The Impact of the 2009 Special Supplemental Nutrition Program for Women, Infants, & Children Food Package Revisions

on Participants: A Systematic Review

Authors: Danial Joseph Schultz, Carmen Byker Shanks, & Bailey Houghtaling

This is a postprint of an article that originally appeared in Journal of the Academy of Nutrition & Dietetics on November 2015.

Schultz, Daniel Joseph, Carmen Byker Shanks, and Bailey Houghtaling. "The Impact of the 2009 Special Supplemental Nutrition Program for Women, Infants, & Children Food Package Revisions on Participants: A Systematic Review." Journal of the Academy of Nutrition & Dietetics 115, no. 11 (November 2015): 1832-1846. DOI#: 10.1016/j.jand.2015.06.381

Made available through Montana State University’s ScholarWorks scholarworks.montana.edu

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authorized WIC stores. The revised food paparticipants. Mixed results were demonstraneeded to assess the influence of WIC 200conclusions about broad nutrition-related im

The missionof the United States DepartmenI

The Impact of the 2009 Sp

cial Supplemental Nutrition Program for Wom en, Infants, andChildren Food Package Revisions onParticipants: A Systematic Review

Daniel Joseph Schultz, MS; Carmen Byker Shanks, PhD; Bailey Houghtaling

ABSTRACTFor the first time since 1980, the US DepaNutrition Program for Women, Infants, anInstitute of Medicine’s nutrition recommengrains, and low-fat dairy to improve nutritiassessed the influence that the 2009 WICbeverage availability, and breastfeeding pfor Systematic Reviews and Meta-AnalysApril 1 and 30, 2014, for peer-reviewed reestablished inter-rater reliability by discusour inclusion criteria. Nine of the studies afood and beverage availability, and three demonstrated an improved dietary intake

tment of Agriculture Food and Nutrition Service Special Supplemental Children (WIC) food package policies were revised in 2009 to meet the ations. These changes included increases in fruits, vegetables, whole n and health of WIC participants. Our systematic review of the literature food package revisions have had on dietary intake, healthy food and rticipation. The systematic review followed Preferred Reporting Items recommendations. Four electronic databases were searched between earch. Two reviewers screened the articles, extracted the data, and ing and resolving discrepancies. Twenty articles were included that met alyzed changes in dietary intake, eight exam-ined changes in healthy valuated breast-feeding participation exclusively. The review nd an increase in the availability of healthier foods and beverages in ckage was also associated with improved dietary intake of WIC

ted in regard to improved breastfeeding outcomes. Further research is 9 food package revisions on breastfeeding outcomes and to make plications.

t of The USDA Food and Nutrition Service charged a 2004

nsti-tute of Medicine (IOM) committee with reviewing the Agriculture (USDA) Food and Nutrition Service Special

Supplemental Nutrition Program for Women, Infants,

and Children (WIC) is to safeguard the health of low-

pro-gram’s current supplemental food packages and

income women, infants, and children up to age 5 years who are at risk for poor nutrition.1 WIC, which was created as a 2-year pilot program in 1972 and made permanent in 1975, addressed the public and medical concern about malnutri-tion among low-income mothers and children.1 WIC provides nutritious foods to supplement diets, nutrition education, and referrals to health care and other social services.1 The majority of WIC participants acquire foods through retail food stores (also called vendors) authorized by WIC state agencies. Authorized vendors carry WIC-approved foods and accept WIC checks, vouchers, and/or electronic benefit transfer.1 The focus of WIC has transitioned from preventing malnourishment to concerns of childhood obesity and exces-sive energy consumption combined with a low intake of fruits, vegetables, and whole grains have become the primary dietary concern of WIC participants.

evaluating the necessity of redesigning them to improve WICparticipants’ diets in regard to nutrition-related diseases.2 The IOM devel-oped a report from their findings entitled, WIC Food Packages: Time For Change,2 which recommended WIC match the current dietary guidance for infants and young children. The commit-tee’s revisions encouraged consumption of fruits and vegetables (F/V), emphasized whole grains, lower saturated fat, and food packages that appealed to diverse populations.2 Informed by the IOM recommendations, the USDA published an interim rule for the food packages on December 6, 2007, that required all revisions to be implemented by October 1, 2009.3 The interim rule largely reflected the IOM recommendations.4 However, due to certain cost containment modifications, the interim ruling did not provide all WIC participants with a $10 cash voucher allotment for F/V purchases as recommended by the IOM. Exclusively breastfeeding mothers were provided with a $10 per month F/V cash value voucher and all other

women received an $8 F/V cash value voucher. This decrease inallotment for F/V cash value vouchers was later changed toprovide all WIC participants with the IOM $10recommendation.4

