Nutrient and Food Group Priorities for the WIC Food Packages

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

5Nutrient and Food Group Priorities for the WIC Food Packages

Informed by its evaluation of nutrient-related health priorities, food safety risks, and dietary intake (see Chapter 4), the committee identified nutrient and food group priorities for the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food packages. These priorities were then considered along with the committee's charge, that is, to align the food packages with current dietary guidance, take into account the health and cultural needs of participants, support efficient program operations, and allow effective administration of the program. Collectively, this process led to development of a decision tree (see Figure 5-1) for determining potential revisions to the WIC food packages (see Tables 5-2 through 5-10).

FIGURE 5-1

Decision tree for determining potential food package changes given the prevalence of nutrient inadequacy or food group intake below recommended amounts among WIC-participating women and children. NOTES: CVV = cash value voucher; DGA = Dietary Guidelines (more...)

TABLE 5-2

Nutrient Priorities and Preliminary Actions, Food Package V for Pregnant Women.

TABLE 5-10

Food Group Priorities and Preliminary Actions, Food Package IV, Children Ages 2 to Less Than 5 Years.

As was the case in the previous WIC report (IOM, 2006), overweight and obesity remain a prominent health concern for WIC participants. However, consistent with its charge, the committee did not directly address problems related to excess energy intake. Rather, these outcomes were considered within the context of alignment of WIC program goals with the 2015–2020 Dietary Guidelines for Americans (DGA), which encourage the use of foods that are nutrient-dense, and limit the amounts of added sugars and saturated fat in WIC-approved foods.

IDENTIFYING NUTRIENT PRIORITIES

Among some subgroups of WIC-participating women and children, nutrient inadequacies were numerous (see Chapter 4). Here, we describe how the committee decided which of these inadequacies, as well as nutrient excesses, to prioritize when revising the food packages. As illustrated in Figure 5-1, nutrient inadequacies and excesses were determined to be higher-priority, middle-priority, or lower-priority.

Identifying Nutrient Priorities for Women and Children Ages 2 to Less Than 5 Years

Micronutrients with EARs

For nutrients with an Estimated Average Requirement (EAR), the committee ranked nutrients for action by the proportion of each WIC subpopulation with inadequate intakes. Nutrients with the highest proportion of inadequacy (e.g., >50 percent) for a particular population were considered first, followed by nutrients with lower proportions of inadequate intakes. In addition, the committee considered whether a nutrient was linked to a known health consequence for the specific WIC-participating population under review (see Table 5-1 for a compilation of nutrients with known health consequences). Nutrients not linked to known health consequences were considered of lower priority, although all nutrients for which inadequacy was evident in 5 percent or more of a subgroup were considered to some degree.

TABLE 5-1

Nutrient Inadequacies and Excesses Linked to Adverse Health Consequences Relevant to WIC-Participating Population Subgroups, Based on the Dietary Guidelines, Literature Review, and Other Expert Guidance.

Special Case: Vitamin E

As was the case with subgroups included in the committee's National Health and Nutrition Examination Survey (NHANES) analyses (see Chapter 4), low vitamin E intake appears to be ubiquitous in the general U.S. population (USDA/HHS, 2016). However, because clinical vitamin E deficiency is uncommon (IOM, 2000a), the DGA do not include it as a nutrient of public health concern (USDA/HHS, 2016). Similarly, despite the very high prevalence of inadequacy across the WIC-participating population, vitamin E was not considered a priority in the food package revisions and was not carried through the decision tree.

Nutrients with an AI

For nutrients with an Adequate Intake (AI) value, the committee first assessed whether mean intake of the nutrient was below the AI. If so, the committee then considered whether or not the nutrient was linked to a known health consequence for the specific WIC-participating population under review. Nutrients not linked to known health consequences were considered lower priority.

Energy from Carbohydrate, Protein, and Fat

Lowering or raising the proportion of energy from one dietary macronutrient affects the proportion of energy from the others. However, beyond recommending that intakes be within the acceptable macronutrient distribution range (AMDR), the DGA (USDA/HHS, 2016) did not include recommendations for energy from total fat, carbohydrates, or protein. Therefore, the proportions of these macronutrients in the food packages were not considered in developing the revised food packages. (See below for the committee's consideration of saturated fat.)

Saturated Fat and Added Sugars

Saturated fat and added sugars were evaluated along with other nutrients, not food groups, because they may occur in several different foods. The current food packages already provide foods that are limited in saturated fat (e.g., only low-fat or nonfat milk and yogurt are allowed in packages for participants over 2 years of age) and added sugars (e.g., ready-to-eat cereals, yogurt, and vegetables and fruits purchased with the cash value voucher (CVV) are allowed in the packages only if they do not exceed required limits). Despite these current limitations, the WIC food packages do contribute some of each nutrient to the diet. Therefore, as described below, they were retained as macronutrients possibly linked to adverse health consequences (see Table 5-1).

Nutrients for Which Intakes Were Excessive

When micronutrient intakes were above the Tolerable Upper Intake Level (UL) in more than 5 percent of a WIC subgroup, the approach applied was similar to what was used when intakes were below the EAR except that the upper ends of intake distributions were examined. For example, nutrients for which intakes exceeded the UL in greater than 50 percent of the subgroup were considered to be of higher priority.

For excess consumption of saturated fat and added sugars, the committee prioritized action according to the proportion of the WIC subpopulation exceeding 10 percent of energy from each (e.g., 5 to <10, 10 to <50, and ≥50 percent of the population).

Identifying Nutrient Priorities for Infants

Because of the known risks of low iron and zinc intakes for breastfed infants, these were the only micronutrient intakes (from complementary foods) that were evaluated (see Table 5-1). Vitamin D was not prioritized because information on the vitamin D status of infants is not available in NHANES. Macronutrient intakes were evaluated against the Dietary Reference Intakes (DRIs), as available. The DGA do not apply to infants. Therefore, intake of added sugars or saturated fat was not evaluated.

Identifying Nutrient Priorities for Children 1 to Less Than 2 Years of Age

Micronutrients for children ages 1 to less than 2 years were evaluated in the same way as for women and for children ages 2 to less than 5 years. Although carbohydrate intakes were below the AMDR in more than 5 percent of this age group, very few children reported carbohydrate intakes below the EAR of 100 grams per day. Therefore, carbohydrate intakes were assumed to be adequate. As with infants, because the DGA do not apply to children 1 to less than 2 years of age, added sugars and saturated fat were not evaluated.

IDENTIFYING FOOD GROUP PRIORITIES

Inasmuch as recommended food group intakes are currently available only for individuals ages 2 years and older, the decision tree was applied to identify priority food groups and subgroups only for women and children ages 2 to less than 5 years. As illustrated in Figure 5-1, food group and subgroup intakes were evaluated separately from nutrient intakes.

Similar to what was done with nutrients, prioritization levels were defined by proportions of the population subgroup with intakes below those recommended in the DGA. Priority was given to food groups (or subgroups) for which intake was below the recommended amount in 75 percent or more of the population subgroup. A second level of priority was given to food groups (or subgroups) for which intake was below the recommended amount in 50 to less than 75 percent of the population subgroup. Although intake of oils fell below recommended amounts in more than 50 percent of some subgroups, this food group was not evaluated because oils do not contain nutrients of public health concern for the WIC-participating population.

IDENTIFYING POTENTIAL ACTIONS FOR FOOD PACKAGE REVISIONS

Nutrients with a high proportion of inadequate intakes and food groups (or subgroups) with lower-than-recommended intakes were evaluated further through the systematic process detailed in Figure 5-1. For each nutrient consumed in inadequate amounts relative to its EAR or AI, or for each food group (or subgroup) consumed in lower-than-recommended amounts relative to the DGA, the committee evaluated whether or not WIC currently offers foods that provide what it considered a supplemental amount of that nutrient or food group (or subgroup).^¹

In cases where the amount of the nutrient or food group or subgroup in the food package is already more than what is considered supplemental, the committee considered reducing the amount and providing a more preferred form to promote intake. In cases where an appropriate (i.e., supplemental) amount is already included in the food packages and preferred and appropriate forms of the food could not be identified, the committee proposed either enhancing nutrition education or applying behavioral approaches to increase consumption of the currently available foods. Alternatively, if a preferred food could be identified, the committee considered adding that food.

