Food Package Revisions Research Articles

A Quasi-Experimental Assessment of the Effect of the 2009 WIC Food Package Revisions on Breastfeeding Outcomes.

Breastfeeding rates among infants participating in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) are consistently lower than those of WIC nonparticipants. The 2009 WIC food package revisions were intended to incentivize breastfeeding among the WIC population. To examine the effectiveness of this policy change, we estimated an intent-to-treat regression-adjusted difference-in-difference model with propensity score weighting, an approach that allowed us to control for both secular trends in breastfeeding and selection bias. We used novel data from the Feeding Infants and Toddlers Survey from 2008 and 2016. We defined our treatment group as infants eligible for WIC based on household income and our control group as infants in households with incomes just above the WIC eligibility threshold. The breastfeeding outcomes we analyzed were whether the infants were ever breastfed, breastfed through 6 months, and breastfed exclusively through 6 months. We observed significant increases in infants that were ever breastfed in both the treatment group (10 percentage points; p < 0.01) and the control group (15 percentage points; p < 0.05); however, we did not find evidence that the difference between the two groups was statistically significant, suggesting that the 2009 revisions may not have had an effect on any of these breastfeeding outcomes.

The Special Supplemental Nutrition Program for Women, Infants, and Children food package revisions and anemia in children aged 2–5 years

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides nutritional assistance to low-income women and children in the United States. The WIC food package was revised to align more closely to dietary recommendations in October 2009. The revised package included more fruits, vegetables, whole grains, and low-fat milk. The objective of this study was to examine the association of the revised WIC package with anemia indicators and iron intake in children. A quasi-experimental difference-in-difference design compared anemia and iron intake variables between WIC (n=1497 and n=1626 for anemia and iron intake variables, respectively) and WIC-eligible nonparticipating children (n=1183 and n=1322 for anemia and iron intake variables, respectively), aged 2-5 y, before and after the 2009 revisions. The NHANES 2003-2008 and 2011-2018 data represented the period pre- and post-2009 revisions, respectively. The 2009 package revisions were significantly associated with reduced probability of anemia (-4.3% points; 95% CI: -7.5, -1.1% points) and nonthalassemic microcytic anemia (-1.7% points; 95% CI: -3.3, -0.1% points) in children from WIC-participating households. The revised WIC package also was significantly related to higher nutrient adequacy ratio (0.04; 95% CI: 0.02, 0.07) and greater probability of meeting the RDA (12.1% points; 95% CI: 3.2, 21.0% points) for iron among WIC participants. This study found that the WIC 2009 revisions were associated with lower probability of nonthalassemic microcytic anemia and better adequacy of dietary iron intake, thereby suggesting the beneficial impact of WIC revisions on iron deficiency anemia in children. The current study findings suggest that nutritional policies could play a crucial role in supporting the health of vulnerable children in the United States.

The role of income and neighbourhood poverty in the association between the 2009 Special Supplemental Nutrition Program for Women, Infants and Children (WIC) food package change and child obesity among WIC-participating children in Los Angeles County, 2003-2016.

To determine whether a previously reported association between the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) food package change and reduced child obesity risk among WIC-participating children in Los Angeles County holds across levels of family income and neighbourhood poverty. Analysis of prospectively collected WIC administrative data. The outcome was obesity at age 4 years (BMI-for-age ≥ 95th percentile). Poisson regression was applied to a matched sample (n 79 502) to determine if the association between the WIC food package change and child obesity was modified by family income (<50 % federal poverty level (FPL), 50-100 % FPL, >100 % but <185 % FPL) and neighbourhood poverty. Los Angeles County, California. Children who participated in WIC in Los Angeles County between 2003 and 2016; children were grouped as receiving the old WIC food package (2003-2009) or the new WIC food package (2010-2016). Receiving the new WIC food package (i.e., post-2009) was associated with 7-18 % lower obesity risk across all family income categories. Neither family income nor neighbourhood poverty significantly modified the association between the WIC food package and child obesity. However, certain sub-groups seemed to benefit more from the food package change than others. In particular, boys from families with income above poverty but residing in the poorest neighbourhoods experienced the greatest reductions in obesity risk (relative risk = 0·77; 95 % CI 0·66, 0·88). The WIC food package revisions were associated with reduced childhood obesity risk among all WIC-participating families in Los Angeles County, across levels of income eligibility and neighbourhood poverty.

