Additionally, the data in these tables are based on an assumption that all foods in the packages are consumed by the intended beneficiaries.

Alignment of the WIC Food Packages with Dietary Guidance for Intake of Fish

The USDA's Food and Nutrition Service (USDA-FNS) specifically tasked the committee to evaluate the inclusion of fish across food packages. As is evident in Tables 3-1 through 3-4, fish is provided only in food package VII for breastfeeding women. The DGA encourage consumption of high omega-3, low-mercury fish species (USDA/HHS, 2016), agreeing with the U.S. Food and Drug Administration/Environmental Protection Agency (FDA/EPA) joint federal fish advisory (2014). Intake of fish high in omega-3 fatty acids is recommended not only in the DGA, but also by the American Heart Association (AHA, 2015), AAP (AAP, 2014), and the World Health Organization (PAHO/WHO, 2003). Table 3-5 presents the guidance from each of these groups. Generally, the recommended intake is between approximately 1 ounce and 2 ounces per day, depending on the target population.

TABLE 3-5

Authoritative Recommendations for Intake of Fish High in Omega-3 Fatty Acids and Low in Mercury.

These recommendations take into account the risks and benefits of fish intake, given that some fish species contain mercury, specifically methylated (organic) mercury, which can be detrimental to human health. Pregnant women are at the greatest risk. The 2015 Dietary Guidelines Advisory Committee (DGAC) report (USDA/HHS, 2015) reviewed and concurred with the Food and Agriculture Organization/World Health Organization (FAO/WHO) Expert Consultation on the Risks and Benefits of Fish Consumption (FAO/WHO, 2010), which stated that the health benefits of low-mercury fish consumption (whether farm raised or wild) outweigh risks with respect to both offspring development and mortality from cancers and cardiovascular diseases. The fish species for which the FDA advises limiting consumption are not included in the food packages.

Alignment of the WIC Food Packages with Dietary Guidance for Nutrients to Limit

The DGA recommend an upper sodium limit of 2,300 mg per day and upper limits of 10 percent of total calories from saturated fat and 10 percent of total calories from added sugars (USDA/HHS, 2016). Alignment of the WIC food packages with each of these recommendations is discussed below.

Sodium in the WIC Food Packages

The DGA recommendation to limit sodium to 2,300 mg per day aligns with the Tolerable Upper Intake Level (UL, a DRI value) for sodium for adults, ages 19 and older (IOM, 2005). In the WIC food packages, sodium is found primarily in cheese, canned vegetables, and canned fish. Sodium is otherwise limited in most other food categories. Although USDA/FNS (2014) encourages states to offer lower-sodium options, the low-sodium versions of some products cost more than their higher-sodium counterparts which may affect their inclusion on state WIC food lists.^⁴ The sodium content of representative allowable WIC foods is presented in Table 3-6.

TABLE 3-6

Sodium Content of Representative Currently Allowable WIC Foods.

TABLE 3-3

WIC Maximum Allowance Compared to the 2015–2020 DGA Food Pattern: Food Package VII, Fully Breastfeeding Women Up to 1 Year Postpartum.

Saturated Fat in the Food Packages

Although the DGA do not include an upper limit for total fat intake, as mentioned above and in Chapter 2, they do include an upper limit of 10 percent of total energy from saturated fat. They also include replacing saturated fats with polyunsaturated alternatives and replacing solid animal fats with nontropical vegetable oils and nuts. Additionally, the DGA describe a healthy food pattern as one that includes “fat-free or low-fat dairy, including milk, yogurt, cheese” (USDA/HHS, 2016, p. 15). Aligning with these recommendations, since 2012, the National School Lunch Program has required that all milk served in schools be low-fat or nonfat and, if flavored, nonfat. Although flavored milks are permitted in the National School Lunch Program, the overall food pattern energy levels limit the levels of added sugars in allowable milks (USDA/FNS, 2012). Another federal nutrition assistance program, the Child and Adult Care Food Program, also requires that all milk provided to individuals 2 years of age or older be low-fat or nonfat (USDA/FNS, 2016a). Similarly, the current WIC food packages allow only 1 percent or nonfat milk for individuals ages 2 years and older. Additionally, depending on the food package, quantities of cheese are limited to 1 or 2 pounds per month. The saturated fat content of various WIC-allowable foods is presented in Table 3-7.

TABLE 3-7

Saturated Fat Content of Representative Currently Allowable WIC Foods.

Added Sugars in the Food Packages

As noted above and in Chapter 2, as with saturated fats, the DGA recommend limiting added sugars to no more than 10 percent of total calories. Added sugars are sweeteners of various types added to foods (e.g., corn syrup, fruit juice concentrate, fructose, maltose) and do not include naturally occurring sugars such as those in 100% fruit juice or lactose in dairy products (USDA/HHS, 2016). The DGA further state that added sugars may have a role in increasing the palatability of nutrient-dense foods and specifically cited whole grain breakfast cereals and nonfat yogurts as examples (USDA/HHS, 2016).

Added sugars are limited in the WIC food packages. Although the FDA has issued a proposed rule on labeling of added sugars, at present, manufacturers are required to include only total sugars on the food label. Thus, specifications for some WIC foods, including ready-to-eat breakfast cereals and yogurt are for total sugars (not added sugars) (USDA/FNS, 2014). At present, USDA does not provide specifications for total sugars for soy beverages or flavored milk in the WIC food packages. The added sugars content of various WIC-allowable foods is presented in Table 3-8.

TABLE 3-8

Added Sugars Content of Representative Currently Allowable WIC Foods.

Alignment of the Current WIC Food Packages with Dietary Guidance for “Calories for Other Uses”

The concept of COU was introduced in the 2015–2020 DGA (replacing the 2010 DGA concept of “discretionary calories”). COU include calories from saturated fats (solid fats), added sugars, added refined starches, and alcohol, as well as additional calories from the food groups beyond amounts recommended. As described in Chapter 2, the limits for COU vary among food patterns, depending on how many “leftover” calories are available after the food group intake recommendations are met. For example, only 100 calories are available to be used as COU in a 1,200-kcal pattern, compared to 390 COU in a 2,600-kcal pattern.

As shown in Table 3-9, based on the committee's calculations of estimated contributions of the food packages to COU,^⁵ assuming full redemption, all food packages provide less than the recommended total limit for COU for the diet as a whole. Considering the kcal provided by the package, the COU provided in each package are generally proportional to or slightly exceed the proportional limit for COU. Food packages for children exceed the proportional recommended limit for COU. The primary contributors to COU are dairy foods. Given that the current food packages are relatively limited in added sugars and saturated fat, these results indicate there is little room for additional COU in foods and beverages outside the WIC food packages. These results also suggest that it is a challenge for many WIC participants, especially children, to ensure that their overall diets fall within the recommended limits for COU.

TABLE 3-9

Contributions of the Food Packages to the DGA Daily Limit for “Calories for Other Uses.

ALIGNMENT OF THE FOOD PACKAGES WITH DIETARY GUIDANCE FOR INDIVIDUALS LESS THAN 2 YEARS OF AGE

The DGA do not currently include dietary guidance for individuals from birth to 24 months of age, although the Agricultural Act of 2014, also known as the Farm Bill, has officially called for future (i.e., 2020) DGA to include infants and toddlers (U.S. Congress, P.L. 113-79, 2014). Meanwhile, without this guidance, it is significantly more difficult to assess the appropriateness of the WIC food packages for children less than 2 years of age. To carry out its task, the committee compiled recommendations from the AAP, the Academy of Nutrition and Dietetics (AND), the World Health Organization (WHO), and other authoritative groups (see Table 3-10) and compared this guidance with the components of the food packages.

TABLE 3-10

Dietary Guidance for Breastfeeding Mothers and Infants and Children Less Than 2 Years of Age.

The committee found that the food packages are generally aligned with dietary guidance for infants and children ages 0 to less than 2 years, with the exception of juice, infant cereal, and jarred infant meat. Specifically, although the amount of juice provided in food package IV (which is provided to children 1 to 2 years of age) falls within the AAP recommended range of 4 to 6 ounces per day, this range is an upper limit. Moreover, the AAP guidelines emphasize whole fruit over 100% juice. Additionally, the AAP recommends a maximum of 4 tablespoons of infant cereal per day and a maximum of 1 to 2 ounces of jarred infant meat per day. The current infant food packages (food package II) provide 6 tablespoons of infant cereal per day (150 percent of the recommended amount) to all infants ages 6 to less than 12 months of age and 2.6 ounces of jarred infant meat (130 percent of the recommended amount) to fully breastfed infants of the same ages.

ALIGNMENT WITH THE DIETARY REFERENCE INTAKES

The committee also evaluated the alignment of the food packages with the DRI values appropriate for each age and physiological-state subgroup (see Appendix J, Tables J-1a to J-1c for a compilation of DRIs). For women and children, most nutrients have an associated Estimated Average Requirement (EAR), which is the intake level at which 50 percent of individuals in a population will meet their needs. Nutrient contributions of the food packages as percentages of EARs are presented in Tables 3-11 through 3-13 (EARs are specific to each target population). For nutrients with only an Adequate Intake (AI), the proportion of the AI offered in the packages is also presented, but interpretation should take into account that, in contrast to the EAR, mean intakes should fall at or above the AI. For infants, most of the DRIs are expressed as AIs. A detailed description of the methodology applied to create the food package nutrient profiles is provided in Appendix R.^⁶

TABLE 3-11

Nutrients Provided per Day in the Current Food Packages Compared to Dietary Reference Intakes: Pregnant, Breastfeeding, and Postpartum Women.

TABLE 3-13

Nutrients Provided per Day in the Current Food Packages Compared to Dietary Reference Intakes: Children Ages 1 to Less Than 5 Years of Age.

Highlights of the nutrient profiles presented in Tables 3-11 through 3-13 are summarized here, with a focus on the provision of shortfall nutrients. As discussed in Chapter 2, the DGA identified 10 shortfall nutrients: vitamin A, vitamin D, vitamin E, vitamin C, folate, calcium, magnesium, fiber, iron, and potassium. Of these, four were identified further as nutrients of public health concern: calcium, vitamin D, fiber, and potassium, as well as iron for adolescent and premenopausal females. All of the food packages provide relatively small amounts of vitamin E, choline, and potassium. Similarly, the majority of the USDA food patterns do not assure adequacy of these nutrients, or of vitamin D (USDA/HHS, 2016), a factor that was considered when determining options for improving nutrient composition of the food packages. None of the food packages exceeded the UL for any nutrient.

Food Packages for Women

Food Package V for Pregnant and Partially Breastfeeding Women

For pregnant women, food package V contributes more than 100 percent of the EAR for calcium, vitamin C, vitamin A, phosphorus, riboflavin, and vitamin B12; close to 100 percent of the EAR for folate; and between approximately 60 and 80 percent of the EAR for iron, magnesium, zinc, selenium, vitamin B6, thiamin, niacin, and vitamin D. Food package V provides approximately 8 g per day of fiber and 1,800 mg per day of potassium, or about one-third of the AI for these nutrients (see Table 3-11).

The DRI for breastfeeding women assumes exclusive breastfeeding. Therefore, it was not possible to estimate the contribution of the food packages to the needs of partially breastfeeding women in reference to a DRI value as no appropriate DRI is available.

Food Package VI for Postpartum Women

Food package VI for women who are postpartum (up to 6 months) provides more than 100 percent of the EAR for iron, folate, phosphorus, riboflavin, vitamin B12, and vitamin A, and nearly 100 percent of calcium, vitamin B6, and vitamin C EARs are provided in the food package. The package also provides between 70 and 80 percent of the EAR for zinc and niacin and approximately 50 percent of the EAR for vitamin D. This food package provides 6 g per day of fiber and approximately 1,300 mg per day of potassium, well below the AIs for these nutrients (see Table 3-11).

Food Package VII for Fully Breastfeeding Women

Food package VII for women who are fully breastfeeding (up to 12 months) provides more than 100 percent of the EAR for calcium, phosphorus, selenium, vitamin C, riboflavin, vitamin B12, and iron. Between 70 and 100 percent of the EAR for protein, zinc, thiamin, niacin, vitamin B6, folate, and vitamin D is provided. This food package provides 8 g of fiber per day and approximately 1,900 mg per day of potassium. As for other food packages, these amounts are below the AI for these nutrients (see Table 3-11).

Food Packages for Infants

Assessment of the contributions of the infant food packages to nutrient requirements was made more challenging by the lack of EAR values for these age groups. Although a full analysis of the food package nutrients was conducted, the committee focused on iron and zinc, which are commonly considered nutrients of concern for infants, particularly if breastfed (AAP, 2014), and for which EAR values have been determined. The results of this analysis are presented in Table 3-12.

TABLE 3-12

Nutrients Provided per Day in the Current Food Packages for Infants Less Than 12 Months of Age.