Finally, in cases where WIC does not currently offer foods that provide supplemental amounts of the nutrient or food group (or subgroup) identified as being consumed in lower-than-recommended amounts, the committee considered whether intake of that nutrient or food group (or subgroup) could be improved by increasing the value of the CVV. If not, then the committee considered whether foods could be added to the packages to address this problem. If appropriate foods could not be identified, no further action was considered. If there were foods that could be added, the committee then evaluated whether adequate consumption of such foods was likely (e.g., whether they were commonly consumed) and also whether such foods were available in acceptable forms. Additionally, the committee made an effort to identify changes to the food packages that could address low intakes while also meeting cultural needs and food preferences.

The results of this process are presented in Tables 5-2 through 5-10. Chapter 6 describes how, given cost-neutral constraints, the outcomes presented in these tables were translated into final food package changes.

Strengths and Limitations of the Decision Tree

The decision tree afforded the committee a systematic way to pare down the large body of information into practical actions. Using the tree, each nutrient, food group (and subgroup), and population subgroup was treated with the same degree of attention. The decision tree was used only for nutrients with evidence of inadequate consumption and food groups with evidence of consumption of less-than-recommended amounts.

Additionally, although the committee conducted separate evaluations for partially breastfeeding and fully breastfeeding women, the evaluation was limited. Because there are no DRI values specifically for partially breastfeeding women, the contribution of the WIC food package for partially breastfeeding women to a set of DRIs could not be evaluated. Additionally, because the intensity of breastfeeding of women coded as “breastfeeding” in NHANES is unknown, the priority nutrients and food groups for these women are presented along with the contents of both food packages V (for partially breastfeeding women) and VII in Tables 5-3 (nutrients) and 5-8 (food groups).

TABLE 5-3

Nutrient Priorities and Preliminary Actions, Food Packages for Breastfeeding Women.

TABLE 5-8

Food Group Priorities and Preliminary Actions, Breastfeeding Women.

Challenges with Translating the Decision Tree Outcomes into Potential Actions

Although the decision tree used by the committee provides transparency about how nutrient and food groups were prioritized, application of the decision tree outcomes to food package changes was less straightforward. Not only may a prioritized nutrient be provided by several different foods, but those foods may or may not belong to one of the prioritized food groups. In addition, the committee was unable to propose some actions suggested by the decision tree outcomes because of requirements set by the WIC program to provide specific nutrients, ensure that the revised set of food packages are of the same weighted average per-participant cost, ensure cultural suitability, and control administrative burden. The committee considered all of these factors in aggregate when translating the decision tree outcomes into final food package changes.

Nutrition Education as a Potential Action

The nutrition education tools developed by states are one strategy to improve the balance between what is provided in the food packages and participants' nutrient and food intake. As reviewed in Chapter 1, WIC is the only federal supplemental nutrition assistance program to have a nutrition education component required by law (USDA/FNS, 2007). The goals of WIC nutrition education are to

emphasize the relationship between nutrition, physical activity, and health with special emphasis on the nutritional needs of pregnant, postpartum, and breastfeeding women, infants and children under five years of age; and 2) assist the individual who is at nutritional risk in achieving a positive change in dietary and physical activity habits, resulting in improved nutritional status and in the prevention of nutrition-related problems through optimal use of the WIC supplemental foods and other nutritious foods.^²

One of the ways the U.S. Department of Agriculture's Food and Nutrition Service (USDA-FNS) provides state agencies with guidance and resources for nutrition education through WIC Works (USDA/FNS, 2016).

Behavioral Approaches as a Potential Action

In addition to nutrition education, behavioral approaches are another option for addressing low consumption of nutrients or food groups. Challenges that prevent individuals from making choices that best align with the DGA include treating losses differently than gains, remaining within the status quo, and placing greater value on the present time as opposed to the future (Kahneman and Tversky, 1984; Loewenstein, 1988; Dhar and Wertenbroch, 2000; USDA/ERS, 2007). The phase I report (NASEM, 2016) included a brief review of behavioral economics approaches that may help individuals to overcome these challenges and that could be applied in WIC (see Appendix M for WIC-specific examples).

RESULTS FROM USE OF THE DECISION TREE

The committee's final proposed revisions to the food packages, which are presented in Chapter 6, are based on information in Chapters 1 through 4; considerations described above in the section titled “Challenges with Translating the Decision Tree Outcomes into Potential Actions”; and outcomes of this chapter's decision tree process, as detailed in Tables 5-2 through 5-10. The tables present all nutrient and food groups of lower, middle, and higher priority; a brief discussion of higher-priority nutrients and food groups and preliminary potential actions is provided here.

Evaluation of Priority Nutrients and Potential Actions

Priority Nutrients Across Subgroups of Women and Children

Across subgroups of women (see Tables 5-2 through 5-4) and children (see Table 5-5), fiber, potassium, sodium, and added sugars were considered to be higher priority, with intakes of sodium, and added sugars being excessive. For all women (except for postpartum women) and children, excessive saturated fat intake was also a higher-priority (saturated fat is a middle priority for postpartum women). For breastfeeding women (see Table 5-4) and children ages 1 to less than 5 years (see Table 5-5), there were no additional higher-priority nutrients. Proposed actions to address low fiber and potassium intakes include increasing the CVV or requiring an option for canned legumes as a means of adding convenience and, therefore, promoting intake. Added sugars and sodium are already limited in WIC foods, but the committee reviewed the specifications for WIC foods to identify possibilities for further limiting these nutrients. Additional priority nutrients and potential actions for pregnant and postpartum, nonbreastfeeding women are outlined below.

TABLE 5-4

Nutrient Priorities and Preliminary Actions, Food Package VI, Postpartum Women.

TABLE 5-5

Nutrient Priorities and Preliminary Actions, Food Package IV, Children Ages 1 to Less Than 5 Years of Age.

Pregnant women Higher-, middle-, and lower-priority nutrients for WIC-participating pregnant women are presented in Table 5-2. In addition to the higher-priority nutrients described above, iron and choline were also identified as higher-priority nutrients for pregnant women. Iron requirements during pregnancy are higher than can be met by diet alone. Low choline intakes could be improved by provision of additional eggs or by increasing consumption of the dairy products already provided by the WIC program.

Postpartum women For postpartum women who are not breastfeeding (food package VI), calcium was identified as another higher-priority nutrient in addition to the nutrients mentioned above (see Table 5-4). Women receiving food package VI currently receive a greater-than-supplemental amount of calcium in this package. Therefore, strategies to improve intake of the calcium that is already provided are needed.

Priority Nutrients for Infants

No priorities were identified for younger (0 to less than 6 months of age) infants or for formula-fed older infants because either human milk or formula meets the nutrient needs of these groups. Given that the protein concentrations of infant formulas are regulated and considered safe by the U.S. Food and Drug Administration, excess intake of protein by formula-fed infants was not considered a priority. Both iron and zinc were considered priority nutrients for breastfeeding infants ages 6 to less than 12 months (see Table 5-6). However, because the amounts of these nutrients in the food package exceeded 100 percent of recommendations, the committee considered the need to decrease amounts of foods provided in the current infant packages and provide a more preferred form to promote intake.

TABLE 5-6

Nutrient Priorities and Preliminary Actions, Food Package II, Partially or Fully Breastfed Infants (Ages 6 to Less Than 12 Months).

Evaluation of Priority Food Groups and Potential Actions

The evaluation of priority food groups was based on DGA food patterns associated with particular calorie levels. Energy levels were selected based on calculated EERs for NHANES subgroups of pregnant, breastfeeding, and postpartum women, and for children as detailed in Appendix J. Inasmuch as the DGA are targeted to individuals ages 2 years and older, the committee provides an evaluation of food priorities for children ages 1 to less than 2 years and infants based on available AAP guidance (as described in Chapter 3). Gap analyses were conducted for nutrients (see Tables 5-2 through 5-6), but not for food groups. This was because food pattern recommendations are set to meet the Recommended Dietary Allowance (RDA) values, which are set to meet the nutrient requirements of nearly all healthy individuals (IOM, 2000b). Therefore a gap analysis would result in food group intake gaps that are unnecessarily high relative to the goal to reduce the prevalence of nutrient inadequacies within a population (i.e., measured as intakes below the EAR).

