Longer Participation in the Special Supplemental Nutrition Program for Women,Infants, and Children Is Not Associated with Reduced Sugar-Sweetened Beverage Intake among Black Participants

This study assessed relationships of duration of family Special Supplemental Nutrition Program for Women, Infants and Children (WIC) participation with racial/ethnic disparities in child sugar-sweetened beverage (SSB) and water intake. Child beverage intake and family duration on WIC were collected during three cross-sectional surveys of WIC-participating families in Los Angeles County, California (2014, 2017 and 2020; n = 11,482). The associations of family duration of WIC participation, a proxy for the amount of WIC services received, with daily intake of total SSBs, fruit-flavored SSBs and water were assessed in race/ethnicity strata with multivariable negative binomial and Poisson regression models. Among English-speaking Hispanic children, those of families reporting 10 years of WIC participation consumed 33% and 27% fewer servings of total and fruit-flavored SSBs compared to those of families reporting 1 year on WIC. Among Black children, those from families reporting 5 and 10 years of participation in WIC consumed 33% and 45% more daily servings of fruit-flavored SSBs than those from families reporting 1 year on WIC. Disparities in daily total and fruit-flavored SSB intake between Black and White children increased with longer family duration on WIC. Duration of family WIC participation is associated with healthier beverage choices for infants and children, but does not appear to be equally beneficial across racial/ethnic groups in Los Angeles County.     

Effect of the Washington Special Supplemental Nutrition Program for Women,Infants and Children (WIC) on Pregnancy Outcomes

Objectives We determined the effect of the Washington State Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) on adverse pregnancy outcomes. Methods We used a record-linkage retrospective cohort design. We matched records of eligible women who enrolled in Washington WIC from 9/1/1999-12/31/2000 to records of their subsequent birth/fetal death from the Washington State Department of Health to determine their pregnancy outcome between 9/1/1999-10/15/2001 (N = 42,495). We selected comparison women from birth/fetal death records who were WIC-eligible but not on WIC (N = 30,751). We used unconditional logistic regression for analysis. Results WIC was protective for preterm delivery depending on history of abortion and adequacy of prenatal care, being most protective for women with abortion and inadequate prenatal care (Odds ratio (OR) = 0.4; 95% confidence interval (CI) = 0.3–0.5). WIC was protective for low birth weight depending on women’s cervical health, with most protection conferred to those with incompetent cervix (OR = 0.2; 95% CI = 0.1–0.6). WIC was protective for fetal death depending on women’s education, being most protective to those with <12 years of education (OR = 0.2; 95% CI = 0.1–0.3). Conclusions WIC is protective for adverse pregnancy outcomes especially for high risk women.     

Impact of Policy Changes on Infant Feeding Decisions Among Low-Income Women Participating in the Special Supplemental Nutrition Program for Women,Infants, and Children