Racial/Ethnic Disparities in Dietary Intake of U.S. Children Participating in WIC.

Recent studies have assessed diet quality of low-income U.S. children participating in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), but differences by race/ethnicity remain unknown. We assessed racial/ethnic disparities in nutrient intake from dietary sources (not supplements) among children participating in WIC, with a focus on priority nutrients and food groups for future WIC food package revisions, as described in a recent report by the National Academies of Sciences, Engineering, and Medicine (NASEM). We used data from the 2011–2014 National Health and Nutrition Examination Surveys (NHANES) and multivariable linear regression analysis to evaluate relationships between race/ethnicity and nutrient/food group intake of children participating in WIC. All data were analyzed using SAS 9.4 survey procedures, accounting for the complex survey design of the NHANES. Compared to non-Hispanic White children, Hispanic children had diets with better nutrient distribution and lower dietary energy density, while non-Hispanic Black children had diets with poorer nutrient intake. Hispanic children had higher potassium and fiber intake, and consumed more legumes, while non-Hispanic Black children had lower calcium and vitamin D intake, higher sodium intake, and lower total dairy intake, compared to non-Hispanic White children. These findings can inform WIC nutrition education messages and future food package revisions.

Changes in nutrient and food group intakes among children and women participating in the Special Supplemental Nutrition Program for Women, Infants, and Children: findings from the 2005-2008 and 2011-2014 National Health and Nutrition Examination Surveys.

To use nationally representative data to evaluate changes in nutrient and food intakes among children and women participating in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) before v. after implementation of the 2009 food package revisions. Cross-sectional study using National Health and Nutrition Examination Survey (NHANES) data. NHANES survey cycles were pooled to assess nutrient/food group intakes among household WIC participants pre- (2005-2008) v. post- (2011-2014) implementation of the 2009 food package revisions. Information regarding WIC participation and 24h diet recalls were collected at NHANES examination. Children 24-59 months old and women 19-50 years of age in households receiving WIC benefits in the NHANES 2005-2008 and 2011-2014. Comparison of WIC participants' dietary intake pre- and post-revision demonstrated changes in mean population intakes of both nutrients and food groups. The food package revisions were associated with increased intakes of fibre (P = 0·004 children, P = 0·013 women) and whole grains (P = 0·001 children, P = 0·087 women). For children only, vegetable intake shifted to higher consumption of legumes (P = 0·013) and decreased intake of starchy vegetables (P = 0·042). No significant changes were observed for dairy or fruit intake of children or women. The study provides insight to what goals of the package revisions were achieved. The findings can inform future food package revisions.

Federal Nutrition Program Revisions Impact Low-income Households’ Food Purchases

The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) required major revisions to food packages in 2009; effects on nationwide low-income household purchases remain unexamined. This study examines associations between WIC revisions and nutritional profiles of packaged food purchases from 2008 to 2014 among 4,537 low-income households with preschoolers in the U.S. (WIC participating versus nonparticipating) utilizing Nielsen Homescan Consumer Panel data. Overall nutrients purchased (e.g., calories, sugar, fat), amounts of select food groups with nutritional attributes that are encouraged (e.g., whole grains, fruits and vegetables) or discouraged (e.g., sugar-sweetened beverages, candy) consistent with dietary guidance, composition of purchases by degree of processing (less, moderate, or high), and convenience (requires preparation, ready to heat, or ready to eat) were measured. Data analysis was performed in 2016. Longitudinal random-effects model adjusted outcomes controlling for household composition, education, race/ethnicity of the head of the household, county quarterly unemployment rates, and seasonality are presented. Among WIC households, significant decreases in purchases of calories (-11%), sodium (-12%), total fat (-10%), and sugar (-15%) occurred, alongside decreases in purchases of refined grains, grain-based desserts, higher-fat milks, and sugar-sweetened beverages, and increases in purchases of fruits/vegetables with no added sugar/fats/salt. Income-eligible nonparticipating households had similar, but less pronounced, reductions. Changes were gradual and increased over time. WIC food package revisions appear associated with improved nutritional profiles of food purchases among WIC participating households compared with low-income nonparticipating households. These package revisions may encourage WIC families to make healthier choices among their overall packaged food purchases.

