Revised WIC food package improves diets of WIC families

Cross-sectional associations of Special Supplemental Nutrition Program for Women, Infants, and Children benefit redemption and diet among children ages 1-4 years in California

BACKGROUND

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides supplemental healthy foods to children aged <5 y in low-income households.

OBJECTIVES

The objectives of this study were to characterize WIC benefit redemption, identify associations between benefit redemption and child dietary intake, and whether child age modifies these associations.

METHODS

The cross-sectional 2023 California Statewide WIC Survey, conducted with caregivers of WIC-participating children aged 1-4 y, was analyzed for this study. Included children had complete benefit redemption data, a complete National Health and Nutrition Examination Survey Dietary Screener Questionnaire (DSQ), and complete covariate data (weighted n = 2244). Monthly household category-specific benefit redemption percentage was averaged across 6 and 3 mo preceding survey completion. Associations between household redemption and child dietary intake (servings or amount/day) were assessed with multivariable linear regression and expressed as estimates and 95% confidence intervals (CI).

RESULTS

Twenty-five percent higher redemption of breakfast cereal, whole grain bread, yogurt and whole milk in the 6 mo prior to the survey were associated with higher child intake frequency for cereal (0.02 servings/d; 95% CI: 0.00, 0.04), whole grain bread (0.02 servings/d; 95% CI: 0.00, 0.03), yogurt (0.04 servings/d; 95% CI: 0.02, 0.06), and whole milk (0.09 servings/d; 95% CI: 0.01, 0.16). Significant effect modification by child age (12 to <24 mo, 24-59 mo) was found for redemption of cheese/tofu and 100% juice (P-interaction = 0.02 and 0.001, respectively), and 25% higher redemption of these benefits were associated with lower intake frequency for cheese (-0.05 servings/d; 95% CI: -0.09, -0.02) and higher intake frequency for juice (0.12 servings/d; 95% CI: 0.06, 0.18), but only among children ages 12 to <24 mo.

CONCLUSIONS

Higher redemption was associated with higher child intake of select WIC foods. Pairing the promotion of benefit redemption among program participants with nutrition education efforts may enhance dietary impacts of WIC participation.

Associations of Increased WIC Benefits for Fruits and Vegetables With Food Security and Satisfaction by Race and Ethnicity

Introduction

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides nutrition support for racially and ethnically diverse populations. In 2021, the monthly cash value benefit (CVB) for the purchase of fruits and vegetables increased from $9 to $35 and was later adjusted to $24. This study investigated, by racial and ethnic groups, whether CVB increases were associated with increases in CVB redemption, household food security, child fruit and vegetable intake, satisfaction with CVB amount, and likelihood of continued participation in WIC if the CVB returned to $9 per month.

Methods

We conducted a longitudinal study of WIC participants (N = 1,770) in southern California at 3 time points, from April 2021 through May 2022; the CVB amount was $9 at baseline, $35 at Survey 2, and $24 at Survey 3. Racial and ethnic groups were Hispanic English-speakers, Hispanic Spanish-speakers, non-Hispanic Asian, non-Hispanic Black, non-Hispanic Other, and non-Hispanic White. We used mixed-effect and modified Poisson regressions to evaluate outcomes by group.

Results

At baseline, groups differed significantly in dollars of CVB redeemed, percentage of CVB redeemed, household food security, and satisfaction with CVB amount. After the increase in CVB, we found increases in all groups in CVB redemption, household food security, and satisfaction. Non-Hispanic Black and Hispanic English-speaking groups, who had low levels of satisfaction at baseline, had larger increases in satisfaction than other groups. Reported likelihood of continued WIC participation if the monthly CVB returned to $9 also differed significantly by group, ranging from 62.5% to 90.0%.

Conclusion

The increase in CVB for children receiving WIC benefited all racial and ethnic groups. Continued investment in an augmented CVB could improve health outcomes for a racially and ethnically diverse WIC population.