Objectives. We present infant feeding data before and after the 2009 Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food package change that supported and incentivized breastfeeding. We describe the key role of California WIC staff in supporting these policy changes.Methods. We analyzed WIC data on more than 180 000 infants in Southern California. We employed the analysis of variance and Tukey (honestly significant difference) tests to compare issuance rates of postpartum and infant food packages before and after the changes. We used analysis of covariance to adjust for poverty status changes as a potential confounder.Results. Issuance rates of the “fully breastfeeding” package at infant WIC enrollment increased by 86% with the package changes. Rates also increased significantly for 2- and 6-month-old infants. Issuance rates of packages that included formula decreased significantly. All outcomes remained highly significant in the adjusted model.Conclusions. Policy changes, training of front-line WIC staff, and participant education influenced issuance rates of WIC food packages. In California, the issuance rates of packages that include formula have significantly decreased and the rate for those that include no formula has significantly increased.The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), funded by the US Department of Agriculture (USDA), provides nutritious food and nutrition and breastfeeding education to low-income pregnant and postpartum women, and children up to age 5 years. It is considered one of the premier public health nutrition programs in the United States; more than 9 million women, infants, and children receive WIC benefits,1 with more than 1.4 million in California alone.2 Nationwide, about half of all infants receive services from the WIC program.1Breastfeeding support is a significant priority of the WIC program and, as outlined in the 2011 Surgeon General’s Call to Action to Support Breastfeeding,3 is a nationally recognized primary prevention strategy for early childhood obesity. Numerous studies have shown breastfeeding to be associated with a 20% to 50% lower risk of overweight and obesity in children, depending on duration of breastfeeding and degree of supplementation.4,5 At the same time, research has documented that WIC participation is associated with lower rates of breastfeeding when one compares WIC participants to nonparticipants.6–12 Obesity disproportionately affects low-income individuals, and implementation of policies that increase breastfeeding rates among low-income families served by WIC may be an important strategy for combatting the obesity epidemic. Motivated by these assumptions, the 2006 Institute of Medicine Committee to Review the WIC Food Packages recommended significant policy changes to the WIC Program to incentivize and support breastfeeding.The year 2009 marked a historic change to the WIC program by increasing support of breastfeeding and aligning the foods available through the WIC program, referred to as the WIC food package, with the 2005 Dietary Guidelines for Americans. On the basis of the Institute of Medicine recommendations, USDA made significant changes to the food packages for women and children to include fruits, vegetables, and whole grains, and to limit milk purchases to only lower-fat options for all women and all children older than 2 years.13 For postpartum women and infants, significant changes were made to the food packages to better incentivize and support breastfeeding: increasing the value of the WIC package for mothers who fully breastfeed, reducing the amount of formula for mothers who partially breastfeed, calibrating formula amounts for infants by age, and postponing complementary infant foods. In addition, California adopted the suggested federal policy of no routine issuance of infant formula to breastfeeding mothers in the first month postpartum.13 These breastfeeding-supportive changes were welcomed by the public health community, with hopes that the changes would increase breastfeeding rates among low-income mothers served by WIC. The objective of this study was to assess whether the key goals of the changes in the breastfeeding policies and food packages—to increase the issuance of the infant food package that does not include formula and decrease the issuance of the infant food packages that include formula—were achieved among a large population of WIC participants in California.     

Factors that Influence Breastfeeding Decisions among Special Supplemental Nutrition Program for Women, Infants, and Children Participants from Central Louisiana

Although human milk provides optimal nutrition for infants, fewer than one third of US infants are breastfed exclusively for 6 months or more. The objectives of this study were to determine the factors that have the greatest impact on the decisions to breastfeed, and to determine the effect of formula provided by the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) on the initiation and duration of breastfeeding among WIC participants in a rural parish in central Louisiana. A cross-sectional study was done between September 2007 and March 2008 among 130 WIC participants. Approximately half (51%) of the participants reported breastfeeding their youngest child for a mean of 15.7±14.9 weeks, with more white mothers breastfeeding than did African-American mothers or other races (P<0.01). Significantly more people reported that incentives provided to encourage breastfeeding did not affect their decision to breastfeed than those who said incentives affected their decision to breastfeed (P<0.029). Finally, study participants who were breastfed as a child were significantly more likely to breastfeed their children than those who were not breastfed as a child (P<0.022). The majority (96%) of the participants in this study indicated that WIC is providing effective and clear education about the benefits of breastfeeding, and that this advice influenced their decision to breastfeed their children. These findings underscore the importance of emphasizing the health benefits of breastfeeding to increase initiation and duration rates among WIC participants.     

Pilot Study of a Farm-to-Special Supplemental Nutrition Program for Women,Infants, and Children (WIC) Intervention Promoting Vegetable Consumption

BackgroundVegetable intake is below recommended levels among adults served by the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).ObjectiveThe aim of this study was to determine whether a novel, theory-driven, farm-to-WIC intervention to promote vegetable intake showed promise of being successful and is therefore appropriate for efficacy testing.DesignFrom June 2019 to January 2020, the intervention was piloted in three WIC agency sites (one randomized to the intervention study group and two to the control group) selected based on similarity in size and the demographics of participants served.Participants/settingRecruited between June 3, 2019 and August 1, 2019, participants were 297 primarily Hispanic adults served by a large WIC agency located in a densely populated urban area in New Jersey (160 were enrolled at the intervention site and 137 at control sites).InterventionThe intervention combined behaviorally focused instruction and handouts with the introduction of a WIC-based farmers’ market, field trips to an area farmers’ market, telephone coaching and support before and after trips, and recipe demonstrations and tastings.Main outcome measuresThe primary outcomes were vegetable intake (measured objectively using dermal carotenoids as a biomarker of intake and via self-report) and the redemption of vouchers provided through the WIC Farmers’ Market Nutrition Program (FMNP) for fruit and vegetable purchases at farmers’ markets (objectively assessed using data provided by WIC).Statistical analyses performedBetween-group differences in vegetable intake were examined at mid- and post-intervention (3 and 6 months post-baseline, respectively) with linear mixed-effects models adjusted for baseline vegetable intake and covariates. Logistic regression analysis was used to relate FMNP voucher redemption to study group and covariates.ResultsAt mid-intervention, objectively measured vegetable intake was higher among participants in the control group as compared with the intervention group; self-reported intake did not differ by group. Post-intervention, objectively measured and self-reported vegetable intake were higher among participants in the intervention group as compared with the control group. Receipt of the intervention was associated with a greater likelihood of FMNP voucher redemption. Voucher redemption rates were 87% in the intervention group and 28% in the control group (odds ratio = 17.39, 95% confidence interval [8.64, 35.02]).ConclusionsMeaningful associations found between the intervention, vegetable intake, and FMNP voucher redemption suggest that the program is appropriate for efficacy testing.     