The healthfulness of food and beverage purchases after the federal food package revisions: The case of two New England states

ObjectiveIn 2009, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) implemented new food packages to improve dietary intake among WIC participants. This paper examines how the healthfulness of food purchases among low-income households changed following this reform. MethodsPoint-of-sale data for 2137 WIC-participating and 1303 comparison households were obtained from a regional supermarket chain. The healthfulness of purchased foods and beverages was determined per their saturated fat, sugar, and sodium content. A pre-post assessment (2009–2010) of the product basket healthfulness was completed using generalized estimating equation models. Data were analyzed in 2015. ResultsAt baseline, healthy products accounted for most of the food volume purchased by WIC participants, but beverages were dominated by moderation (less healthy) items. With new subsidies for fruit, vegetables and whole grains, the WIC revisions increased the volume of healthy food purchases of WIC-participating households by 3.9% and reduced moderation foods by 1.8%. The biggest improvements were reductions in moderation beverages (down by 24.7% in volume), driven by milk fat restrictions in the WIC food package revisions. The healthfulness of the product basket increased post-WIC revisions; mainly due to a reduction in the volume of moderation food and beverages purchased (down by 15.5%) rather than growth in healthy products (up by 1.9%). No similar improvements were seen in a comparison group of low-income nonparticipants. ConclusionsAfter the WIC revisions, the healthfulness of participant purchases improved, particularly for beverages. Efforts to encourage healthy eating by people receiving federal food assistance are paying off.

Revised WIC Food Package and Children’s Diet Quality

In October 2009, the Special Supplemental Nutrition Program for Women, Infant, and Children (WIC) food package was revised to include more fruits, vegetables, whole grains, and lower-fat milk. We examined the impact of the WIC food package revisions on the diet quality of children in households using WIC. A total of 1197 children aged 2 to 4 years from low-income households were studied from before and after the policy implementation (using the 2003-2008 and 2011-2012 National Health and Nutrition Examination Survey). The Healthy Eating Index-2010 (HEI-2010) was calculated using two 24-hour diet recalls. Linear regression was used to examine the difference in HEI-2010 score attributable to the food package change, adjusting for baseline and secular trends among WIC participants and nonparticipants, as well as child and household characteristics. Component scores of the HEI-2010 index were analyzed with generalized linear models. Average HEI-2010 scores for participants and nonparticipants were 52.4 and 50.0 at baseline, and 58.3 and 52.4 after the policy change, respectively. The WIC food package revisions were associated with an adjusted average of 3.7 additional HEI-2010 points (95% confidence interval, 0.6-6.9) for WIC participants compared with nonparticipants. In particular, the revisions were associated with a 3.4-fold relative increase (95% confidence interval, 1.3-9.4) in the Greens and Beans component score for WIC participants compared with nonparticipants. Results from this national sample indicate that the WIC food package revisions were associated with higher diet quality for children participating in WIC.

The Impact of the 2009 Special Supplemental Nutrition Program for Women, Infants, and Children Food Package Revisions on Participants: A Systematic Review

For the first time since 1980, the US Department of Agriculture Food and Nutrition Service Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food package policies were revised in 2009 to meet the Institute of Medicine’s nutrition recommendations. These changes included increases in fruits, vegetables, whole grains, and low-fat dairy to improve nutrition and health of WIC participants. Our systematic review of the literature assessed the influence that the 2009 WIC food package revisions have had on dietary intake, healthy food and beverage availability, and breastfeeding participation. The systematic review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations. Four electronic databases were searched between April 1 and 30, 2014, for peer-reviewed research. Two reviewers screened the articles, extracted the data, and established inter-rater reliability by discussing and resolving discrepancies. Twenty articles were included that met our inclusion criteria. Nine of the studies analyzed changes in dietary intake, eight examined changes in healthy food and beverage availability, and three evaluated breastfeeding participation exclusively. The review demonstrated an improved dietary intake and an increase in the availability of healthier foods and beverages in authorized WIC stores. The revised food package was also associated with improved dietary intake of WIC participants. Mixed results were demonstrated in regard to improved breastfeeding outcomes. Further research is needed to assess the influence of WIC 2009 food package revisions on breastfeeding outcomes and to make conclusions about broad nutrition-related implications.

Information for CME Credit - The 18-Month Impact of Special Supplemental Nutrition Program for Women, Infants, and Children Food Package Revisions on Diets of Recipient Families

Information for CME Credit - The 18-Month Impact of Special Supplemental Nutrition Program for Women, Infants, and Children Food Package Revisions on Diets of Recipient Families

The 18-month impact of special supplemental nutrition program for women, infants, and children food package revisions on diets of recipient families.

