Overall Increases in the CVV

WIC is a source of access to vegetables and fruits for low-income women. Yet, evidence indicates that WIC and SNAP benefits combined may be inadequate for low-income pregnant women to have a steady supply of vegetables and fruits throughout the month (Hromi-Fiedler et al., 2016).³ Given the current CVV of $8 for children and $11 for women, there is substantial room to improve the extent to which the food packages provide supplemental amounts of vegetables and whole fruits. These current amounts permit participants to purchase less than one cup-equivalent of vegetables or fruits per day. Based on the committee's composite cost for vegetables and fruits most commonly purchased among WIC participants,⁴ $23, $41, or $45 would be required for individuals who consumed a 1,300-, 2,300-, or 2,600-kcal diet, respectively, to meet half of the recommended intakes of vegetables and fruits. The committee increased the CVV across food packages to the extent possible within cost-neutral restrictions (see Tables 6-1 and 6-2).

The CVV not only provides participants with access to two food groups (vegetables and fruits) for which intakes were below recommended amounts across several population subgroups (see Chapter 5), but it is also the component of the food packages that offers participants the most flexibility to meet their cultural needs. Evidence indicates that preferences for vegetables and fruits vary among WIC participants depending upon race, ethnicity, and geographic region of origin (Di Noia et al., 2016). Additionally, the CVV may help to increase dietary variety, which has been associated with improved diet quality (Arimond and Ruel, 2004).

The committee recognizes that WIC participants have the option to purchase either vegetables, fruits, or a combination of both. Available redemption data (from two states) indicate that the CVV is more commonly used to purchase fruits (67 percent of voucher dollars) than vegetables (33 percent of voucher dollars). Inasmuch as individuals already purchase both vegetables and fruits, the increase in benefit is predicted to enhance the amount of vegetables purchased and may be more effective in doing so with enhanced attention to nutrition education about the selection and preparation of vegetables (see the discussion on nutrition education in Chapter 11).

At Least Two Forms of Vegetables and Fruits Can Be Purchased with the CVV for Women, Infants, or Children

As outlined in the March 2014 Final Rule, states are currently required to authorize fresh vegetables and fruits and may also authorize canned, frozen, or dried forms (USDA/FNS, 2014). At the time of this writing, 10 states offered only fresh forms of vegetables and fruits (USDA/FNS, 2015a). Given the increase in the CVV across food packages in the revised packages, states must authorize at least two forms of vegetables and two forms of fruits: fresh and at least one additional form (frozen, canned, or dried). Limiting participants' options to fresh-only may compromise available options seasonally and in certain geographic regions. Fresh, frozen, or canned forms of vegetables and fruits offer similar nutritional benefits. In some cases, processing may preserve nutrients that would otherwise be lost (Rickman et al., 2007; USDA/HHS, 2010; HHS, 2011; Miller and Knudsen, 2014; PBHF, 2016). Vegetables and fruits preserved through canning, freezing, or drying are also less perishable, thereby adding convenience. Additionally, in some cases, canned or frozen vegetables and fruits may be more economical than fresh (Miller and Knudsen, 2014; USDA/ERS, 2016), thereby increasing the purchasing power of the CVV. Although the sodium content of canned vegetables may be higher than that of other forms, canned vegetables can be prepared in ways that reduce sodium content (CFA, 2016).

The committee recognizes that state agencies that do not currently allow canned, frozen, or dried vegetables and fruits will need to ensure that vendors have electronic benefit card (EBT)–linked Universal Product Codes (UPCs) (i.e., for new WIC-eligible canned, frozen, or dried vegetables and fruits). The USDA-FNS effort to develop a more comprehensive national UPC database (USDA/FNS, 2016a) should facilitate state efforts to meet requirements to stock new or additional products.

Vendors Are Required to Stock at Least Three Varieties of Vegetables and Two Varieties of Fruits

The current regulations require vendors to stock at least two varieties of vegetables and two varieties of fruits. Given the increased value of the CVV, the higher ratio of fruits (67 percent) that are purchased compared to vegetables (33 percent), and the low intakes of vegetables (particularly in contrast to fruits) in all WIC-participating subgroups, the committee decided that weighting the stocking requirements in favor of vegetables is a strategy that may facilitate participant purchase of vegetables over fruits.