For infants ages 6 to less than 12 months, food package II provides between 14 and 21 mg per day of iron depending on the feeding mode (formula fed, partially breastfed, or fully breastfed), compared to an EAR of 6.9 mg per day. The same food package provides between approximately 3 and 6 mg per day of zinc, compared to an EAR of 2.5 mg, again depending on feeding mode.

Food Package IV for Children Ages 1 to Less Than 5 Years

The nutrient contributions of the food package are different between children ages 1 to less than 2 years compared to children ages 2 to less than 5 years because the former are required to be issued whole milk products (see Table 3-13). Overall, provision of most nutrients is well over 100 percent of the EAR, with some as high as approximately 400 percent (iron and vitamin C). For children ages 2 to less than 5 years, the food package provides over 100 percent of the EAR for calcium, iron, vitamins C and A, and folate among other nutrients. The package provides approximately 50 percent of the average vitamin D requirements for children of all qualifying ages.

FORMS AND COMPOSITION OF FOODS PROVIDED IN THE FOOD PACKAGES AND ALIGNMENT WITH DIETARY GUIDANCE

In addition to evaluating the quantities of nutrients and food groups provided by the food packages, the committee evaluated the appropriateness of the types of food for the intended recipients. Table 3-14 lists the current WIC foods that are authorized across food packages and the dietary guidance related to food types and food composition. In nearly all cases, the foods provided are consistent with this guidance. For example, only whole milk is provided to children 1 to less than 2 years of age, and milk provided to individuals ages 2 years and older is low-fat or nonfat. In only two cases are the foods provided not well aligned with dietary guidance. First, juice provided to children meets 100 percent of the lower end of the AAP limit. Yet whole fruit is the preferred form of fruit (see Table 3-10). Second, although intake of fish, particularly varieties high in omega-3 and low in mercury, is recommended for children and women (see Table 3-5), fish is currently provided only to fully breastfeeding women in food package VII.

TABLE 3-14

Dietary Guidance Related to Types or Composition of Foods in Current WIC Food Packages.

ALIGNMENT OF THE FOOD PACKAGES WITH SPECIAL DIETARY NEEDS AND PREFERENCES

In Chapters 8 and 9 of the phase I report for this study, the ability of the food packages to meet the needs of WIC participants with particular medical conditions, cultural eating patterns, or food preferences was reviewed (NASEM, 2016). In this section, key components of that review that affected the committee's decisions on food package changes are summarized along with additional relevant information collected in phase II.

Foods to Address Medical Conditions

The current WIC food packages can accommodate a wide range of medical conditions. This section summarizes, first, the circumstances under which food package III can be issued and, second, the extent to which the WIC food packages accommodate the dietary needs of individuals with food allergies and other food-triggered sensitivities.

The Special Case of Food Package III

At the discretion of a health care provider, participants may be considered “medically fragile” and can receive food package III for either themselves or their children. There exists no generally accepted definition of medical fragility. Examples include an infant with failure to thrive and an adult with a wired jaw. Individual states have policies regarding who may qualify under WIC. Approximately 3 percent of WIC participants are recipients of this package, 75 percent of whom are infants, 25 percent children, and less than 1 percent adults (USDA/FNS, 2016b).

Depending on a participant's specific medical needs, food package III is tailored to include either infant formula, noncontract^⁷ infant formulas with unique nutritional composition, or WIC-eligible nutritionals (a “WIC formula”^⁸). Most WIC participants who are issued food package III receive non-contract formulas (USDA/FNS, 2016b). The WIC definition for WIC-eligible nutritionals (see Box 3-1) is similar to the FDA definition of a medical food (Section 5(b)(3) of the Orphan Drug Act (21 U.S.C. 360ee(b)(3)), except that the WIC definition does not include “administered under the supervision of a physician” and does not acknowledge “distinctive nutritional requirements, based on recognized scientific principles … established by medical evaluation.” However, a medical professional prescription or recommendation is still needed for a participant to receive food package III, therefore in practice, the definitions are essentially the same and the WIC definition was considered by the committee to be appropriate.

BOX 3-1

Definition of WIC-Eligible Nutritionals*.

The types and quantities of WIC formula and supplemental foods must be determined by the medical professional with appropriate documentation provided to the state agency. State agencies may allow the health care provider to refer to the WIC registered dietitian and/or qualified nutritionist for identifying appropriate supplemental foods (excluding WIC formula) and their prescribed amounts, as well as the length of time the participant requires the supplemental foods. Participants receiving food package III may be issued 455 ounces of WIC formula per month in addition to the maximum allowance of all other foods in the package appropriate for their life stage. Exceptions to these food package regulations may be made as necessary and as dictated by the Final Rule (USDA/FNS, 2014).^⁹

In some cases, participants under the care of a health care provider may be prescribed foods atypical for the participant's age category, such as when jarred infant foods are issued to individuals over 1 year of age. Under current regulations, participants must be prescribed a WIC formula to be issued food package III, whether or not it is included in the health care provider prescription and whether or not this required issuance suits the participant's condition (i.e., a participant 2 years of age or older who is prescribed whole milk is unlikely to also be in need of a WIC formula).^¹⁰

Food-Triggered Immune-Mediated Sensitivities

All of the food packages can support the nutritional needs of several different types of food-triggered immune-mediated sensitivities, including food allergies, celiac disease, non-celiac gluten sensitivity (NCGS), and lactose intolerance. Chapter 8 of the phase I report included a summary of evidence from the literature on the nutritional needs of individuals with these medical conditions (NASEM, 2016). Here, the ways that the current food packages accommodate individuals with these conditions and potential gaps are highlighted.

Food allergies Allergy has been defined as a hypersensitivity disorder of the immune system where the immune system reacts to substances in the environment normally considered harmless (CDC, 2013). The most common food allergies are allergies to peanut, tree nuts, seafood, milk, hen's eggs, wheat, fish, and soy (Chafen et al., 2010), all of which were considered relevant to this review.

The committee's review of the literature indicated that, for infants at risk of developing allergy, most experts recommend breastfeeding for approximately 6 months and the provision of hydrolyzed^¹¹ protein formula for nonbreastfed infants (Greer et al., 2008; Chafen et al., 2010; Fleischer et al., 2013). Historically, the AAP Committee on Nutrition (2000) recommended avoidance of some foods by breastfeeding mothers. However, authors of a recent systematic review of maternal intake during pregnancy or lactation did not find any conclusive evidence of an effect of maternal diet on the development of allergy in infants (Netting et al., 2014). In accordance with these recommendations, hydrolyzed protein infant formulas for allergy at-risk infants are available to formula-fed WIC infants with a physician's prescription.

There is no currently defined role for WIC-provided infant foods in allergy prevention because it is not fully understood how introduction of solid foods in the first year of life might influence the development of allergy. However, there is some evidence that early introduction of peanut protein reduces the likelihood of peanut allergy (Du Toit et al., 2008, 2015; Gruchalla and Sampson, 2015). Based on this evidence, the AAP issued interim guidance in September 2015 for the early (between 4 and 11 months of age) introduction of peanut protein to high-risk infants under care of a health care provider (Fleischer et al., 2015). In the fall of 2016, the National Institute of Allergy and Infectious Disease is set to release a policy to formally recommend the introduction of peanut to high-risk children at between 4 to 6 months of age (Greenhawt, 2016).

For children and adults, the current WIC packages include substitutions for allergenic foods so individuals with most major food allergies can be accommodated (see Table 3-15). However, as noted in the table, there is no current substitution for individuals with egg or fish allergies or those allergic to both cow's milk and soy. The committee considered the latter to be a medical condition for which food package III should be prescribed by the health care provider. Importantly, WIC offers participants with food allergies a number of educational resources to support adherence to dietary restrictions (USDA/FNS, 2015b).

TABLE 3-15

Options in WIC Food Package Categories Potentially Unsuitable for Special Diets and Major Allergies.

Celiac disease Approximately 1 in 200 individuals living in the United States has celiac disease, an immune-mediated inflammation of the small bowel caused by sensitivity to dietary gluten (a protein found in wheat and other grains) and related proteins (Guandalini and Assiri, 2014; Mooney et al., 2014). Women with celiac disease may have an increased risk of obstetrical complications and adverse birth outcomes (AND, 2006; Saccone et al., 2016). An Academy of Nutrition and Dietetics (AND) systematic review indicated that women with undiagnosed or untreated celiac disease have an increased risk of several adverse pregnancy outcomes (evidence graded as fair) (AND, 2006).

Treatment for celiac disease includes lifelong avoidance of wheat, barley, and rye. Individuals with symptoms for celiac disease should be tested and, if positive, receive detailed nutritional counseling on gluten avoidance, because even milligram levels in the diet can have severe long-term health consequences (Rubio-Tapia et al., 2013). Because gluten-free grains (e.g., rice, potato flour, tapioca flour, corn) are not typically fortified, gluten-free diets may be low in iron and folate, as well as dietary fiber (Thompson, 2000). Nutrients of particular concern for pregnant women who follow a gluten-free diet include carbohydrates, iron, folic acid, niacin, calcium, phosphorus, zinc, and fiber (AND, 2014).

All state agencies now offer a nonwheat option for the “whole grain bread” food category (USDA/FNS, 2016b). These are suitable for gluten-free diets if the state-approved products are certified gluten-free. The Final Rule for the WIC food packages does not require that states provide a gluten-free option for cereals, although the provision allows state agencies to offer oat, corn, or rice-based cereals that may be appropriate for participants who must avoid gluten (USDA/FNS, 2014). However, such cereals are not necessarily certified as gluten-free and, thus, the gluten content of state-approved products may not fall under the FDA limit of 20 parts per million of gluten (an amount tolerated by most individuals with celiac disease) (21 C.F.R. § 101). Individuals with non-celiac gluten sensitivity (NCGS)^¹² may also benefit from these non-wheat options. Table 3-15 indicates the currently available WIC foods and substitutions that meet the dietary needs of individuals who must or choose to avoid gluten.

Lactose intolerance Lactose intolerance is a set of symptoms caused by lactase deficiency. Individuals with lactose intolerance may be able to consume small amounts of dairy products (up to 8 ounces of milk or yogurt at one time) (Suarez et al., 1995, 1997; Lomer et al., 2008) or dairy products in specific forms. For example, natural cheddar cheese contains 0.18 percent lactose, whereas nonfat milk contains 5.09 percent lactose (USDA/ARS, 2016). For lactose-intolerant individuals, nutrition education might be necessary to ensure adequate calcium intake. A 2013 consensus statement issued by the National Medical Association and the National Hispanic Medical Association indicates that dairy intake may be low among African Americans and Hispanic Americans because of either perceived or actual lactose intolerance. In these cases, consumption of yogurt containing live and active cultures was suggested as a strategy for including dairy in the diet (Bailey et al., 2013).

Table 3-15 also indicates the currently available WIC foods and substitutions that meet the dietary needs of individuals who choose to avoid lactose. Soy products (soy beverages and tofu) are available as substitution options for cow's milk. Although there is no substitution for cheese for fully breastfeeding women, most individuals with lactose intolerance are able to consume cheese in small quantities.

Alignment of Foods with Specific Preferences and Dietary Practices

The committee considered how WIC food packages accommodate preferences for vegetarian and vegan diets and food-related religious practices (e.g., Kosher and Halal diets). This section summarizes the committee's evaluation of evidence supporting inclusion of foods in the packages that comply with these practices.

Vegetarian or Vegan Diets

Plant-based diets can be nutritionally adequate for infants, children, and adults (AND, 2009; AAP, 2014; USDA/HHS, 2016). A vegetarian diet does not include animal flesh foods (i.e., meat, fish, seafood), but it does include other animal products (e.g., eggs, milk, cheese, yogurt), whereas a vegan diet excludes all animal foods and products. Individuals who consume a vegan diet should pay particular attention to their intakes of vitamins B12, calcium (AND, 2009), and vitamin D (AND, 2009; Craig, 2009), but their requirement for these nutrients can be met by consuming fortified foods (AND, 2009). An additional concern exists for intakes of choline by pregnant women consuming vegan diets, but no research to date has assessed the intakes of choline by vegans. Individuals following a vegan diet may also have low intakes of eicosapentaenoic (EPA) and docosahexaenoic acids (DHA) (AND, 2009). The position of AND is that both vegetarian and vegan diets are not only adequate, but they may promote the prevention or aid in the treatment of certain health conditions (AND, 2009).

In cases where an infant's caretaker prefers to provide a vegetarian or vegan diet (as well as in cases where an infant does not tolerate cow's milk formula), the AAP supports the provision of soy protein–based formulas (Bhatia et al., 2008; AAP, 2014). A nutrition-related health challenge for breastfed infants adhering to a vegetarian or vegan diet is ensuring adequate iron intake. The introduction of complementary foods to infants at approximately 6 months of age is recommended, in part, to ensure adequate iron intake, and the AAP (2014) encourages early introduction of red meats and other foods rich in iron. AAP (2014) further indicates that oral iron supplementation may be needed for infants 6 to 12 months of age who are not consuming the recommended amount of iron from formula and complementary foods.