The final ruling on March 4, 2014, expanded whole-grainoptions, provided yogurt as a partial substitute, allowedparents to buy fresh F/V instead of jarred baby food, and gavestates the flexibility to meet the needs and cultural prefer-ences of their WIC participants.5 The final ruling still includedthe revisions of more fruits, vegetables, whole grains, areduction in juice consumption, and a switch from wholemilk to low-fat milk for children aged 2 years and younger.5

The revisions also incentivized and supported breastfeedingby increasing the amount of food allotted and the length oftime the exclusive breastfeeding package could be provided.In contrast, the amount of formula for women partiallybreastfeeding was decreased to incentivize the exclusivebreastfeeding package.5 The 49,000 WIC-authorized retailstores were required to stock specific items such as fruits,vegetables, and whole-grain products to benefit from salesrelated to WIC.5 Overall, these revisions aimed to improvedietary intake, increase breastfeeding participation rates, andexpand healthy food and beverage availability at retail stores.Although evidence exists about dietary intake, healthy food

and beverage availability, and breastfeeding participation ofthe 2009 WIC food package revisions, to our knowledge, nosystematic review exists that assesses the overall influence ofthe 2009WIC food package revisions. Therefore, the objectiveof this review was to assess the effects of the 2009 foodpackage revisions on healthy food and beverage availability,breastfeeding outcomes, and dietary intake of WIC programparticipants 5 years later using only peer-reviewed research.

METHODSArticles included in this review were extracted from CINAHL,Cochrane Database, Web of Knowledge, and PubMed througha systematic review of literature utilizing the PreferredReporting Items for Systematic Reviews and Meta-Analysesformat.6 The authors tested potential key words related toWIC packages and revisions found in the Medical SubjectHeadings Library (http://www.nlm.nih.gov/mesh/) throughmock searches to ensure that the final list of terms capturedrelevant articles that met inclusion and exclusion criteria.Final terms used in this search included a combination of thefollowing words: WIC; The Special Supplemental NutritionProgram for Women, Infants, and Children; food package; and2009 revisions. Reference lists of primary studies were scan-ned for additional citations. Inclusion criteria for manuscriptswere peer-reviewed, English language, and United States.Meeting abstracts were excluded due to limited informationprovided. Articles were added to the initial review in caseswhere the title, abstract, or key words indicated that thestudy analyzed the implications of the 2009 WIC food pack-age revisions, measured availability of healthy food andbeverages at WIC retail locations, breastfeeding participation,and dietary intake, and were published before the peer-reviewed study was started April 1, 2014, and ended April30, 2014. Articles were excluded if published before the 2009WIC revisions occurred, did not analyze changes due to 2009WIC revisions, or focused on other federal food and nutritionassistance programs.

Two coders (D. J. S. and C. B. S.) independently extractedand then compared data to resolve any discrepancies throughconsensus. Both coders extracted information into a stan-dardized form from selected articles and eligibility criteriainto a table to note author, year published, research design,participants, location, data collection, study description, andresults (see Table 1). Risk of bias was noted by assessingpublication and funding mechanisms, experimental design(eg, whether there was a control group), sample size, follow-up measures, validity and reliability of the data collectioninstrument, and reporting. Where quantitative results exis-ted, no summary measures were addressed due to inconsis-tent measurement methods across studies.In total, 28 articles were identified in the initial review. Full

articles were read for inclusion in the study. Two articleswere excluded because they did not assess the 2009 WICrevisions and six articles were excluded because they wereconference abstracts (see the Figure). This study was exemptfrom institutional review board review because there was nointeraction with human subjects.

RESULTSTwenty articles met the aforementioned study criteria (seethe Figure). The following sections summarize changes indietary intake, availability of healthy foods and beverages,and breastfeeding outcomes. Eight of the studies examinedchanges in the availability of healthy foods and beverages,nine analyzed changes in dietary intake, and three evaluatedan increase in breastfeeding participation. The articles re-ported a variety of quantitative and qualitative researchmethods, including cross-sectional surveys, secondary dataanalysis, inventories, and interview methodology.

Dietary IntakeDietary changes after the 2009 WIC food package revisionswere observed among WIC participants across several foodgroups.7-15 Households enrolled in WIC purchased morewhole-grain breads and brown rice.7 Retail scanner datademonstrated that WIC households also decreased purchasesof juice.8 Native-American children participating in WIC re-ported increased consumption of whole-wheat bread at ratesof four to seven times per week and two or more times perday and decreased consumption of white bread in an inter-view setting.9

Significant changes were observed in dietary intake inanother study, with increased fruit consumption by 0.33servings (one fruit serving is equivalent to 1 medium fruit,whereas 1/4 cup dried fruit is equivalent to 1/2 cup fresh,frozen, or canned fruit based on the 2005 Dietary Guidelinesfor Americans [DGA]) per day among Hispanic mothersenrolled in WIC.10 In the same study, low-fat dairy intakeincreased by 0.21 servings (one milk serving is equivalent to1 cup milk, 1 cup yogurt, and 1.5-oz cheese based on the 2005DGA) per day among Hispanic WIC-enrolled mothers, 0.34servings per day among Hispanic WIC-enrolled children, and0.24 servings per day for African-American WIC-enrolledchildren.10 Native-American WIC-enrolled childrenconsuming F/V four or more times per day increased from7.0% and 3.9%, respectively, to 11.5% and 8.0% after the 2009WIC food package revisions.9 Saturated fat intake decreasedas the purchase of milk and cheese declined by 85 g/month