Impact of the Revised Special Supplemental Nutrition Program for Women,Infants, and Children (WIC) Food Package Policy on Fruit and Vegetable Prices

Obesity is generally inversely related to income among women in the United States. Less access to healthy foods is one way lower income can influence dietary behaviors and body weight. Federal food assistance programs, such as the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), are an important source of healthy food for low-income populations. In 2009, as part of a nationwide policy revision, WIC added a fruit and vegetable (F/V) voucher to WIC food packages. This quasi-experimental study determined whether F/V prices at stores authorized to accept WIC (ie, WIC vendors) decreased after the policy revision in seven Illinois counties. It also examined cross-sectional F/V price variations by store type and neighborhood characteristics. Two pre-policy observations were conducted in 2008 and 2009; one post-policy observation was conducted in 2010. Small pre- to post-policy reductions in some F/V prices were found, particularly for canned fruit and frozen vegetables at small stores. Compared with chain supermarkets, mass merchandise stores had lower prices for fresh F/V and frozen F/V and small stores and non-chain supermarkets had higher canned and frozen F/V prices, but lower fresh F/V prices. Limited price differences were found across neighborhoods, although canned vegetables were more expensive in neighborhoods with higher concentrations of either Hispanics or blacks and fresh F/V prices were lower in neighborhoods with more Hispanics. Results suggest the WIC policy revision contributed to modest reductions in F/V prices. WIC participants’ purchasing power can differ depending on the type and neighborhood of the WIC vendor used.     

Factors Involved in the Persistence of Overweight among Children Enrolled in the Supplemental Food Program for Women,Infants, and Children

Objective To investigate differences between children ages 2 and 5 years enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in Texas whose overweight persisted and those whose overweight resolved. Methods The study involved administration of a survey to a randomly selected stratified sample of parents and guardians of WIC children residing in the 11 public health regions in Texas. Subjects volunteered to complete the survey during a scheduled WIC appointment. A total of 445 surveys were completed, 206 by parents/guardians of children classified as having persistent overweight, and 239 by those with children classified as having non-persistent overweight. Results and Conclusions A higher percentage of children in the non-persistent group were male, younger, white, consumed more dairy products, had a mother living in the household, and a family member who participated in physical activity with the child. A higher percentage of parents of children in the persistent group reported that they had been told their child was overweight and received information about overweight in children from the WIC staff. A higher percentage also felt their child was overweight, that their child’s weight could be improved, that their child’s weight did not improve in the last year and were concerned about their child’s weight. This study identified several variables associated with overweight persistence. WIC personnel and other public health educators can utilize these findings to identify overweight children who are at higher risk for non-improvement and to plan more effective intervention strategies for the population studied.     

Trends in blood lead levels among children enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children from 1996 to 2000

We analyzed data from the Wisconsin Childhood Lead Poisoning Prevention Program to examine the distribution of and trends in elevated blood lead levels among WIC-enrolled children from 1996 until 2000. Higher blood lead levels were seen among WIC-enrolled children, and although not statistically significant, the rate of blood lead level decline among WIC-enrolled children was greater than among non-WIC-enrolled children.     