Soy formula is an option in all WIC packages for formula-fed infants. The WIC food packages include several foods that by nature are compliant with vegetarian and vegan diets, including fruits, vegetables, legumes, peanut butter, and grains. However, there are currently no vegetarian/vegan substitutions for fish and no vegan substitutions for eggs or cheese (see Table 3-2). A vegetarian or vegan substitution for infant meat is not permitted in the current WIC food packages.

TABLE 3-2

WIC Maximum Allowance Compared to the 2015–2020 DGA Food Pattern: Food Package VI, Women Up to 6 Months Postpartum.

Kosher or Halal Diets

Although federal regulations do not require foods that meet the needs of individuals who follow Kosher or Halal diets (in accordance with Jewish and Islamic dietary laws, respectively),^¹³ states have the option to accommodate these individuals (USDA/FNS, 2014). At least 53 percent of WIC participants are served by WIC agencies that allow either Kosher or Halal, or both Kosher and Halal substitutions (USDA/FNS, 2011; personal communication, N. Cole, Mathematica, March 17, 2015) (see Appendix H, Table H-1). A 2015 update of state options indicated that 7 percent of state agencies allowed Kosher milk, no state agencies specified whether they allowed Kosher eggs, 92 percent did not specify whether Kosher juice was allowed, and 8 percent did not allow Kosher juice. No additional data were available for other Kosher options, and an update of the national availability of Halal options was not presented (USDA/FNS, 2016b).

Only limited data are available to assess the proportion of WIC participants who observe Kosher or Halal practices, and these data indicate that such individuals are rare in the WIC-participating population. In a nationally representative study in which 2,649 WIC-participating mothers were interviewed, less than 1 percent were found to observe Kosher or Halal feeding practices (see Appendix H, Table H-2). In the same study, 0.4 percent of mothers were found to be vegetarian, and less than 0.1 percent reported following a vegan diet (personal communication, K. Castellanos-Brown, USDA/FNS, April 27, 2016).

Alignment with Other Cultural Needs, Preferences, and Practices

Given the culturally diverse populations served by WIC, it is important to consider the appropriateness of WIC foods in meeting the food preferences of its varied racial and ethnic subgroups. The AAP acknowledges the strong influence of culture on parental behaviors related to food choice, preparation, and consumption (AAP, 2014). However, cultural eating practices, and feeding styles of WIC participants in particular have been examined in only a few studies. What studies do exist have reported cultural differences in breastfeeding initiation and duration, foods available and accessible to young children in the home, parent modeling, parent encouragement, and family rules (Bonuck et al., 2005; Kasemsup and Reicks, 2006; Hurley et al., 2008; Mistry et al., 2008; Arthur, 2010; Evans et al., 2011; Skala et al., 2012; Marshall et al., 2013; Odoms-Young et al., 2014; St. Fleur and Petrova, 2014). In addition, one study indicated that vegetable and fruit consumption differs depending upon the race/ethnicity of WIC participants (Di Noia et al., 2016).

These varying parental styles and practices for infant and child feeding may shape early food preferences and eating patterns that, in turn, have been associated with the risk of overweight or obesity (Adair, 2008; Weng et al. 2012), although no connection has been established with specific foods or food groups (Grote and Theurich, 2014).

Cultural variations in infant and child feeding practices may also affect the use of specific WIC foods. Kim et al. (2013) reported that satisfaction with jarred baby foods varied across ethnic groups, with about half of whites and African Americans preferring cash value vouchers (CVVs) for fruits and vegetables over jarred baby foods compared to more than two-thirds of Latinos and those identifying as “Other” preferring CVVs for vegetables and fruits. However, redemption of jarred infant foods declined at similar rates with increasing infant age across all ethnic groups. Redemption data reviewed by the committee indicate that overall use of jarred infant vegetables and fruits may be poor. The committee also received many public comments requesting that the CVV replace jarred infant foods. This information suggests that in general, the CVV would allow the infant food packages to meet cultural needs and preferences for vegetables and fruits.

Other foods currently in the WIC food packages may also be more or less preferred by certain cultural groups. In the March 31, 2016, workshop convened by the committee,^¹⁴ panelists who were asked to speak about cultural preferences of WIC participants shared the following:

There is variation within broader cultural groups. For example, Latin American diets vary by region. In Mexico, corn and beans are core foods; in South America, potato, rice, and corn are staples; and in the Caribbean, preferences are for starchy root vegetables in addition to rice and beans.
Dairy, legumes, and peanut butter are not part of most traditional Asian diets.
WIC staff should avoid making assumptions about the stage of clients in the acculturation process, but instead should ask clients what foods are acceptable to them.
Several whole grain options offered by WIC, such as whole wheat pasta, brown rice, and whole wheat bread, are not widely accepted by many cultural groups.
Dry breakfast cereals are popular and often seen as status symbols, but people from porridge-based cultures may prefer hot cereals or boiled root vegetables.

FINDINGS AND CONCLUSIONS: POTENTIAL AREAS FOR FOOD PACKAGE MODIFICATIONS

In this chapter, the alignment of the current food packages with the most recent dietary guidance and the suitability of WIC foods for particular medical conditions and to meet dietary preferences and practices are reviewed. Table 3-16 summarizes the committee's findings on key aspects of the food package as well as the conclusions the committee drew from these findings.

TABLE 3-16

Alignment of the Current Food Packages with Dietary Guidance, Special Dietary Needs, and Cultural Eating Practices or Food Preferences.