Beginning in 2009, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) revised its food packages and provided more whole grains, fruits, and vegetables and fewer foods with high saturated fat content. However, knowledge of the impact of this policy shift on the diets of WIC participants remains limited. To examine the longer-term impact of the 2009 WIC food package change on nutrient and food group intake and overall diet quality among African American and Hispanic WIC child participants and their mothers/caregivers. In this natural experiment, 24-hour dietary recalls were collected in the summer of 2009, immediately before WIC food package revisions occurred in Chicago IL and at 18 months following the food package change (winter/spring 2011). Generalized estimating equation models were used to compare dietary intake at these two time points. Data were analyzed in July 2013. Eighteen months following the WIC food package revisions, significant decreases in total fat (p=0.002) and saturated fat (p=0.0004) and increases in dietary fiber (p=0.03) and overall diet quality (p=0.02) were observed among Hispanic children only. No significant changes in nutrient intake or diet quality were observed for any other group. The prevalence of reduced-fat milk intake significantly increased for African American and Hispanic children, whereas the prevalence of whole milk intake significantly decreased for all groups. Positive dietary changes were observed at 18 months post policy implementation, with the effects most pronounced among Hispanic children.

Satisfaction of California WIC Participants With Food Package Changes

Assess California Women, Infants, and Children (WIC) participant satisfaction with the 2009 food package revisions and compare satisfaction based on language preference and timing of WIC enrollment relative to the revisions. Computer-assisted telephone interviews of 2,996 WIC participants in 2010. Most participants (91.3%) were satisfied with checks for new WIC foods (fruits/vegetables, whole grains, and lower-fat milk) and 82.7% of participants were satisfied with amounts of foods that were reduced in the revised food package (milk, cheese, eggs, and juice). Difficulty using new checks was reported by 13.7% of participants. Compared with English-speaking participants, a higher percentage of Spanish speakers reported satisfaction (P < .01) and a lower percentage reported difficulties using checks (P < .001). A higher percentage of newer enrollees reported satisfaction compared with those participating in WIC before the revisions (P < .01). This research suggests that recent policy change to the WIC food package improves WIC participant access to healthful food options without decreasing satisfaction.

WIC Infant and Toddler Feeding Practices Study: protocol design and implementation

The federal Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), which began in the 1970s, has undergone revisions in the past several years, including revision to contents of the supplemental food "packages" in 2009 based on recommendations provided by an Institute of Medicine (IOM) committee of The National Academies. In 2010, the IOM held a workshop to examine and recommend research priorities for the program. The overall purpose of the current (ie, second) WIC Infant and Toddler Feeding Practices Study (ITFPS-2) is to conduct a nationally representative, longitudinal study of contemporary WIC infant and toddler feeding practices. This study will update earlier studies and collect information on variations in WIC program components. The study will also assess ways in which WIC may address obesity in early childhood and examine changes in feeding practices that may stem from the 2009 food package revisions. The sample is drawn from the universe of WIC sites nationally, excluding only those with an insufficient volume of eligible participants. Eligibility for the study includes the ability to be interviewed in English or Spanish. Approximately 8000 women and infants are being sampled, and ∼ 4000 are expected to participate. Eligible women are invited to participate during their WIC enrollment visit, and informed consent is sought. The design includes a core sample to be followed until the infant reaches age 2 y and a supplemental sample to be used in some cross-sectional analyses to ensure adequate representation of groups that might be underrepresented in the core sample. Participants will complete up to 11 interviews (core sample) or 4 interviews (supplemental sample) each except for the prenatal interview, which includes a quantitative 24-h recall of food intake for the infant. Eighty sites have been sampled across 26 states and 1 territory. Instruments have been developed and pretested in both English and Spanish, and interviewers have been rigorously trained. Recruitment and interviewing began in July 2013. This study will provide the only current large-sample longitudinal feeding data available on a nationally representative sample of infants in low-income families, and results will be available to inform the 2020 Dietary Guidelines for Americans for the 0- to 24-mo age group.

Evaluating the initial impact of the revised Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food packages on dietary intake and home food availability in African-American and Hispanic families.