Priority Food Groups Across Subgroups of Women

Across subgroups of women (see Tables 5-7 through 5-9), food groups of higher priority (75 percent or more of women consumed less than the recommended amount) included: dark green vegetables, total red and orange vegetables, beans and peas, other vegetables, whole grains, seafood, as well as nuts, seeds, and soy. The committee considered increasing the value of the CVV as a possible approach to addressing intakes of vegetables, including subgroups of vegetables.^³ Inasmuch as legumes and peanut butter are already provided in greater-than-supplemental amounts in most food packages, the quantities of these foods were a target for reduction along with nutrition education or behavioral approaches to improve intakes. The committee also considered increasing the amounts or types of whole grains and adding fish to food packages where it is not currently provided as possible approaches to addressing lower-than-recommended intakes of these food groups. There were no additional higher-priority food groups identified for pregnant women. Additional higher-priority food groups for partially breastfeeding, fully breastfeeding, and postpartum subgroups of women are described below.

TABLE 5-7

Food Group Priorities and Preliminary Actions, Food Package V, Pregnant Women.

TABLE 5-9

Food Group Priorities and Preliminary Actions, Food Package VI, Postpartum Women.

Breastfeeding Women

Additional higher-priority food groups for breastfeeding women included total fruits, total starchy vegetables, total grains, and total protein foods (see Table 5-8). The committee considered increasing the value of the CVV as a means to increase intakes of fruits and providing a greater quantity and wider variety of grain options to increase intake of grains. For partially breastfeeding women, protein intake could be addressed by providing canned fish. For fully breastfeeding women, low total protein foods intakes could be addressed by including more preferred options or through nutrition education or behavioral approaches to improving intake of protein foods currently provided.

Postpartum Women

For postpartum women, the committee also considered total fruit, total vegetable, and total starchy vegetable intakes to be higher-priority food groups (see Table 5-9). Increasing the value of the CVV would likely lead to improved intakes of these food groups. Dairy intakes were also below recommended amounts, which may be addressed by allowing options for more preferred forms of dairy in place of milk.

Children Ages 2 to Less Than 5 Years

Food groups and subgroups for which intakes were below recommended levels in more than 75 percent of children ages 2 to less than 5 years included total vegetables, dark green vegetables, total red and orange vegetables, whole grains, seafood, as well as nuts, seeds, and soy (see Table 5-10). The potential actions to address consumption of foods in these food groups were the same as those identified for subgroups of women.

Children Less Than 2 Years of Age and Infants

Although the DGA do not cover individuals ages 2 years and younger, the committee evaluated foods in the packages for these participants in Chapter 3. The amount of juice provided in food package IV-A (which is provided to children ages 1 to 2 years) exceeds the lower end of the AAP recommended limit 4 to 6 ounces per day (see Table 3-10), and a reduction could be considered. Food package II for fully breastfed infants ages 6 to less than 12 months provides 150 percent of the AAP recommended amount of infant cereal, and 130 percent of the recommended amount of jarred infant food meat. This information suggests that reductions in juice, infant cereal, and jarred infant food meat could be considered.

SUMMARY

This chapter describes the committee's decision tree (see Figure 5-1) and how it was used to identify potential changes to and actions for WIC food package revisions based on the committee's findings related to nutrition-related health risks, food safety, and nutrient and food intake among WIC participants. The current food packages were evaluated against the DRIs and the DGA. Packages for individuals less than 2 years of age were evaluated against the DRIs and guidance from AAP and other authorities. In many cases, the current food packages provide more than a supplemental amount of a nutrient or food group or even provide more than 100 percent of recommended intakes of a nutrient or food group. As a result of the diversity of nutrients that can be provided through the CVV, the committee considered it important to increase this component of the food packages in cases of nutrient intake shortfalls. In other cases, the committee considered that an alternative form of a food (e.g., yogurt as a substitute for milk, canned legumes instead of dry legumes) could be a useful means of promoting consumption of foods already included in the packages. The committee considered fish as a possible addition to the food packages, both because seafood intakes are below recommended amounts and because fish is currently provided in only one food package. These priorities were considered simultaneously with costs and administrative factors to produce actionable revisions to the food packages. For this reason, not all of the proposed actions identified in this chapter resulted in a corresponding change to a food package. In the next chapter, the committee used the potential actions outlined in Tables 5-2 through 5-10 to develop its recommended revisions to the WIC food packages. Proposed changes and the rationale for each are described in detail.

REFERENCES

AAP (American Academy of Pediatrics). Pediatric nutrition. 7th ed. Kleinman RE, Greer FR, editors. Elk Grove Village, IL: American Academy of Pediatrics; 2014.
AAPD (American Academy of Pediatric Dentistry). Policy on dietary recommendations for infants, children, and adolescents. Pediatric Dentistry. 2012;30(7 Suppl):47–48. [PubMed: 19216383]
Dhar R, Wertenbroch K. Consumer choice between hedonic and utilitarian goods. Journal of Marketing Research. 2000;37(1):60–71.
IOM (Institute of Medicine). 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; 2000a. [PubMed: 25077263]
IOM. Dietary Reference Intakes: Applications in dietary assessment. Washington, DC: National Academy Press; 2000b.
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; 2011. [PubMed: 21796828]
Kahneman D, Tversky A. Choices, values, and frames. American Psychologist. 1984;39(4):341–350.
Loewenstein GF. Frames of mind in intertemporal choice. Management Science. 1988;34(2):200–214.
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]
USDA/ARS (U.S. Department of Agriculture/Agricultural Research Service). What we eat in America, NHANES 2005-2012. Beltsville, MD: USDA/ARS; 2005-2012. [December 21, 2016]. http://www.cdc.gov/nchs/nhanes/wweia.htm.
USDA/ARS. What we eat in America, NHANES 2011-2012. Beltsville, MD: USDA/ARS; 2011-2012. [December 21, 2016]. http://www.ars.usda.gov/services/docs.htm?docid=13793.
USDA/ERS (U.S. Department of Agriculture/Economic Research Service). Could behavioral economics help improve diet quality for nutrition assistance program participants? Beltsville, MD: USDA/ERS; 2007. [December 21, 2016]. http://ben.cornell.edu/pdfs/USDA-BeEcon.pdf.
USDA/FNS (U.S. Department of Agriculture/Food and Nutrition Research Service). Interim Rule, 7 C.F.R. § 246. 2007. Special Supplemental Nutrition Program for Women, Infants and Children (WIC): Revisions in the WIC food packages.
USDA/FNS. WIC works resource system: Nutrition education. 2016. [August 30, 2016]. https://wicworks.fns.usda.gov/nutrition-education.
USDA/HHS (U.S. Department of Agriculture/U.S. Department of Health and Human Services). Dietary Guidelines for Americans 2015. Washington, DC: U.S. Government Printing Office; 2016. [August 29, 2016]. https://health.gov/dietaryguidelines/2015.

Footnotes

1: The committee's application of the term supplemental is described in Chapter 6. The committee also evaluated the nutrients provided by the food packages considering the quantities of foods that WIC participants actually redeem (see Appendix R for detail on redemption rates).

2: Section 246.11(b) of the federal WIC regulations p. 392.

3: As described in Appendix U, it was not considered administratively feasible to provide a separate voucher for vegetables and for fruits.

Publication Details

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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. 5, Nutrient and Food Group Priorities for the WIC Food Packages.