REFERENCES

AAP (American Academy of Pediatrics). Breastfeeding and the use of human milk. Pediatrics. 2012;129(3):e827–e841. [PubMed: 22371471]
AAP. Pediatric nutrition. 7th ed. Kleinman RE, Greer FR, editors. Elk Grove Village, IL: American Academy of Pediatrics; 2014.
AAP Committee on Nutrition. Hypoallergenic infant formulas. Pediatrics. 2000;106(2):346–349. [PubMed: 10920165]
AAP Committee on Nutrition. Lipid screening and cardiovascular health in childhood. Pediatrics. 2008;122(1):198–208. [PubMed: 18596007]
AAP Committee on Nutrition. Diagnosis and prevention of iron deficiency and iron-deficiency anemia in infants and young children (0-3 years of age). Pediatrics. 2010;126(5):1040–1050. [PubMed: 20923825]
AAP Committee on Injury, Violence, and Poison Prevention. Policy statement—prevention of choking among children. Pediatrics. 2010;125(3):601–607. [PubMed: 20176668]
Adair LS. Child and adolescent obesity: Epidemiology and developmental perspectives. Physiology & Behavior. 2008;94(1):8–16. [PubMed: 18191968]
AHA (American Heart Association). Fish and omega-3 fatty acids. 2015. [August 30, 2016]. http://www.heart.org/HEARTORG/HealthyLiving/HealthyEating/HealthyDietGoals/Fish-and-Omega-3-Fatty-Acids_UCM_303248_Article.jsp.
AND (Academy of Nutrition and Dietetics). Pregnancy and nutrition—gluten-free diet. 2006. [October 18, 2016]. http://andevidencelibrary.com/conclusion.cfm?conclusion_statement_id=250329.
AND. Position of the Academy of Nutrition and Dietetics: Vegetarian diets. Journal of the Academy of Nutrition and Dietetics. 2009;109:1266–1282. [PubMed: 19562864]
AND. Position of the Academy of Nutrition and Dietetics: Nutrition and lifestyle for a healthy pregnancy outcome. Journal of the Academy of Nutrition and Dietetics. 2014;114(7):1099–1103. [PubMed: 24956993]
AND. Position of the Academy of Nutrition and Dietetics: Promoting and supporting breastfeeding. Journal of the Academy of Nutrition and Dietetics. 2015;115(3):444–449. [PubMed: 25721389]
Arthur TM. An examination of household environmental influences on healthy eating behaviors among African American primary caregivers and children. College Station: Texas A&M University; 2010. [October 18, 2016]. http://hdl.handle.net/1969.1/ETD-TAMU-2010-12-9028.
Bailey RK, Fileti CP, Keith J, Tropez-Sims S, Price W, Allison-Ottey SD. Lactose intolerance and health disparities among African Americans and Hispanic Americans: An updated consensus statement. Journal of the National Medical Association. 2013;105(2):112–127. [PubMed: 24079212]
Bhatia J, Greer F., American Academy of Pediatrics Committee on Nutrition. Use of soy protein-based formulas in infant feeding. Pediatrics. 2008;121(5):1062–1068. [PubMed: 18450914]
Bonuck KA, Freeman K, Trombley M. Country of origin and race/ethnicity: Impact on breastfeeding intentions. Journal of Human Lactation. 2005;21(3):320–326. [PubMed: 16113020]
Branchi F, Aziz I, Conte D, Sanders DS. Noncoeliac gluten sensitivity: A diagnostic dilemma. Current Opinion in Clinical Nutrition and Metabolic Care. 2015;18(5):508–514. [PubMed: 26147528]
CDC (Centers for Disease Control and Prevention). Trends in allergic conditions among children: United States, 1997-2011. NCHS Data Brief. 2013;(121):1–8.
Chafen JS, Newberry S, Riedl M, Bravata DM, Maglione M, Suttorp M, Sundaram V, Paige NM, Towfigh A, Hulley BJ, Shekelle PG. Prevalence, natural history, diagnosis, and treatment of food allergy: A systematic review of the evidence. Santa Monica, CA: RAND; 2010. [October 18, 2016]. http://www.rand.org/content/dam/rand/pubs/working_papers/2010/RAND_WR757-1.pdf.
Craig WJ. Health effects of vegan diets. American Journal of Clinical Nutrition. 2009;89(5):1627S–1633S. [PubMed: 19279075]
Di Noia J, Monica D, Cullen KW, Pérez-Escamilla R, Gray HL, Sikorskii A. Differences in fruit and vegetable intake by race/ethnicity and by Hispanic origin and nativity among women in the Special Supplemental Nutrition Program for Women, Infants, and Children. Preventing Chronic Disease. 2016;13(E115) [PMC free article: PMC5003529] [PubMed: 27560723] [CrossRef]
DiGiacomo DV, Tennyson CA, Green PH, Demmer RT. Prevalence of gluten-free diet adherence among individuals without celiac disease in the USA: Results from the continuous National Health and Nutrition Examination Survey 2009-2010. Scandinavian Journal of Gastroenterology. 2013;48(8):921–925. [PubMed: 23834276]
Du Toit G, Katz Y, Sasieni P, Mesher D, Maleki SJ, Fisher HR, Fox AT, Turcanu V, Amir T, Zadik-Mnuhin G, Cohen A, Livne I, Lack G. Early consumption of peanuts in infancy is associated with a low prevalence of peanut allergy. Journal of Allergy and Clinical Immunology. 2008;122(5):984–991. [PubMed: 19000582]
Du Toit G, Roberts G, Sayre PH, Bahnson HT, Radulovic S, Santos AF, Brough HA, Phippard D, Basting M, Feeney M, Turcanu V, Sever ML, Gomez Lorenzo M, Plaut M, Lack G, Team LS. Randomized trial of peanut consumption in infants at risk for peanut allergy. New England Journal of Medicine. 2015;372(9):803–813. [PMC free article: PMC4416404] [PubMed: 25705822]
Eliasi JR, Dwyer JT. Kosher and halal. Journal of the American Dietetic Association. 2002;102(7):911–913. [PubMed: 12146548]
Elli L, Branchi F, Tomba C, Villalta D, Norsa L, Ferretti F, Roncoroni L, Bardella MT. Diagnosis of gluten related disorders: Celiac disease, wheat allergy and non-celiac gluten sensitivity. World Journal of Gastroenterology. 2015;21(23):7110–7119. [PMC free article: PMC4476872] [PubMed: 26109797]
Evans A, Seth JG, Smith S, Harris KK, Loyo J, Spaulding C, Van Eck M, Gottlieb N. Parental feeding practices and concerns related to child underweight, picky eating, and using food to calm differ according to ethnicity/race, acculturation, and income. Maternal and Child Health Journal. 2011;15(7):899–909. [PubMed: 19771501]
FAO/WHO (Food and Agriculture Organization/World Health Organization). Joint FAO/WHO expert consultation on the risks and benefits of fish consumption. Rome/Geneva: WHO/FAO; 2010. [December 21, 2016]. http://www.fao.org/docrep/014/ba0136e/ba0136e00.pdf.
FDA/EPA (U.S. Food and Drug Administration/Environmental Protection Agency). Fish: What pregnant women and parents should know. Silver Spring, MD: FDA; 2014. [December 21, 2016]. http://www.fda.gov/food/foodborneillnesscontaminants/metals/ucm393070.htm.
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]
Fleischer DM, Spergel JM, Assa'ad AH, Pongracic JA. Primary prevention of allergic disease through nutritional interventions. Journal of Allergy and Clinical Immunology: In Practice. 2013;1(1):29–36. [PubMed: 24229819]
Fleischer DM, Sicherer S, Greenhawt M, Campbell D, Chan E, Muraro A, Halken S, Katz Y, Ebisawa M, Eichenfield L, Sampson H, Lack G, Du Toit G, Roberts G, Bahnson H, Feeney M, Hourihane J, Spergel J, Young M, As'aad A, Allen K, Prescott S, Kapur S, Saito H, Agache I, Akdis CA, Arshad H, Beyer K, Dubois A, Eigenmann P, Fernandez-Rivas M, Grimshaw K, Hoffman-Sommergruber K, Host A, Lau S, O'Mahony L, Mills C, Papadopoulos N, Venter C, Agmon-Levin N, Kessel A, Antaya R, Drolet B, Rosenwasser L. Consensus communication on early peanut introduction and the prevention of peanut allergy in high-risk infants. Journal of Allergy and Clinical Immunology. 2015;136(2):258–261. [PubMed: 26100082]
Greenhawt M. Early allergen introduction for preventing development of food allergy. Journal of the American Medical Association. 2016;316(11):1157–1159. [PubMed: 27654600]
Greer FR, Sicherer SH, Burks AW., American Academy of Pediatrics Committee on Nutrition. Effects of early nutritional interventions on the development of atopic disease in infants and children: The role of maternal dietary restriction, breastfeeding, timing of introduction of complementary foods, and hydrolyzed formulas. Pediatrics. 2008;121(1):183–191. [PubMed: 18166574]
Grote V, Theurich M. Complementary feeding and obesity risk. Current Opinion in Clinical Nutrition and Metabolic Care. 2014;17(3):273–277. [PubMed: 24613861]
Gruchalla RS, Sampson HA. Preventing peanut allergy through early consumption—ready for prime time? New England Journal of Medicine. 2015;372(9):875–877. [PubMed: 25705823]
Guandalini S, Assiri A. Celiac disease: A review. JAMA Pediatrics. 2014;168(3):272–278. [PubMed: 24395055]
Hurley KM, Black MM, Papas MA, Quigg AM. Variation in breastfeeding behaviours, perceptions, and experiences by race/ethnicity among a low-income statewide sample of Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participants in the United States. Maternal and Child Nutrition. 2008;4(2):95–105. [PMC free article: PMC6860842] [PubMed: 18336643]
Husby S, Murray J. Non-celiac gluten hypersensitivity: What is all the fuss about? F1000Prime Rep. 2015;7(54) [PMC free article: PMC4447038] [PubMed: 26097727]
IOM (Institute of Medicine). Dietary Reference Intakes for calcium, phosphorus, magnesium, vitamin D, and fluoride. Washington, DC: National Academy Press; 1997. [PubMed: 23115811]
IOM. Dietary Reference Intakes for thiamin, riboflavin, niacin, vitamin B6, folate, vitamin B12, pantothenic acid, biotin, and choline. Washington, DC: National Academy Press; 1998. [PubMed: 23193625]
IOM. Dietary Reference Intakes for vitamin C, vitamin E, selenium, and carotenoids. Washington, DC: National Academy Press; 2000. [PubMed: 25077263]
IOM. Dietary Reference Intakes for vitamin A, vitamin K, arsenic, boron, chromium, copper, iodine, iron, manganese, molybdenum, nickel, silicon, vanadium, and zinc. Washington, DC: National Academy Press; 2001. [PubMed: 25057538]
IOM. Dietary Reference Intakes for energy, carbohydrate, fiber, fat, fatty acids, cholesterol, protein and amino acids. Washington, DC: The National Academies Press; 2002/2005. [PubMed: 12449285]
IOM. Dietary Reference Intakes for water, potassium, sodium, chloride, and sulfate. Washington, DC: The National Academies Press; 2005.
IOM. WIC food packages: Time for a change. Washington, DC: The National Academies Press; 2006.
IOM. Dietary Reference Intakes for calcium and vitamin D. Washington, DC: The National Academies Press; 2011a. [PubMed: 21796828]
IOM. Updating the USDA national breastfeeding campaign: Workshop summary. Washington, DC: The National Academies Press; 2011b.
Kasemsup R, Reicks M. The relationship between maternal child-feeding practices and overweight in Hmong preschool children. Ethnicity & Disease. 2006;16(1):187–193. [PubMed: 16599369]
Kim LP, Whaley SE, Gradziel PH, Crocker NJ, Ritchie LD, Harrison GG. Mothers prefer fresh fruits and vegetables over jarred baby fruits and vegetables in the new Special Supplemental Nutrition Program for Women, Infants, and Children food package. Journal of Nutrition Education and Behavior. 2013;45(6):723–727. [PubMed: 23591317]
Lebwohl B, Ludvigsson JF, Green PH. Celiac disease and non-celiac gluten sensitivity. BMJ. 2015;351(h4347) [PMC free article: PMC4596973] [PubMed: 26438584]
Lomer MC, Parkes GC, Sanderson JD. Review article: Lactose intolerance in clinical practice—myths and realities. Alimentary Pharmacology and Therapeutics. 2008;27(2):93–103. [PubMed: 17956597]
Marshall C, Gavin L, Bish C, Winter A, Williams L, Wesley M, Zhang L. WIC participation and breastfeeding among white and black mothers: Data from Mississippi. Maternal and Child Health Journal. 2013;17(10):1784–1792. [PubMed: 23203317]
Mistry Y, Freedman M, Sweeney K, Hollenbeck C. Infant-feeding practices of low-income Vietnamese American women. Journal of Human Lactation. 2008;24(4):406–414. [PubMed: 18776168]
Mooney PD, Hadjivassiliou M, Sanders DS. Coeliac disease. BMJ. 2014;348(g1561) [PubMed: 24589518]
NASEM (National Academies of Sciences, Engineering, and Medicine). Review of WIC food packages: Proposed framework for revisions: Interim report. Washington, DC: The National Academies Press; 2016. [PubMed: 27512745] [CrossRef]
Netting MJ, Middleton PF, Makrides M. Does maternal diet during pregnancy and lactation affect outcomes in offspring? A systematic review of food-based approaches. Nutrition. 2014;30(11-12):1225–1241. [PubMed: 25280403]
NHLBI (National Heart, Lung, and Blood Institute). Expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents: Summary report. Bethesda, MD: NIH; 2011. [May 24, 2015]. http://www.nhlbi.nih.gov/health-pro/guidelines/current/cardiovascular-health-pediatric-guidelines/summary. [PMC free article: PMC4536582] [PubMed: 22084329]
Odoms-Young AM, Kong A, Schiffer LA, Porter SJ, Blumstein L, Bess S, Berbaum ML, Fitzgibbon ML. Evaluating the initial impact of the revised Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food packages on dietary intake and home food availability in African-American and Hispanic families. Public Health Nutrition. 2014;17(1):83–93. [PMC free article: PMC3858404] [PubMed: 23544992]
PAHO/WHO (Pan American Health Organization/World Health Organization). Guiding principles for complementary feeding of the breastfed child. Geneva: PAHO/WHO; 2003. [August 30, 2016]. http://www.who.int/maternal_child_adolescent/documents/a85622/en.
Rubio-Tapia A, Hill ID, Kelly CP, Calderwood AH, Murray JA., American College of Gastroenterology. ACG clinical guidelines: Diagnosis and management of celiac disease. American Journal of Gastroenterology. 2013;108(5):656–676. quiz 677. [PMC free article: PMC3706994] [PubMed: 23609613]
Saccone G, Berghella V, Sarno L, Maruotti GM, Cetin I, Greco L, Khashan AS, McCarthy F, Martinelli D, Fortunato F, Martinelli P. Celiac disease and obstetric complications: A systematic review and metaanalysis. American Journal of Obstetrics and Gynecology. 2016;214(2):225–234. [PubMed: 26432464]
Skala K, Chuang RJ, Evans A, Hedberg AM, Dave J, Sharma S. Ethnic differences in the home food environment and parental food practices among families of low-income Hispanic and African-American preschoolers. Journal of Immigrant and Minority Health. 2012;14(6):1014–1022. [PMC free article: PMC3368054] [PubMed: 22262411]
St.Fleur R, Petrova A. Knowledge and perception of breastfeeding practices in Hispanic mothers in association with their preferred language for communication. Breastfeeding Medicine. 2014;9(5):261–265. [PubMed: 24784835]
Suarez FL, Savaiano DA, Levitt MD. A comparison of symptoms after the consumption of milk or lactose-hydrolyzed milk by people with self-reported severe lactose intolerance. New England Journal of Medicine. 1995;333(1):1–4. [PubMed: 7776987]
Suarez FL, Savaiano D, Arbisi P, Levitt MD. Tolerance to the daily ingestion of two cups of milk by individuals claiming lactose intolerance. American Journal of Clinical Nutrition. 1997;65(5):1502–1506. [PubMed: 9129483]
Thompson T. Folate, iron, and dietary fiber contents of the gluten-free diet. Journal of the American Dietetic Association. 2000;100(11):1389–1396. [PubMed: 11103663]
USDA/ARS (U.S. Department of Agriculture/Agricultural Research Service). Food patterns equivalents database 2011-12: Methodology and user guide. Beltsville, MD: USDA/ARS; 2014. [December 21, 2016]. http://www.ars.usda.gov/SP2UserFiles/Place/80400530/pdf/fped/FPED_1112.pdf.
USDA/ARS. USDA National Nutrient Database for Standard Reference. Release 28. Beltsville, MD: USDA/ARS; 2016. [November 11, 2016]. https://www.ars.usda.gov/northeast-area/beltsville-md/beltsville-human-nutrition-research-center/nutrient-data-laboratory/docs/usda-national-nutrient-database-for-standard-reference.
USDA/FNS (U.S. Department of Agriculture/Food and Nutrition Service). WIC food packages policy options study, final report. Alexandria, VA: USDA/FNS; 2011. [February 15, 2017]. http://www.fns.usda.gov/sites/default/files/WICFoodPackageOptions.pdf.
USDA/FNS. Nutrition standards in the National School Lunch and School Breakfast Programs. Final Rule. Federal Register. 2012;77(17):4088–4167. [PubMed: 22359796]
USDA/FNS. final rule, 7 C.F.R. § 246. 2014. Special Supplemental Nutrition Program for Women, Infants and Children (WIC): Revisions in the WIC food packages;
USDA/FNS. WIC food packages policy options II, final report. Alexandria, VA: USDA/FNS; 2015a. [February 15, 2017]. https://www.fns.usda.gov/sites/default/files/ops/WICFoodPolicyOptions2.pdf.
USDA/FNS. Food allergies. 2015b. [December 21, 2016]. http://wicworks.nal.usda.gov/topics-z/food-allergies.
USDA/FNS. Policy memorandum CACFP 17-2016: Nutrition requirements for fluid milk and fluid milk substitutions in the Child and Adult Care Food Program, questions and answers. Alexandria, VA: 2016a.
USDA/FNS. WIC participant and program characteristics 2014 food package report. Alexandria, VA: USDA/FNS; 2016b. [August 30, 2016]. http://www.fns.usda.gov/wic-participant-and-program-characteristics-2014-food-package-report.
USDA/HHS (U.S. Department of Agriculture/U.S. Department of Health and Human Services). The report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines for Americans, 2015, to the Secretary of Agriculture and the Secretary of Health and Human Services. Washington, DC: USDA/HHS; 2015. [December 21, 2016]. http://www.health.gov/dietaryguidelines/2015-scientific-report/PDFs/Scientific-Report-of-the-2015-DietaryGuidelines-Advisory-Committee.pdf.
USDA/HHS. 2015-2020 Dietary Guidelines for Americans. Washington, DC: U.S. Government Printing Office; 2016. [August 29, 2016]. https://health.gov/dietaryguidelines/2015.
Weng SF, Redsell SA, Swift JA, Yang M, Glazebrook CP. Systematic review and meta-analyses of risk factors for childhood overweight identifiable during infancy. Archives of Disease in Childhood. 2012;97(12):1019–1026. [PMC free article: PMC3512440] [PubMed: 23109090]
WHO (World Health Organization). Guiding principles for feeding non-breastfed children 6-24 months of age. Geneva, Switzerland: WHO; 2005. [August 30, 2016]. http://www.who.int/maternal_child_adolescent/documents/9241593431/en.
WHO. Infant and young child feeding. Geneva, Switzerland: World Health Organization; 2009.

Footnotes

1: References to the DGA in this chapter are specific to 2015–2020 unless otherwise noted.

2: Based on the lower end of the AAP range of 4 to 6 ounces per day.

3: The food patterns applied in this report were selected based on the Estimated Energy Requirements calculated or assumed for each age and physiological-state subgroup, as outlined in Appendix J.

4: States may implement cost-containment practices in order to reduce the average food cost per WIC participant. This may include limiting food selection by size, form, or price, as well as mandating the use of particular brands.

5: These estimates are based on several assumptions, as described in detail in Appendix R.