Lower redemption of monthly Special Supplemental Nutrition Program for Women, Infants and Children benefits associated with higher risk of program discontinuation

OBJECTIVE

To determine whether Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food benefit redemption is associated with discontinuing WIC participation, failure to recertify, overall and by race/ethnicity-language preference and participant category.

DESIGN

Retrospective cohort study, using multivariable modified Poisson regression to determine risk ratios (RR) and 95 % CI for associations between household-level food benefit redemption (interval-scaled benefit redemption percent, averaged across WIC benefit subcategories, for the final 3, 6 and 12 months of certification) and failure to recertify in WIC, overall and within strata of race/ethnicity-language preference and participant category.

SETTING

WIC administrative data collected November 2019-July 2021 in Southern California.

PARTICIPANTS

WIC-participating children ages 0-3 years at initial certification from November 2019 to May 2020 (n 41 263).

RESULTS

In all time periods, and for all subgroups, every 10 % lower food benefit redemption was associated with increased risk of failure to recertify. Among households without missing food benefit data, failure to recertify risk peaked at 505 % higher (RR = 6·05, 95 % CI (5·63, 6·51)) in households with average 12-month redemption <10 % compared with households with ≥70 % redemption.

CONCLUSIONS

Lower WIC benefit redemption was associated with higher risk of failing to recertify among participants. Focused nutrition education around benefit redemption may improve WIC retention and child health through incremental increases in food benefit redemption.

Associations between Participation in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and Maternal Diet Quality

BACKGROUND

An objective of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is to improve maternal diet quality, but its effectiveness remains unclear. Better understanding how WIC participation shapes women's diet quality is crucial given that maternal diet plays a critical role in determining mothers' and children's short- and long-term overall health.

OBJECTIVES

This study aimed to compare the diet quality of WIC-participating women to WIC-eligible nonparticipating women and higher-income pregnant and postpartum women using a nationally representative sample.

METHODS

This was a cross-sectional analysis of the National Health and Nutrition Examination Survey (NHANES) 2011-2018 cycles. Women aged 20 to 44 with at least one 24-h recall and complete data on pregnancy and postpartum status and WIC participation were included (n = 626). Diet quality was evaluated using the Healthy Eating Index-2015 (HEI-2015). Multivariable Tukey-adjusted linear models were used to compare HEI-2015 total and component scores between groups. Models were adjusted for age, pregnancy and postpartum status, breastfeeding status, race and ethnicity, and food security.

RESULTS

Most women were postpartum and not pregnant (75%), nonbreastfeeding (60%), identified as non-Hispanic White (58%), and food secure (64%). WIC participants, WIC-eligible nonparticipants, and income-ineligible women had mean Total HEI-2015 scores of 52.7 (95% confidence interval [CI]: 50.6, 54.8), 54.2 (95% CI: 51.6, 56.7), and 55.0 (95% CI: 51.8, 58.2), respectively. There were no differences between groups for total and most component scores. Income-ineligible women had better Fatty Acids scores (5.7; 95% CI: 5.0, 6.4) than WIC participants (4.7; 95% CI: 4.1, 5.3; P < 0.05). WIC-eligible nonparticipants had better Refined Grains scores (6.0; 95% CI: 5.3, 6.6) than WIC participants (5.0; 95% CI: 4.4, 5.6; P < 0.05).

CONCLUSIONS

Overall diet quality was similar across WIC and income groups. Lower HEI-2015 component scores for WIC participants compared with WIC-eligible nonparticipants warrant further exploration. Research evaluating WIC's impact on maternal diet quality is needed to ensure continued support for low-income women's health.

Increased WIC Benefits for Fruits and Vegetables Increases Food Security and Satisfaction Among California Households with Young Children

BACKGROUND

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is a critical source of nutrition support for young children in low-income families, providing access to healthy foods and a cash value benefit (CVB) for the purchase of fruits and vegetables (FV). In 2021, the WIC CVB increased substantially for women and children aged 1 to 5 years.

OBJECTIVE

To investigate whether or not the increased WIC CVB for purchasing FV was associated with greater redemption of the FV benefit, satisfaction, household food security, and child FV intake.