TABLE 5-1Nutrient Inadequacies and Excesses Linked to Adverse Health Consequences Relevant to WIC-Participating Population Subgroups, Based on the Dietary Guidelines, Literature Review, and Other Expert Guidance

Nutrients to Increase	Population Subgroup
Nutrients to Increase	Women, P	Women, BF	Women, PP	BF Infants 6 to Less Than 12 Months	Children 1 to Less Than 2 Years	Children 2 to Less Than 5 Years
Calcium	✓^a	✓^a	✓^a			✓^a
Iron	✓^b,c	✓^b	✓^b	✓^c,d	✓c	✓^b
Zinc				✓^c^,^e
Folate	✓^c	✓^c	✓^c
Vitamin D	✓^a	✓^a	✓^a			✓^a
Fiber	✓^a	✓^a	✓^a		✓^f	✓^a
Potassium	✓^a	✓^a	✓^a		✓^f	✓^a
Choline	✓^c
Nutrients to Limit
Added sugars	✓^a	✓^a	✓^a		✓^h	✓^a
Saturated fat	✓^a	✓^a	✓^a			✓^a
Sodium	✓^a	✓^a	✓^a		✓^g	✓^a

: NOTES: BF = breastfeeding/breastfed; DGA = Dietary Guidelines for Americans; P = pregnant; PP = postpartum. For infants 0 to less than 6 months of age, or formula-fed infants 6 to less than 12 months of age, no nutrients were linked to relevant adverse health consequences. Because the DGA apply only to individuals ages 2 years and older, recommendations from other authoritative groups were applied to determine nutrients linked to adverse health outcomes for children under 2 years of age and infants. Nutrients were linked to adverse health outcomes relevant to the WIC-participating population based on the following evidence:

a: A DGA nutrient of public health concern (shortfall nutrients for which under consumption has been linked in the scientific literature to adverse health outcomes) or DGA nutrient to limit.

b: A DGA nutrient of public health concern; heme iron was considered especially important for young children or women who are capable of becoming pregnant or who are pregnant.

c: Based on the committee's literature review.

d: The American Academy of Pediatrics (AAP) recommends that complementary foods rich in iron be introduced early to help meet iron demands of BF infants 6 months and older (AAP, 2014).

e: The AAP emphasizes foods containing zinc for breastfed infants after 6 months of life (AAP, 2014).

f: Although the DGA apply only to individuals ages 2 years and older, health effects linked to consumption of these nutrients as described in the Dietary Reference Intake (DRI) report (IOM, 2002/2005, 2005) were considered applicable to younger children.

g: Although the DGA apply only to individuals ages 2 years and older, sodium intakes exceeding the Tolerable Upper Intake Level (UL) were also considered of concern for young children.

h: Although not limited to added sugars, the American Academy of Pediatric Dentistry reports that early childhood caries have been associated with frequent in-between meal consumption of sugar-containing snacks or drinks (AAPD, 2012).

FIGURE 5-1Decision tree for determining potential food package changes given the prevalence of nutrient inadequacy or food group intake below recommended amounts among WIC-participating women and children

NOTES: CVV = cash value voucher; DGA = Dietary Guidelines for Americans. This figure provides a visual description of the committee's strategy for determining priorities for action and possible solutions to inadequate consumption of nutrients or food group intakes below that recommended for WIC-participating populations. The committee's approach to excess consumption of nutrients, food groups, and calories for other uses is described in the text of this chapter.

^a For nutrients with an EAR; for nutrients with an AI, mean intakes below the AI value were considered higher-priority.

^b Assessment based on the DGA where applicable and, where the DGA do not apply, on the committee's literature review and expert guidance (see Table 5-1).

^c In addition, are the proposed foods culturally suitable for WIC participants? Are more culturally suitable foods available in acceptable forms?

TABLE 5-2Nutrient Priorities and Preliminary Actions, Food Package V for Pregnant Women

Nutrient	Rationale for Prioritization	Amount per Day			WIC Foods That Provide a Supplemental Amount of This Nutrient	Potential Action^d
Nutrient	Rationale for Prioritization	Guideline (EAR, AI, UL, or DGA)	Gap to Reduce Inadequacy or Excess to 5%^b	Amount in the Food Package (% of the EAR, AI, or DGA limit)^c		Potential Action^d
Higher Priority
Iron	Inadequacy was 82%; inadequate iron status is associated with health risks in pregnancy and development; heme iron is especially important for women who are capable of becoming pregnant or who are pregnant (as noted in the DGA)	22 mg (EAR)	10.5 mg	13.5 mg (62%)	Breakfast cereal, whole wheat bread, whole wheat pasta, legumes, peanut butter	Retain current sources because iron requirements for this group are higher than can be met by diet alone; foods outside of the food package or dietary supplements are required
Choline	Mean intakes fell below the AI; considered a nutrient linked to adverse health consequences, based on the committee's literature review	450 mg (AI)	102 mg	75 mg (17%)	Milk, eggs	Consider additional eggs
Potassium	Mean intakes fell below the AI; potassium is a DGA nutrient of public health concern	4,700 mg (AI)	1,748 mg	1,837 mg (39%)	Milk, cheese, legumes, CVV	Consider canned legumes to promote intake; additional yogurt to promote intake of dairy; consider increase in the CVV
Fiber	Mean intakes fell below the AI; fiber is a DGA nutrient of public health concern	25 g (AI)	10 g	8.0 g (29%)	Bread (and alternatives), legumes, CVV	Consider increasing whole grains; promote intake of legumes by providing a canned option; consider increase in the CVV
Higher-Priority Nutrients to Limit
Sodium	Intake exceeded the UL in >90% of the subgroup	2,300 mg (UL)	2,630 mg	727 mg (48%)	Milk, cheese, RTE breakfast cereal, vegetables (canned), legumes (canned), bread	Consider low-sodium choices when possible; nutrition education to reduce sodium in canned foods
Saturated fat^a	Intake exceeded the DGA limit in 75% of the subgroup	<10% of energy (DGA)	15 g	8.5 g (29%)	Milk (1%), cheese	Consider reducing the key sources of saturated fat or offering lower-fat options
Added sugars^a	Intake exceeded the DGA limit in 68% of the subgroup	<10% of energy (DGA)	147 g	7.4 g (11%)	Yogurt, soy beverage, peanut butter, breakfast cereal	Consider reducing the maximum allowable amounts of added sugars in yogurt or cereals; propose a maximum for soy beverage and milk
Middle Priority
Folate	Inadequacy was 22%; inadequate folate status is associated with health risks in pregnancy	520 µg DFE (EAR)	108 µg DFE	473 µg DFE (91%)	RTE breakfast cereal, legumes, CVV	Consider canned legumes to promote intake; consider increasing the CVV
Lower Priority
Magnesium	Inadequacy was 32%; no known health consequence for WIC population	290 mg (EAR)	69 mg	198 mg (68%)	Milk, legumes, RTE breakfast cereal, CVV	Retain RTE breakfast cereals; consider additional options and nutrition education or behavioral interventions to promote intake of milk, legumes, breakfast cereal, and vegetables and fruits already provided
Vitamin A	Inadequacy was 20%; no known health consequence for WIC population	550 µg RAE (EAR)	124 µg RAE	646 µg RAE (117%)	Milk, RTE breakfast cereal, CVV	Consider reducing sources because nutrient amount in the food package is more than supplemental
Zinc	Inadequacy was 20%; no known health consequence for WIC population	9.5 mg (EAR)	1.8 mg	6.6 mg (69%)	Milk, RTE breakfast cereal	Retain RTE breakfast cereals; consider additional options and nutrition education or behavioral interventions to promote intake of milk and breakfast cereal already provided
Vitamin C	Inadequacy was 17%; no known health consequence for WIC population	70 mg (EAR)	24 mg	72.2 mg (103%)	Juice, CVV	Consider reducing sources because nutrient amount in the food package is more than supplemental
Vitamin B6	Inadequacy was 12%; no known health consequence for WIC population	1.6 mg (EAR)	0.2 mg	1.3 mg (79%)	RTE breakfast cereal	Retain RTE breakfast cereals; consider additional options and nutrition education or behavioral interventions to promote intake of cereal already provided
Vitamin D	Serum vitamin D inadequacy was 9%; vitamin D is a DGA nutrient of public health concern	400 IU or 40 nmol/L (EAR)	268 IU	291 IU (73%)	Milk, soy beverage	Consider additional options and nutrition education or behavioral interventions to promote intake of milk already provided
Calcium	Inadequacy was 6%; calcium is a DGA nutrient of public health concern	800 mg (EAR)	27 mg	1,029 mg (129%)	Milk, cheese, tofu, soy milk, lactose-free milk, yogurt, RTE breakfast cereal	Consider reducing sources because nutrient amount in the food package is more than supplemental

: NOTES: AI = Adequate Intake level; CVV = cash value voucher; DFE = dietary folate equivalent; DGA = 2015–2020 Dietary Guidelines for Americans; EAR = Estimated Average Requirement; IU = international units; RAE = retinol activity equivalents; RTE = ready-to-eat; UL = Tolerable Upper Intake Level. Vitamin E inadequacy was apparent in nearly 100 percent of WIC subgroups. However, because clinical vitamin E deficiency is uncommon (IOM, 2000a), the DGA do not include it as a nutrient of public health concern (USDA/HHS, 2016). Similarly, despite the very high prevalence of inadequacy across the WIC population, it was not prioritized for action by the committee.

a: Saturated fat and added sugars intakes were evaluated based on a 2,600-kcal food pattern selected to align with the Estimated Energy Requirement calculated for pregnant women participating in WIC.

b: For nutrients with an EAR and inadequate intake, the gap is the difference between the EAR and the 5th percentile of intake; for nutrients with an AI and intake below the AI, the gap is the difference between the AI and the median intake; for sodium, saturated, and added sugars, for which there is excess intake, the gap is the difference between the UL and the 95th percentile of intake. Complete results of the gap analysis are presented in Appendix L.

c: The percent values assume that the food package is fully consumed.

d: Translation of potential actions into the final food packages depended upon cost and other practical and administrative considerations.