6: To develop the food package nutrient profiles, the nutrient contribution of each WIC food category (i.e., “milk” or “bread”) was determined. The category may include the nutrient contributions of substitution options (i.e., cheese for milk) as described in Appendix R.

7: Any formula that is noncontract is not subject to rebates. Exempt infant formula is always noncontract. By federal regulation, for WIC participants who are also on Medicaid, the Medicaid program is the primary payer for exempt infant formulas, as well as for WIC-eligible nutritionals. WIC is not the primary payer for Medicaid beneficiaries but may be the payer for those not on Medicaid. Some private insurance may also cover exempt formula.

8: WIC formula refers to infant formula, exempt infant formula, or a WIC-eligible nutritional.

9: As specified in the Final Rule, exceptions to the maximum monthly allowance of all other foods may be made for recipients of food package III, including (1) whole milk may be provided to children over 2 years of age and to women with a qualifying condition; (2) state agencies have the flexibility to provide children and women the option of receiving commercial jarred infant food fruits and vegetables in lieu of the cash value voucher; and (3) WIC formula may be provided in lieu of foods at 6 months of age.

10: Text in this paragraph is updated from the original prepublication version.

11: Hydrolyzed refers to formulas containing cow's milk proteins that have been extensively broken down so they are unlikely to cause an allergic reaction.

12: NCGS is defined as the occurrence of gastrointestinal symptoms after the ingestion of wheat-containing foods in the absence of celiac disease or wheat allergy. Because there is no biomarker for gluten sensitivity, NCGS is not clinically diagnosable and is generally self-diagnosed (Branchi et al., 2015; Elli et al., 2015; Lebwohl et al., 2015). DiGiacomo et al. (2013) reported a 0.55 percent prevalence of NCGS in NHANES 2009–2010, although gluten-free diets may have become more prevalent since then. Additional studies are needed to understand the etiology and underlying physiology of NCGS (Husby and Murray, 2015).

13: Eliasi and Dwyer (2002) provide a detailed description of Kosher and Halal diets. Very generally, for Kosher diets, meats must be prepared a certain way, animal products must come from Kosher-prepared animals, and packaged foods must be Kosher-certified. Fruits and vegetables are considered inherently Kosher. To be considered Halal, meats must be prepared in a particular way and milk and foods prepared from milk must come from Halal animals.

14: See Appendix D for workshop agendas.

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. 3, Alignment of the Current Food Packages with Dietary Guidance, Special Dietary Needs, and Cultural Eating Practices or Food Preferences.

TABLE 3-1WIC Maximum Allowance Compared to the 2015–2020 DGA Food Pattern: Food Package V, Pregnant and Partially Breastfeeding Women, Up to 1 Year Postpartum

WIC Food Category	DGA Food Group	Units/d	WIC Maximum Allowance	DGA 2,600-kcal Food Pattern	% of 2,600-kcal DGA Recommendation^a
Total fruit	Total fruit	c-eq	1.0	2.0	52
Juice, 100%^b	Fruit, as juice	c-eq	0.6	1.0	60
Fruit, 67% of CVV^c	Fruit, whole	c-eq	0.4	1.0	45
Total vegetables	Total vegetables	c-eq	0.5	3.5	13
Vegetable, 33% of CVV^d		c-eq	0.2	3.5	6
Legumes (as a vegetable)^e	Beans and peas	c-eq	0.3	0.4	71
Total dairy	Total dairy	c-eq	2.9	3.0	98
Milk		c-eq	2.9	3.0	98
Total grains	Total grains	oz-eq	1.7	9.0	19
Breakfast cereal^f	Refined grains	oz-eq	1.0	4.5	22
Breakfast cereal	Whole grains	oz-eq	0.2	4.5	17^g
Whole wheat bread	Whole grains	oz-eq	0.5
Total protein foods	Total protein foods	oz-eq	1.6	6.5	28
Peanut butter	Nuts, seeds, and soy	oz-eq	1.2	0.7	168
Eggs	Meat, poultry, and eggs	oz-eq	0.4	4.4	9
Fish	Seafood	oz-eq	0.0	1.4	0

: NOTES: c-eq = cup-equivalents; CVV = cash value voucher; DGA = Dietary Guidelines for Americans; oz-eq = ounce-equivalents.

a: This kcal level most closely matched the calculated Estimated Energy Requirement for pregnant or breastfeeding WIC-participating women in NHANES 2005–2012. In the current WIC food packages, pregnant women and partially breastfeeding women receive the same benefits. Percentages represent the proportion of the recommended food pattern amount in the corresponding row of the DGA food pattern column.

b: The DGA recommend that not more than 50 percent of total fruit intakes come from 100 percent fruit juice (USDA/HHS, 2016).

c: Assumes that 67 percent of the CVV is used to purchase fruits, based on redemption data from Texas and Wyoming. A weighted composite cost of fruit ($0.55/c-eq) was developed, based on a composite of the most commonly consumed fruits (bananas, apples, oranges, berries, grapes, melon [watermelon was used in this case]) from an average of Massachusetts, Texas, and Wyoming redemption data. Only fresh fruit was included as all states allow fresh forms; ERS 2013 price data were updated with a consumer price index to 2015 values.

d: Assumes that 33 percent of the CVV is used to purchase vegetables, based on redemption data from Texas and Wyoming. A weighted composite cost of vegetables ($0.55/c-eq) was developed, based on a composite of the most commonly consumed vegetables (tomatoes, avocados, potatoes, peppers, lettuce) from an average of Massachusetts, Texas, and Wyoming redemption data. Only fresh vegetables were included as all states allow fresh forms; ERS 2013 price data were updated with a consumer price index to 2015 values. Because potatoes were not yet available in Wyoming, the same proportion of potatoes was assumed for this state as for Texas.

e: Legumes can also be assessed as a protein, but were placed in the vegetable group because a higher proportion of individuals had low intakes of vegetables across WIC participating subgroups compared to protein.

f: In the current food packages, a ratio of 81 percent refined grains and 19 percent whole grains was applied, based on redemption data.

g: To compare the food package contribution to the DGA recommended amounts of whole grains, the whole grain portion of breakfast cereal was added to the whole grain contribution of bread.

: SOURCES: USDA/ARS, 2014; USDA/FNS, 2014; USDA/HHS, 2016. State-specific data are available in the public access file for this study (Email: paro@nas.edu).

TABLE 3-2WIC Maximum Allowance Compared to the 2015–2020 DGA Food Pattern: Food Package VI, Women Up to 6 Months Postpartum

WIC Food Category	DGA Food Group	Units/d	WIC Maximum Allowance	DGA 2,300-kcal Food Pattern	% of 2,300-kcal DGA Recommendation^a
Total fruit	Total fruit	c-eq	0.8	2.0	42
Juice, 100%^b	Fruit, juice	c-eq	0.4	1.0	40
Fruit, 67% of CVV^c	Fruit, whole	c-eq	0.4	1.0	45
Total vegetables	Total vegetables	c-eq	0.3	3.0	12
Vegetable, 33% of CVV^d		c-eq	0.2	3.0	7
Legumes (as a vegetable)^e,f	Beans and peas	c-eq	0.1	0.3	44
Total dairy	Total dairy	c-eq	2.1	3.0	71
Milk		c-eq	2.1	3.0	71
Total grains	Total grains	oz-eq	1.2	7.5	16
Breakfast cereal^g	Refined grains	oz-eq	1.0	3.8	26
Breakfast cereal	Whole grains	oz-eq	0.2	3.8	6
Total protein foods	Total protein foods	oz-eq	1.3	6.3	20
Peanut butter^f	Nuts, seeds, and soy	oz-eq	0.6	0.7	84
Eggs	Meat, poultry, and eggs	oz-eq	0.4	4.2	10
Fish	Seafood	oz-eq	0.0	1.4	0

: NOTES: c-eq = cup-equivalents; CVV = cash value voucher; DGA = Dietary Guidelines for Americans; oz-eq = ounce-equivalents; PP = postpartum.

a: The 2,300-kcal food pattern level most closely matched the calculated Estimated Energy Requirement for postpartum WIC-participating women in NHANES 2005–2012. Percentages represent the proportion of the recommended food pattern amount in the corresponding row of the DGA food pattern column.

b: The DGA recommend that not more than 50 percent of total fruit intake come from 100 percent fruit juice (USDA/HHS, 2016).

c: Assumes that 67 percent of the CVV is used to purchase fruits, based on redemption data from Texas and Wyoming. A weighted composite cost of fruit ($0.55/c-eq) was developed, based on a composite of the most commonly consumed fruits (bananas, apples, oranges, berries, grapes, melon [watermelon was used in this case]) from an average of Massachusetts, Texas, and Wyoming redemption data. Only fresh fruit was included as all states allow fresh forms; ERS 2013 price data were updated with a consumer price index to 2015 values.

d: Assumes that 33 percent of the CVV is used to purchase vegetables, based on redemption data from Texas and Wyoming. A weighted composite cost of vegetables ($0.55/c-eq) was developed, based on a composite of the most commonly consumed vegetables (tomatoes, avocados, potatoes, peppers, lettuce) from an average of Massachusetts, Texas, and Wyoming redemption data. Only fresh vegetables were included as all states allow fresh forms; ERS 2013 price data were updated with a consumer price index to 2015 values. Because potatoes were not yet available in Wyoming, the same proportion of potatoes was assumed for this state as for Texas.

e: Legumes can also be assessed as a protein, but were placed in the vegetable group because a higher proportion of individuals had low intakes of vegetables across WIC participating subgroups compared to protein.

f: Assumes 50 percent legumes and 50 percent peanut butter. Because these values account for the proportion of the maximum allowance of legumes and peanut butter provided per month, they are lower than those presented in the phase I report (NASEM, 2016).

g: In the current food packages, a ratio of 81 percent refined grains and 19 percent whole grains was applied, based on redemption data.

: SOURCES: USDA/ARS, 2014; USDA/FNS, 2014; USDA/HHS, 2016. State-specific data are available in the public access file for this study (Email: paro@nas.edu).

TABLE 3-3WIC Maximum Allowance Compared to the 2015–2020 DGA Food Pattern: Food Package VII, Fully Breastfeeding Women Up to 1 Year Postpartum

WIC Food Category	DGA Food Group	Units/d	WIC Maximum Allowance	DGA 2,600-kcal Food Pattern	% of 2,600-kcal DGA Recommendation^a
Total fruit	Total fruit	c-eq	1.0	2.0	52
Juice, 100%^b	Fruit, juice	c-eq	0.6	1.0	60
Fruit, 67% of CVV^c	Fruit, whole	c-eq	0.4	1.0	45
Total vegetables	Total vegetables	c-eq	0.5	3.5	13
Vegetable, 33% of CVV^d		c-eq	0.2	3.5	6
Legumes (as a vegetable)^e	Beans and peas	c-eq	0.3	0.4	71
Total dairy	Total dairy	c-eq	3.6	3.0	119
Milk		c-eq	3.2	3.0	107
Cheese		c-eq	0.4	3.0	12
Total grains	Total grains	oz-eq	1.7	9.0	19
Breakfast cereal^f	Refined grains	oz-eq	1.0	4.5	22
Breakfast cereal	Whole grains	oz-eq	0.2	4.5	17^g
Whole wheat bread	Whole grains	oz-eq	0.5
Total protein foods	Total protein foods	oz-eq	3.3	6.5	50
Peanut butter	Nuts, seeds, and soy	oz-eq	1.2	0.7	168
Eggs	Meat, poultry, and eggs	oz-eq	0.8	4.4	18
Fish	Seafood	oz-eq	1.0	1.4	70

: NOTES: c-eq = cup-equivalents; CVV = cash value voucher; DGA = Dietary Guidelines for Americans; oz-eq = ounce-equivalents.

a: The 2,600-kcal food pattern level most closely matched the calculated Estimated Energy Requirement for breastfeeding WIC-participating women in NHANES 2005–2012. Percentages represent the proportion of the recommended food pattern amount in the corresponding row of the DGA food pattern column.

b: The DGA recommend that not more than 50 percent of fruit intakes come from 100 percent fruit juice (USDA/HHS, 2016)

c: Assumes that 67 percent of the CVV is used to purchase fruits, based on redemption data from Texas and Wyoming. A weighted composite cost of fruit ($0.55/c-eq) was developed, based on a composite of the most commonly consumed fruits (bananas, apples, oranges, berries, grapes, melon [watermelon was used in this case]) from an average of Massachusetts, Texas, and Wyoming redemption data. Only fresh fruit was included as all states allow fresh forms; ERS 2013 price data were updated with a consumer price index to 2015 values.

d: Assumes that 33 percent of the CVV is used to purchase vegetables, based on redemption data from Texas and Wyoming. A weighted composite cost of vegetables ($0.55/c-eq) was developed, based on a composite of the most commonly consumed vegetables (tomatoes, avocados, potatoes, peppers, lettuce) from an average of Massachusetts, Texas, and Wyoming redemption data. Only fresh vegetables were included as all states allow fresh forms; ERS 2013 price data were updated with a consumer price index to 2015 values. Because potatoes were not yet available in Wyoming, the same proportion of potatoes was assumed for this state as for Texas.

e: Legumes can also be assessed as a protein, but were placed in the vegetable group because a higher proportion of individuals had low intakes of vegetables across WIC participating subgroups compared to protein.

f: In the current food packages, a ratio of 81 percent refined grains and 19 percent whole grains was applied, based on redemption data.

g: To compare the food package contribution to the DGA recommended amounts of whole grains, the whole grain portion of breakfast cereal was added to the whole grain contribution of bread.