DESIGN

Longitudinal study of WIC participants receiving WIC benefits from May 2021 through May 2022. Through May 2021, the WIC CVB for children aged 1 to 4 years was $9/month. The value increased to $35/month from June through September 2021, and changed to $24/month starting October 2021.

PARTICIPANTS AND SETTING

WIC participants from seven WIC sites in California with one or more child aged 1 to 4 years during May 2021 and one or more follow-up surveys during September 2021 or May 2022 (N = 1,770).

MAIN OUTCOMES AND MEASURES

CVB redemption (in US dollars), satisfaction with the amount (prevalence), household food security (prevalence), and child FV intake (cups per day).

STATISTICAL ANALYSES

Associations of increased CVB issuance following the June 2021 CVB augmentation with child FV intake and CVB redemption were assessed using mixed effects regression, and associations with satisfaction and household food security were assessed using modified Poisson regression.

RESULTS

The increased CVB was associated with significantly greater redemption and satisfaction. At the second follow-up (May 2022), household food security increased by 10% (95% CI 7% to 12%); total FV intake decreased by 0.03 c/day (95% CI -0.06 to -0.01) in the overall sample, but increased by 0.23 c/day (95% CI 0.17 to 0.29) among children with the lowest baseline FV intake.

CONCLUSIONS

This study documented benefits of augmentation to the CVB for children. WIC policy augmenting the value of WIC food packages to increase access to FV had the intended effects, lending support to making the increased FV benefit permanent.

Early introduction of complementary foods/drinks and milk feeding type in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC)

Infants younger than 4 months are not ready for complementary foods/drinks (any solid or liquid other than breast milk or infant formula). Almost half of US infants participate in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC), which provides nutrition education and support to low-income families. We describe the prevalence of early introduction (<4 months) of complementary foods/drinks and examine the association of milk feeding type (fully breastfed, partially breastfed or fully formula fed) with early introduction of complementary foods/drinks. We used data from 3310 families in the longitudinal WIC Infant and Toddler Feeding Practices Study-2. We described the prevalence of early introduction of complementary foods/drinks and modeled the association of milk feeding type at Month 1 with early introduction of complementary foods/drinks using multi-variable logistic regression. Thirty-eight percent of infants were introduced early to complementary foods/drinks (<4 months). In adjusted models, infants who were fully formula fed or partially breastfed at Month 1 were 75% and 57%, respectively, more likely to be introduced early to complementary foods/drinks compared with fully breastfed infants. Almost two in five infants were given complementary foods/drinks early. Formula feeding at Month 1 was associated with higher odds of early introduction of complementary foods/drinks. There are opportunities to support families participating in WIC to prevent early introduction of complementary foods/drinks and promote child health.

Increased WIC Cash Value Benefit is Associated with Greater Amount and Diversity of Redeemed Fruits and Vegetables among Participating Households

Background

Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food packages for children ages 1 to 4 y include a cash value benefit (CVB) redeemable for fruits and vegetables (FVs) with participating vendors. The CVB value was increased beginning in June 2021.

Objectives

This study evaluated associations of the augmented CVB with the amount and diversity of redeemed FVs.

Methods

Price look-up codes (PLUs) in redemption data determined outcomes including any redemption (any, none), amount redeemed (United States dollars [USD]/mo), and percent of total CVB redemption (percent) in 54 FV commodity groups among a cohort of 1770 WIC-participating children in Southern California. Outcomes across all commodity groups for fresh fruits, fresh vegetables, and all FVs were evaluated including dollar amount redeemed, percentage of redemption, and diversity of produce redeemed (variety and balance among items redeemed). Comparisons were made between augmented CVB periods (35 USD/mo in June-September 2021, 24 USD/mo October 2021-June 2022) and the preaugment period (9 USD/mo in June 2020-May 2021). Associations were tested in multivariable generalized estimating equation Poisson (any redemption) and linear (amount, percent, diversity) regression models.