Legumes

The amount of legumes in the current food packages for children provides 177 percent of recommended amounts of beans and peas, and for women between 44 and 71 percent of recommended amounts (see Chapter 3, Tables 3-1 through 3-4). Legumes are key sources of several nutrients (i.e., potassium, fiber, and folate) for which intakes were found by the committee to be below recommended amounts in several WIC participant subgroups. Therefore, legumes are a valuable component of the WIC food packages. However, to align with the criterion of supplemental, the committee reduced the amounts provided in the revised food packages for children and equalized the amounts provided for women. The reduction in legumes (which are not highly redeemed) increases the funds available for the CVV, one of the most highly redeemed “foods” in the packages which may also serve as a source of vegetables. For children and postpartum women who currently choose peanut butter over legumes, the revised package provides both foods on a regular basis (therefore, legumes may actually be increased for some individuals). Legumes are now provided once every 3 months to all children and women (food packages IV, V-A, V-B, VI, and VII). Children are issued 1 pound of dry legumes (or four 15–16 ounce cans) and women are issued 2 pounds of dry legumes (or eight 15–16 ounce cans). The revised food packages for children still provide 120 percent of recommended amounts because package sizes prohibit reasonable further reductions (see Appendix T). For women, the revision brings the amount provided closer to what is considered supplemental: between 47 and 59 percent of the DGA recommended amount.

Offering Options for Both Dried and Canned Legumes

At present, states may authorize either dried and/or canned legumes. Although dried legumes are more commonly used in some cultures, they require significantly more preparation time, which may serve as a barrier to consumption of legumes for some WIC participants. In the revised packages, states are required to offer both dried and canned legumes in all packages as a way to promote both redemption and consumption. Canned legumes are more convenient because they are essentially ready-to-eat. Dry legumes should still be offered for those with a preference (cultural or personal) for this product, and to offer an easier-to-carry option.

According to the 2015 Food Policy Options report, 85 percent of WIC state agencies have already authorized canned legumes (USDA/FNS, 2015a). Therefore, the committee considered this change to be administratively feasible. Although the mandates to provide canned legumes (as well as processed vegetables and fruits) increase the administrative burden related to ensuring that vendors have EBT-linked UPCs, the USDA-FNS national UPC database mentioned previously (USDA/FNS, 2016a) should facilitate state efforts to meet requirements to stock canned legumes.

Peanut Butter

The amount of peanut butter in the current food packages provides approximately 84 to 168 percent of recommended amounts of nuts, seeds, and soy (a protein food subgroup) to children and women. In the proposed revisions to the food packages, the same quantities of peanut butter currently provided every month will still be provided, but only once every 3 months. This reduces food package provision of nuts, seeds, and soy to between approximately 56 and 111 percent of recommended amounts. Although the latter amount does not meet the committee's criteria for supplemental, the limited availability of smaller package sizes (at a reasonable cost) prohibited further reduction.

Authoritative Recommendations Related to 100% Fruit Juice

The amount of juice in the current packages for children (food package IV) is equivalent to 107 percent of the lower end of the American Academy of Pediatrics (AAP) recommended range (i.e., 4 ounces per day) (AAP, 2014). The AAP (2014) also states that most fruit intake should be from whole fruit because whole fruit also contributes fiber and other plant-based compounds that are removed during processing. The DGA include a recommendation that at least half of fruit intake should be from whole fruit, and state that most individuals in the United States “would benefit from increasing intakes of fruit, mostly whole fruit” (USDA/HHS, 2016). The food packages for women (with the exception of food package VI) currently provide a disproportionate number of fruit servings from juice compared to fruit servings from whole fruit (see Chapter 3, Tables 3-1 through 3-3).⁶ As described in Chapter 3, the committee concluded that the amounts of juice in the current food packages are more than supplemental and not aligned with dietary guidance.

Juice in the Revised Food Packages

Based on these considerations, the amount of juice offered in the revised food packages was reduced by approximately half.⁷ Juice now provides approximately 50 percent of the AAP recommendation for juice intake for children and 27 percent of the DGA limit for fruit intake from juice for women. The funds saved by the reduction in juice were reallocated to the CVV, a priority component of the revised food packages. In addition, participants now have the option to substitute the remaining amount of juice with a further increase in their CVV (described later in this chapter).

Moreover, the amounts of juice in the revised packages are aligned with sizes available in the marketplace. This provides states and vendors with reasonable stocking options. Results of the small study by Andreyeva et al. (2013) indicated that WIC participants did not compensate for 2009 food package reductions in juice with a comparable increase in purchases of other nonjuice beverages.

Substitution of Juice with the CVV

As mentioned in the previous section about juice, in the revised food packages, participants are permitted to choose an additional $3 CVV in place of the 64 ounces of juice. This option aligns with dietary guidance to encourage intake of whole fruit over juice and is consistent with the committee's goal of increasing choice.