: SOURCES: IOM, 1998, 2000a, 2001, 2002/2005, 2005, 2011; USDA/ARS 2005–2012; USDA/HHS, 2016.

TABLE 5-3Nutrient Priorities and Preliminary Actions, Food Packages for Breastfeeding Women^a

Nutrient	Rationale for Prioritization	Amount per Day				WIC Foods That Provide a Supplemental Amount of This Nutrient	Potential Action^e
Nutrient	Rationale for Prioritization	Guideline (EAR, AI, UL, or DGA)	Gap to Reduce Inadequacy or Excess to 5%^c	Amount in Food Package V	Amount in Food Package VII (% of the EAR, AI, or DGA limit)^d		Potential Action^e
Higher Priority
Potassium	Mean intakes fell below the AI; potassium is a 2015 DGA nutrient of public health concern	5,100 mg (AI)	2,254 mg	1,836 mg	1,958 (38%)	Milk, cheese, legumes, CVV	Consider increasing the CVV; canned legumes to promote intake; nutrition education or behavioral interventions to promote consumption of dairy that is already provided in the food package
Fiber	Mean intakes fell below the AI; fiber is a DGA nutrient of public health concern	29 g (AI)	13 g	8.0 g	8.0 g (29%)	Bread (and alternatives), legumes, CVV	Consider increasing whole grains; promote intake of legumes by providing a canned option; consider increase in the CVV
Higher-Priority Nutrients to Limit
Sodium	Intake exceeded the UL in 96% of the subgroup	2,300 mg (UL)	2,139 mg	727 mg	1,007 mg (67%)	Milk, cheese, RTE breakfast cereal, vegetables (canned), legumes (canned), bread	Consider low-sodium choices when possible; nutrition education to reduce sodium in canned foods
Saturated fat^b	Intakes exceeded the DGA limit in 79% of the subgroup	<10% of energy (DGA)	17 g	8.5 g	12.8 g (44%)	Milk (1%), cheese	Consider reducing the key sources of saturated fat or lower-fat options
Added sugars^b	Intake exceeded the DGA limit in 24% of subgroups	<10% of energy (DGA)	45 g	7.4 g	6.6 g (10%)	Yogurt, soy beverage, peanut butter, RTE breakfast cereal	Consider reducing the maximum allowable amounts of added sugars in yogurt or cereals; propose a maximum for soy beverage and milk
Middle Priority
Folate	Inadequacy was 27%; folate is a DGA nutrient of public health concern for premenopausal women	450 µg DFE (EAR)	127 µg DFE	473 µg DFE	489 µg DFE (108%)	RTE breakfast cereal, legumes, CVV	Consider reducing sources because nutrient amount in the food package is more than supplemental
Vitamin D	Serum vitamin D inadequacy was 21%; vitamin D is a DGA nutrient of public health concern	400 IU or 40 nmol/L (EAR)	308 IU	291 IU	371 IU (86%)	Milk, soy beverage, fish	Consider additional options; sun exposure in combination with WIC foods may be required to improve status
Calcium	Inadequacy was 16%; calcium was a DGA nutrient of public health concern	800 mg (EAR)	136 mg	1,029 mg	1,232 mg (154%)	Milk, yogurt, soy beverage, cheese, breakfast cereals	Consider reducing sources because nutrient amount in the food package is more than supplemental
Lower Priority
Vitamin A	Inadequacy was 75%; no known health consequence for WIC population	900 µg RAE (EAR)	498 µg RAE	646 µg RAE	754 µg RAE (84%)	Milk, RTE breakfast cereal, CVV	Consider additional options; nutrition education or behavioral interventions to promote intake of milk, breakfast cereal, and vegetables and fruits already provided
Magnesium	Inadequacy was 39%; no known health consequence for WIC population	255 mg (EAR)	73 mg	198 mg	214 mg (81%–84%)	Milk, legumes, RTE breakfast cereal, CVV	Consider additional options and nutrition education or behavioral interventions to promote intake of milk, legumes, breakfast cereal, and vegetables and fruits already provided
Zinc	Inadequacy was 39%; no known health consequence for WIC population	10.4 mg (EAR)	3.3 mg	6.6 mg	7.7 mg (74%)	Milk, RTE breakfast cereal	Consider additional options and nutrition education or behavioral interventions to promote intake of milk and breakfast cereal already provided
Vitamin C	Inadequacy was 33%; no known health consequence for WIC population	100 mg (EAR)	47 mg	72.2 mg	72.4 mg (72%)	Juice, CVV	Consider increasing the CVV
Vitamin B6	Inadequacy was 30%; no known health consequence for WIC population	1.7 mg (EAR)	0.5 mg	1.3 mg	1.4 mg (83%)	RTE breakfast cereal	Retain RTE breakfast cereals
Copper	Inadequacy was 22%; no known health consequence for WIC population	1.0 mg (EAR)	0.2 mg	0.44 mg	0.5 mg (48%)	Milk, legumes, breakfast cereal, CVV	Consider additional options and nutrition education or behavioral interventions to promote intake of milk, legumes, breakfast cereal, and vegetables and fruits already provided
Thiamin	Inadequacy was 10%; no known health consequence for WIC population	1.2 mg (EAR)	0.1 mg	0.91 mg	0.9 mg (78%)	RTE breakfast cereal	Retain RTE breakfast cereals

: NOTES: AI = Adequate Intake level; CVV = cash value voucher; DFE = dietary folate equivalent; DGA = 2015–2020 Dietary Guidelines for Americans; EAR = Estimated Average Requirement; IU = international units; RAE = retinol activity equivalents; RTE = ready-to-eat; UL = Tolerable Upper Intake Level. Vitamin E inadequacy was apparent in nearly 100 percent of WIC subgroups. However, because clinical vitamin E deficiency is uncommon (IOM, 2000a), the 2015 DGA do not include it as a nutrient of public health concern (USDA/HHS, 2016). Similarly, despite the very high prevalence of inadequacy across the WIC-participating population, it was not prioritized for action by the committee.

a: Inadequacy data in this table are for women coded as “breastfeeding” and participating in WIC in NHANES 2005–2012. The intensity of breastfeeding is not known, but these data represent the best available for evaluation of the degree to which food packages V and VII meet the needs of these women.

b: Saturated fat and added sugars intakes were evaluated based on a 2,600-kcal food pattern selected to align with the Estimated Energy Requirement calculated for breastfeeding women participating in WIC.

c: For nutrients with an EAR and inadequate intake, the gap is the difference between the EAR and the 5th percentile of intake; for nutrients with an AI and intake below the AI, the gap is the difference between the AI and the median intake; for sodium, saturated fat, and added sugars, for which there is excess intake, the gap is the difference between the UL and the 95th percentile of intake. Complete results of the gap analysis are presented in Appendix L.

d: Because DRI values for women that are partially breastfeeding have not been published, no comparison to nutrient intake recommendations is made for food package V.

e: Translation of potential actions into the final food packages depended upon cost and other practical and administrative considerations.

: SOURCES: IOM, 1998, 2000a, 2001, 2002/2005, 2005, 2011; USDA/ARS, 2005–2012; USDA/HHS, 2016.

