Annual Conference April 4 2017 Kathleen Rasmussen Chair Shannon E Whaley Vice Chair Committee to Review the WIC Food Packages Review of WIC Food Packages Improving Balance and Choice ID: 932246
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Slide1
National WIC AssociationAnnual ConferenceApril 4, 2017Kathleen Rasmussen, Chair Shannon E. Whaley, Vice ChairCommittee to Review the WIC Food Packages
Review of WIC Food Packages:
Improving Balance and Choice
Slide2DisclosuresAny views not attributed to the report are those of the authors and do not necessarily represent the views of the National Academies of Sciences, Engineering, and Medicine
Slide3Outline: Part I3
Slide4The Task4
Slide5The Task
“Recommend revisions for the WIC food packages that are culturally suitable, cost-neutral, efficient for nationwide distribution, and nonburdensome to administration”
Review the scientific literature to assess the current WIC food packages for consistency with the Dietary Guidelines for Americans (DGA)
Review the nutritional requirements of the WIC population and conduct analyses of
their intakes of nutrients and foods
Conduct food expenditure analyses
Conduct sensitivity
analyses and prepare a regulatory
impact
analysis
5
Slide6The Task
Additional components included evaluations of and recommendations related to:
Energy density of infant formula;
Iron requirements for infant formula;
Inclusion of fish in additional food packages, including wild salmon;
Functional ingredients and a potential USDA-FNS approach to inclusion;
Actions should USDA-FNS have funding above or below the cost-neutral level.
6
Slide7Study Products
February 3, 2015
November 30, 2015
January 5, 2017
7
Slide8Framework and Criteria for Food Package Revisions8
Slide9Criteria for Food Package Revisions
The
packages should
provide a balanced supplement to the diets of women and children
.
The WIC food packages should provide a moderate proportion of an individual’s requirement for a particular nutrient or recommended amount of a food group
The supplementation target may differ depending upon the nutrient or food group and the degree to which foods available in the marketplace can supply these amounts
Accommodation for cultural suitability and food preferences is acceptable
9
Slide10Additional Criteria
The
packages contribute
to:
T
he
reduction of the
prevalence of
inadequate
and excessive nutrient intakes
A
n overall dietary pattern that is consistent with the relevant dietary guidance.10
Slide11Additional Criteria
The
foods in the
packages
:
Are available
in forms and amounts suitable for low-income
persons
Are readily
acceptable, commonly consumed, widely available,
account for cultural
eating patterns and food preferences, and provide incentives for families to participate in the WIC programDo not create an undue burden on state agencies or vendors.11
Slide12Unique Information: Redemption Rates
WIC Food Category
Average Percent Redemption
Infant formula
94
Eggs
80
Cash value voucher
77
Whole milk
75
Juice
70
Cheese
70
Fish
69
WIC-eligible medical foods
66
Low-fat milk
65
Breakfast cereal
60
Whole grain bread
53
Infant food fruits/vegetables
51
Peanut butter/legumes
51
Infant cereal
47
Infant food meats
31
Slide13Unique Information: Redemption Rates
WIC Food Category
Average Percent Redemption
Infant formula
94
Eggs
80
Cash value voucher
77
Whole milk
75
Juice
70
Cheese
70
Fish
69
WIC-eligible medical foods
66
Low-fat milk
65
Breakfast cereal
60
Whole grain bread
53
Infant food fruits/vegetables
51
Peanut butter/legumes
51
Infant cereal
47
Infant food meats
31
More
h
ighly
redeemed
Slide14Unique Information: Redemption Rates
WIC Food Category
Average Percent Redemption
Infant formula
94
Eggs
80
Cash value voucher
77
Whole milk
75
Juice
70
Cheese
70
Fish
69
WIC-eligible medical foods
66
Low-fat milk
65
Breakfast cereal
60
Whole-grain
bread
53
Infant food
vegetables/fruits
51
Peanut butter/legumes
51
Infant cereal
47
Infant-food
meats
31
Less
h
ighly
redeemed
Slide15Decision-Making Process15
Slide16Determining Potential ActionsNutrient inadequacy
Food group intake below amounts recommendedAmount of nutrient and food in the package compared to recommendations“Gap” to reduce low intakes
Acceptability of foods
Availability of
foods
Public comments
Decision Tree
Priorities
Potential change in food amounts
Potential substitution options
Potential new foods or food forms
Potential increase in the CVVNo actionInputs
Outputs
16
Slide17Major Findings from Using the Decision Tree
Amounts of several foods could be reduced
to
meet the criterion of “supplemental”
The cash value voucher (CVV) could be increased to address the low intakes of several priority nutrients
Additional forms of
various foods
could be considered to promote intake
(e.g.