Additional Milk Substitutions

Inasmuch as dairy intakes are below recommended amounts across participant subgroups, milk, or the substitution options currently permitted, may not be preferred forms of dairy. The revised food packages allow more substitution options for milk in food packages IV, V-A, V-B, VI, and VII as follows: (1) 1 pound of cheese and 1 quart of yogurt for 4 quarts of milk; or (2) 2 quarts of yogurt for 2 quarts of milk. Women who receive food package VII have a third option of 2 pounds of cheese for 6 quarts of milk. Soy-based yogurt or soy-based cheese substitutes meeting the specifications outlined later in this chapter are also allowed. The yogurt 1-quart substitution may range from 30 to 32 ounces to allow states the option to accommodate the smaller container sizes (approximately 5 ounces) that are commonly available in the marketplace today. These substitution options are also structured to eliminate the need for a single quart (“dangling quart”) of milk, which may be more difficult to find in stores and is typically more expensive. These additional choices may improve redemption of milk and milk substitutes.

Milk Amounts in the Food Packages for Women

Inasmuch as the Estimated Average Requirement (EAR) for calcium is the same for all subgroups of WIC-participating women (i.e., 800 milligrams),⁹ it is reasonable to provide the same quantity of the key food group for calcium (i.e., dairy) across food packages for women. The DGA recommendation for the intake of dairy for all subgroups of women is 3 cup-equivalents per day. Yet, the current food packages for women provide widely varying amounts of dairy (again, see Tables 3-1 through 3-3.) With these factors in mind, the amounts of dairy provided in food packages for pregnant (V-A), partially breastfeeding (V-B), and fully breastfeeding (VII) women were reduced to match the amount of dairy provided in food package VI for postpartum women. This change includes removal of the additional 1 pound of cheese for fully breastfeeding women (VII).¹⁰ The amount of milk in the revised food packages provides 71 percent of the recommended amount of dairy for women.

Milk Amounts in the Food Packages for Children

The current food package for children ages 2 to less than 5 years (IV-B) provides 85 percent of the DGA recommended amount of dairy. The committee considered this a greater than supplemental amount and reduced the amount of dairy provided in this food package to 75 percent of the DGA recommended amount.

Although the DGA food patterns do not apply to children ages 1 to less than 2 years, the amount of dairy suitable for this group is likely to be lower (in proportion to energy and nutrient needs) than those for children ages 2 to less than 5 years. Therefore, in the revised food packages, the amount of dairy in food package IV-A was reduced to provide 2 quarts less milk per month (the equivalent of 71 percent of the recommended amounts of dairy for a 1,300-kcal diet) compared to food package IV-B (for children ages 2 to less than 5 years).

Implications of the Revised Amounts of Milk

Not only are the revised amounts of milk better aligned with the committee's concept of supplemental, but the amounts of milk in the revised food packages are closer to the amounts of milk that are currently redeemed (see Appendix T). Therefore, it is anticipated that the volume of milk redeemed in the revised package will be similar to the amount currently redeemed (with the exception of food package VII), or even slightly higher as a result of the additional yogurt option, which may be preferred to fluid milk in some racial and ethnic groups.

Whole Grains Are Expanded to a Range of 16 to 24 Ounces

The committee's analysis of data from National Health and Nutrition Examination Survey (NHANES) indicated that intakes of whole grains continue to be poor and intakes of refined grains are excessive across the WIC subgroups studied. A recent study found that purchases of whole grain products by WIC households were higher after states introduced the requirement that half of cereals offered meet the Final Rule whole grain requirements (Oh et al., 2016). Increasing the focus on whole grains in the WIC food packages may help to increase whole grain intake and improve acceptability of whole grains for the longer term.¹¹

For women, the current food packages provide between 6 and 17 percent of the recommended amounts of whole grains, but 58 percent of recommended amounts of whole grains for children. Whole grains in the revised food packages provide 16 to 31 percent of recommended amounts of whole grains for women and 61 percent of recommended amounts of whole grains for children (see Appendix T). The total grains (which is the sum of whole and refined grains) provided to children is less than what the current package provides because allowing the more commonly available 24-ounce bread size, as explained below, removes the need to provide two 1-pound loaves of bread. The ratio of whole grains to refined grains is improved for all food packages.