Results

The augmented CVB was associated with higher any redemption prevalence and amount redeemed for 53 of 54 commodity groups at both 35 USD/mo and 24 USD/mo compared with 9 USD/mo. Redemption diversity increased for both fruits, vegetables, and all produce during both augment periods, and modestly greater increases in redeemed fruits relative to vegetables were observed at 35 USD/mo. The most commonly redeemed vegetables were tomatoes, onions, cucumbers, peppers, and avocados and the most commonly redeemed fruits were bananas, apples, grapes, limes, and melons.

Conclusions

The augmented CVB was associated with greater redeemed FV amount and greater redeemed FV diversity. Data on FV intake diversity among WIC-participating children are needed to understand dietary impacts of the CVB increase.

Variation in the infant health effects of the women, infants, and children program by predicted risk using novel machine learning methods

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) has an extensive literature documenting positive effects on infant health outcomes, specifically preterm birth, low birthweight, small size for gestational age, and infant mortality. However, existing studies focus on average effects for these relatively infrequent outcomes, thus providing no evidence for how WIC affects those at greatest risk of negative infant health outcomes. Our study focuses on documenting how WIC's infant health effects vary by level of risk. In doing so, we leverage a uniquely rich database describing maternal and infant outcomes and risk factors. Additionally, we use high dimensional data to generate predictions of risk and combine these predictions with the novel double machine learning method to stratify the effects of WIC by predicted risk. Our estimates of WIC's average treatment effects align with those in the existing literature. More importantly, we document significant variation in the effects of WIC on infant health by predicted risk level. Our results show that WIC is most beneficial among those at greatest risk of poor outcomes.

How Does Consistency of Food and Nutrition Support Effect Daily Food Consumption among Children Living in Poverty? Recession-Era Implications

Underutilization of the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) and the Supplemental Nutrition Assistance (SNAP) food safety net programs may compromise child nutritional benefits for families with limited incomes. Using a sample of children surveyed before (2003−2006) and after the Great Recession (2007−2009), we examine whether consistent access to WIC and SNAP during times of increased economic stress moderated the association between poverty level (i.e., income-needs ratio [INR]) and fruits and vegetables (FV) or foods high in saturated fats and added sugars (SFAS). Fragile Families and Child Wellbeing Study income-eligible mothers/children (≤185% of poverty) with available FV and SFAS data at the 5- (2003−2006) and 9-year (2007−2010) waves (n = 733) were included. Main effects of INR and interaction effects of consistency of WIC, SNAP, and dual WIC and SNAP support from birth through age 5 were examined. INR was associated with decreased FV consumption frequency from age 5 to 9, conditional upon consistency of dual WIC/SNAP enrollment. FV declined when there was low consistency (<1 year) of dual support. FV consumption was stable across INR when combined WIC/SNAP support lasted at least 2 years. Results can inform strategies for optimizing the nutritional impact of WIC and SNAP by focusing on those most at risk for underutilization of multiple benefits.

The effect of the 2009 WIC revision on maternal and child health: A quasi-experimental study

BACKGROUND

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is the largest U.S. nutrition program for low-income pregnant women. It was revised in 2009, with the goal of improving nutritional content of food packages, enhancing nutrition education, and strengthening breast feeding support. Few studies have assessed the effects of this revision on perinatal health.

OBJECTIVES

To investigate the impact of the revised WIC program on maternal and child health in a large, multi-state data set.

METHODS

We conducted a quasi-experimental difference-in-differences analysis, comparing the pre/post changes among WIC recipients to changes among non-recipients. We adjusted for key sociodemographic covariates in multivariable linear models. We used data from the Pregnancy Risk Assessment Monitoring System (PRAMS) for 18 states from 2004 to 2017.

RESULTS

The main analysis included 331,946 mother-infant dyads. WIC recipients were more likely to be younger, Black or Hispanic/Latina, unmarried, and of greater parity. The revised WIC program was associated with reduced likelihood of more-than-recommended GWG (-1.29% points, 95% confidence interval [CI] -2.03, -0.56) and increased likelihood of ever breast fed (1.18% points, 95% CI 0.28, 2.08). We also identified heterogeneous effects on GWG, with more pronounced associations among women 35 and older. There were no associations with foetal growth.