canned
vegetables
/legumes, yogurt, whole grains)
C
anned
fish could
be included in more food packages to address
low intakes of seafood
Slide18Iterative process:
Framework for Revisions
18
Slide19Iterative process:
Framework for Revisions
19
Slide20Cost Neutrality20
Slide21The Cost-Neutral Requirement
Cost-neutral = The weighted average per-participant cost of the revised and current food packages must be within $0.10
Calculated by determining the cost of each food, then package, then linking to participants per-package nationwide
How does this affect the revisions?
Something must be reduced to allow for any additions
Children comprise 53% of participants = small changes have large
effects
(↑ $1.00 in CVV = +$
0.40 on average)
Fully breastfeeding women comprise 3% = big changes have small
effects
(
↑ $1.00 in CVV = +$
0.03 on average)
21
Slide22Outline: Part II22
Slide23The Revised Food Packages23
Slide24The amounts of foods reflect the concepts of
balance
among the food groups and
supplemental
Increased
:
CVV, whole grains,
seafood
Decreased
:
Juice, milk, legumes (for most), peanut butter,
infant cereal, infant
vegetables
and
fruits, infant
meats
The Revised Food Packages: Overview
24
Slide25The Revised Food Packages: Major Changes and Rationale25
Slide26The CVV Is Increased
by $4 to $24
26
CVV Amounts
Per
Month ($)
Food Package Recipient
Current
Revised
Difference
Children
8
12
+4
Women, pregnant
11
15
+4
Women, partially breastfeeding
11
25
+14
Women, postpartum
11
15
+4
Women, fully breastfeeding
11
35
+24
Slide27The CVV Is Increased
by $4 to $24: Rationale
Given the high redemption of the CVV, it:
O
ffers
the most
flexibility
for aligning the packages with
both cultural
eating patterns and other food
preferences
Has the
potential to provide a
wide range of nutrients
, including priority nutrients
(e.g. potassium
and
fiber
)
O
ffers
the
potential to increase vegetable intakes
, which are low for 50-100% of WIC
participants—once their preferences
for fruit are
met
27
Slide28Additional Opportunities to Increase the CVV
28
Participants have the option to:
Exchange 64 ounces of juice for $3 in
CVV
;
Exchange jarred infant food veg/
fr
for a CVV:
Half (64
oz
) for $10 in CVV, or;
All (128
oz
)
for $20 in CVV.
Slide2929
Additional Opportunities to Increase the CVV (cont.)
Maximum CVV Amounts
Per
Month ($)
Food Package Recipient
Current
Revised
Difference
Infants
9
(6 as revised)
to
11
months
4-8
20
+12
Children
8
15
+7
Women, pregnant
11
18
+7
Women, partially breastfeeding
11
28
+17
Women, postpartum
11
15
+4
Women, fully breastfeeding
11
38
+27
Slide30Juice Is Reduced to 0 to 64 oz
30
Juice Amounts
Per Month
(
oz
)
Food Package Recipient
Current
Revised
Difference
Children
128
64
-64
Women, pregnant
144
64
-80
Women, partially breastfeeding
144
64
-80
Women, postpartum
96
0
-96
Women, fully breastfeeding
144
64
-80
Slide31Whole fruit is the universally preferred form
of fruit
American Academy of Pediatrics
Dietary Guidelines for Americans
Children
Current: 107% of the AAP limit is provided*
Revised: 53% of the AAP limit is provided
Reduction
partially allows
for increased CVV
* The AAP recommended upper limit for intake of 100 percent juice is 4 to 6 oz per day.