Table 1. Food and Nutrition Service Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) 2009 package policy revision: Influence ondietary intake of participants (N¼9)

Author(s), y Design Participants Location Data collection Stu escription Results

Andreyeva andcolleagues, 201411

Observational preepost analysis(longitudinal data)

WIC households Supermarket chain,60þ stores inConnecticut andMassachusetts

Loyalty card systemrecorded purchasesand paymentmethod (SNAP,a

WIC benefits, cashassistance, orpersonal funds)

Pur ng datac red beforea ter there ns tod ine effect onw -milk andc purchases

Reductions in whole-milk and cheesepurchases in bothstates

Andreyeva andLuedicke, 20137

Observational preepost analysis(longitudinal data)

WIC households Supermarket chain,60þ stores inConnecticut andMassachusetts

Loyalty card systemrecorded purchasesand paymentmethod (SNAP, WICbenefits, cashassistance, orpersonal funds)

Pur ng datac red beforea ter there ns tod ine effect onw -wheat breada rown ricep ses

Increase in purchasesof whole-grainbread and brownrice

Andreyeva andcolleagues, 20138

Preepost design WIC households Supermarket chain,60þ stores inConnecticut andMassachusetts

Loyalty card systemrecorded purchasesand paymentmethod (SNAP, WICbenefits, cashassistance, orpersonal funds)

Pur ng datac red beforea ter there ns tod ine changesin % juice ando beveragep ses

Decrease in juice andsoft drinkpurchases. Increasein fruit drink,noncarbonateddrink, and juicepurchases by non-WIC funds

(continued on next page)

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chasiompand afvisioetermholend burcha

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Table 1. Food and Nutrition Service Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) 2009 food package policy revision: Influence ondietary intake of participants (N¼9) (continued)

Author(s), y Design Participants Location Data collection Study description Results

Black and colleagues,200914

Cross-sectional study,qualitative

WIC participants,pregnant, orprimary caregiver toWIC-enrolled child

WIC clinics (n¼7) indiverse counties inMaryland

Interviews and focusgroups, adaptedfood frequencyquestionnaire, andcost analysis

Examined responsesto food packagechanges, racial/ethnic differences,and cost ofproducts

Frequently consumedare fruits andvegetables andcommercial babyfoods. Consumptionof vegetables didnot differ amongethnicities andpreference of form(fresh, frozen,canned) did. Whitebread and nonelow-fat optionspreferred.

Chiasson andcolleagues, 201313

Cross-sectional study WIC-enrolled infantsand children (aged0-4 y)

New York 3.5 millionþ WICadministrativerecords (StatewideInformationSystem) and parentcertificationinterviews

Examined WICrevision influenceon nutrition-relatedbehavior andobesity

Delayed introductionof solid foods anddaily fruit andvegetable andwhole-grain intake.Low nonfat milkconsumption bychildren (aged 2-4y). Weightreductions.

Ishdorj and Capps,20139

Cross-sectional, preepost design

Native-American WIC-enrolled children(aged 2-4 y)

States in United States(n¼40)

National Food andNutrition Survey forWIC responses fromcaregivers ofpreschool-agedchildren

Consumption patternsincluding milk,fruits andvegetables, andgrains

Increasedconsumption offruits andvegetables, wholegrains, and low-fator fat-free milk

(continued on next page)

Table 1. Food and Nutrition Service Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) 2009 food package policy revision: Influence ondietary intake of participants (N¼9) (continued)

Author(s), y Design Participants Location Data collection Study description Results

Kim and colleagues,201315

Cross-sectional, preepost design

California WIC dyadswith infants (aged6-11 mo)

California California NutritionEducation & FoodPackage ImpactSurvey andCalifornia WICvoucherredemptioninformation

Determined use andsatisfaction of JBFb

and preferences forcash value vouchersfor fruits andvegetables incomparison to JBF

Decrease in JBFconsumption withage among allethnic groups.Preference toreceive additionalcash value vouchersfor fruits andvegetables in placeof JBF.

Odoms-Young andcolleagues, 201310

Natural experiment Hispanic and African-American WICdyads with children(aged 2-3 y)

WIC clinics (n¼12) inChicago, IL

Cross-sectional surveyprovided baselinedata for naturalexperiment

Postrevision influenceon home foodavailability anddietary change

Variations by ethnicgroup and nosignificantcorrelates betweenhome foodavailability anddietary change.Increased homefood availability oflow-fat dairy andwhole grains.Hispanic dyads andAfrican-Americanchildren increasedlow-fat dairy intake.Hispanic mothersincreased fruitintake.