TABLE 5-4Nutrient Priorities and Preliminary Actions, Food Package VI, Postpartum Women

Nutrient	Rationale for Prioritization	Amount per Day			WIC Foods That Provide a Supplemental Amount of This Nutrient	Potential Action^d
Nutrient	Rationale for Prioritization	Guideline (EAR, AI, UL, or DGA)	Gap to Reduce Inadequacy or Excess to 5%^b	Amount in the Food Package (% of the EAR, AI, or DGA limit)^c		Potential Action^d
Higher Priority
Calcium	Inadequacy was 52% in postpartum women; calcium is a DGA nutrient of public health concern	800 mg (EAR)	371 mg	739 mg (92%)	Milk, yogurt, soy beverage, cheese, RTE breakfast cereals	Consider reducing sources because nutrient amount in the food package is more than supplemental
Potassium	Mean intakes fell below the AI; potassium is a DGA nutrient of public health concern	4,700 mg (AI)	2,802 mg	1,302 mg (28%)	Milk, cheese, legumes, CVV	Consider increasing the CVV; promote intake of legumes by providing a canned option
Fiber	Mean intakes fell below the AI; fiber is a DGA nutrient of public health concern	25 g (AI)	13 g	5.7 g (23%)	Bread (and alternatives), CVV, legumes	Consider increasing whole grains; consider increase in the CVV; promote intake of legumes by providing a canned option
Higher-Priority Nutrients to Limit
Sodium	Intake exceeded the UL in >79% of the subgroup	2,300 mg (UL)	1,771 mg	527 mg (35%)	Milk, cheese, RTE breakfast cereal, vegetables (canned), legumes (canned), bread	Consider low-sodium choices when possible; nutrition education to reduce sodium in canned foods
Added sugars^a	Intake exceeded the DGA limit in 78% of the subgroup	<10% of energy (DGA)	35 g	6.9 g (12%)	Yogurt, soy beverage, peanut butter, RTE breakfast cereal	Consider reducing the maximum allowable amounts of added sugars in yogurt or cereals; propose a maximum for soy beverage and milk
Middle Priority
Folate	Inadequacy was 33%; inadequate folate status is associated with health risks in pregnancy	520 µg DFE (EAR)	131 µg DFE	425 µg DFE (133%)	RTE breakfast cereal, legumes, CVV	Consider canned legumes to promote intake; consider increase in the CVV
Vitamin D	Inadequacy was 13%; vitamin D is a DGA nutrient of public health concern	400 IU or 40 nmol/L (EAR)	364 IU	213 IU (53%)	Milk, soy beverage	Consider additional options; sun exposure in combination with WIC foods may be required to improve status
Iron	Inadequacy was 13%; iron was a DGA nutrient of public health concern for premenopausal females	8.1 mg (EAR)	1.6 mg	12.3 mg (152%)	Breakfast cereal, whole wheat bread, whole wheat pasta, legumes, peanut butter	Consider reducing sources because nutrient amount in the food package is more than supplemental
Middle Priority Nutrient to Limit
Saturated fat^a	Intakes exceeded the DGA limit in 49% of the subgroup	<10% of energy (DGA)	8 g	6.4 g (25%)	Milk, cheese	Consider reducing the key sources of saturated fat (milk, cheese)
Lower Priority
Magnesium	Inadequacy was 78%; no known health consequence for WIC population	265 mg (EAR)	144 mg	132 mg (50%–52%)	Milk, legumes, RTE breakfast cereal, CVV	Consider additional options; nutrition education or behavioral interventions to promote intake of milk, legumes, breakfast cereal, and vegetables and fruits already provided in the food package
Vitamin A	Inadequacy was 69%; no known health consequence for WIC population	500 µg RAE (EAR)	355 µg RAE	522 µg RAE (104%)	Milk, RTE breakfast cereal, CVV	Consider reducing sources because nutrient amount in the food package is more than supplemental
Vitamin C	Inadequacy was 38%; no known health consequence for WIC population	60 mg (EAR)	37 mg	57 mg (95%)	Juice, CVV	Consider reducing sources because nutrient amount in the food package is more than supplemental
Copper	Inadequacy was 32%; no known health consequence for WIC population	0.7 mg (EAR)	0.3 mg	0.3 mg (42%)	Milk, legumes, RTE breakfast cereal, CVV	Consider additional options; nutrition education or behavioral interventions to promote intake of milk, legumes, breakfast cereal, and vegetables and fruits already provided in the food package
Zinc	Inadequacy was 30%; no known health consequence for WIC population	6.8 mg (EAR)	2.5 mg	5.2 mg (76%)	Milk, RTE breakfast cereal	Consider additional options; nutrition education or behavioral interventions to promote intake of milk and breakfast cereal already provided in the food package
Thiamin	Inadequacy was 20%; no known health consequence for WIC population	0.9 mg (EAR)	0.2 mg	0.7 mg (81%)	RTE breakfast cereal	Retain RTE breakfast cereals
Vitamin B6	Inadequacy was 20%; no known health consequence for WIC population	1.1 mg (EAR)	0.3 mg	1.1 mg (97%)	RTE breakfast cereal	Consider reducing sources because nutrient amount in the food package is more than supplemental
Vitamin B12	Inadequacy was 14%; no known health consequence for WIC population	2.0 µg (EAR)	0.6 µg	3.6 µg (180%)	RTE breakfast cereal	Consider reducing sources because nutrient amount in the food package is more than supplemental
Riboflavin	Inadequacy was 11%; no known health consequence for WIC population	0.9 mg (EAR)	0.2 mg	1.4 mg (153%)	Milk, RTE breakfast cereal	Consider reducing sources because nutrient amount in the food package is more than supplemental
Niacin	Inadequacy was 6%; no known health consequence for WIC population	11 mg (EAR)	0.4 mg	8.0 mg (72%)	RTE breakfast cereal	Retain RTE breakfast cereals

: NOTES: AI = Adequate Intake level; CVV = cash value voucher; DFE = dietary folate equivalent; DGA = 2015–2020 Dietary Guidelines for Americans; EAR = Estimated Average Requirement; IU = international units; RAE = retinol activity equivalents; RTE = ready-to-eat; UL = Tolerable Upper Intake Level. Vitamin E inadequacy was apparent in nearly 100 percent of WIC subgroups. However, because clinical vitamin E deficiency is uncommon (IOM, 2000a), the 2015 DGA do not include it as a nutrient of public health concern (USDA/HHS, 2016). Similarly, despite the very high prevalence of inadequacy across the WIC-participating population, it was not prioritized for action by the committee.

a: Values are based on the DGA recommended limits for a 2,300-kcal food pattern selected to align with the estimated energy requirement calculated for postpartum women participating in WIC.

b: For nutrients with an EAR and inadequate intake, the gap is the difference between the EAR and the 5th percentile of intake; for nutrients with an AI and intake below the AI, the gap is the difference between the AI and the median intake; for sodium, saturated fat, and added sugars, for which there is excess intake, the gap is the difference between the UL and the 95th percentile of intake. Complete results of the gap analysis are presented in Appendix L.

c: The percent values assume that the food package is fully consumed.

d: Translation of potential actions into the final food packages depended upon cost and other practical and administrative considerations.

: SOURCES: IOM, 1998, 2000a, 2001, 2002/2005, 2005, 2011; USDA/ARS, 2005–2012; USDA/HHS, 2016.

TABLE 5-5Nutrient Priorities and Preliminary Actions, Food Package IV, Children Ages 1 to Less Than 5 Years of Age

Nutrient	Rationale for Prioritization	Amount per Day (Ages 1–3 y/Age 4 y)			WIC Foods That Provide a Supplemental Amount of This Nutrient	Potential Action^d
Nutrient	Rationale for Prioritization	Guideline (EAR, AI, UL, or DGA)	Gap to Reduce Inadequacy or Excess to 5%^b	Amount in the Food Package (% of the EAR, AI, or DGA limit)^c		Potential Action^d
Higher Priority
Fiber	Mean intakes fell below the AI; fiber is a DGA nutrient of public health concern	19/25 g (AI)	7/13 g	7.1 g (38/29%)	Bread (and alternatives), legumes, CVV	Consider increasing the CVV; promote intake of legumes by providing a canned option
Potassium	Mean intakes fell below the AI; potassium is a DGA nutrient of public health concern	3,000/3,800 mg (AI)	929/1,729 mg	1,267/1,357 mg (42/36%)	Milk, cheese, CVV, legumes	Consider increasing the CVV; promote intake of legumes by providing a canned option
Higher-Priority Nutrients to Limit
Sodium	Intake exceeded the UL in 59 to 65% of the subgroups	1,500/1,900 mg (UL)	806/1,495/1,095^e mg	587/639 (59/53%)	Milk, cheese, RTE breakfast cereal, vegetables (canned), legumes (canned), bread	Consider low-sodium choices when possible; nutrition education to reduce sodium in canned foods
Saturated fat^a	Intakes exceeded the DGA limit in 70% of the subgroup (children 2 to less than 5 years)	<10% of energy (DGA)	15 g	6.6 g (46%)	1% milk, cheese	Consider reducing the key sources of saturated fat
Added sugars^a	Intake exceeded the DGA limit in 80% of subgroups (children 2 to less than 5 years)	<10% of energy (DGA)	59 g	6.9 g (21%)	Yogurt, soy beverage, peanut butter, RTE breakfast cereal	Consider reducing the maximum allowable amounts of added sugars in yogurt or cereals; propose a maximum level for soy beverage and milk