Juice Is Reduced: Rationale
31
Slide32Fish Is Included in Nearly All Packages
32
Maximum Fish
Amounts
Every 3 Months
(
oz
)
Food Package Recipient
Current
Revised
Difference
Infants 6 to 11 months,
fully
breastfeeding
0
30*
+30
Children
0
10
+10
Women, pregnant
0
10
+10
Women, partially breastfeeding
0
30
+30
Women, postpartum
0
10
+10
Women, fully breastfeeding
90
60
-30
*10
oz
of fish may be substituted for 10
oz
of jarred infant food meat.
Slide33Seafood intakes were below recommended amounts in 82-100% of WIC
participants, and
f
ish
is currently
issued only to fully breastfeeding women
Inclusion of fish
improves balance across the food groups and consistency with the DGA;
it also introduces
seafood into the diets of WIC
participants
To
contain costs
, fish is included as part of a rotation with legumes and peanut butter
33
Fish Is Included in Nearly All Packages: Rationale
Slide34Legumes/Peanut
Butter/Fish Rotation: Rationale
34
Brings amounts of legumes (beans) and peanut butter into the “supplemental” range
Amounts exceed “supplemental” for children, but align with reasonable package
sizes
Allows for inclusion of fish in more packages
All are shelf-stable
Slide35Proportion of DGA Recommended Amounts (%): Current Packages**Assumes full redemption and that children and postpartum women select legumes 50% of the time.
Food Package Recipient
Legumes
Peanut Butter
Children
177
167
Women, pregnant
71
168
Women, partially breastfeeding
71
168
Women, postpartum
44
84
Women, fully breastfeeding
71
168
Slide36Legume (Bean)
Amounts
Per Month (
lb
)
Food Package Recipient
Current*
Revised
Difference
Children
0.5
0.3
-0.2
Women, pregnant
1.0
0.7
-0.3
Women, partially breastfeeding
1.0
0.7
-0.3
Women, postpartum
0.5
0.7
+0.2
Women, fully breastfeeding
1.0
0.7
-0.3
Legumes ar
e Reduced in Most Packages
*Assumes that children and postpartum women select legumes 50% of the time.
Slide37Maximum Peanut Butter Amounts Per Month
(
oz
)
Food Package Recipient
Current*
Revised
Difference
Children
9
6
-3
Women, pregnant
18
6
-12
Women, partially breastfeeding
18
6
-12
Women, postpartum
9
6
-3
Women, fully breastfeeding
18
6
-12
Peanut Butter is
Reduced in All Packages
*Assumes that children and postpartum women select peanut butter 50% of the time.
Slide38Whole Grains
A
re Offered in
16
to 24
oz
Package Sizes
38
Maximum Whole Grain Amounts
Per Month
(
oz
)
Food Package Recipient
Current
Revised
Difference
Children
32
24
-8
Women, pregnant
16
24
+8
Women, partially breastfeeding
16
24
+8
Women, postpartum
16
24
+8
Women, fully breastfeeding
16
24
+8
Slide39Additional grains recommended for authorization include:
Corn meal (including blue), corn masa flour*, buckwheat,
teff
These options are commonly available in a 24
oz
size
All breakfast cereals must meet the whole grain-rich criteria
Whole Grain Options are Expanded
39
*Not a whole grain
Slide40Intakes of whole grains are below recommended amounts in 100% of WIC
participants
The range of package sizes permits commonly available sizes
of all options to
be
acquired
Whole Grain Changes:
Rationale
40
Slide41Dairy Is Reduced to
12 to 16 qt per Month
41
Dairy (Milk) Amounts
Per Month
(quarts)
Food Package Recipient
Current
Revised
Difference
Children
16
12 to 14
-2 to
-4
Women, pregnant
22
16
-6
Women, partially breastfeeding
22
16
-6
Women, postpartum
16
16
0
Women, fully breastfeeding
24
16
-8
Slide42Dairy Substitution Options
42
Substitution Option: Participants May Choose 1
Food
Package Recipient
2
qt
milk =
2
qt
yogurt
4
qt
milk =
1
qt
yogurt +1
lb
cheese
6
qt
milk =