In the current food packages, a 1-pound (16-ounce) loaf of bread is permitted, which may be substituted with oatmeal, brown rice, barley, corn tortillas, whole wheat tortillas, or whole wheat pasta of the same weight. As reviewed in the phase I interim report (NASEM, 2016) and in Chapter 2 of this report, the 1-pound size of bread was uncommon in the marketplace when the current food packages were introduced and posed a challenge for vendors and manufacturers. The price per ounce of the more commonly available size of whole grain bread ($0.10 per ounce for a 24-ounce size) is lower than for the 1-pound loaf size ($0.14). Thus, a more economical way to provide whole grains to participants is to increase the size of the whole grain bread to one that is more commonly available. The committee therefore changed the whole grain category to a range of 16 to 24 ounces. This range allows for the purchase of bread in 22- to 24-ounce sizes, thereby reducing the burden for vendors to stock the uncommon 1-pound size. Second, it eliminates the need for manufacturers to create WIC-specific product sizes, reducing overall program costs. Third, additional options for package size may increase availability and promote intake of whole grains, for which intake is inadequate in 100 percent of WIC-participating women and more than 90 percent of WIC-participating children. The lower price per ounce allows for delivery of 50 percent more whole grains to participants at an increased cost of only $0.17 per loaf.¹²

Additional Whole Grain Options Are Allowed

A greater degree of flexibility in size, as described above, is one way that the revised packages will allow states to offer a greater number of grain options. The committee further recommends that the WIC food category of whole grains also include fortified corn masa flour (which is not a whole grain, see further description below), cornmeal, teff, and buckwheat, and that states authorize as many of these options as cost constraints allow. Some options may be more or less suitable to a state's particular WIC-participating population. Of note, with the exception of fortified corn masa flour, these products are generally not fortified and, thus, their primary contribution to the diet is provision of whole grains (see Appendix Q, Table Q-1).

In accordance with the Final Rule, in the current food packages state agencies are encouraged to offer corn tortillas with whole grain corn listed as the primary ingredient (USDA/FNS, 2014). The revised food packages include the additional option of ground corn masa flour, even though this option is not whole grain. The committee concluded that this option should be permitted because (1) tortillas made with corn masa flour are currently permitted to improve the cultural suitability of the packages and, (2) early in 2016, the U.S. Food and Drug Administration (FDA) approved corn masa flour for fortification with folic acid (FDA, 2016a). Data from the Centers for Disease Control and Prevention indicate that only 17 percent of Hispanic women report intake of 400 µg or more of folic acid daily through fortified foods or supplements, compared with 30 percent of non-Hispanic white women (Williams et al., 2015). States are therefore encouraged to offer fortified corn masa flour and tortillas made with fortified corn masa flour once such products become available in the marketplace. The other expanded options must be whole grain.

Fortified Ready-to-Eat Breakfast Cereals Are Retained

Fortified ready-to-eat (RTE) cereals offer higher concentrations of nearly all nutrients compared to other whole grain products, so they were retained as a separate food category, in part to address nutrients of concern. Folate and iron are particularly important to the WIC-participating population and are not required fortificants in whole grain products, but are typically added to ready-to-eat breakfast cereals. Therefore, the committee considered that retention of fortified ready-to-eat cereals would support intake of these nutrients. The committee also recognized that RTE cereals may be important to retain as a delivery mechanism for fluid milk (Song et al., 2006). Additional details related to the folic acid content of RTE cereals can be found in the section on food specifications, and additional data supporting this conclusion are available in Appendix Q.

Canned Fish May Be Packed in Water and May Include Sauces and Flavorings

In the current food packages, fish may be packed in water or oil and may include added sauces and flavorings. In the revised food packages, fish may be water-packed (not oil-packed), but may include the same sauces and flavorings that are currently allowed. Water-packed varieties are higher in nutrient density because water-packed fish is lower in energy but contains the same levels of key nutrients per serving (see Appendix O, Table O-3). Currently, approximately 43 percent of WIC participants are allowed to purchase oil-packed varieties (based on state WIC food lists [USDA/FNS, 2015a]). Therefore this specification change will affect less than half of the WIC participating population.

Rotating Fish, Legumes, and Peanut Butter

In the revised food packages, legumes and peanut butter are rotated on a quarterly basis to provide more supplemental amounts, and amounts that better align with participant preferences.¹³ In most packages (IV, V-A, and VI), fish is added to the quarterly rotation. For food packages V-B and VII, states may decide how best to provide fish based on the capabilities of their individual Management Information Systems (i.e., quarterly or monthly). Although this may appear to add administrative burden, it is similar to the current rotation allowed between legumes and peanut butter. Although legumes, peanut butter, and fish are not nutritionally interchangeable, the revised amounts of legumes and peanut butter not only improve their alignment with recommended dietary intake but also help to allow for the cost-neutral inclusion of fish. It is anticipated that states will create food packages that rotate the issuance of legumes, peanut butter, and fish over each 3-month period, eliminating the burden of asking for the participants' preference between legumes and peanut butter and optimizing nutrients available to participants through these nonperishable foods.