CONCLUSIONS

The revised WIC program was associated with improvements in women's gestational weight gain and infant breast feeding.

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

BACKGROUND

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.

OBJECTIVES

The objective of this study was to examine the association of the revised WIC package with anemia indicators and iron intake in children.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

California WIC Participants Report Favorable Impacts of the COVID-Related Increase to the WIC Cash Value Benefit

The United States Department of Agriculture approved an increase to the Cash Value Benefit (CVB) for the purchase of fruits and vegetables issued to participants receiving an eligible Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food package. In order to understand satisfaction, perceptions, and the overall impact of additional benefits for fruits and vegetables at the household level, a qualitative study consisting of structured phone interviews was conducted with families served by WIC in Southern California from November to December 2021 (n = 30). Families were selected from a large longitudinal study sample (N = 2784); the sample was restricted by benefit redemption and stratified by language and race. WIC participants were highly satisfied with the CVB increase, reporting increased purchasing and consumption of a variety of fruits and vegetables. Respondents noted the improved quality and variety of fruits and vegetables purchased due to the increased amount. Findings are expected to inform policy makers to adjust the CVB offered in the WIC food package with the potential to improve participant satisfaction and increase participation and retention of eligible families with benefits from healthy diets supported by WIC.

Longer Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Participation Duration Is Associated with Higher Diet Quality at Age 5 Years

BACKGROUND

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides supplemental healthy foods and nutrition education to children under age 5 y in low-income households.

OBJECTIVES

We aimed to identify characteristics associated with duration of WIC participation and assess how participation duration relates to household food insecurity (HFI), child diet quality, and child weight status at age 60 mo.

METHODS

This analysis of the WIC Infant and Toddler Feeding Practices Study-2, a prospective cohort of WIC-participating children enrolled in 2013, included children with complete baseline-60 mo data (n = 836). Outcomes assessed with WIC participation duration in multivariable regression were HFI (USDA 6-item Household Food Security Screener), child diet quality on a given day [Healthy Eating Index (HEI)-2015], and obesity (CDC BMI-for-age ≥95th percentile).

RESULTS

Factors associated with longer WIC participation included male sex; lower household income; reported diet changes in response to WIC nutrition education; household Supplemental Nutrition Assistance Program participation; English-speaking Hispanic, Spanish-speaking Hispanic, and non-Hispanic other maternal race-ethnicity and language preference; an ever-married mother; lower maternal education; higher maternal age; earlier enrollment during pregnancy; and reporting a subsequent pregnancy. Longer WIC participation was associated with lower HFI odds (OR: 0.69; 95% CI: 0.51, 0.95), higher total HEI-2015 (β: 0.73; 95% CI: 0.20, 1.25), and higher obesity odds (OR: 1.20; 95% CI: 1.05, 1.37) in multivariable-adjusted regression models.

CONCLUSIONS

Longer WIC participation was associated with reduced HFI and higher diet quality, and unexpectedly with higher obesity odds, at 60 mo. Further research is needed to confirm and understand mechanisms underlying the unexpected associations identified with longer WIC participation (e.g., male sex, obesity). Groups with shorter participation durations may benefit from targeted WIC retention efforts to maximize nutrition security.

An Investigation of Social Ecological Barriers to and Facilitators of WIC Farmers Market Nutrition Program Voucher Redemption

In the United States, many communities lack sufficient access to fresh produce. To improve access to fresh fruits and vegetables, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides eligible participants vouchers through the Farmers Market Nutrition Program (FMNP) that can be redeemed directly from farmers at markets or farm stands. However, FMNP voucher redemption rates in New Jersey remain lower than those in neighboring states. This article used the social ecological model to examine differences between FMNP participants who redeem vouchers (Redeemers) and those who do not (non-Redeemers) in the areas of: produce procurement practices and consumption frequency, and barriers to and facilitators of FMNP voucher redemption. This cross-sectional study included WIC FMNP participants (N = 329) in northern New Jersey, USA. Analyses were conducted using descriptive statistics, independent sample t-tests, and one-way ANOVA. Compared to Redeemers, non-Redeemers consumed fewer average daily vegetable servings, were more likely to shop at small grocery/corner stores, and encountered significant barriers to FMNP redemption, e.g., difficulty finding time to redeem vouchers.