(continued on next page)

Table

1.Fo

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dNutritionServiceSp

ecialS

upplem

entalNutritionProg

ram

forWom

en,Infan

ts,a

ndChildren(W

IC)20

09food

packag

epo

licyrevision

:Infl

uenceon

dietaryintake

ofpa

rticipan

ts(N¼9

)(con

tinued)

Autho

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Design

Participan

tsLo

cation

Dataco

llection

Stud

ydescription

Results

Wha

ley,

2012

12

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post,cross-

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rison

Preg

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caregivers

ofchild

renin

WIC

Califo

rnia

Teleph

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Influe

nceof

WIC

revision

son

consum

ptionof

fruits

and

vege

tables,w

hole

grains,a

ndlow-fat

milk

Increased

consum

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new

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sign

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increase

inintake

ofwho

le-grain

food

san

dmilk

a SNAP¼S

upplem

entalN

utritionAssistanceProgram.

b JBF¼jarredbaby

food.

per WIC household in Connecticut and 107 g/mo in Massa-chusetts.11 Another study observed an increase in caregiverand child consumption of whole grains and fruits and adecrease of whole milk and fruit juice.12 In addition, a studyassessing the New York State WIC program demonstratedthat daily consumption of fruit, vegetables, and whole grainsincreased for WIC-enrolled children aged 1 to 4 years.13

Similarly, rates for �95th percentile weight-for-recumbentlength among 1-year-old WIC-enrolled children and bodymass index �95th percentile among 2- to 4-year-old WIC-enrolled children decreased after the revised WIC foodpackages were implemented.13

WIC participants who were interviewed supported the2009 WIC food package revisions, specifically with regard tofruits, vegetables, and whole-grain products. On the otherhand, the same WIC participants did not enjoy the reduced-fat milk and soy product options.14 In addition, caregiversenjoyed the addition of jarred F/V to the food package forinfants aged 6 to 11 months, but many caregivers also wantedthe option to choose between jarred foods and fresh F/V.15

Results for dietary intake are compiled in Table 1.

Availability of Healthy Foods and BeveragesManagers and owners of WIC-authorized and noneWIC-authorized vendors had mixed perceptions about consumerdemand (eg, number of customers, sales, and profits) forhealthy products and impressions of the 2009 WIC foodpackage changes.16-18 WIC-authorized and noneWIC-autho-rized vendors at 58 nonesupermarket retailers in five townsin Connecticut perceived lower customer demand for healthyfood and beverage items compared with unhealthy foods andbeverages after the 2009 WIC changes.16 Another study foundthat WIC-authorized retail storeowners’ and managers’ atti-tudes toward offering healthy foods positively increased afterthe revisions.17 These attitudes, collected through interviewmethodology, differed in non-WIC store managers; however,these changes were not statistically significant.17 Many re-tailers had a positive (46%) or neutral (36%) overall impres-sion of the 2009 WIC food package revisions, compared with18% who had a negative overall impression of consumerdemand.16

Four studies demonstrated that WIC-authorized vendorsimproved healthy food and beverage availability comparedwith non-WIC vendors as a result of WIC food package re-visions.18-21 WIC-authorized vendors demonstrated thegreatest benefit, showing an increase in sales of the empha-sized food products17,22 and improved stocking of brown rice,fruits,23 whole-grain breads, and low-fat dairy options, but nosignificant change in fresh vegetables compared with non-WIC vendors.21 Furthermore, the WIC food package re-visions influenced food prices, with modest reductions inprice for canned F/V at small stores in seven Illinoiscounties.18 Price reduction for F/V did depend on the storesize and location. Results for health food and beverageavailability are compiled in Table 2.

Breastfeeding OutcomesThe 2009 WIC food package revisions had mixed resultsabout breastfeeding initiation and duration.13,22-25 After the2009 WIC food package revisions, the partial breastfeedingpackage issuance decreased, the full breastfeeding package

Figure. Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2009 flow diagram. Terms used in this search includeda combination of the following words: WIC; The Special Supplemental Nutrition Program for Women, Infants, and Children; foodpackage; 2009; and revisions. Inclusion criteria for manuscripts were peer-reviewed, English language, and United States.

issuance increased, and the full formula package increasedfor mother-and-infant dyads during the birth month.24 Thefull breastfeeding package issuance did not change fordyads with infants aged 3 to 5 months. After the 2009 WICfood revisions, breastfeeding initiation rates were stableeven with the changed assignments in the food packages24