The Amounts of Infant Cereals Are Reduced

The current food package II (for infants ages 6 to 11 months) provides approximately 6 tablespoons of infant cereal per day, which is 150 percent of the maximum amount recommended by the AAP (4 tablespoons per day) (AAP, 2014). Although iron-fortified infant cereals are a favored first food and are good sources of iron and zinc, this amount is substantially greater than supplemental. Infants who receive formula generally exceed their iron and zinc intake recommendations, so the provision of these nutrients through cereal is not critical for them. Therefore, the committee recommends that the amount of infant cereal provided in food package II to formula-fed or partially breastfed infants be reduced to 8 ounces per month, which provides 50 percent of the AAP-recommended amount of iron-fortified infant cereal (AAP, 2014). Iron and zinc are critical nutrients for fully breastfed infants because human milk contains low levels of these nutrients. Therefore, the revised food package II provides more infant cereal to fully breastfed infants per month: 16 ounces, which is 100 percent of the AAP-recommended amount. As described below, fully breastfed infants also receive jarred infant food meats, which are another good source of iron and zinc.

The Amount of Jarred Infant Food Vegetables and Fruits for Fully Breastfed Infants Is Reduced

The current package II (for infants ages 6 to 11 months) provides fully breastfed infants with 256 ounces of jarred infant food vegetables and fruits. This is more than 1 cup-equivalent per day, which may be appropriate for older infants but is likely to be difficult for younger infants to consume. AAP does not recommend specific intake amounts of vegetables and fruits for infants. Instead, these foods are considered useful as a transition to solid foods (AAP, 2014). The IOM (2006) report also did not provide a nutrient-based rationale for the recommended quantities of these infant foods. Rather, it stated, “To encourage or promote full breastfeeding, the recommended amounts of [infant] food vegetables and fruits are more generous for fully breast-fed infants than other infants” (p. 103). Given that there appears to be no nutritional rationale for providing more vegetables and fruits to fully breastfed infants compared to other infants and that the food packages for formula-fed or partially breastfed infants are distinguished in other ways in this revision, the committee recommends providing the same amount of jarred infant food vegetables and fruits to all infants receiving food package II: 128 ounces per month. The revised amounts provide approximately 0.5 cup-equivalents of vegetables and fruits per day to all infants who receive food package II. This decision allowed the committee to provide further support to the breastfeeding dyad by moving the savings from the jarred infant vegetables and fruits to a significantly enhanced CVV for both partially and fully breastfeeding women. Behavioral economics evidence suggests that shifting the benefit closer in time (to a higher CVV when the infant is born, compared to more jarred infant food vegetables and fruits in 6–12 months in the future), may enhance the probability that women choose the fully breastfeeding package (Loewenstein, 1988).

Infant Food Vegetables and Fruits May Be Substituted with the CVV

In the current food packages, infants ages 9 to 11 months may receive either a $4 (partially breastfed) or $8 (fully breastfed) CVV in place of half of the jarred infant food vegetables and fruits. In the revised food packages, the proposed CVV substitution is $10 plus half of the jarred infant foods or $20 and no jarred infant foods for all infants ages 6 to 11 months. The committee compared the nutrient content of infant fruit and vegetable products to noninfant products and found that nutrients provided to infants with the jarred foods were similar to those provided with a CVV of the same value (see Appendix O, Tables O-1 and O-2). Additionally, the committee compared the cost of 4 ounces of infant jarred fruits or vegetables ($0.64) to the composite average cost of the most popular vegetables and fruits purchased by WIC participants ($0.55 per cup-equivalent serving).¹⁶ Not only are the amounts of the proposed CVV substitution cost-neutral options, but participants may be able to buy more servings (of vegetables or fruits) using the CVV. This option also allows caregivers to prepare foods with developmentally appropriate textures for older infants.