2
lb
cheese
Children
Women, pregnant
Women, partially breastfeeding
Women, postpartum
Women, fully breastfeeding
Slide43Dairy is Reduced: Rationale
43
Amounts in the current food package were greater than “supplemental”
Allows for additional (more expensive) yogurt substitution to promote intake
Substitution options (including allowing 2 quarts of yogurt) eliminate need for the “dangling quart”
1
qt
yogurt = 30 to 32
oz
Slide44Proportion of the DGA Food
Groups and Subgroups
Provided in the Current and Revised Food
Packages
for Children
as Redeemed
Proportion of the DGA Recommended Amount as Redeemed (%)
Slide45Packages for the mother-infant dyad45
Slide46Breastfeeding is part of WIC’s goal to improve infants’ nutritional status; it:
Provides education, anticipatory guidance about and support for breastfeeding
Encourages women to breastfeed for as long as possible, with stronger support for EBF than PBF
Support is not uniformly available
But
PBF may be more achievable than EBF
Breastfeeding in WIC
46
Slide47All
women
receive
adequate counseling and support
for breastfeeding prenatally and
through
the first month
postpartum
Infant formula is not
issued
routinely in the first 30
days
For women who request infant formula, its issuance
is individually
tailored
to the needs of
the dyad
Breastfeeding
of any intensity
is supported
The Committee’s Vision for Breastfeeding in WIC
47
Slide48Decreased issuance of the partial breastfeeding package
Increased issuance of the formula-feeding package
Most likely because:
Women who
were not confident about breastfeeding
or who
needed some formula to
be able
to breastfeed at
all moved to the formula-feeding package
Unintended Consequences of the Food
P
ackage
C
hanges in 2009
48
Slide49Maintains no formula for exclusively breastfeeding dyads
For partially breastfeeding dyads:
Pending a careful assessment of the needs of the dyad
, increase the allowance for formula from 104
up to
364 fl oz in the first month
Food Package I for Breastfed Infants: The First 30 Days
49
Slide50Fully Breastfeeding Dyad
Partially (Mostly) Breastfeeding Dyad
Formula-Feeding
Dyad
WIC Food Categories
0 to 5 Months
6 to 11 Months
0 to 5 Months
6 to 11 Months
0 to 5 Months
6 to 11 Months
For Infants
Formula
--
--
Up to 364 or 442
fl
oz
Up
to 312
fl
oz
Up to 806 or 884 fl
oz
Up
to 624
fl
oz
Infant
meats
Infant
cereal
Infant jarred FV
--
--
--
40
oz
16
oz
128
oz
--
--
--
--
8
oz
128
oz
--
--
--
--
8
oz
128oz
F
or
Women
Vegetables and
fruits
$35 CVV
$25 CVV
$15 CVV
--
Eggs
2 dozen
1 dozen
1 dozen
--
Fish
60 oz every 3 months
30 oz every 3 months
10 oz every 3 months
--
Dyadic Packages: Major Changes
50
Slide51Fully Breastfeeding Dyad
Partially (Mostly) Breastfeeding Dyad
Formula-Feeding
Dyad
WIC Food Categories
0 to 5 Months
6 to 11 Months
0 to 5 Months
6 to 11 Months
0 to 5 Months
6 to 11 Months
For Infants
Formula
--
--
Up to 364 or 442
fl
oz
Up
to 312
fl
oz
Up to 806 or 884
fl oz
Up
to 624
fl
oz
Infant
meats
Infant
cereal
Infant jarred FV
--
--
--
40
oz
16
oz
128
oz
--
--
--
--
8
oz
128
oz
--
--
--
--
8
oz
128oz
F
or
Women
Vegetables and
fruits
$35 CVV
$25 CVV
$15 CVV
--
Eggs
2 dozen
1 dozen
1 dozen
--
Fish
60 oz every 3 months
30 oz every 3 months
10 oz every 3 months
--
Dyadic Packages: Major Changes
51
Slide52Fully Breastfeeding Dyad
Partially (Mostly) Breastfeeding Dyad
Formula-Feeding
Dyad
WIC Food Categories
0 to 5 Months
6 to 11 Months
0 to 5 Months
6 to 11 Months
0 to 5 Months
6 to 11 Months
For Infants
Formula
--
--
Up to 364 or 442
fl
oz
Up
to 312
fl
oz
Up to 806 or 884 fl
oz
Up
to 624