: SOURCES: USDA/ARS, 2014; USDA/FNS, 2014; USDA/HHS, 2016. State-specific data are available in the public access file for this study (Email: paro@nas.edu).

TABLE 3-4WIC Maximum Allowance Compared to the 2015–2020 DGA Food Pattern: Food Package IV, Children 2 to Less Than 5 Years of Age^*

WIC Food Category	DGA Food Group	Units/d	WIC Maximum Allowance	DGA 1,300-kcal Food Pattern	% of 1,300-kcal DGA Recommendation^b
Total fruit	Total fruit	c-eq	0.9	1.25	69
Juice, 100%	Fruit, juice	c-eq	0.5	0.5^h	107
Fruit, 67% of CVV^c	Fruit, whole	c-eq	0.3	0.7	43
Total vegetables	Total vegetables	c-eq	0.3	1.5	19
Vegetable, 33% of CVV^d		c-eq	0.2	1.5	11
Legumes (as a vegetable)^e,f	Beans and peas	c-eq	0.13	0.07	177
Total dairy	Total dairy	c-eq	2.1	2.5	85
Milk		c-eq	2.1	2.5	85
Total grains	Total grains	oz-eq	2.3	4.5	50
Breakfast cereal^g	Refined grains	oz-eq	1.0	2.3	43
Breakfast cereal	Whole grains	oz-eq	0.2	2.3	58ⁱ
Whole wheat bread	Whole grains	oz-eq	1.1
Total protein foods	Total protein foods	oz-eq	1.0	3.5	29
Peanut butter^f	Nuts, seeds, and soy	oz-eq	0.6	0.4	167
Eggs	Meat, poultry, and eggs	oz-eq	0.4	2.4	17
Fish	Seafood	oz-eq	0.0	0.6	0

: NOTES: c-eq = cup-equivalents; CVV = cash value voucher; DGA = Dietary Guidelines for Americans; NR = no recommendation; oz-eq = ounce-equivalents.

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

a: The DGA apply to individuals ages 2 years and older; therefore, although food package IV is issued to younger children, the table is applicable only to those ages 2 to less than 5 years.

b: For children ages 2 to less than 5 years, the median calculated Estimated Energy Requirement was 1,517 kcals. A food pattern of 1,300 kcal was selected for this age group because (1) 1,500 kcal/d may reflect recent increases in body weights for young children and was considered too high for normal weight children in this age group, particularly in light of efforts to reduce and/or contain the prevalence of childhood obesity, and (2) the 1,300-kcal pattern was applied in both the previous WIC food package review (IOM, 2006) and the Child and Adult Care Food Program (CACFP) report (IOM, 2011a) and should similarly be appropriate for current WIC participating children of the same ages. Percentages represent the proportion of the recommended food pattern amount in the corresponding row of the DGA food pattern column.

c: Assumes that 67 percent of the CVV is used to purchase fruits, based on redemption data from Texas and Wyoming. A weighted composite cost of fruit ($0.55/c-eq) was developed, based on a composite of the most commonly consumed fruits (bananas, apples, oranges, berries, grapes, melon [watermelon was used in this case]) from an average of Massachusetts, Texas, and Wyoming redemption data. Only fresh fruit was included as all states allow fresh forms; ERS 2013 price data were updated with a consumer price index to 2015 values.

d: Assumes that 33 percent of the CVV is used to purchase vegetables, based on redemption data from Texas and Wyoming. A weighted composite cost of vegetables ($0.55/c-eq) was developed, based on a composite of the most commonly consumed vegetables (tomatoes, avocados, potatoes, peppers, lettuce) from an average of Texas, Wyoming, and Massachusetts redemption data. Only fresh vegetables were included as all states allow fresh forms; ERS 2013 price data were updated with a consumer price index to 2015 values. Because potatoes were not yet available in Wyoming, the same proportion of potatoes was assumed for this state as for Texas.

e: Legumes can also be assessed as a protein, but were placed in the vegetable group because a higher proportion of individuals had low intakes of vegetables across WIC participating subgroups compared to protein.

f: Assumes 50 percent legumes and 50 percent peanut butter. Because these values account for the proportion of the maximum allowance of legumes and peanut butter provided per month, they are lower than those presented in the phase I report (NASEM, 2016).

g: In the current food packages, a ratio of 81 percent refined grains and 19 percent whole grains was applied, based on redemption data.

h: Equivalent to 4 oz per day, the lower end of AAP guideline of not more than 4–6 ounces per day.

i: To compare the food package contribution to the DGA recommended amounts of whole grains, the whole grain portion of breakfast cereal was added to the whole grain contribution of bread.

: SOURCES: USDA/ARS, 2014; USDA/FNS, 2014; USDA/HHS, 2016. State-specific data are available in the public access file for this study (Email: paro@nas.edu)

TABLE 3-5Authoritative Recommendations for Intake of Fish High in Omega-3 Fatty Acids and Low in Mercury

Recommending Authority	Recommendation
Recommending Authority	Quantity of Seafood Recommended (oz per day)	Target Population
2015–2020 DGA	1.3	Adults, 2,200 kcal diet
2015–2020 DGA	1.0	Children, 1,300 kcal diet
2015–2020 DGA	1.1–1.7	Pregnant or breastfeeding women
FDA-EPA	1.1–1.7	Pregnant or breastfeeding women
AHA	1.0	Children and adults
AAP	0.6–1.1	Breastfeeding women
AAP	1–5 of flesh foods, including fish	Children ages 2 to 4
WHO	Flesh foods, including fish, as often as possible	Infants beginning complementary feeding

: NOTES: AAP = American Academy of Pediatrics; AHA = American Heart Association; DGA = Dietary Guidelines for Americans; FDA-EPA = Food and Drug Administration-Environmental Protection Agency; WHO = World Health Organization.

: SOURCES: PAHO/WHO, 2003; AAP, 2014; FDA-EPA, 2014; AHA, 2015; USDA/HHS, 2016.

TABLE 3-6Sodium Content of Representative Currently Allowable WIC Foods

Daily Limit or Food and Serving-Equivalent	Sodium (mg)
DGA daily limits
1,300 kcal pattern	1,500
2,300 and 2,600 kcal patterns	2,300
Food option and serving-equivalent^a
Canned green beans, 1 c-eq	424
Canned sweet corn, 1 c-eq	422
Canned whole tomatoes, 1 c-eq	218
Cheese, 1 oz-eq	185
Yogurt, plain, low fat, 1 c-eq	172
Chocolate milk, 1%, reduced sugar, 1 c-eq	162
Chocolate milk, 1%, 1 c-eq	159
Yogurt, vanilla, low fat, 1 c-eq^b	140
Cereal, toasted oats, 1 oz-eq	139
Cereal, oat flakes with almonds, 1 oz-eq	118
Canned light tuna, packed in oil, 1 oz-eq	118
Soymilk, generic, 1 c-eq	115
Milk, 1%, 1 c-eq	108
Milk, nonfat, 1 c-eq	103
Soymilk, original, 1 c-eq^c	95
Soymilk, vanilla, 1 c-eq^c	85
Whole wheat bread, 1 oz-eq	73
Egg, 1 oz-eq	71
Canned light tuna, packed in water, 1 oz-eq	70
Peanut butter, salted, 1 oz-eq	68
Instant oats, 1 oz-eq	62
Canned pinto beans, 1 c-eq	41
Tofu, 1 oz-eq	9

: NOTES: c-eq = cup-equivalents; DGA = Dietary Guidelines for Americans; oz-eq = ounce-equivalents. Nutrient amounts are from the National Nutrient Database for Standard Reference, release 28 (USDA/ARS, 2016) except where noted. For comparison, limits noted at the top of the table indicate 10 percent of kcal.

a: Cup- and ounce-equivalent servings are per the Food Patterns Equivalents Database 2011–2012: Methodology and User Guide (USDA/ARS, 2014).

b: Values based on the food label of a WIC-approved low-fat vanilla yogurt.

c: Values based on the food label of a WIC-approved soymilk.

: SOURCES: USDA/ARS, 2014, 2016; USDA/FNS, 2014; USDA/HHS, 2016; other sources where noted.

TABLE 3-7Saturated Fat Content of Representative Currently Allowable WIC Foods

Daily Limit or Food and Serving-Equivalent	Saturated Fat (g)
DGA daily limits
1,300 kcal pattern	14.4
2,300 kcal pattern	25.6
2,600 kcal pattern	28.9
Food option and serving-equivalent^a
Cheese, 1 oz-eq	5.3
Yogurt, plain, low fat, 1 c-eq	2.5
Peanut butter, salted, 1 oz-eq	1.7
Milk, 1%, 1 c-eq	1.6
Egg, 1 oz-eq	1.6
Chocolate milk, 1%, reduced sugar, 1 c-eq	1.5
Chocolate milk, 1%, 1 c-eq	1.4
Yogurt, vanilla, low fat, 1 c-eq^b	1.0
Tofu, 1 oz-eq	0.9
Soymilk, generic, 1 c-eq	0.5
Soymilk, original, 1 c-eq^c	0.5
Cereal, toasted oats, 1 oz-eq	0.4
Instant oats, 1 oz-eq	0.4
Canned light tuna, packed in oil, 1 oz-eq	0.4
Canned pinto beans, 1 c-eq	0.3
Cereal, oat flakes with almonds, 1 oz-eq	0.2
Milk, nonfat, 1 c-eq	0.1
Whole wheat bread, 1 oz-eq	0.1
Canned light tuna, packed in water, 1 oz-eq	0.1
Soymilk, vanilla, 1 c-eq^c	0

: NOTES: c-eq = cup-equivalents; DGA = Dietary Guidelines for Americans; oz-eq = ounce-equivalents. Nutrient amounts are from the National Nutrient Database for Standard Reference, release 28 (USDA/ARS, 2016) except where noted. For comparison, limits noted at the top of the table indicate 10 percent of kcal.

a: Cup- and ounce-equivalent servings are per the Food Patterns Equivalents Database 2011–2012: Methodology and User Guide (USDA/ARS, 2014).

b: Values based on the food label of a WIC-approved low fat vanilla yogurt.

c: Values based on the food label of a WIC-approved soymilk.

: SOURCES: USDA/ARS, 2014, 2016; USDA/FNS, 2014; USDA/HHS, 2016; other sources where noted.

TABLE 3-8Added Sugars Content of Representative Currently Allowable WIC Foods

Daily Limit or Food and Serving-Equivalent	Added Sugars (g)^b
DGA daily limits
1,300 kcal pattern	32.5
2,300 kcal pattern	57.5
2,600 kcal pattern	65.0
Food option and serving-equivalent^a
Yogurt, vanilla, low fat, 1 c-eq^c	16.6
Chocolate milk, 1%, 1 c-eq	11.6
Soymilk, vanilla, 1 c-eq^d	11.0
Soymilk, generic, 1 c-eq	8.9
Soymilk, original, 1 c-eq^d	6.0
Cereal, oat flakes with almonds, 1 oz-eq	5.4
Chocolate milk, 1%, reduced sugar, 1 c-eq^e	5.1
Whole wheat bread, 1 oz-eq	1.4
Peanut butter, salted, 1 oz-eq	1.0
Cereal, toasted oats, 1 oz-eq	0.9
Milk, nonfat, 1 c-eq	0
Milk, 1%, 1 c-eq	0
Cheese, 1 oz-eq	0
Yogurt, plain, low fat, 1 c-eq	0
Tofu, 1 oz-eq	0
Egg, 1 oz-eq	0
Instant oats, 1 oz-eq	0
Canned light tuna, packed in water, 1 oz-eq	0
Canned light tuna, packed in oil, 1 oz-eq	0
Canned pinto beans, 1 c-eq	0

: NOTES: c-eq = cup-equivalents; DGA = Dietary Guidelines for Americans; oz-eq = ounce-equivalents. Nutrient amounts are from the National Nutrient Database for Standard Reference, release 28 (USDA/ARS, 2016) except where noted. For comparison, limits noted at the top of the table indicate 10 percent of kcal.

a: Cup- and ounce-equivalent servings are per the Food Patterns Equivalents Database 2011–2012: Methodology and User Guide (USDA/ARS, 2014).

b: Added sugars were calculated by subtracting naturally occurring sugar from total sugar in the food option. The USDA Final Rule permits ≤40 grams of total sugar per cup of yogurt and ≤6 grams per ounce of breakfast cereal.

c: Values based on the food label of a WIC-approved low fat vanilla yogurt containing 31.6 grams of total sugars. The plain low fat version of this yogurt contains 15 grams of sugar.

d: Values based on the food label of a WIC-approved soymilk.

e: Based on flavored milks approved for the School Meals Program that are not commercially available.