Estimated Reductions in Added Sugar Intake among US Children and Youth in Response to Sugar Reduction Targets

BackgroundIn 2021, the National Salt and Sugar Reduction Initiative (NSSRI) released voluntary sugar reduction targets for packaged foods and drinks in the United States.ObjectiveThe objectives of this study were to describe trends in added sugar intake from NSSRI foods and beverages among children and youth and estimate possible reductions if industry were to meet the targets.DesignThis study consisted of cross-sectional and trend analyses of demographic and 24-hour dietary recall data from eight survey cycles (2003-2004 to 2017-2018) of the National Health and Nutrition Examination Survey.Participants/settingThe study sample included 23,248 children and youth (aged 2 to 19 years).Main outcome measuresThe main outcome measure was the percent of daily calories from added sugar for foods and beverages in NSSRI categories.Statistical analyses performedFoods and beverages reported by participants were mapped to one of the NSSRI’s categories or coded as a non-NSSRI item. Trends over time in added sugar intake were assessed using regression models. To assess possible reductions in added sugar intake if industry were to meet the targets, sales-weighted mean percent reductions for 2023 and 2026 targets were applied to NSSRI items in the 2017-2018 National Health and Nutrition Examination Suvey data. Results were examined overall and by demographic characteristics.ResultsFrom 2003-2004 to 2017-2018, added sugar intake from NSSRI foods and beverages declined, but consumption remained high. During 2017-2018, NSSRI categories accounted for 70% of US child and youth added sugar intake. If industry met the NSSRI targets, US children and youth would consume 7% (2023 targets) to 21% (2026 targets) less added sugar.ConclusionsAlthough added sugar intake from NSSRI foods and drinks has declined over the past decade, added sugar intake from all sources remains high and consumption of added sugar from certain NSSRI categories has remained steady over time. If met, the NSSRI targets are expected to result in meaningful reductions in added sugar intake for US children and youth.     

Predictors of breastfeeding duration for employees of the Special Supplemental Nutrition Program for Women,Infants, and Children (WIC)

During the past decade there has been increasing breastfeeding support within the Women, Infants, and Children (WIC) program. For this study, it was hypothesized that employees at WIC would initiate and continue to breastfeed significantly longer than the National averages. Female employees, mostly paraprofessionals, from six Los Angeles County WIC agencies participated in the study to determine breastfeeding rates and predictors of breastfeeding success. As expected, 99% of WIC employees initiated breastfeeding and 68.6% continued to breastfeed to one year, significantly exceeding National averages. Four variables accounted for 30% of the variance in duration of breastfeeding: intent to exclusively breastfeed, delayed introduction of infant formula, attendance at breastfeeding support groups and availability of work-site breastpumps. Given that nearly 70% of the study participants reached the American Academy of Pediatrics goal of breastfeeding to 12 months or more, it is clear that full-time employment and breastfeeding can be compatible given appropriate work-site support.     

Food security status and produce intake and behaviors of Special Supplemental Nutrition Program for Women, Infants, and Children and Farmers' Market Nutrition Program participants

OBJECTIVE: This study identified differences between women from the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)- and WIC/Farmers' Market Nutrition Program-participating households regarding household food security status, fruit and vegetable intake and behaviors, perceived diet quality, and education level; and assessed the relationship between household food security status and perceived diet quality and perceived health. DESIGN, SUBJECTS/SETTING: Cross-sectional survey of women from Athens County, Ohio (WIC, n=829; Farmers' Market Nutrition Program, n=246) living in WIC households. RESULTS: Of 228 participants completing the food security portion of the survey, 61 (26.8%) were living in food secure households, while 47 (20.6%), 75 (32.9%), and 45 (19.7%) were living in households at risk for (marginal) food insecurity, with low food security, and with very low food security, respectively. For the entire sample, food insecurity was associated with poorer diet quality (r=-0.248, P<0.001). Food security status (chi(2)=2.117, P=0.548) did not differ between groups. Farmers' Market Nutrition Program reported higher education levels (P=0.027). Unlike fruit intake (t test, P=0.769), vegetable intake servings were greater among Farmers' Market Nutrition Program (2.2+/-1.2), compared to WIC (1.9+/-1.0) (t test, P=0.040). Both perceived benefit (chi(2)=4.574, P=0.032) and perceived diet quality (chi(2)=7.219, P=0.027) were greater for Farmers' Market Nutrition Program. CONCLUSIONS: Farmers' Market Nutrition Program participants exhibit more indicators of a healthful diet, but appear not to be more food secure. Nutrition education regarding the benefits of fresh produce intake can help to improve diet quality and increase Farmers' Market Nutrition Program participation.     