Associations Among Food Security, Diet Quality, and Dietary Intake During Pregnancy in a Predominantly African American Group of Women from North Carolina

BACKGROUND

Low food security during pregnancy can negatively affect women's physical and mental health. Although many women make a greater effort to eat a healthy diet during pregnancy, the influence of low food security during pregnancy on maternal diet is not well understood.

OBJECTIVE

This study aimed to assess the association between adult food security and maternal diet during pregnancy in a sample from North Carolina.

DESIGN

This was a cross-sectional, secondary data analysis of food security (marginal, low, and very low vs high) and maternal diet during pregnancy.

PARTICIPANTS AND SETTING

This study included 468 predominantly Black/African American women during pregnancy from the Nurture cohort, enrolled through prenatal clinics in central North Carolina between 2013 and 2016.

MAIN OUTCOME MEASURE

Diet quality was assessed using the Alternate Healthy Eating Index-Pregnancy and the Mediterranean Diet Score. Dietary intake from seven food groups included in the Alternate Healthy Eating Index-Pregnancy and/or Mediterranean Diet Score was assessed as well.

STATISTICAL ANALYSIS PERFORMED

Multiple linear regression models were used to examine the association between food security and diet quality and dietary intake during pregnancy, adjusting for race/ethnicity; participation in the Special Supplemental Nutrition Program for Women, Infants, and Children; education; prepregnancy body mass index; age; parity; and mean daily energy intake.

RESULTS

In this study, there was no association between maternal food security status and diet quality during pregnancy. However, researchers observed an association between low and marginal food security and greater intake of red and processed meats (marginal: β = 2.20 [P = 0.03]; low: β = 2.28 [P = 0.04]), as well as an association between very low food security and decreased vegetable consumption (β = -.43; P = 0.03).

CONCLUSIONS

Very low food security was associated with reduced vegetable intake. In addition, low and marginal food security were associated with greater red and processed meat intake. Future research should focus on nationally representative populations and include longitudinal assessments to allow for the study of the influence of food security on health during pregnancy.

Longer Family Participation in WIC is Associated With Lower Childhood Sugar-Sweetened Beverage Intake

OBJECTIVE

To evaluate if children of families with a longer duration of participation in the Special Supplementation Nutrition Program for Women, Infants, and Children (WIC) consume fewer sugar-sweetened beverages (SSB) and more water.

DESIGN

A repeated cross-sectional study.

SETTING

Conducted among representative samples of WIC-participating families in Los Angeles County, California, in 2014, 2017, and 2020.

PARTICIPANTS

Children aged 4-59 months participating in WIC.

MAIN OUTCOME MEASURES

Daily servings of total SSBs, daily servings of specific types of SSBs, and daily servings of water.

ANALYSIS

Multivariable count regression models were used to estimate incidence rate ratios (IRR) and 95% confidence intervals (CI) for associations of the duration of family WIC participation with daily servings of total SSBs, water, and specific types of SSBs. Zero-inflated negative binomial regression models were used for total SSBs and specific types of SSBs, and Poisson regression was used for water.

RESULTS

Children of families with 2 years of WIC participation consumed significantly fewer daily servings of total SSBs (IRR, 0.95; 95% CI, 0.93-0.98; P = 0.002), fruit-flavored SSBs (IRR, 0.95; 95% CI, 0.91-0.99; P = 0.02), soda (IRR, 0.86; 95% CI, 0.76-0.98; P = 0.02), and water (IRR, 0.99; 95% CI, 0.98 to < 1.00; P = 0.03) than children of families with 1 year of WIC participation. Protective associations for total SSBs, fruit-flavored SSBs, and soda remained statistically significant and increased in magnitude through 10 years of family WIC participation.