fl
oz
Infant
meats
Infant
cereal
Infant jarred FV
--
--
--
40
oz
16
oz
128
oz
--
--
--
--
8
oz
128
oz
--
--
--
--
8
oz
128oz
F
or
Women
Vegetables and
fruits
$35 CVV
$25 CVV
$15 CVV
--
Eggs
2 dozen
1 dozen
1 dozen
--
Fish
60 oz every 3 months
30 oz every 3 months
10 oz every 3 months
--
Dyadic Packages: Major Changes
52
Slide53Fully Breastfeeding Dyad
Partially (Mostly) Breastfeeding Dyad
Formula-Feeding
Dyad
WIC Food Categories
0 to 5 Months
6 to 11 Months
0 to 5 Months
6 to 11 Months
0 to 5 Months
6 to 11 Months
For Infants
Formula
--
--
Up to 364 or 442
fl
oz
Up
to 312
fl
oz
Up to 806 or 884 fl
oz
Up
to 624
fl
oz
Infant
meats
Infant
cereal
Infant jarred FV
--
--
--
40
oz
16
oz
128
oz
--
--
--
--
8
oz
128
oz
--
--
--
--
8
oz
128oz
F
or
Women
Vegetables and
fruits
$35 CVV
$25 CVV
$15 CVV
--
Eggs
2 dozen
1 dozen
1 dozen
--
Fish
60 oz every 3 months
30 oz every 3 months
10 oz every 3 months
--
Dyadic Packages: Major Changes
53
Slide54Fully Breastfeeding Dyad
Partially (Mostly) Breastfeeding Dyad
Formula-Feeding
Dyad
WIC Food Categories
0 to 5 Months
6 to 11 Months
0 to 5 Months
6 to 11 Months
0 to 5 Months
6 to 11 Months
For Infants
Formula
--
--
Up to 364 or 442
fl
oz
Up
to 312
fl
oz
Up to 806 or 884 fl
oz
Up
to 624
fl
oz
Infant
meats
Infant
cereal
Infant jarred FV
--
--
--
40
oz
16
oz
128
oz
--
--
--
--
8
oz
128
oz
--
--
--
--
8
oz
128oz
F
or
Women
Vegetables and
fruits
$35 CVV
$25 CVV
$15 CVV
--
Eggs
2 dozen
1 dozen
1 dozen
--
Fish
60 oz every 3 months
30 oz every 3 months
10 oz every 3 months
--
Dyadic Packages: Major Changes
54
Slide55Fully Breastfeeding Dyad
Partially (Mostly) Breastfeeding Dyad
Formula-Feeding
Dyad
WIC Food Categories
0 to 5 Months
6 to 11 Months
0 to 5 Months
6 to 11 Months
0 to 5 Months
6 to 11 Months
For Infants
Formula
--
--
Up to 364 or 442
fl
oz
Up
to 312
fl
oz
Up to 806 or 884 fl
oz
Up
to 624
fl
oz
Infant
meats
Infant
cereal
Infant jarred FV
--
--
--
40
oz
16
oz
128
oz
--
--
--
--
8
oz
128
oz
--
--
--
--
8
oz
128oz
F
or
Women
Vegetables and
fruits
$35 CVV
$25 CVV
$15 CVV
--
Eggs
2 dozen
1 dozen
1 dozen
--
Fish
60 oz every 3 months
30 oz every 3 months
10 oz every 3 months
--
Dyadic Packages: Major Changes
55
Slide56Fully Breastfeeding Dyad
Partially (Mostly) Breastfeeding Dyad
Formula-Feeding
Dyad
WIC Food Categories
0 to 5 Months
6 to 11 Months
0 to 5 Months
6 to 11 Months
0 to 5 Months
6 to 11 Months
For Infants
Formula
--
--
Up to 364 or 442
fl
oz
Up
to 312
fl
oz
Up to 806 or 884 fl
oz
Up
to 624
fl
oz
Infant
meats
Infant
cereal
Infant jarred FV
--
--
--
40
oz
16
oz
128
oz
--
--
--
--
8
oz
128
oz
--
--
--
--
8
oz
128oz
F
or
Women
Vegetables and
fruits
$35 CVV
$25 CVV
$15 CVV
--
Eggs
2 dozen
1 dozen
1 dozen
--
Fish
60 oz every 3 months
30 oz every 3 months
10 oz every 3 months
--
Dyadic Packages: Major Changes
56
Slide57Outline: Part III57
Slide58Regulatory Impact Analysis58
Slide59Regulatory Impact Analysis
RIA =
A longer-term (5-year) analysis of effects on participation, stakeholders, and overall program costs
Significant burden is not anticipated because the revisions build upon the 2009 changes
Compared
to the current food
packages, the
revised food packages
are expected to
save a small amount
(about $44 million annually)
program-wide
in FY2018
through
FY2022
59
Slide60Implementation Recommendations60
Slide61Implementation Recommendations
USDA-FNS should:
Develop
the tools and strategies needed to assist state agencies, local agencies, and vendors to inform participants about and support them to make the best use of the expanded options of the revised food packages.