In All Food Packages, the CVV Can Be Used to Purchase All Authorized Forms of Vegetables and Fruits

In the current food packages, the infant CVV may only be used to purchase fresh vegetables or fruits. Limiting the infant CVV to only fresh vegetables and fruits creates a significant burden for participants and local agencies in states whose EBT systems already authorize a voucher allowing multiple forms of vegetables and fruits for women and children (personal communication, public comment submitted by Texas WIC, July 30, 2015). In the revised packages, all forms of vegetables and fruits authorized for purchase with the CVV for women and children must be authorized for the infant CVV.¹⁷ As noted previously, the nutritional value of canned or frozen vegetables and fruits can be comparable to that of fresh forms (see Appendix O). Moreover, this expansion of forms offers the opportunity to create foods of varying textures that are suitable to an infant's developmental stage and meet cultural needs. The AAP's (2014) and USDA's (2016e) guidance for home preparation of infant foods is shown in Box 6-1.

BOX 6-1

Guidance for Home of Infant Foods.

The Amount of Jarred Infant Food Meat for Fully Breastfed Infants Is Reduced

The committee agrees with the IOM (2006) recommendation to provide jarred infant food meat as a key source of iron and zinc for fully breastfed infants. The AAP (2014) recommends 1 to 2 ounces of meat per day (30 to 60 ounces per month). The current WIC food packages provide 130 percent of the maximum of this range, which may be one factor in the low redemption of jarred infant food meat (generally 40 percent or less). Jarred infant food meat is not a common complementary food. In the 2008 Feeding Infants and Toddlers Study (FITS 2008) study, infant food meat was consumed by only 4.6 percent of infants ages 6 to less than 9 months and 1.2 percent of infants ages 9 to less than 12 months (Siega-Riz et al., 2010). In the committee's independent analysis of breastfed infants ages 6 to less than 12 months participating in WIC (NHANES 2009–2012), 10 percent consumed any amount of jarred infant food meat. Although noninfant food meat was consumed by 33 percent of older infants (ages 9 to less than 12 months) in the FITS 2008 study (Siega-Riz et al., 2010), provision of noninfant food meat in the WIC food packages, in amounts and forms appropriate for infants as young as age 6 months, was considered and ruled out as administratively unfeasible. The committee considered potential nutritionally equivalent but preferred alternatives to jarred infant food meat, but was unable to identify any options suitable to the WIC food packages in the marketplace.

Given this evidence and in line with providing supplemental amounts of foods in the WIC food packages, the committee reduced the amount of jarred infant food meat provided to fully breastfed infants to 40 ounces per month (approximately 65 percent of the AAP recommended maximum amount). It is noteworthy that, despite reductions in both jarred infant food meats and infant cereals (see above), the revised food package for fully breastfed infants still provides 130 percent of the EAR for iron and 72 percent of the EAR for zinc.

Fish May Be Substituted for a Portion of Jarred Infant Food Meat

Given that redemption of jarred infant food meat is poor and jarred infant food meat is not a preferred infant food, coupled with the importance of providing a bioavailable source of iron as infants begin complementary feeding (AAP, 2014), the committee considered possible substitutions. Global authorities recommend that infants consume flesh foods, including fish, as early as possible (PAHO/WHO, 2003). Canned fish can provide an amount of iron comparable to that of jarred infant food meats (with similar amounts of highly bioavailable heme iron), some (but less) zinc per ounce, and costs approximately half as much per ounce (see Appendix O, Table O-3). Inasmuch as jarred infants food meats are often sold in packages that contain 12 2.5-ounce jars (30 ounces), substitution of two cans of fish (10 ounces) for four jars of infant food meat (10 ounces) is feasible and well suited to package sizes commonly available in the marketplace.

Given this summary of evidence, the committee recommends the following adjustments to the food packages for infants to (1) improve alignment of the food packages with dietary guidance for individuals less than 2 years of age, (2) better reflect typical eating patterns of infants who are consuming complementary foods, and (3) increase flexibility to align with cultural eating patterns, preferences, and developmental needs:

• 6-4. USDA-FNS should reduce the amounts of infant cereal across food package II for all infants, and reduce the amounts of jarred infant food vegetables and fruits and jarred infant food meats provided in food package II for fully breastfed infants. Caregivers should be permitted to substitute all or part of the jarred infant food vegetables and fruits with a cash value voucher, and a portion of jarred infant food meat with canned fish.

Specific changes recommended are

• Provide 8 ounces of infant cereals to formula-fed and partially breastfed infants, and 16 ounces to fully breastfed infants in food package II.
• Provide 128 ounces per month of jarred infant food vegetables and fruits to all infants in food package II.
• Allow participants to substitute half or all jarred infant food vegetables and fruits with a CVV of comparable value. Caregivers of infants ages 6 to 11 months should have the option to choose a $10 CVV plus 64 ounces of jarred infant food vegetables and fruits or a $20 CVV in place of all jarred infant food vegetables and fruits.
• Allow the purchase of fresh, frozen, or canned vegetables and fruits that meet other current specifications for these forms with CVVs issued to any participant, including infants.
• Provide 40 ounces per month of jarred infant food meats in food package II for fully breastfed infants.
• Allow caregivers to substitute 10 ounces of jarred infant food meat with 10 ounces of canned fish. Fish options should adhere to the revised WIC specifications for canned fish.

