The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) began 40 years ago as a pilot program and has since grown to serve more than 8 million pregnant women, and mothers and their infants and young children. Today the program serves more than a quarter of the pregnant women and half of the infants in the United States, at an annual cost of about $6.2 billion. Through its contribution to the nutritional needs of pregnant, breastfeeding, and postpartum women; infants; and children under 5 years of age, this federally supported nutrition assistance program is integral to meeting national nutrition policy goals for a significant portion of the U.S. population.

To assure the continued success of WIC, Congress mandated that the Food and Nutrition Service of the U.S. Department of Agriculture (USDA) reevaluate the program's food packages every 10 years to assure they remain aligned with the goals of the Dietary Guidelines for Americans (DGA). In 2014, USDA asked the Institute of Medicine (IOM) to undertake this reevaluation. This complex task included consideration of whether or not WIC participants should be permitted to purchase white potatoes with the cash value voucher (CVV), a part of the benefit package that provides access to vegetables and fruits. In its first of three reports, published early in 2015, the committee recommended that white potatoes be allowed as a WIC-eligible vegetable for purchase with the CVV. The second report of this series, published in 2016, provided a summary of the work of phase I of the study as well as the analytical underpinnings for phase II. This is the third and final report in this series. It provides further data analyses, a regulatory impact analysis, and the committee's final recommendations.

The revised food packages were constrained to be cost neutral with the current food packages, which means that any increases in the costs of components of the packages or allowed substitutions had to be balanced by corresponding decreases in costs elsewhere. This required the committee to be creative in responding to its charge to align the packages with the DGA. When making these revisions, the committee considered the supplemental nature of the WIC program and used a systematic approach. The committee was able to make changes to the packages that improve their alignment with the DGA and, thus, the dietary balance of the packages. The committee was able to improve the number of substitution options included in the packages and, thus, the choices available to participants to meet their cultural and personal preferences. The revised packages increase the cash value voucher for all participants, although the amounts differ by food package, and include fish in nearly all food packages. In addition, the committee provided enhanced support for breastfeeding, both exclusive and partial breastfeeding, along with greater flexibility for breastfeeding in the first 30 days after delivery.

This report is the first review of the WIC food packages to contain a regulatory impact analysis. This may permit USDA to move more rapidly to implement the changes proposed. These changes build on administrative actions taken in response to the IOM's 2006 Time for a Change report for further ease of implementation. It is noteworthy that the regulatory impact analysis not only shows that the revisions to the food packages should be cost neutral when implemented but also that they are projected to provide substantial cost savings over time, savings that could be used to make further nutritional improvements to the food packages.

The work of the committee was greatly enhanced by the contributions of many individuals who participated in the study's public activities. The committee is grateful to the speakers in its data-gathering workshops who gave valuable insights as well as their time to assist the committee with its task. The committee also thanks the members of the public who provided comments in open sessions or through the committee's website. Lastly, the committee is indebted to the many WIC staff members who gave their time and expertise to help committee members better understand administration of and participation in the WIC program.

The size of this report is testimony to the magnitude of the committee's task. It exists thanks to the hard work of many individuals. Committee members volunteered many hours of their time to this work. Their collaborative spirit as well as careful thinking and writing are to be commended. The committee was supported in its work by several consultants. Suzanne Murphy provided critical insights based on her experience in leading the committee that produced the first major reevaluation of the WIC food packages, published in 2006. Her sage advice is much appreciated. Mei Chung led the development and execution of all of the committee's literature reviews. Rose Gladstein assisted with the regulatory impact analysis.

The committee would like to thank the staff of the Center for Agricultural and Rural Development (CARD) and the Department of Statistics at Iowa State University for their analysis of the data from the National Health and Nutrition Examination Survey (NHANES) and National Household Food Acquisition and Purchase Survey. Committee members Helen Jensen and Alicia Carriquiry guided the CARD's work, which was carried out by David Osthus, Miyoung Oh, and Hocheol Jeon. John A. Kirlin and David Levin of USDA's Economic Research Service reviewed the committee's application of the FoodAPS and IRI datasets to the study, and Kevin Dodd and Susan Krebs-Smith of the National Cancer Institute provided helpful guidance on analyses of NHANES.

To accomplish this task numerous staff members at the National Academies of Sciences, Engineering, and Medicine supported the work of the committee. Marie Latulippe served as the project's study director and provided leadership, creative ideas, and an optimistic and calm spirit against tight deadlines. She was assisted by Meghan Quirk after March 2015, who led the regulatory impact analysis. Bernice Chu assisted with literature reviews and data management, and Ambar Saeed dealt with administrative logistics. Leslie Pray assisted with report organization and editing, and Rebecca Morgan of the National Academies Library/Research Center with fact checking. Alice Vorosmarti assisted with literature reviews and other data-oriented tasks. Naisi Zhao assisted the committee from January to April 2016 as a Mirzayan Fellow. Ann Yaktine, director of the Food and Nutrition Board, supervised the work of the staff and provided useful insights at many points in the committee's deliberation. The committee owes them all a debt of gratitude for their hard work and professionalism.

Kathleen M. Rasmussen, Chair

Committee to Review WIC Food Packages