: NOTES: AI = Adequate Intake level; CVV = cash value voucher; DFE = dietary folate equivalent; DGA = 2015–2020 Dietary Guidelines for Americans; EAR = Estimated Average Requirement; IU = international units; RAE = retinol activity equivalents; RTE = ready-to-eat; UL = Tolerable Upper Intake Level. There were no nutrients linked to adverse health outcomes for which intakes were inadequate in 5 to 50 percent of the subgroup. Vitamin E inadequacy was apparent in nearly 100 percent of WIC subgroups. However, because clinical vitamin E deficiency is uncommon (IOM, 2000a), the 2015 DGA do not include it as a nutrient of public health concern (USDA/HHS, 2016). Similarly, despite the very high prevalence of inadequacy across the WIC-participating population, it was not prioritized for action by the committee.

a: Values are based on the DGA recommended limits for a 1,300-kcal food pattern selected to approximate the estimated energy needs of children ages 2 to less than 5 years. Data for saturated fat and added sugars specifically represent children of these ages because no limits have been defined for children ages 1 to less than 2 years.

b: For nutrients with an EAR and inadequate intake, the gap is the difference between the EAR and the 5th percentile of intake; for nutrients with an AI and intake below the AI, the gap is the difference between the AI and the median intake; for sodium, saturated fat, and added sugars, for which there is excess intake, the gap is the difference between the UL and the 95th percentile of intake. Complete results of the gap analysis are presented in Appendix L.

c: The percent values assume that the food package is fully consumed.

d: Translation of potential actions into the final food packages depended upon cost and other practical and administrative considerations.

e: UL intake gap from 95th percentile for children 1–2 years, 2–3 years, and 4–5 years.

: SOURCES: IOM, 1998, 2000a, 2001, 2002/2005, 2005, 2011; USDA/ARS, 2011–2012; USDA/HHS, 2016.

TABLE 5-6Nutrient Priorities and Preliminary Actions, Food Package II, Partially or Fully Breastfed Infants (Ages 6 to Less Than 12 Months)

Nutrient	Rationale for Prioritization	Amount per Day			WIC Foods That Provide a Supplemental Amount of This Nutrient	Potential Action^c
Nutrient	Rationale for Prioritization	EAR	Gap to Reduce Inadequacy to 5%^a	Amount in the Food Package (% of the EAR)^b		Potential Action^c
Iron	Inadequacy was 38%; Based on the committee's literature review, breastfed infants are at risk for low iron intakes	6.9 mg	4.8 mg	14.1–20.1 mg (204%–303%)	Infant cereal, infant food meat	Consider decreasing the amounts of infant food meat or infant cereals and providing a more preferred alternative
Zinc	Inadequacy was 44%; Based on the committee's literature review, breastfed infants are at risk for low zinc intakes	2.5 mg	2.0 mg	3.3–5.9 mg (132%–236%)	Infant cereal, infant food meat	Consider decreasing the amounts of infant food meat or infant cereals and providing a more preferred alternative

: NOTES: EAR = Estimated Average Requirement.

a: For nutrients with an EAR and inadequate intake, the gap is the difference between the EAR and the 5th percentile of intake; for nutrients with an AI and intake below the AI, the gap is the difference between the AI and the median intake. Complete results of the gap analysis are presented in Appendix L.

b: Values represent the amounts in the partially and fully breastfed infant packages, respectively. The percent values assume that the food package is fully consumed.

c: Translation of potential actions into the final food packages depended upon cost and other practical and administrative considerations.

: SOURCES: IOM, 2001; USDA/ARS, 2011–2012.

TABLE 5-7Food Group Priorities and Preliminary Actions, Food Package V, Pregnant Women

DGA Food Group	Identification in the DGA as a Food Group or Subgroup	Amount per Day			WIC Foods That Provide a Supplementa Amount of This Food Group	l Potential Action^d
DGA Food Group	Identification in the DGA as a Food Group or Subgroup	Rationale for Prioritization (% of WIC Women Consuming Less Than the Recommended Intake)	DGA Recommendatio	Food Package Contribution to the DGA Recommendation n^a (%)^b		l Potential Action^d
Higher Priority
Whole grains	Subgroup	100	4.5 oz-eq/d	17	Bread and alternatives, breakfast cereal	Consider increasing whole grain allowance or adding grain options
Total vegetables	Group	99	3.5 c-eq/d	13	CVV	Consider increasing the CVV
Dark green vegetables	Subgroup	97	2.5 c-eq/wk	—^c	CVV	Consider increasing the CVV
Total red and orange vegetables	Subgroup	97	7 c-eq/wk	—^c	CVV	Consider increasing the CVV
Nuts, seeds, and soy	Subgroup	87	5 oz-eq/wk	168	Peanut butte	Consider reducing amount in the food package because it is more than supplemental
Other vegetables	Subgroup	83	5.5 c-eq/wk	—^c	CVV	Consider increasing the CVV
Total dairy	Group	82	3 c-eq/d	98	Milk, cheese, yogurt	Consider additional yogurt substitution; amount in the food package is more than supplemental and could be reduced
Seafood	Subgroup	82; authoritative bodies recommend intake of fish varieties high in omega-3 and low in mercury during all life stages that affect development	10 oz-eq/wk	0	None	Consider adding canned fish
Beans and peas computed as vegetables	Subgroup	NA	2.5 c-eq/wk	71	Legumes	Consider providing canned options to promote intake of legumes
Lower Priority
Total protein foods	Group	75	6.5 oz-eq/d	28	Milk and alternatives, cheese, eggs, legumes, and peanut butter	Consider adding canned fish
Total grains	Group	71	9 oz-eq/d	19	Bread and alternatives, breakfast cereal	Consider increasing whole grain allowance or adding grain options
Total fruit	Group	69	2 c-eq/d	52	CVV	Consider increasing the CVV
Total starchy vegetables	Subgroup	65	7 c-eq/wk	—^c	CVV	Consider increasing the CVV
Whole fruit	Subgroup	64	1–2 c-eq/d	45	CVV	Consider increasing the CVV
Meat, poultry, and eggs (not seafood)	Subgroup	56	31 oz-eq/wk	9	Eggs	Consider additional eggs

: NOTES: c-eq = cup-equivalents; CVV = cash value voucher; DGA = Dietary Guidelines for Americans; NA = data not available because too few survey respondents reported intake of the food group or subgroup to generate estimates of intake; oz-eq = ounce-equivalents.

a: Based on a 2,600-kcal food pattern.

b: Based on the same assumptions applied to develop Table 3-1 in Chapter 3.

c: The quantity of vegetable subgroups provided by the CVV depends upon the participants' selection.

d: Translation of potential actions into the final food packages depended upon cost and other practical and administrative considerations.