(see Table 3).Another study showed an 86% increased issuance rate of

the full breastfeeding package and a 10% decrease in issu-ance rates for formula-only packages after revisions.25 Ac-cording to the study, training and education policies before

the implementation of 2009 WIC food package revisionsincreased breastfeeding package issuance, decreased partialbreastfeeding package issuance, and decreased formulapackage issuance.25 A study looking at WIC participants inLos Angeles county demonstrated an 8% increase in WICparticipants exclusively breastfeeding through 3 monthsafter the revisions occurred.26 An increase of 9% of WICparticipants exclusively breastfeeding through 6 monthsalso occurred in this population.26 In contrast, the studydemonstrated that overall the new food package appearedto have had little or no effect on overall breastfeeding at

Table 2. Food and Nutrition Service Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) 2009 food package policy revision: Influence onhealthy food and beverage availability (HFA) in both WIC and Non-WIC stores (n¼8)

Author(s), y Design Participants Location Data collection Study description Results

Andreyeva andcolleagues, 201220

Preepost design Nonchain grocerystores, both WIC-certified (n¼33) andnon-WIC (n¼229)

Towns (n¼5) inConnecticut

Nutrition EnvironmentMeasurementSurvey in stores

Measured availability,price, variety, andquality of WIC-approved foods andbefore and after theintervention, effecton HFA

WIC-certified storesimprovedavailability andvariety of healthyfoods.

Non-WIC stores hadmild increase.

Andreyeva andcolleagues, 201117

Preepost design Owners/managers ofWIC-certified andnon-WIC stores

Nonsupermarketretailers inConnecticut towns(n¼5)

In-personstandardizedinterviews

Perception ofdemand, supply,and barriers tostocking healthyfoods

Demand primaryfactor in stockingdecisions withweaker demand forhealthier food.Some productdemands increasedafter the revision.

Ayala and colleagues,201216

Cross-sectional study Owners/managers(1 y experience) ofsmall WIC-certifiedstores

Major cities (n¼8) inMaryland, Illinois,Minnesota,Connecticut,Louisiana,Pennsylvania, andCalifornia

In-depth interviewswith open andclose-endedquestions

Influence of WICrevisions onperceived sales,product selection,and stocking habits

Consumer requests,cold storage, andprofitabilityimportant forstocking decisions.Perceived increasein sales for mostproducts. Nochange in sales forprocessed fruits andvegetables.

Gittelsohn andcolleagues, 201218

Qualitative study Owners/managers (1y experience) ofsmall WIC-certifiedstores

Major cities (n¼8) inMaryland, Illinois,Minnesota,Connecticut,Louisiana,Pennsylvania, andCalifornia

In-depth interviews Vendor perspectivesof WIC foodpackage revisions

Reported increase incustomers, sales,and profits. Steadysupply of perishablefoods andexplaining newrules are challenges.

(continued on next page)

Table 2. Food and Nutrition Service Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) 2009 food package policy revision: Influence onhealthy food and beverage availability (HFA) in both WIC and Non-WIC stores (n¼8) (continued)

Author(s), y Design Participants Location Data collection Study description Results

Havens andcolleagues, 201222

Preepost design Corner stores (n¼45) Hartford, CT Store inventories withuse of revisedNutritionEnvironmentMeasurementSurvey in stores

Availability of freshfruits andvegetables, wholegrains, and low-fatmilk in WIC-certifiedstores incomparison to non-WIC stores

Increased availabilityof produce, whole-grain foods, andlower-fat milk inWIC-certified stores

Hillier and colleagues,201221

Preepost design Supermarket, grocerystores, andnonchain cornerstores (n¼141)

Philadelphia, PA Stores identifiedthrough fieldenumeration andsurveyed usingNutritionEnvironmentMeasurementSurvey in stores

Influence of WIC foodpackage revisionson HFA in 2 low-income areas

Increase in HFApostpolicy changeoverall withsubstantialincreases in WIC-certified stores

Zenk and colleagues,201219

Quasiexperimental,1-group, preepostdesign

WIC-certified vendors Northern Illinoiscounties (n¼7) notinclusive of Chicago

Trained observersassessed fresh,frozen, and cannedfruits andvegetables usingadapted instrument

Examined availabilityand selection ofcommon andculturally specificfruit and vegetableavailability

Improved selection ofcommon fresh fruitsand vegetables andavailability toAfrican-Americanculturally specifıcfresh fruits andvegetables. Mildlyimprovedavailability ofcanned (low-sodium) vegetablesand frozen fruitsand vegetables.Data differed byvendor, notneighborhoodcharacteristics.

(continued on next page)

Table 2. Food and Nutrition Service Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) 2009 food package policy revision: Influence onhealthy food and beverage availability (HFA) in both WIC and Non-WIC stores (n¼8) (continued)

Author(s), y Design Participants Location Data collection Study description Results

Zenk and colleagues,201423

Quasiexperimental,preepost design

WIC-certified vendors Northern Illinoiscounties (n¼7) notinclusive of Chicago

WIC Northern IllinoisVendor Projectinstrumentadaptation

Determinedavailability andprice of fruits andvegetables withvendorcharacteristics

Higher canned andfrozen fruits andvegetables pricesand lower freshfruits andvegetables pricesamong smallvendors. Lowercanned and frozenfruits andvegetables pricesand higher freshprices among largevendors.Differencesdependent on typeand neighborhoodof vendor.