: SOURCES: USDA/ARS, 2014, 2016; USDA/FNS, 2014; USDA/HHS, 2016; other sources where noted.

TABLE 3-9Contributions of the Food Packages to the DGA Daily Limit for “Calories for Other Uses^*

Percent of Total Daily kcals Available for COU^a	Total kcal in FP^b	FP COU Daily Limit^c	Amount Provided by the Food Package Per Day
			Saturated Fat^b		Added Sugar^b		Total COU kcal in the FP^d	Proportion of the Total Daily COU Limit (%)^e	Proportion of Food Package COU Daily Limit (%)^f
			g	kcal	g	kcal	Total COU kcal in the FP^d	Proportion of the Total Daily COU Limit (%)^e	Proportion of Food Package COU Daily Limit (%)^f
FP V: Women, Pregnant and Partially Breastfeeding (based on a 2,600-kcal pattern)
15	787	118	9	77	7	30	107	27	90
FP VI: Women, Postpartum (based on a 2,300-kcal pattern)
14	572	80	6	58	7	27	85	26	106
FP VII: Women, Fully Breastfeeding (based on a 2,600-kcal pattern)
15	918	138	13	115	7	27	142	36	103
FP IV: Children ages 2 to less than 5 years (based on a 1,300-kcal pattern)
8	648	52	7	59	7	27	87	83	167

: NOTES: COU = calories for other uses, defined in the DGA as the combined calories from saturated fats (solid fats), added sugars, refined carbohydrates, and alcohol; DGA = 2015–2020 Dietary Guidelines for Americans; FP = food package. Kcal patterns were selected based on the calculated Estimated Energy Requirement for WIC participants, using NHANES 2011–2012 (children) or 2005–2012 (women). Calculations assume full redemption of the food packages.

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

a: Based on the DGA food pattern indicated.

b: Based on the nutrient profiles of the food packages as developed using the methodology described in Appendix R, and presented in Appendix T.

c: (percent of total daily kcals available for COU) × (total kcal in the food package). To calculate this value, it was considered that the COU provided by the package should be in the same proportion as the COU in the USDA daily food pattern. For example, the USDA food pattern for a 2,600-kcal diet allows 15 percent of calories from COU. Thus, if food package V provides approximately 787 kcal, 15 percent, or 118 kcal, can be proportionally allotted to COU.

d: (saturated fat kcal) + (added sugars kcal).

e: (total COU kcal in the package × 100)/(number of COU kcal for the food pattern [data not shown]).

f: (proportion of the total daily COU limit × 100)/(FP COU daily limit). For example, food package V provides 107 kcal from COU, an amount that is 90 percent of 118 kcal.

: SOURCES: USDA/ARS, 2016; USDA/HHS, 2016.

TABLE 3-10Dietary Guidance for Breastfeeding Mothers and Infants and Children Less Than 2 Years of Age

Feeding Mode	Reference
Breastfeeding—Guidance for Infant Nutrition
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.^a	WHO, 2009; IOM, 2011b; AAP, 2014; AND, 2015
To improve the intake of long-chain omega-3 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.^b	AAP, 2014
All breastfed infants should receive an oral supplement of vitamin D, 400 IU per day, beginning at hospital discharge.	AAP, 2012
Starting at 4 months of age exclusively breastfed infants should be supplemented with iron.	AAP Committee on Nutrition, 2010
Formula Feeding
For infants who are not breastfed, iron-fortified formula is the recommended alternative for feeding the baby during the first year of life.	AAP, 2014
Supplementary fluoride should not be provided to formula-fed infants during the first 6 months of life. After 6 months of age, the need for fluoride supplementation depends on the fluoride concentration of water used to prepare formula.	AAP, 2014
There are a limited number of medical conditions in which breastfeeding is contraindicated.	AAP, 2012, 2014
Therapeutic (noncontract) formula should be made available through physician prescription for specific medical conditions.	AAP, 2014
Complementary Feeding
Complementary foods should be gradually introduced to infants at approximately 6 months of life.	AAP, 2014
Complementary food 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 per serving) or 1 to 2 oz of meat per day.	AAP Committee on Nutrition, 2010; AAP, 2012, 2014
Introduce single-ingredient new foods, one at a time, observing for adverse reactions or intolerance.	AAP, 2014
Avoid cow's milk until 1 year of age. Whole milk may be provided at 1 year of age. 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 ounces. Intakes above 25 ounces/day may contribute to iron deficiency.	AAP Committee on Nutrition, 2008; NHLBI, 2011; AAP, 2014
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.	AAP, 2014
Avoid foods that could cause choking or aspiration (e.g., hot dogs, nuts, grapes, raisins, raw carrots, popcorn, hard candies); avoid eating peanut butter from a spoon.	AAP Committee on Injury, Violence, and Poison Prevention, 2010; AAP, 2014
Developing Healthy Eating Patterns
Allow lower-fat milks for children 1 year of age and older for whom obesity or overweight is a concern.	AAP Committee on Nutrition, 2008
Total daily juice intake should be limited to 4 to 6 ounces per day from 1 to 6 years of age. Encourage whole fruit over juice.	AAP, 2014
Avoid added sugar and added salt.	AAP, 2014
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.	AAP, 2014

a: 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, 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.”

b: This level of maternal fish intake has been associated with improved neurobehavioral development in infants. 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).

: SOURCES: As noted in the Reference column.

TABLE 3-11Nutrients Provided per Day in the Current Food Packages Compared to Dietary Reference Intakes: Pregnant, Breastfeeding, and Postpartum Women

Nutrient	EAR/AI Pregnant	EAR/AI Breastfeeding	EAR/AI Postpartum	FP V, Pregnant		FP VII, Breastfeeding		FP VI, Postpartum^*
Nutrient	EAR/AI Pregnant	EAR/AI Breastfeeding	EAR/AI Postpartum	Amount	% DRI	Amount	% DRI	Amount	% DRI
Energy (kcal)	2,625^a	2,492^a	2,350^a	787	30	918	37	572	24
Protein (g)	71^b	71^b	46^b	39	55	52	74	27	60
Fiber (g)	28^c	29^c	25^c	8.0	29	8.0	28	5.7	23
Calcium (mg)	800	800	800	1,029	129	1,232	154	739	92
Copper (mg)	0.8	1	0.7	0.4	55	0.5	48	0.3	42
Iron (mg)	22	6.5	8.1	13.5	62	14	221	12.3	152
Magnesium (mg)	290/300^d	255/265^d	255/265^d	198	68/68	214	84/81	132	52/50
Phosphorus (mg)	580	580	580	976	168	1,178	203	690	119
Selenium (µg)	49	59	45	31.6	65	64	108	25	56
Zinc (mg)	9.5	10.4	6.8	6.6	69	7.7	74	5.2	76
Potassium (mg)	4,700^c	5,100^c	4,700^c	1,837	39	1,958	38	1,302	28
Vitamin A (µg RAE)	550	900	500	646	117	754	84	522	104
Vitamin E (mg)	12	16	12	3.6	30	4.0	25	2.5	20
Vitamin D (IU)	400	400	400	291	73	371	93	213	53
Vitamin C (mg)	70	100	60	72	103	72	72	57	95
Thiamin (mg)	1.2	1.2	0.9	0.9	76	0.9	78	0.7	81
Riboflavin (mg)	1.2	1.3	0.9	1.8	148	2.0	153	1.4	153
Niacin (mg)	14	13	11	9.9	71	13	98	8.0	72
Vitamin B6 (mg)	1.6	1.7	1.1	1.3	79	1.4	83	1.1	97
Folate (µg DFE)	520	450	320	473	91	487	108	425	133
Vitamin B12 (µg)	2.2	2.4	2	4.4	198	5.6	234	3.6	180
Choline (mg)	450^c	550^c	425^c	75	17	147	27	71	17
Nutrients to Limit
Added sugars (g)	65^e	65^e	57.5^e	7.4	12	6.6	10	6.9	12
Saturated fat (g)	29^e	29^e	26^e	8.5	29	13	44	6.4	25
Sodium (mg)	1,500^c	1,500^c	1,500^c	727	48	1,007	67	527	35

: NOTES: AI = adequate intake; DGA = Dietary Guidelines for Americans; EAR = Estimated Average Requirement; FP = food package; RAE = retinol activity equivalents; RDA = Recommended Dietary Allowance; Nutrient profiles were developed by applying the assumptions outlined in Appendix R.

*: Some values in these columns are corrected from the original prepublication version.

a: Value is the median estimated energy requirement (EER) calculated by the committee. Values differ slightly from those in Chapter 4 because EER values for that chapter were re-calculated in a different statistical program to generate percentiles. The means are equivalent for the two analyses.

b: Values represent an RDA. The RDA is used for evaluation of the food package protein content because the EAR for protein is in units of g per kg body weight and therefore must be calculated for an individual.

c: Indicates an AI. Other values are an EAR unless otherwise noted.

d: Magnesium has two values: 19-30y/31-50y;

e: Based the DGA recommended limit of 10 percent of kcal.

: SOURCES: IOM, 1997, 1998, 2000, 2001, 2002/2005, 2005, 2011a; USDA/ARS, 2016; USDA/HHS, 2016.

TABLE 3-12Nutrients Provided per Day in the Current Food Packages for Infants Less Than 12 Months of Age^*

Nutrient	AI, Infants Less Than 6 Months	EAR/AI, Infants 6 to Less Than 12 Months	FF 0–3 mo	FF 4–5 mo	0–1 mo	BF/FF 1–3 mo	BF/FF 4–5 mo	FF 6–11 mo	BF/FF 6–11 mo	BF 6–11 mo
Energy (kcal)	617^a	727^a	588	645	71	289	347	621	409	300
Protein (g)	9.1^b	11^b	13	14	1.6	6.4	7.7	14	8.8	13
Fiber (g)	ND	ND	0	0	0	0	0	3.7	3.7	5.9
Calcium (mg)	200	260	560	607	68	276	327	604	404	208
Copper (mg)	0.2	0.22	0.48	0.52	0.06	0.24	0.28	0.52	0.35	0.28
Iron (mg)	0.27	6.9^c	11	12	1.3	5.3	6.3	21	17	14
Magnesium (mg)	30	75	46	50	5.5	23	27	68	52	58
Phosphorus (mg)	100	275	342	369	41	168	199	388	266	220
Selenium (µg)	15	20	15	16	1.8	7.2	8.6	18	13	14
Zinc (mg)	2	2.5^c	5.1	5.6	0.6	2.5	3.0	5.9	4.1	3.3
Potassium (mg)	400	700	641	702	77	316	377	830	599	669
Vitamin A (µg RAE)	400	500	531	582	64	262	313	550	358	262
Vitamin E (mg)	4	5	7.2	7.8	0.9	3.5	4.2	7.0	4.4	2.2
Vitamin D (IU)	400	400	348	370	42	171	199	313	192	58
Vitamin C (mg)	40	50	62	68	7.4	30	37	71	49	46
Thiamin (mg)	0.2	0.30	0.5	0.6	0.1	0.3	0.3	0.70	0.52	0.35
Riboflavin (mg)	0.3	0.40	0.78	0.87	0.09	0.39	0.47	0.92	0.63	0.47
Niacin (mg)	2	4	6.3	6.9	0.8	3.1	3.7	9.7	7.4	7.5
Vitamin B6 (mg)	0.10	0.30	0.36	0.40	0.04	0.18	0.21	0.29	0.16	0.09
Folate (µg DFE)	65	80	152	159	18	75	86	158	105	62
Vitamin B12 (µg)	0.4	0.5	1.8	1.9	0.2	0.9	1.0	2.1	1.4	1.2
Choline (mg)	125	150	100	113	12	49	61	100	63	60
Nutrients to Limit
Added sugars (g)	NA	NA	0	0.7	0	0	0.4	0.5	0.3	0
Saturated fat (g)	NA	NA	13.4	14.6	1.6	6.6	7.8	10.7	5.9	1.4
Sodium (mg)	120	370	178	194	21	88	104	156	93	64

: NOTES: AI unless otherwise noted; AI = adequate intake; BF = breastfed; BF/FF = partially breastfed; DFE = dietary folate equivalents; DGA = Dietary Guidelines for Americans; EAR = Estimated Average Requirement; FF = formula fed; RAE = retinol activity equivalents; RDA = Recommended Dietary Allowance. Nutrient profiles were developed by applying the assumptions outlined in Appendix R.