The present study assessed the impact of the 2009 food packages mandated by the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) on dietary intake and home food availability in low-income African-American and Hispanic parent/child dyads. A natural experiment was conducted to assess if the revised WIC food package altered dietary intake, home food availability, weight and various lifestyle measures immediately (6 months) following policy implementation. Twelve WIC clinics in Chicago, IL, USA. Two hundred and seventy-three Hispanic and African-American children aged 2-3 years, enrolled in WIC, and their mothers. Six months after the WIC food package revisions were implemented, we observed modest changes in dietary intake. Fruit consumption increased among Hispanic mothers (mean = 0·33 servings/d, P = 0·04) and low-fat dairy intake increased among Hispanic mothers (0·21 servings/d, P = 0·02), Hispanic children (0·34 servings/d, P < 0·001) and African-American children (0·24 servings/d, P = 0·02). Home food availability of low-fat dairy and whole grains also increased. Dietary changes, however, varied by racial/ethnic group. Changes in home food availability were not significantly correlated with changes in diet. The WIC food package revisions are one of the first efforts to modify the nutrition guidelines that govern foods provided in a federal food and nutrition assistance programme. It will be important to examine the longer-term impact of these changes on dietary intake and weight status.

Fruit and Vegetable Availability and Selection: Federal Food Package Revisions, 2009

With nearly 49,000 authorized retailers nationwide, a policy change that added fruits and vegetables (FV) to the U.S. Department of Agriculture's Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food packages in 2009 had the potential to expand neighborhood FV availability. This study examined changes in availability and selection of commonly consumed and culturally specific FV at authorized retailers (WIC vendors) before and after implementation of the revised WIC food packages. Quasi-experimental, one-group design with two pre-policy observations and one post-policy observation. Trained observers assessed a list of fresh, frozen, and canned FV at each vendor in seven northern Illinois counties. Eight indices of FV availability and selection were derived. Multiple regression estimated relationships. Data were collected in 2008-2010 and analyzed in 2011. Overall, availability and selection of commonly consumed fresh FV and availability of African-American culturally specific fresh FV improved after implementation of the new policy. Modest improvements in the overall availability of canned low-sodium vegetables and frozen FV were observed. Changes differed by vendor type (large vendor, small vendor, and pharmacy). Changes in availability or selection did not differ by neighborhood characteristics (population density, median household income, racial/ethnic composition). Expansion of WIC foods was associated with small positive externalities on the food environment. Larger subsidies to create more demand and more-substantial stocking requirements for retailers may yield significantly larger improvements and thus warrant further investigation. Approaches targeting rural, low-income, and racial/ethnic minority neighborhoods also may be needed.

Positive Influence of the Revised Special Supplemental Nutrition Program for Women, Infants, and Children Food Packages on Access to Healthy Foods

BackgroundThe Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) has important potential for preventing diet-related disease in low-income children. WIC food packages were recently revised to offer foods that better reflect dietary recommendations for Americans. ObjectiveThis article reports on how implementation of the new healthier WIC food packages affected access of low-income populations to healthy foods (eg, whole grains, fruit and vegetables, and lower-fat milk). DesignA pre–post store inventory was completed using a standardized instrument to assess availability, variety, quality and prices of WIC-approved foods (65 food items). Stores were assessed before (spring 2009) and shortly after the new WIC package implementation (spring 2010). Participants/settingAll convenience stores and nonchain grocery stores located in five towns of Connecticut (N=252), including 33 WIC-authorized stores and 219 non-WIC stores. Statistical analyses performedThe healthy food supply score was constructed to summarize postrevision changes in availability, variety, prices of healthy foods, and produce quality. The effect of the WIC food package revisions was measured by differential changes in the scores for stores authorized to accept WIC benefits and stores not participating in WIC, including differences by neighborhood income. Multivariate multilevel regression models were estimated. ResultsThe 2009 introduction of the revised WIC food packages has significantly improved availability and variety of healthy foods in WIC-authorized and (to a smaller degree) non-WIC convenience and grocery stores. The increase in the composite score of healthy food supply varied from 16% in WIC convenience and grocery stores in higher-income neighborhoods to 39% in lower-income areas. Improved availability and variety of whole-grain products were responsible for most of the increase in the composite score of healthy food supply. ConclusionsDesigned as cost-neutral changes, the WIC food package revisions have improved access to healthy foods for WIC participants and society at large.

Decrease in WIC Benefit Use among Pregnant Women After Revisions to the Food Package

To examine the effect on participant food choices and acceptance of the Women, Infants and Children (WIC) food package revisions by linking point-of-sale data from WIC vendors in Wisconsin with state WIC program data. This presentation focuses on pregnant women participating in the program.