Table 3. Food and Nutrition Service Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) 2009 food package policy revision: Influence onbreastfeeding (BF) initiation and duration and issuance of BF packages (n¼3)

Author(s), y Design Participants Location Data collection Study description Results

Langellier andcolleagues,201426

Repeated cross-sectional study

WIC participants,Latina (majority)

Los Angeles County,CA

Survey adapted fromLos Angeles CountyHealth Survey withinput fromCalifornia State WICDivision and WIClocal agency staff

Demonstrates effectof WIC revisions onBF initiation andduration

Increase in BFinitiation withsignificant increaseat 3 and 6 mo

Whaley andcolleagues,201225

Preepost design WIC infants Southern California WIC administrativedata

Prerevisionparticipanteducation focusedon packagechanges, BFincentives, andimportance ofmaking BF decisionearly on

Full BF packageincreasedpostrevision (86%)

Wilde andcolleagues,201224

Preepost design WIC-enrolled dyadswith infant (aged 0-5 mo)

California, Florida,Georgia, Idaho,Illinois, Minnesota,Rhode Island,Tennessee, Texas,and Utah

Administrativerecords for localWIC agencies

Assessed changes inWIC food-packageassignments, infantformula, and BFinitiation

Increased issuance ofboth full BFpackages and fullformula packages.No change in BFinitiation rates.

3 and 6 months, after adjustment for other factors.26 Inaddition, a study that looked at various influences of thefood pack revisions demonstrated a 7.3% increase inbreastfeeding initiation13 (see Table 3).

DISCUSSIONThe 2009 WIC food revisions demonstrated a positive influ-ence on WIC participants’ dietary intake. Increased con-sumption of fruits, vegetables, and whole-grain productswere prevalent after the revisions. WIC participants boughtless juice, white bread, and whole milk postimplementation.Overall, improvement in whole-grain consumption waswidely established in the research.Although studies demonstrated improved F/V consump-

tion, this improvement was minimal. Future research shouldassess why the improved F/V consumption was limited. Po-tential studies could focus on assessing higher cash valuevoucher allotments for acquiring produce. Furthermore,research could focus on the required WIC educational lessonsand how to integrate education on preparing and purchasingfresh, frozen, dried, or canned produce.In February 2015, an expert IOM committee published

the first of three reports on the WIC food packages.27 Thefirst report addressed the topic of white potatoes beingineligible for purchase with the WIC cash value voucher.27

The committee recommended that white potatoes containsimilar nutritional properties of other starchy vegetablesthat are currently permitted for purchase with the cashvalue voucher.27 The committee found no direct evidenceto support that consumption of white potatoes adverselyaffected the health outcomes for WIC participants.27 Thecommittee decided to allow white potatoes to henceforthbe a WIC-eligible vegetable in the cash value voucher.Future research should assess whether the allowance ofwhite potatoes increases vegetable intake with WIC par-ticipants and whether this cash value voucher white potatoeligibility displaces consumption of other vegetablesources.Despite the minimal produce consumption change,

improvement in dietary intake among WIC participants fromthe 2009 revisions are closer to meeting the 2010 DGA.28

Specific improvements that are particularly importantinvolve helping WIC participants reduce consumption ofsugar and solid fats and increase consumption of wholegrains, low-fat dairy, and fruits.28 WIC can also continue tolimit juice allotments to help reduce higher consumptionrates among WIC participants.29 With the recent publicationof the 2015 DGA, future research should assess whether thefood packages meet these new recommendations. Similarly,WIC could be modified to meet the DGA recommendationsthrough the upcoming 2015 Child Nutrition ReauthorizationAct.As the revisions become more established, future

research should analyze long-term effects of 2009 WIC foodpackage revisions. For example, robust anthropometricmeasurements, such as body mass index, could be assessedwith WIC participants. Future research should assess thespecific use of specific food package products throughmultiple pass dietary recalls. Additional qualitative in-terviews should be conducted with participants about food

package products are incorporated into the diet, such asbrown rice, beans, and vegetables.The 2009 WIC food package revisions have demonstrated

that USDA policy can improve dietary intake for consumersand healthy food and beverage availability in the retailenvironment. Researchers, practitioners, and policy havesuggested improving the nutritional quality of foodsallowed in other federal food and nutrition assistanceprograms, such as the Supplemental Nutrition AssistanceProgram (SNAP), also operated by the USDA.30 Whereas theWIC program serves a large population of infants andchildren, 48% of SNAP participants are children and SNAPencompasses three times more children than WIC.31 Due tothis large reach, SNAP could test the influence of settingnutrition guidelines similar to other supplemental feedingprograms such as WIC, National School Lunch Program,and USDA’s Child and Adult Care Food Program. In addi-tion, the 2015 Dietary Guidelines Advisory Committeesupported aligning food assistance programs such as SNAPand WIC with their recommendations.32 Like WIC’s vendorstocking requirements, research has shown that more than58% of key stakeholders interviewed in regard to nutrition-related changes to SNAP recommended SNAP retailersshould stock a minimum quantity of healthful foods.30