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

TABLE 5-8Food Group Priorities and Preliminary Actions, Breastfeeding Women

DGA Food Group	Identification in the DGA as a Food Group or Subgroup	Rationale for Prioritization (% of WIC Women Consuming Less Than the Recommended Intake)	Amount per Day			WIC Foods That Provide a Supplemental Amount of This Food Group	Potential Action^e
DGA Food Group	Identification in the DGA as a Food Group or Subgroup		DGA Recommendation^a	Food Package V Contribution to the DGA Recommendation (%)^b	Food Package VII Contribution to the DGA Recommendation (%)^c		Potential Action^e
Higher Priority
Whole grains	Subgroup	100	4.5 oz-eq/d	19	19	Bread and alternatives, breakfast cereal	Consider increasing whole grain allowance or adding grain options
Total red and orange vegetables	Subgroup	97	7 c-eq/wk	—^d	— ^d	CVV	Consider increasing the CVV
Other vegetables	Subgroup	92	5.5 c-eq/wk	— ^d	— ^d	CVV	Consider increasing the CVV
Total grains	Group	88	9 oz-eq/d	19	19	Bread and alternatives, breakfast cereal	Consider increasing whole grain allowance or adding grain options
Total starchy vegetables	Subgroup	84	7 c-eq/wk	— ^d	— ^d	CVV	Consider increasing the CVV
Total fruit	Group	79	2 c-eq/d	52	52	CVV	Consider increasing the CVV
Total Protein foods	Group	76	6.5 oz-eq/d	28	50	Milk and alternatives, cheese, eggs, legumes and peanut butter	Consider additional options; nutrition intervention or behavioral interventions to promote intake of foods already provided
Dark green vegetables	Subgroup	NA	2.5 c-eq/wk	— ^d	— ^d	CVV	Consider increasing the CVV
Beans and peas computed as vegetables	Subgroup	NA	2.5 c-eq/wk	71	71	Legumes	Consider providing a canned option to promote intake of legumes
Seafood	Subgroup	NA	10 oz-eq/wk	0	70	None	Enhance nutrition education or use behavioral approaches
Nuts, seeds, and soy	Subgroup	NA	5 oz-eq/wk	168	168	Peanut butter	Consider reducing amount in the food package because it is more than supplemental
Lower Priority
Whole fruit	Subgroup	79	1–2 c-eq/d	45	45	CVV	Consider increasing the CVV
Total dairy	Group	73	3 c-eq/d	98	119	Milk, cheese, yogurt	Consider additional yogurt substitution; amount in the food package is more than supplemental and could be reduced
Total vegetables	Group	50	3.5 c-eq/d	13	13	CVV	Consider increasing the CVV

: NOTES: c-eq = cup-equivalents; CVV = cash value voucher; DGA = Dietary Guidelines for Americans; NA = data not available because too few survey respondents reported intake of the food group or subgroup to generate estimates of intake; oz-eq = ounce-equivalents.

a: Based on a 2,600-kcal food pattern. The energy needs of partially breastfeeding women may be less.

b: Based on the same assumptions applied to develop Table 3-1 in Chapter 3.

c: Based on the same assumptions applied to develop Table 3-3 in Chapter 3.

d: The quantity of vegetable subgroups provided by the CVV depends upon the participants' selection.

e: Translation of potential actions into the final food packages depended upon cost and other practical and administrative considerations.

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

TABLE 5-9Food Group Priorities and Preliminary Actions, Food Package VI, Postpartum Women

DGA Food Group	Identification in the DGA as a Food Group or Subgroup	Rationale for Prioritization (% of WIC Women Consuming Less Than the Recommended Intake)	Amount per Day		WIC Foods That Provide a Supplemental Amount of This Food Group	Potential Action^d
DGA Food Group	Identification in the DGA as a Food Group or Subgroup		DGA Recommendation^a	Food Package Contribution to the DGA Recommendation (%)^b		Potential Action^d
Higher Priority
Whole grains	Subgroup	100	3.75 oz-eq/d	6	Bread and alternatives, breakfast cereal	Consider increasing whole grain allowance or adding grain options
Total vegetables	Subgroup	100	3 c-eq/d	12	CVV	Consider increasing the CVV
Total starchy vegetables	Subgroup	99	6 c-eq/wk	—^c	CVV	Consider increasing the CVV
Total dairy	Group	96	3 c-eq/d	71	Milk, cheese, yogurt	Consider additional yogurt substitution; amount in the food package is more than supplemental and could be reduced
Whole fruit Total red and orange vegetables	Subgroup Subgroup	96 94	1–2 c-eq/d 6 c-eq/wk	45 —^c	CVV CVV	Consider increasing the CVV Consider increasing the CVV
Nuts, seeds, and soy	Subgroup	91	5 oz-eq/wk	84	Peanut butter	Consider reducing amount in the food package because it is more than supplemental
Total fruit	Group	90	2 c-eq/d	42	CVV	Consider increasing the CVV
Dark green vegetables	Subgroup	89	2 c-eq/wk	— ^c	CVV	Consider increasing the CVV
Other vegetables	Subgroup	85	5 c-eq/wk	— ^c	CVV	Consider increasing the CVV
Beans and peas computed as vegetables	Subgroup	NA	2 c-eq/wk	44	Legumes	Consider providing canned option to promote intake of legumes
Seafood	Subgroup	NA	9.5 oz-eq/wk	0	None	Consider adding canned fish
Lower Priority
Total protein foods	Group	75	6.25 oz-eq/d	20	Milk and alternatives, cheese, eggs, legumes, and peanut butter	Consider additional options (i.e., fish for partially breastfeeding women); nutrition intervention or behavioral interventions to promote intake of foods already provided
Total grains	Group	58	7.5 oz-eq/d	16	Bread and alternatives, breakfast cereal	Consider increasing whole grains or adding grain options
Meat, poultry, and eggs (not seafood)	Subgroup	54	29.5 oz-eq/wk	10	Eggs	Consider additional eggs

: NOTES: c-eq = cup-equivalents; CVV = cash value voucher; DGA = Dietary Guidelines for Americans; NA = data not available because too few survey respondents reported intake of the food group or subgroup to generate estimates of intake; oz-eq = ounce-equivalents.

a: Based on a 2,300-kcal food pattern.

b: Based on the same assumptions applied to develop Table 3-2 in Chapter 3.

c: The quantity of vegetable subgroups provided by the CVV depends upon the participants' selection.

d: Translation of potential actions into the final food packages depended upon cost and other practical and administrative considerations.

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

TABLE 5-10Food Group Priorities and Preliminary Actions, Food Package IV, Children Ages 2 to Less Than 5 Years^a

DGA Food Group	Identification in the DGA as a Food Group or Subgroup	Rationale for Prioritization (% of WIC-Participating Children Consuming Less Than the Recommended Intake)	Amount per Day		WIC Foods That Provide a Supplemental Amount of This Food Group	Potential Action^e
DGA Food Group	Identification in the DGA as a Food Group or Subgroup		DGA Recommendation^b	Food Package Contribution to the DGA Recommendation (%)^c		Potential Action^e
Higher Priority
Seafood	Subgroup	100	5 oz-eq/wk	0	None	Consider adding canned fish
Total vegetables	Group	99	1.5 c-eq/d	19	CVV	Consider increasing the CVV
Dark green vegetables	Subgroup	94	1 c-eq/wk	—^d	CVV	Consider increasing the CVV
Whole grains	Subgroup	93	2.25 oz-eq/d	58	Bread and alternatives, breakfast cereal	Consider increasing whole grain allowance or adding grain options
Total red and orange vegetables	Subgroup	90	3 c-eq/wk	— ^d	CVV	Consider increasing the CVV
Nuts, seeds, and soy	Subgroup	77	2.5 oz-eq/wk	167	Peanut butter	Consider reducing amount in the food package because it is more than supplemental
Lower Priority
Total starchy vegetables	Subgroup	73	3.5 c-eq/wk	— ^d	CVV	Consider increasing the CVV
Other vegetables	Subgroup	73	2.5 c-eq/wk	— ^d	CVV	Consider increasing the CVV
Total dairy	Group	73	2.5 c-eq/d	85	Milk, cheese, yogurt	Consider increasing the yogurt substitution; enhance nutrition education or use behavioral approaches to promote intake of milk already provided in the food package
Total protein foods	Group	68	3.5 oz-eq/d	29	Milk and alternatives, cheese, eggs, legumes and peanut butter	Consider adding canned fish
Beans and peas computed as vegetables	Subgroup	59	0.5 c-eq/wk	177	Legumes	Consider reducing amount in the food package because it is more than supplemental and providing canned option to promote intake of legumes

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

a: Data are specific to children 2 to less than 5 years of age because the DGA apply only to individuals ages 2 years and older.

b: Based on a 1,300-kcal food pattern.

c: Based on the same assumptions applied to develop Table 3-4 in Chapter 3.

d: The quantity of vegetable subgroups provided by the CVV depends upon the participants' selection.

e: Translation of potential actions into the final food packages depended upon cost and other practical and administrative considerations.

: SOURCES: USDA/ARS, 2011–2012; USDA/HHS, 2016.