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

a: Value is the median estimated energy requirement (EER) calculated by the committee.

b: Value represents an RDA. The RDA is used for evaluation of the food package protein content because the EAR for protein is in units of g per kg body weight and therefore must be calculated for an individual.

c: Value represents an EAR.

: SOURCES: IOM, 1997, 1998, 2000, 2001, 2002/2005, 2005, 2011a; USDA/ARS, 2016; USDA/FNS, 2016b.

TABLE 3-13Nutrients Provided per Day in the Current Food Packages Compared to Dietary Reference Intakes: Children Ages 1 to Less Than 5 Years of Age^*

Nutrient	EAR/AI, 1–3 y	EAR/AI, 4–8 y	Children 1 to Less Than 2 Years		Children 2 to Less Than 5 Years
Nutrient	EAR/AI, 1–3 y	EAR/AI, 4–8 y	Amount	% DRI	Amount	% DRI, 1–3 y	% DRI, 4–5 y
Energy (kcal)	917^a	1,517^a	725	79	648	71	43
Protein (g)	13^b	19^b	29	224	31	236	162
Fiber (g)	19^c	25^c	7.1	38	7.1	38	29
Calcium (mg)	500	800	717	143	787	157	98
Copper (mg)	0.26	0.34	0.42	161	0.35	134	102
Iron (mg)	3	4.1	13.4	445	13.5	449	328
Magnesium (mg)	65	110	138	212	154	237	140
Phosphorus (mg)	380	405	690	182	762	201	188
Selenium (µg)	17	23	35.2	207	32	187	138
Zinc (mg)	2.5	4	5.5	221	5.7	227	142
Potassium (mg)	3,000^c	3,800^c	1,267	42	1,357	45	36
Vitamin A (µg RAE)	210	275	417	199	532	253	194
Vitamin E (mg)	5	6	1.1	22	3.0	60	50
Vitamin D (IU)	400	400	254	63	213	53	53
Vitamin C (mg)	13	22	56	429	60	458	271
Thiamin (mg)	0.4	0.5	0.8	211	0.8	206	165
Riboflavin (mg)	0.4	0.5	1.4	345	1.4	353	282
Niacin (mg)	5	6	8.9	179	9.0	179	150
Vitamin B6 (mg)	0.4	0.5	1.1	268	1.1	277	222
Folate (µg DFE)	120	160	430	358	431	359	269
Vitamin B12 (µg)	0.7	1	3.8	546	3.6	514	360
Choline (mg)	200^c	250^c	71	36	77	38	31
Nutrients to Limit
Added sugars (g)	NA	32.5^d	8.4	NA	6.9	21	21
Saturated fat (g)	NA	14.4^d	11.9	NA	6.6	47	46
Sodium (mg)	1,000^c	1,200^c	587	59	639	64	53

: NOTES: AI = adequate intake; DFE = dietary folate equivalents; DGA = Dietary Guidelines for Americans; EAR = Estimated Average Requirement; NA = not applicable; RAE = retinol activity equivalents. Nutrient profiles were developed by applying the assumptions outlined in Appendix R.

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

a: Value is the median estimated energy requirement (EER) calculated by the committee.

b: Values represent a Recommended Dietary Allowance (RDA). The RDA is used for evaluation of the food package protein content because the EAR for protein is in units of g per kg body weight and therefore must be calculated for an individual.

c: Indicates an AI. Other values are an EAR unless otherwise noted.

d: For added sugars and saturated fat, value is the percent of the Dietary Guidelines for Americans (DGA) limit.

: SOURCES: IOM, 1997, 1998, 2000, 2001, 2002/2005, 2005, 2011a; USDA/ARS, 2016; USDA/HHS, 2016.

TABLE 3-14Dietary Guidance Related to Types or Composition of Foods in Current WIC Food Packages

Foods in Current WIC Food Packages	Dietary Guidance for Infants and Children Less Than 2 Years^*	Dietary Guidance for Children and Women^*
100% juice with vitamin C, starting at 1 year of age	Infants less than 1 year of age should not consume juice; total daily juice intake should be limited to 4 to 6 ounces per day for children 1 to 6 years of age; encourage whole fruit over juice (AAP, 2014)	Young children (up to 6 years of age) should limit their juice intake to 4 to 6 ounces per day (AAP, 2014) Individuals more than 2 years of age should not consume more than 50% of their total fruit intake as juice (USDA/HHS, 2016)
Milk, whole for those 1 to 2 years of age, nonfat or 1% for older participants; fat-reduced milks to be issued to 1-year-old children (12 months to 2 years of age) for whom overweight or obesity is a concern	Avoid cow's milk until 1 year of age. Whole milk may be provided at 1 year of age. Lower fat milk may be allowed for children 1 year of age if obesity or overweight is a concern (AAP Committee on Nutrition, 2008; AAP, 2014; NHLBI, 2011) Intakes above 32 ounces/day may contribute to iron deficiency in children 1 to 2 years of age (AAP, 2014)	Most dairy consumed by individuals ages 2 and older should be low-fat (USDA/HHS, 2016)
Breakfast cereal, iron-fortified: may be hot or ready-to-eat, refined or whole grain	Infant cereal should be fortified with iron and zinc; two servings per day are recommended (1–2 T per serving) (AAP Committee on Nutrition, 2010a; AAP, 2012, 2014)	At least 50% of total grain intake should be from whole grains
Cheese, starting at 1 year of age	NR	Appropriate intake depends upon the total dairy intake recommendations as well as the amount of saturated fat and sodium in the overall diet; one strategy to reduce saturated fat intake is to replace regular cheese with low-fat cheese (USDA/HHS, 2016)
Eggs, starting at 1 year of age	Eggs may be introduced along with other complementary foods (PAHO/WHO, 2003; WHO, 2005; AAP, 2014)	No specific recommendations related to eggs
Vegetables and fruits, CVV option for breastfeeding infants, ages 9 to 11 months	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 (AAP, 2014)	Whole fruit should be encouraged over juice (AAP, 2014)
Whole wheat or whole grain bread, starting at 1 year of age	NR	At least 50% of total grains intake should be from whole grains (USDA/HHS, 2016)
Fish (canned), fully breastfeeding women only	Infants should consume flesh foods, including fish, as soon as possible (PAHO/WHO, 2003)	Children should consume 1 oz of low-mercury seafood per day (USDA/HHS, 2016) Pregnant or breastfeeding women should consume between 1.1 and 1.3 ounces of low-mercury seafood per day (AAP, 2014; FDA-EPA, 2014; USDA/HHS, 2016)
Legumes and/or peanut butter, starting at 1 year of age	NR	No specific recommendations on types or composition of legumes or peanut butter
Iron-fortified infant formula	For infants that are not breastfeeding, iron-fortified formula is the recommended alternative for feeding the baby during the first year of life (AAP, 2014)	NA
Infant food meat, single-ingredient	Complementary foods should be introduced gradually to infants after 6 months of life; 1–2 ounces of meat or 1–2 small jars of commercially prepared meat per day (AAP Committee on Nutrition, 2010b; AAP, 2012, 2014)	NA

: NOTES: DGA = Dietary Guidelines for Americans; NA = not applicable; NR = no recommendation; T = tablespoon.

*: Sources of guidance as cited in parentheses.

BOX 3-1Definition of WIC-Eligible Nutritionals*

(7 C.F.R. § 246.3)

WIC-eligible nutritionals means certain enteral products that are specifically formulated to provide nutritional support for individuals with a qualifying condition, when the use of conventional foods is precluded, restricted, or inadequate. Such WIC-eligible nutritionals must serve the purpose of a food, meal, or diet (may be nutritionally complete or incomplete) and provide a source of calories and one or more nutrients; be designed for enteral digestion via an oral or tube feeding; and may not be a conventional food, drug, flavoring, or enzyme. WIC-eligible nutritionals include many, but not all, products that meet the definition of medical food in Section 5(b)(3) of the Orphan Drug Act (21 U.S.C. 360ee(b)(3)).

: * The term WIC-eligible medical foods was changed to WIC-eligible nutritionals in the Final Rule (USDA/FNS, 2014).

TABLE 3-15Options in WIC Food Package Categories Potentially Unsuitable for Special Diets and Major Allergies

WIC Food Category	Special Diet				Major Allergen
WIC Food Category	Vegetarian	Vegan	Gluten Free	Lactose Free	Milk	Eggs	Fish	Peanuts	Wheat	Substitutions Allowed (% of state agencies allowing substitution)
Ready to eat cereal			✓						✓	Gluten-free corn cereal (88); gluten-free rice cereal (86)
Whole wheat bread			✓						✓	Brown rice (97); certified gluten-free corn tortillas (86); certified gluten-free oats (77)
Milk		✓		✓	✓					Soy beverage (95); tofu (63); lactose-free milk (>44)
Cheese		✓		✓	✓					No substitution
Eggs		✓				✓				No substitution
Peanut butter								✓		Canned legumes (85); dry legumes (100)
Canned fish	✓	✓					✓			No substitution

: NOTES: ✓ Indicates that the primary food in the category is not likely to be suitable for the particular diet or allergy unless a suitable substitution is made available. The major allergens shellfish and tree nuts were excluded from the table because no WIC foods are provided in these categories. Soy is excluded as a major allergen because the baseline food packages do not contain soy products. The WIC food categories mature legumes, juice, and the CVV were excluded from the table because they are suitable for all cases covered in this table.

: SOURCES: USDA/FNS, 2014, 2015a.

TABLE 3-16Alignment of the Current Food Packages with Dietary Guidance, Special Dietary Needs, and Cultural Eating Practices or Food Preferences

Aspect of the Food Packages Evaluated	Findings and Conclusions
Contribution to recommended intakes of food groups	The food packages provide a more-than-supplemental amount of infant cereal, jarred infant food meats, dairy foods, juice, and peanut butter across food packages for women and children. The amounts of legumes in the food packages for children were also greater than supplemental. Reductions in the foods provided in greater-than-supplemental amounts may be warranted.
Contributions to recommended intakes of nutrients	The quantities of many nutrients in the food packages could be reduced and still provide a significant proportion of the DRI. Although food packages are particularly low in vitamin E, choline, and potassium, it is difficult to increase amounts of these nutrients while still contributing to intakes of other nutrients of concern. Reductions in the foods that provide nutrients in greater-than-supplemental amounts may be warranted.
Alignment with dietary guidance for specific forms of foods	Foods in the WIC packages are generally aligned with dietary guidance. Two exceptions were identified. Fish high in omega-3 fatty acids is provided only to fully breastfeeding women, although it is considered beneficial during all stages of growth and development. Consideration of the addition of seafood to food packages for other women and children is warranted. The amount of juice provided to children is 100 percent of the lower end of the AAP limit; the AAP recommends whole fruit over juice. Therefore, replacement of some juice with whole fruit (in the form of increased CVV) is warranted.
Alignment with dietary guidance for calories for other uses (COU)	The percent of calories from COU in the food package for children (specifically, percent of calories from saturated fat and added sugars) exceeded the recommended daily proportions based on the energy content of the package. The food packages for women provided a generally proportional amount of COU based on the proportion of energy provided in these packages. For all food packages, however, the absolute contribution to COU was less than the total daily limit. Dairy was the primary contributor to COU. Based on a serving-equivalent contribution of specific foods to a daily diet, the committee identified some foods with the potential to contribute significant amounts of added sugars. For example, an 8-oz serving of yogurt with 40 g of total sugars would contribute over 100 percent of the recommended daily limit of added sugars for a child participating in WIC. Reductions in foods that contribute disproportionately to COU could be considered.
Foods for medical needs	The required issuance of WIC formulas (for example, when jarred infant foods are prescribed for participants over age 1) may result in the issuance of excessive supplemental food. This requirement merits re-evaluation.
Foods for allergies, lactose intolerance, or celiac disease	The current food packages generally provide substitution options for individuals with the most common allergies, lactose intolerance, and celiac disease, with a few exceptions. The committee was unable to identify suitable substitution options for individuals with allergies to eggs or fish. It is appropriate that individuals with both cow's milk and soy allergies be referred to food package III and be followed by a health care provider.
Foods for individuals following vegetarian, vegan, Kosher, or Halal diets	The current food packages lack vegetarian or vegan substitutions for eggs, fish, and cheese. Options for individuals who follow Kosher or Halal diets are limited. Possibilities for expanding options to meet these preferences and practices merits consideration.
Alignment with cultural eating preferences of the WIC-participating population	Redemption data, published reports, and public comments suggest that the CVV may provide more culturally suitable options for infant feeding than jarred infant foods. Some foods provided in the WIC packages are not typically consumed by specific racial and ethnic groups served by WIC; these foods include peanut butter, milk, and ready-to-eat cereals. Expanding to allow more culturally suitable options merits consideration. The proportion of women who choose to breastfeed differs by racial and ethnic group and is lowest for African-American women. Breastfeeding promotion and support activities may be particularly critical for African-American women.

: NOTES: COU = calories for other uses; CVV = cash value voucher; DRI = Dietary Reference Intake.