Total Sugars in Yogurt

The committee proposes reducing sugars in yogurt to 30 grams or less of total sugars per 8 ounces. The current limit for total sugars in yogurt (40 grams per 8 ounces) was set by the IOM (2006) committee and was based on amounts of total sugars in yogurts available in the marketplace at that time (personal communication, S. Murphy, July 6, 2016). Over the past decade, yogurt formulations have changed dramatically. In 2015, 55 percent²² of name-brand yogurt products sold in the United States that met all other WIC specifications contained 30 grams or less of total sugars per 8 ounces (personal communication, National Yogurt Association, March 3, 2016). These data indicate that yogurts containing less total sugars than the current WIC specification permits are widely available. Because private-label products typically follow the formulation changes of name-brand products (personal communication, National Yogurt Association, March 3, 2016), the availability of private-label yogurts with lower amounts of added sugar will probably expand in coming years.

Not only is the added sugars content of yogurts in the marketplace declining, but the committee's proposed reduction of added sugars in yogurt is aligned with the USDA-FNS Final Rule that requires all yogurt provided in the Child and Adult Care Food Program (CACFP) to contain no more than 23 grams of total sugars per 6 ounces (or 30 grams per 8 ounces) (USDA/FNS, 2016d). Market research conducted by USDA-FNS in support of this rule also indicated that yogurts with this amount of total sugars were widely available (USDA/FNS, 2016d).

At the time of this writing, yogurt had been added to WIC-approved food lists in only a few states. As a result, acceptance of this option by WIC participants could not be determined.

Total Sugars in Soy Beverages

At present, there are no specifications for total sugars in WIC-approved soy beverages. Although most states authorize soy beverages that contain 10 grams or less of total sugars, the committee considered it advisable to provide states with guidance about how to identify appropriate soy beverage choices as the market expands. Soy beverages currently available in the marketplace may contain as much as 20 grams of total sugars per 8-ounce serving (USDA/ARS, 2016). The committee proposes that the limit for total sugars in soy beverages selected by states be as low as possible, but not higher than 12 grams per 8 ounce serving. The level of 12 grams was selected because it is equivalent to the amount of total sugars from naturally occurring lactose in 8 ounces of unsweetened cow's milk.

Only Unflavored Milk Is Permitted

The Final Rule permits provision of flavored milk in the current WIC food packages. However, the CACFP allows only low-fat, unflavored milk and does not permit flavored milk to children up to age 5 (USDA/FNS, 2016d). To align the WIC food packages with CACFP regulations and to limit added sugars in the food packages, only unflavored milk is authorized in the revised WIC food packages. Although nonfat, flavored milk is permitted in the school meals programs (USDA/FNS, 2012), the nonfat, low-added-sugars flavored milk provided to schools is not widely commercially available (personal communication, C. Patey, National Dairy Council, July 16, 2016). The committee considered it appropriate for WIC to not only provide children with an easy transition into CACFP, but also to avoid contributing to early establishment of a preference for sweet taste (Beauchamp and Menella, 2009; Ventura and Worobey, 2013; personal communication, S. Johnson, University of Colorado, shared with the committee at the March 20, 2016 workshop).

At present, flavored milk is offered in 6 percent of states and 40 percent of Indian Tribal Organizations (ITOs), which together cover 3 percent of WIC participants (USDA/FNS, 2015a). At least one ITO is removing flavored milk from its food list to align with CACFP policy (personal communication, D. Tipton, Chickasaw Nation WIC, July 2016). Therefore, the recommendation is not expected to cause a significant disruption in administration of food packages nationally.

All Breakfast Cereals Must Meet “Whole Grain-Rich” Criteria

The current specifications for WIC-approved breakfast cereals (ready-to-eat and instant and regular hot cereals) require that half of such cereals made available by WIC vendors include whole grain as the primary ingredient by weight and meet the FDA labeling requirement for a “health claim notification for whole grain foods with moderate fat content” (i.e., these foods must also contain ≥51 percent whole grain ingredients by weight, but using dietary fiber as a marker [≥1.6 grams fiber per 28.35 grams of cereal]) (USDA/FNS, 2014). In the revised packages, this specification is changed in two ways: (1) “whole grain” breakfast cereals must meet the “whole grain-rich” criteria that is applied in CACFP,²³ the National School Lunch Program, and the National Breakfast Program (USDA/FNS, 2016d); and (2) all breakfast cereals offered by the WIC program must meet these criteria. All cereals must still meet current WIC requirements for iron (i.e., 28 milligrams of iron per 100 grams of cereal) and added sugars (not more than 6 grams per ounce serving).