CONCLUSIONS AND IMPLICATIONS

Duration of WIC participation was associated with decreased SSB intake by young children. Given the role that increasing water intake in lieu of SSBs plays in child obesity, improving the effectiveness of WIC nutrition education on parental perceptions and provision of fruit-flavored SSBs and water to their children merits detailed evaluation.

WIC Participation and Dietary Quality among US Children: Impact of the 2009 Food Package Revision

This study aims to assess the effectiveness of the WIC program at improving children's dietary quality and to evaluate whether the 2009 food benefit revision further improved the WIC program. A sample of 1,753 children aged between 2 to 4 years from the 2005-2008 and 2011-2016 NHANES was analyzed using a propensity score weighted difference-in-difference approach. Results show that WIC-participating children scored 2.98 points higher (SD: 0.89; P<0.01) in HEI-2015 total scores compared with income-eligible non-participants during 2011-2016. No significant change was observed in the differences of HEI-2015 scores between WIC participants and eligible non-participants from 2005-2008 to 2011-2016.

Mixed Infant Feeding Is Not Associated With Increased Risk of Decelerated Growth Among WIC-Participating Children in Southern California

Background: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides nutrition assistance to half of infants born in the United States. The nationally representative WIC Infants and Toddler Feeding Practices Study-2 (ITFPS-2) reported a caloric deficit at 7 months among infants receiving WIC mixed feeding packages, suggesting these infants may be at risk for growth deceleration/faltering. Methods: Longitudinal administrative data collected prospectively from WIC participants in Southern California between 2010 and 2019 were used (n = 16,255). Infant lengths and weights were used to calculate weight-for-length (WLZ), weight-for-age (WAZ) and length-for-age (LAZ) z-scores at different time points. Growth deceleration/faltering was determined at 9, 12, 18, and 24 months by the change in z-score from the last measurement taken ≤ 6 months of age. Infant feeding was categorized by the food package (breastfeeding, mixed feeding, and formula feeding) infants received from WIC at 7 months. Poisson regression models were used to evaluate the association between WIC infant package at 7 months and deceleration/faltering at 9, 12, 18, and 24 months. Results: The proportion of infants displaying decelerated/faltering growth was low for all infant food package groups. Receiving the WIC mixed feeding package at 7 months of age was not associated with WLZ, WAZ, and LAZ deceleration/faltering growth. Conclusions: Growth deceleration/faltering rates were very low among WIC participating children in Southern California, highlighting the critical role of nutrition assistance in supporting adequate growth in early childhood.

App Usage Associated With Full Redemption of WIC Food Benefits: A Propensity Score Approach

OBJECTIVE

To examine the relationship between WICShopper application (app) usage and full redemption of Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food benefits.

DESIGN

A cross-sectional study.

SETTING

West Virginia WIC program.

PARTICIPANTS

A total of 23,050 West Virginia WIC households in 2019.

MAIN OUTCOME MEASURES

Full redemptions were defined as the redemption rate of ≥ 90% for a given food benefit.

ANALYSIS

App/non-app users were defined as households with someone using/not using the WICShopper app. Multivariate logistic regressions were applied. To address the potential self-selection bias in app usage, the propensity score (PS) of app usage was estimated. The regressions were rerun with the balanced sample by matching the PS.

RESULTS

With PS matching, the prevalence of full redemption at the household level was 7.2% for app users vs 4.7% for nonapp users (odds ratio, 1.64; 95% confidence interval, 1.40-1.92; P < 0.001). App users had a higher prevalence of full redemption in most food categories, even with PS matching.

CONCLUSIONS AND IMPLICATIONS

Use of the WICShopper app was associated with a higher prevalence of full redemptions in most food benefits after controlling the self-selection bias.

