CRITERION 1

Criterion 1 states: “The packages provide a balanced supplement to the diets of women and children.”

To meet this criterion, the committee reduced food group or subgroup quantities that met or exceeded 100 percent of recommended food group or subgroup intakes. At the same time, it increased food group or subgroup quantities that were either missing or present below an amount that was considered supplemental (and for which intakes were below recommended levels). Together, these two actions reapportioned the food groups and subgroups offered in a way that achieves a more balanced food package. Preferences and cost were also factors in determining the final amounts of foods in the revised packages. To illustrate the concepts of “balanced” and “supplemental,” Figure 9-1 compares the currently offered food groups and subgroups, as redeemed, to the amounts of food groups and subgroups in the revised package, as redeemed, for food package IV-B (children ages 2 to less than 5 years). Food package IV-B is used as an example throughout this chapter, as was done in Chapter 8.¹ As shown in Figure 9-1, the proportions of food groups or subgroups provided at above-supplemental levels are reduced while the proportions provided at levels below-supplemental are increased. A comparison of all current and revised food packages as the proportion of DGA food groups and subgroups is presented in Appendix T, Figures T-1 through T-5.

FIGURE 9-1

Proportion of the Dietary Guidelines for Americans (DGA) food groups and subgroups provided in the current and revised food package IV-B as redeemed. NOTE: The methodology for calculating redemption rates is detailed in Appendix R.

As a result of the constraint to remain cost neutral, the committee was unable to meet criterion 1 fully. Adding servings of some food groups, particularly of vegetables and fruits, seafood, and whole grain cereals, is expensive relative to the cost of servings from the other food groups or subgroups that were replaced. Inasmuch as each food group contains unique and important nutrients, rebalancing of food groups to align with the DGA necessarily increases some nutrients while decreasing others.

CRITERION 2

Criterion 2 states: “The packages contribute to reduction of the prevalence of inadequate nutrient intakes and of excessive nutrient intakes.”

Changes to the Prevalence of Nutrient Inadequacy are Anticipated to Be Minimal

The gap analysis presented in Table 9-2 illustrates that revisions to close nutrient gaps for priority nutrients identified for food package IV-B are likely to be too minimal to affect nutrient adequacy. In general, the magnitude of nutrient availability from food group adjustments was limited by the need to remain cost neutral. This allowed the committee to predict similar small increments in nutrient adequacy across other population subgroups. More precise predictions of nutrient adequacy related to the food package revisions would require information on consumption of Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) foods.³

TABLE 9-2

Effects of the Food Package Revisions on Priority Nutrient Intakes: Gap Analysis for Food Package IV-B Based on Redemption.

CRITERION 3

Criterion 3 states: “The package contributes to an overall dietary pattern that is consistent with the Dietary Guidelines for Americans for individuals 2 years of age and older.”

The committee met criterion 3 by rebalancing the WIC package food groups and subgroups consistent with its definition of supplemental. As illustrated in Figure 9-1, this process reduced the food groups and subgroups offered at levels greater than that required to meet recommended intakes and increased amounts of food groups and subgroups offered at lower levels. The revised food packages are better aligned with the DGA because:

• Fruit is shifted from juice to whole fruit. Although total fruit offered varies depending on the food package, overall, the revisions decrease juice and increase whole fruit in all food packages. These changes align with the DGA, which recommend greater consumption of whole fruit in proportion to fruit juice.
• Grains are shifted from refined to whole grains. The proposed revisions increase the proportion of whole grains compared to refined grains in all food packages, consistent with the recommendations of the DGA.
• Fish is available in all WIC food packages. The revised food packages provide fish to all WIC participants,⁵ no longer only to exclusively breastfeeding women.
• Total sodium is reduced. Appendix T, Tables T-6a through T-11b illustrate that sodium is reduced in all of the food packages, primarily due to the reductions in dairy.
• Contributions to “calories for other uses (COU)” are reduced. Overall, the contribution of the food packages to the total daily limits for COU are reduced or remained relatively stable (see Table 9-3).
• Estimates indicate that food group intakes are either unchanged or change slightly. Estimating the effects on intake of food groups is highly dependent on knowing the distribution of both redemption and consumption of WIC foods relative to the food package issued. As noted elsewhere in the report, this information was not uniformly available to the committee. Thus, to generate a rough estimate of effects of the revised packages on intake of food groups, the committee conducted a second “gap analysis” to assess the effect of changes in food groups or subgroups provided in food package IV-B on the gap (i.e., the difference between the food group or subgroup intake at the median [50th percentile]). The results of this analysis are presented in Table 9-4.