Participants enrolled in SNAP have also demonstratedsupport for incentives to encourage F/V consumption andlimitations to decrease consumption of sugar-sweetenedbeverages.33 Currently, SNAP is not supporting partici-pants in meeting the 2010 DGA.34 The positive WIC re-visions of improved dietary intake, limiting consumption ofunhealthy products, and improved healthy food andbeverage availability could also provide positive changes toSNAP.30

The 2009 WIC food package revisions were associated withimproved healthy food and beverage accessibility, althoughlimitations still existed. Overall, availability of F/V increasedin 7 northern Illinois counties after the revision.18 WIC ven-dors’ inventories carried more varieties of fruit and increasedthe availability of whole grains and low-fat milk. To a lesserdegree, the revisions affected non-WIC vendors, who alsoincreased their availability of healthy food.16 Further analysisshould be completed to identify why stores do not participatein WIC and strategies to address any challenges. Futurestudies should assess the quality and diversity of foodsoffered byWIC vendors. In addition, purchasing data could beused to assess what F/V are being purchased with cash valuevouchers. These inventory questions should be evaluated tounderstand issues in product sourcing and consumerdemand.The mission of increasing breastfeeding participation with

the 2009 WIC food package revisions had mixed results.Whaley and colleagues25 demonstrated a decline in issuanceof partial breastfeeding packages and an increase in fullbreastfeeding and formula packages. In total, three studieshave been published to date on breastfeeding participationafter the 2009 WIC food package changes. Further researchshould assess strategies to increase breastfeeding participa-tion (ie, both initiation and duration).Despite WIC’s overwhelming support for breastfeeding

mothers, the breastfeeding rate of WIC participants is 20%lower than non-WIC participants.35 Currently, non-WIC

10. Odoms-Young AM, Kong A, Schiffer LA, et al. Evaluating the initialimpact of the revised Special Supplemental Nutrition Program forWomen, Infants, and Children (WIC) food packages on dietary intakeand home food availability in African-American and Hispanic fam-ilies. Public Health Nutr. 2014;17(01):83-93.

11. Andreyeva T, Luedicke J, Henderson KE, Schwartz MB. The positiveeffects of the revised milk and cheese allowances in the SpecialSupplemental Nutrition Program for Women, Infants, and Children.J Acad Nutr Diet. 2014;114(4):622-630.

12. Whaley SE, Ritchie LD, Spector P, Gomez J. Revised WIC food packageimproves diets of WIC families. J Nutr Educ Behav. 2012;44(3):204-209.

13. Chiasson MA, Findley SE, Sekhobo JP, et al. Changing WIC changeswhat children eat. Obesity. 2013;21(7):1423-1429.

14. Black MM, Hurley KM, Oberlander SE, et al. Participants’ commentson changes in the revised Special Supplemental Nutrition Programfor Women, Infants, and Children food packages: The Maryland foodpreference study. J Am Diet Assoc. 2009;109(1):116-123.

15. Kim LP, Whaley SE, Gradziel PH, Crocker NJ, Ritchie LD, Harrison GG.Mothers prefer fresh fruits and vegetables over jarred baby fruitsand vegetables in the new Special Supplemental Nutrition Programfor Women, Infants, and Children food package. J Nutr Educ Behav.2013;45(6):723-727.

16. Andreyeva T, Middleton AE, Long MW, Luedicke J, Schwartz MB.Food retailer practices, attitudes and beliefs about the supply ofhealthy foods. Public Health Nutr. 2011;14(06):1024-1031.

17. Gittelsohn J, Laska MN, Andreyeva T, et al. Small retailer perspectivesof the 2009 Women, Infants and Children Program food packagechanges. Am J Health Behav. 2012;36(5):655-665.

18. Zenk SN, Odoms-Young A, Powell LM, et al. Fruit and vegetableavailability and selection Federal Food Package revisions, 2009. Am JPrev Med. 2012;43(4):423-428.

19. Andreyeva T, Luedicke J, Middleton AE, Long MW, Schwartz MB.Positive influence of the revised Special Supplemental NutritionProgram for Women, Infants, and Children food packages on accessto healthy foods. J Acad Nutr Diet. 2012;112(6):850-858.

20. Hillier A, McLaughlin J, Cannuscio CC, Chilton M, Krasny S, Karpyn A.The impact of WIC food package changes on access to healthful foodin 2 low-income urban neighborhoods. J Nutr Educ Behav.2012;44(3):210-216.