Assessment and related immunization issues in the Special Supplemental Nutrition Program for Women, Infants and Children: a status report.

This article reports the results of a survey undertaken to determine the current level of collaboration between Women, Infants and Children (WIC) programs and immunization services. While the results of this study are encouraging, WIC needs to continue to place emphasis on using written or computerized immunization records for client screening, utilize available computer hardware and software to assist assessments, and expand the use of food voucher incentives as a strategy to improve coverage.     

Effect of a targeted subsidy on intake of fruits and vegetables among low-income women in the Special Supplemental Nutrition Program for Women, Infants, and Children

Objectives. Intake of fruits and vegetables protects against several common chronic diseases, and low income is associated with lower intake. We tested the effectiveness of a subsidy for fruits and vegetables to the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).Methods. Women who enrolled for postpartum services (n=602) at 3 WIC sites in Los Angeles were assigned to an intervention (farmers’ market or supermarket, both with redeemable food vouchers) or control condition (a minimal nonfood incentive). Interventions were carried out for 6 months, and participants’ diets were followed for an additional 6 months.Results. Intervention participants increased their consumption of fruits and vegetables and sustained the increase 6 months after the intervention was terminated (model adjusted R²=.13, P<.001). Farmers’ market participants showed an increase of 1.4 servings per 4186 kJ (1000 kcal) of consumed food (P<.001) from baseline to the end of intervention compared with controls, and supermarket participants showed an increase of 0.8 servings per 4186 kJ (P=.02).Conclusions. Participants valued fresh fruits and vegetables, and adding them to the WIC food packages will result in increased fruit and vegetable consumption.Fruit and vegetable intake protects against various common chronic diseases.1^–4 Low income is a risk factor for poor dietary quality and for low consumption of fruits and vegetables.1^–5 Interventions using nutrition education to increase consumption of fruits and vegetables have reported some successes, although the magnitude of the behavior change has been modest.6 Recent analyses have drawn attention to the potential for more “upstream” strategies, including policy, pricing, and environmental change to affect food access and availability as well as consumer information and motivation.7Strategies to promote the choice of targeted foods by lowering their cost relative to those of alternative foods have been little tested, probably because of the cost of implementing such strategies, but the available evidence suggests that they are highly effective. Reducing the prices of lower-fat vending-machine snacks, fresh fruits, and baby carrots in work sites and secondary schools has resulted in substantially increased sales of these items.8^–10 Two published reports on the provision of coupons for the purchase of fruits and vegetables at farmers’ markets, one with low-income older adults over a 5-year period11 and the other for participants in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in Connecticut,10 showed high levels of coupon use.The WIC program provides an ideal context for investigating means to improve the consumption of fruits and vegetables. It is targeted to a low-income population and is designed to improve dietary quality both through subsidizing nutrient-dense foods and through nutrition education. The program currently reaches about half of all infants born in the United States, along with their mothers, and about 25% of preschool children.12 The WIC program was developed prior to appreciation of the relationship of intake of fruits and vegetables to chronic disease risk, and the supplemental foods were selected to provide the nutrients most limited in the diets of women and children—protein, calcium, vitamin A, and vitamin C. To date, the only fruits and vegetables provided have been juice (for all participants older than 4 months) and fresh carrots for breastfeeding women.An evaluation of nutrition education within the WIC program to increase the consumption of fruits and vegetables in Maryland13 showed that compared with control participants, intervention participants increased intake by more than one half serving a day on average. Predictors of increased consumption included the number of nutrition education sessions attended, ethnicity, education, and self-efficacy.13There has been considerable discussion about adding fruits and vegetables to the WIC supplemental food “package.” A recent report by the Institute of Medicine recommended a number of changes, including the addition of fruits and vegetables to the packages for all participants older than 6 months.14 The food package for postpartum women at the time we conducted our study included fluid milk, cheese, eggs, iron-fortified cereal, fruit juice, and for breastfeeding women, canned tuna and fresh carrots.We sought to determine whether an additional economic subsidy for fresh fruits and vegetables for postpartum WIC participants would result in increased consumption of fruits and vegetables. We tested the hypothesis that effective and sustained improvement in fruit and vegetable intake would result from improved economic access to fresh produce for a 6-month period.