TABLE 9-3

Comparison of COUs Based on Redemption in the Current and Revised Food Packages for Children and Women.

TABLE 9-4

Estimated Effect of the Revised Food Packages on DGA Food Group and Subgroup Intakes Based on Redemption: Children Ages 2 to Less Than 5 Years, Food Package IV-B.

As shown in Table 9-4, most of the food package changes are expected to either not affect intake or to reduce the gap in food group or subgroup intake. For dairy and nuts, seeds, and soy, however, the gap is increased. This should be interpreted with attention to the fact that these foods are provided in the current food package in amounts that are nearly, or exceed, 100 percent of that recommended. For this food subgroup, the amount in the revised food package IV-B still exceeds 100 percent of recommended amounts owing to container size limitations.

The Healthy Eating Index–2010 Score May Improve

Estimates indicate that the Healthy Eating Index–2010 (HEI–2010) score may improve slightly. The committee estimated the effects of the revised food package against the HEI–2010 for food package IV-B (see Table 9-5).⁶ The difference in redeemed amounts of the food groups corresponding to HEI–2010 components between the current and revised food package was calculated, making the assumption that the median intake of participants would increase or decrease by this difference. The new intake values were then used to calculate the HEI–2010 score for the revised food packages. As shown in Table 9-5, the revised food package IV-B is predicted to increase several HEI–2010 subscores (e.g., total vegetables, whole grains, and total protein foods, refined grains, and sodium with increases of at least 0.1 points), while decreasing others (e.g., greens and beans, dairy, seafood, and plant proteins with decreases of at least 0.1 points). The scores for components to consume in moderation (refined grains, sodium, and empty calories) were increased or unchanged. Overall, the total HEI–2010 score is improved, increasing by approximately 1 point, a positive change of approximately 1.4 percent. This small increase may be important because WIC participants generally have poor diets.

TABLE 9-5

Estimated Effect of the Revised Food Packages on the Healthy Eating Index–2010 of Children Ages 2 to Less Than 5 Years: Food Package IV-B Based on Redemption.

The revised food package changes align with select DGA recommendations in other ways as well, as summarized in Table 9-6. Recommendations related to physical activity or alcohol consumption were not considered relevant to this review.

TABLE 9-6

Consistency of the Revised Food Packages with Selected Recommendations from the 2015–2020 Dietary Guidelines for Americans for Individuals Ages 2 Years and Older (Criterion 3).

CRITERION 4

Criterion 4 states: “The packages contribute to an overall diet that is consistent with established dietary recommendations for infants and children less than 2 years of age, including encouragement of and support for breastfeeding.”

The dietary recommendations for infants and children less than 2 years of age that were considered by the committee are summarized in Chapter 3, Table 3-10. The recommendations cover breastfeeding, formula feeding, complementary feeding, and the promotion of healthy eating habits.

Table 9-7 presents a side-by-side comparison of how the revised food packages align with these recommendations. The revised food packages account for the nutritional needs of exclusively breastfed, partially breastfed, and formula-fed infants in the first few months of life, the developmental and nutritional needs during the first 2 years of life, the promotion of healthy eating patterns, and the safety of foods consumed.

TABLE 9-7

Consistency of the Revised Food Packages with Selected Dietary Recommendations for Infants and Children Less Than 2 Years of Age (Criterion 4).

In addition to the comparisons in Table 9-7, the revised food packages are designed to provide incentives for breastfeeding of any intensity with 3 strategies: (1) further increasing the value of the exclusive breastfeeding package by increasing the CVV, (2) increasing the value of the packages for partially breastfeeding women by increasing the CVV and allowing more fish compared to the postpartum package, and by (3) increasing the flexibility of the food packages in the first month so that women may be issued the amount of formula needed based on a professional assessment, instead of having only the choices of no formula, nine cans of formula, or, in states where it is offered, one can of formula.

CRITERION 5

Criterion 5 states: “The foods in the packages are available in forms and amounts suitable for low-income persons who may have limited transportation options, storage, and cooking facilities.”

The 2009 food package revisions included the addition of several options for tailoring food packages to meet participant needs related to transportation and limited storage and/or cooking facilities. The revised food packages retain these options, and include additional changes that allow for further flexibility in meeting the needs of participants with limited transportation. Table 9-8 summarizes how the WIC food packages (including current policies and recommended changes) address criterion 5.