21. Havens EK, Martin KS, Yan J, Dauser-Forrest D, Ferris AM. FederalNutrition Program changes and healthy food availability. Am J PrevMed. 2012;43(4):419-422.

22. Ayala GX, Laska MN, Zenk SN, et al. Stocking characteristics andperceived increases in sales among small food store managers/owners associated with the introduction of new food productsapproved by the Special Supplemental Nutrition Program forWomen, Infants, and Children. Public Health Nutr. 2012;15(09):1771-1779.

23. Zenk SN, Powell LM, Odoms-Young AM, et al. Impact of the revisedSpecial Supplemental Nutrition Program for Women, Infants, andChildren (WIC) food package policy on fruit and vegetable prices.J Acad Nutr Diet. 2014;114(2):288-296.

24. Wilde P, Wolf A, Fernandes M, Collins A. Food-package assignmentsand breastfeeding initiation before and after a change in the SpecialSupplemental Nutrition Program for Women, Infants, and Children.Am J Clin Nutr. 2012;96(3):560-566.

25. Whaley SE, Koleilat M, Whaley M, Gomez J, Meehan K, Saluja K.Impact of policy changes on infant feeding decisions among low-

income women participating in the Special Supplemental NutritionProgram for Women, Infants, and Children. Am J Public Health.2012;102(12):2269-2273.

26. Langellier BA, Chaparro MP, Wang MC, Koleilat M, Whaley SE. Thenew food package and breastfeeding outcomes among Women, In-fants, and Children participants in Los Angeles County. Am J PublicHealth. 2014;104(suppl 1):S112-S118.

27. National Research Council. Review of WIC food packages: An eval-uation of white potatoes in the cash value voucher: Letter report.https://www.iom.edu:443/Reports/2015/Review-WIC-Food-Packages-Letter-Report.aspx. Published February 2015. Accessed March 8,2015.

28. Nutrition and Your Health: Dietary Guidelines for Americans, 2010, 7thedition. Washington, DC: US Government Printing Office; 2010.

29. Watowicz RP, Taylor CA. A comparison of beverage intakes in USchildren based onWIC participation and eligibility. J Nutr Educ Behav.2014;46(3 suppl):S59-S64.

30. Leung CW, Hoffnagle EE, Lindsay AC, et al. A qualitative study ofdiverse experts’ views about barriers and strategies to improve thediets and health of Supplemental Nutrition Assistance Program(SNAP) beneficiaries. J Acad Nutr Diet. 2013;113(1):70-76.

31. Long MW, Leung CW, Cheung LW, Blumenthal SJ, Willett WC. Publicsupport for policies to improve the nutritional impact of the Sup-plemental Nutrition Assistance Program (SNAP). Public Health Nutr.2014;17(1):219-224.

32. US Department of Agriculture Food and Nutrition Service. Buildinga healthy America: A profile of the Supplemental NutritionAssistance Program. http://www.fns.usda.gov/sites/default/files/BuildingHealthyAmerica.pdf. Published April 2012. AccessedApril 2014.

33. US Departments of Agriculture and Health and Human Services.Scientific report of the 2015 Dietary Guidelines Advisory Committee.http://health.gov/dietaryguidelines/2015-scientific-report/PDFs/Scientific-Report-of-the-2015-Dietary-Guidelines-Advisory-Committee.pdf. Pub-lished February 2015. Accessed February 2015.

34. Hilmers A, Chen T-A, Dave JM, Thompson D, Cullen KW. Supple-mental Nutrition Assistance Program participation did not help lowincome Hispanic women in Texas meet the dietary guidelines. PrevMed. 2014;62:44-48.

35. Lawrence RA. Lower breastfeeding rates among SupplementalNutrition Program for Women, Infants, and Children participants: Acall for action. Pediatrics. 2006;117(4):1432-1433.

36. Ryan AS, Zhou W. Lower breastfeeding rates persist among theSpecial Supplemental Nutrition Program for Women, Infants, andChildren participants, 1978e2003. Pediatrics. 2006;117(4):1136-1146.

37. Baumgartel KL, Spatz DL. WIC (The Special Supplemental NutritionProgram for Women, Infants, and Children): Policy versus practiceregarding breastfeeding. Nurs Outlook. 2013;61(6):466-470.

38. Gross SM, Resnik AK, Cross-Barnet C, Nanda JP, Augustyn M,Paige DM. The differential impact of WIC peer counseling programson breastfeeding initiation across the state of Maryland. J Hum Lact.2009;25(4):435-443.

39. Darfour-Oduro SA, Kim J. WIC mothers’ social environment andpostpartum health on breastfeeding initiation and duration. Breast-feed Med. 2014;9(10):524-529.

40. Crossland N, Thomson G, Morgan H, Dombrowski SU, Hoddinott P.Incentives for breastfeeding and for smoking cessation in pregnancy:An exploration of types and meanings. Soc Sci Med. 2015;128:10-17.

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