Although the DGA have consistently specified that at least half of grain intake should be from whole grains since 2005, the 2015–2020 DGA additionally state that intake of refined grains should be limited but that individuals (particularly women capable of becoming pregnant) who consume all grains as whole should include in their diets at least some sources that are fortified with folic acid as a means of preventing neural tube defects (USDA/HHS, 2016). Table 6-6 illustrates the folic acid content of commonly redeemed ready-to-eat WIC cereals, including some fortified whole grain cereals. Although there is some variability, the popular whole grain cereals presented in the table provide an average of 160 percent of the EAR for folate for children ages 1 to 4 years and 47, 56, and 70 percent of the EAR for pregnant, breastfeeding, and postpartum women, respectively. These data indicate that whole grain and refined grain breakfast cereals are generally fortified with comparable amounts of folic acid.

TABLE 6-6

Folate Content of Commonly Redeemed Selected Cereals in WIC Food Packages.

Although there are no specific regulations about fortification of ready-to-eat breakfast cereals other than enrichment of the refined grain portion with 140 micrograms of folic acid per 100 grams grain, both refined and whole grain cereals are generally fortified with at least 25 percent of micronutrient needs for a 2,000-kcal diet (the current basis for Daily Values on the food label²⁴) (USDA/ARS, 2016). Therefore, there is no substantive difference in micronutrient content of refined grain cereals compared to whole grain cereals that meet the revised WIC “whole grain-rich” criteria.

All Breads Are 100 Percent Whole Wheat

At present, WIC-authorized breads include both 100 percent whole wheat bread (i.e., whole grain wheat is the primary ingredient by weight) and whole grain breads that meet the FDA requirement for a “health claim notification for whole grain foods with moderate fat content” (again, these foods must also contain at least 51 percent whole grain ingredients by weight, but using dietary fiber as a marker [at least 1.6 grams fiber per 28.35 grams]) (USDA/FNS, 2014). The committee proposes that this specification be revised such that all bread in the WIC food packages be 100 percent whole wheat and that whole grain bread no longer be permitted. Currently, very few states offer a whole grain bread option, possibly as a result of the expansive selection of bread products in the marketplace that include the words whole grain but that contain various proportions of whole grain and refined grain. Manufacturers are permitted to make factual statements about the amounts of whole grains on the labels of their products (e.g., “this product contains 5 grams of whole grains per serving”), but products for which the labels include the words “whole grain” are not required to contain a minimum amount of this ingredient (FDA, 2006). The committee concluded that WIC-approved breads should be restricted to those that contain 100 percent whole wheat to reduce confusion, align WIC-authorized breads with most current state offerings, and improve WIC participants' overall dietary balance of whole to refined grains. For individuals with celiac disease or gluten intolerance, other grain options are available.

Specifications for New Grain Options

The revised food packages offer additional grain options to accommodate cultural eating patterns and other food preferences. Cornmeal (including blue), buckwheat, and teff must be 100 percent whole grain. Cornmeals should align with the USDA-FNS specifications for cornmeal in USDA-FNS child nutrition programs (e.g., CACFP), that is, products must be labeled as “whole corn” (or be labeled with other “whole” corn designations, such as whole grain corn, whole ground corn, whole cornmeal [including blue], and whole corn flour) (USDA-CNP-01-2008). To align with USDA-FNS allowances for tortillas (USDA/FNS, 2014), corn masa flour that is not 100 percent whole grain is permitted. States should be encouraged to offer corn masa flour and tortillas made with corn masa flour that is fortified with folic acid when these products become available.

Specifications for New Soy Options

To expand options for WIC participants who are lactose-intolerant or who follow a vegan diet, soy-based cheese and soy-based yogurt substitute products are added to the revised packages as substitutions for milk. These products are required to contain 250 milligram of calcium and 6.5 grams of protein per serving equivalent (1.5 ounces of soy-based cheese substitute or 8 ounces of soy-based yogurt substitute). These specifications ensure that these substitutes supplement the diets of WIC participants with key nutrients that the WIC food packages are intended to provide.