TABLE 9-8

How the Revised Food Packages Can Be Tailored for Suitability for Individuals with Limited Resources (Criterion 5).

CRITERION 6

Criterion 6 states: “The foods in the packages are readily acceptable, commonly consumed, widely available, take into the account cultural eating patterns and food preferences, and provide incentives for families to participate in the WIC program.”

The 2009 food package changes also included several additional options to improve alignment with cultural eating patterns and food preferences, as reviewed in Chapter 3. In particular, the increase of the CVV with very few restrictions on choice provides participants with the flexibility to choose vegetables and fruits that meet cultural needs (Sucher et al., 2017). Redemption data indicate that the CVV is among the most well-redeemed components of the food packages (see Chapter 2, Table 2-14). The revised food packages increase the value of the CVV further, to the maximum extent possible, while balancing other nutrient and food group priorities and maintaining cost neutrality. Additionally, changes were made that consider participants' personal preferences and cultural needs and/or to incorporate container sizes that are more commonly available (see Table 9-9).

TABLE 9-9

How the Revised Food Packages Were Tailored to Be Readily Acceptable (Criterion 6).

CRITERION 7

Criterion 7 states: “The foods in the packages do not create an undue burden on state agencies or vendors.”

For each proposed change to the food packages, the committee considered the effects on program administration across state and local WIC agencies and vendors. These considerations were informed by public comments from stakeholder groups and the committee members' observations during their WIC shopping experiences. Table 9-10 summarizes the major issues that were considered and how the proposed changes address these concerns.

TABLE 9-10

How the Revised Food Packages Address Selected Concerns for Impact on WIC Agencies and Vendors (Criterion 7).

SUMMARY

As was done in the previous WIC report (IOM, 2006), the committee's proposed revisions to the WIC food packages are based on a set of criteria. As elaborated in this chapter, the revised food packages meet these criteria as closely as possible. However, because of specified cost constraints, meeting the criteria required making trade-offs among food groups and subgroups, as well as considering allowable substitutions within food groups. Generally, the proposed revisions improve the balance of nutrients and food groups provided with respect to the current Dietary Reference Intake and DGA, they are consistent with authoritative dietary guidance for individuals less than 2 years of age, and they increase choice by including additional substitution options and a higher CVV. In addition, women have more flexibility to breastfeed to the extent possible in the first month.

Revising the WIC food packages to satisfy alignment with the DGA may not by itself optimize nutrient adequacy; such optimization also requires that participants actually redeem and consume the foods in the packages. In addition, the likelihood of a change in intakes of nutrients or recommended food groups based on the revised compared to the current food packages depends on both the nutrient or food group (or food subgroup) and also the food package being considered. In some cases, the expected change may be large relative to current consumption (when current consumption is especially low) and, in other cases, it may be modest at best. Overall, the revised packages are not different enough from the current packages to change the likely effect of the food packages on participants' health. It is noteworthy that if participants were to use the CVV to consume a higher proportion of vegetables (relative to fruits) than anticipated in the committee's modeling, this could create a substantial increase in both their fiber intake and their intake of several food groups and subgroups (see Appendix T, Tables T-11 and T-12).

Expanding the container size ranges for some foods relieves the vendor burden to stock uncommon sizes and increases the likelihood of increasing the availability of these foods to participants. Inasmuch as these changes build on the food package changes implemented in 2009, the committee anticipates that administration of these revisions will be less burdensome than those recommended in 2006.

REFERENCES

• AAP (American Academy of Pediatrics). Pediatric nutrition. 7th ed. Kleinman RE, Greer FR, editors. Elk Grove Village, IL: American Academy of Pediatrics; 2014.
• Fewtrell MS, Morgan JB, Duggan C, Gunnlaugsson G, Hibberd PL, Lucas A, Kleinman RE. Optimal duration of exclusive breastfeeding: What is the evidence to support current recommendations? American Journal of Clinical Nutrition. 2007;85(2):635S–638S. [PubMed: 17284769]
• IOM (Institute of Medicine). WIC food packages: Time for a change. Washington, DC: The National Academies Press; 2006.
• Sucher K, Kittler PG, Nelms M. Food and culture. 7th ed. Boston, MA: Cengage Learning; 2017.
• USDA/ARS (U.S. Department of Agriculture/Agricultural Research Service). What we eat in America, NHANES 2005-2012. 2005-2012. [December 15, 2016]. http://www​.cdc.gov/nchs/nhanes/wweia.htm.
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