Slide62Maximize
the extent to which the revised food packages motivate the choice to initiate and continue breastfeeding among all racial and ethnic groups by enhancing and stabilizing the funding available (independent of the food packages) for peer counseling and other lactation support staff in WIC sites
.
Implementation Recommendations (cont.)
Slide63Research Recommendations63
Slide64USDA-FNS should
:
F
und research to evaluate the effects of the recommended revisions to the WIC food packages on participant satisfaction, participation in the program, redemption of WIC foods, and participants’ diets and health.
Research
Recommendations
Collect
WIC state agency policies on an annual basis and establish a national database of EBT expenditures by program participants
.
Slide65Research
Recommendations
(cont.)
Fund
data collection and analysis of that data toward optimizing support for breastfeeding and increasing the proportion of WIC participants who choose to initiate and continue breastfeeding, and tailoring food package options to best meet the needs and goals of the breastfeeding
dyad.
Slide66Research
Recommendations
(cont.)
Collaborate
with the U.S. Department of Health and Human Services to achieve expansion of nationally representative collection of data on the dietary intakes for pregnant, breastfeeding, and postpartum women and breastfed infants in the National Health and Nutrition Examination Survey.
Slide67Fund
research to assess how inclusion of the
CVV as
a component of WIC food packages affects:
food-package
redemption
rates,
participant choice of vegetable and fruit
varieties,
overall diet
quality,
and
vendor-stocking
practices.
Research
Recommendations
(cont.)
Slide68The revised food
packages:
Improve the balance of the packages relative to the DGA
Increase
flexibility and
choice to meet cultural needs and other preferences
Provide better support for the mother-infant dyad
The Revised Food Packages Improve Balance and Choice
Adequate
and consistent
support of breastfeeding is
critical
to achieve WIC breastfeeding goals
Collection and accessibility of WIC program data
are
critical for future program improvement
68
Slide69Committee to Review the WIC Food Packages
69
Slide70Kathleen M. Rasmussen, Chair Cornell UniversityShannon E. Whaley, Vice Chair
Public Health Foundation Enterprises WICSusan S. Baker
University of Buffalo
Marianne P. Bitler
University of California, Davis
Patsy M. Brannon
Cornell University
Alicia L. Carriquiry
Iowa State UniversityDavid E. Davis South Dakota State UniversityMary Kay Fox Mathematica Policy Research, Inc.
Tamera J. Hatfield
University of California, Irvine
Helen H. Jensen
Iowa State University
Rachel K. Johnson
University of Vermont
Angela Odoms-Young
University of Illinois at Chicago
Rafael Perez-Escamilla
Yale University
A.
Catharine
Ross
Pennsylvania State University
Charlene Russell-Tucker
Connecticut
Department
of EducationMarie E. Latulippe, Study Director; Meghan E. Quirk, Program Officer; Bernice Chu, Research Associate; Ambar Saeed, Senior Program Assistant ; Ann L. Yaktine, Director, Food and Nutrition BoardCommittee to Review the WIC Food Packages70
Slide71Thank you!
Download the report and
other materials at:
www.nationalacademies.org/WICfoodpackages
Infographic:
WIC Food Packages: From Then to Now
http://
resources.nationalacademies.org/Infographics/wictimeline/wic.html