Cost and Affordability of Healthy, Equitable and Sustainable Diets in Low Socioeconomic Groups in Australia

Few Australians consume a healthy, equitable and more sustainable diet consistent with the Australian Dietary Guidelines (ADGs). Low socioeconomic groups (SEGs) suffer particularly poor diet-related health problems. However, granular information on dietary intakes and affordability of recommended diets was lacking for low SEGs. The Healthy Diets Australian Standardised Affordability and Pricing protocol was modified for low SEGs to align with relevant dietary intakes reported in the National Nutrition Survey 2011–2012(which included less healthy and more discretionary options than the broader population), household structures, food purchasing habits, and incomes. Cost and affordability of habitual and recommended diets of low SEGs were calculated using prices of ‘standard brands’ and ‘cheapest options’. With ‘standard brands’, recommended diets cost less than habitual diets, but were unaffordable for low SEGs. With ‘cheapest options’, both diets were more affordable, but recommended diets cost more than habitual diets for some low SEGs, potentially contributing to perceptions that healthy food is unaffordable. The study confirms the need for an equity lens to better target dietary guidelines for low SEGs. It also highlights urgent policy action is needed to help improve affordability of recommended diets.

Prioritization of Features for Mobile Apps for Families in a Federal Nutrition Program for Low-Income Women, Infants, and Children: User-Centered Design Approach

Background

The Special Supplemental Nutrition Assistance Program for Women, Infants, and Children (WIC) is a federal nutrition program that provides nutritious food, education, and health care referrals to low-income women, infants, and children up to the age of 5 years. Although WIC is associated with positive health outcomes for each participant category, modernization and efficiency are needed at the clinic and shopping levels to increase program satisfaction and participation rates. New technologies, such as electronic benefits transfer (EBT), online nutrition education, and mobile apps, can provide opportunities to improve the WIC experience for participants.

Objective

This formative study applies user-centered design principles to inform the layout and prioritization of features in mobile apps for low-income families participating in the WIC program.

Methods

To identify and prioritize desirable app features, caregivers (N=22) of the children enrolled in WIC participated in individual semistructured interviews with a card sorting activity. Interviews were transcribed verbatim and analyzed using constant comparative analysis for themes. App features were ranked and placed into natural groupings by each participant. The sum and average of the rankings were calculated to understand which features were prioritized by the users. Natural groupings of features were labeled according to participant descriptions.

Results

Natural groupings focused on the following categories: clinics/appointments, shopping/stores, education/assessments, location, and recipes/food. Themes from the interviews triangulated the results from the ranking activity. The priority app features were balance checking, an item scanner, and appointment scheduling. Other app features discussed and ranked included appointment reminders, nutrition training and quizzes, shopping lists, clinic and store locators, recipe gallery, produce calculator, and dietary preferences/allergies.

Conclusions

This study demonstrates how a user-centered design process can aid the development of an app for low-income families participating in WIC to inform the effective design of the app features and user interface.

Timing of WIC Enrollment and Responsive Feeding among Low-Income Women in the US

We examined associations between the timing of The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) enrollment and responsive feeding and assessed food security as a possible effect modifier. We used data from the nationally representative WIC Infant and Toddler Feeding Practices Study-2. Our sample includes women-infant dyads interviewed through the first 13 months of age (n = 1672). We dichotomized WIC enrollment as occurring prenatally or after childbirth. The responsive feeding outcome was feeding on demand versus feeding on schedule. We used covariate-adjusted logistic regressions. Of women, 61.8% had a high school education or less and 62.9% lived at 75% or less of the federal poverty guideline. The majority (84.5%) of women enrolled in WIC before childbirth. In unadjusted estimates, 34% of women who enrolled prenatally practiced responsive feeding, compared to 25% of women who enrolled after childbirth. We found no evidence of food security as an effect modifier. In adjusted estimates, women who enrolled in WIC prenatally had 78% higher odds of practicing responsive feeding (OR: 1.78, 95% CI: 1.16, 2.73), compared to women who enrolled after childbirth. Prenatal enrollment in WIC was associated with higher odds of responsive feeding. Future studies should examine how the timing of WIC enrollment relates to responsive feeding in older children and over time.

Perceptions of SNAP and Stocking Standards: A Qualitative Study of California Small Food Store Owners and Managers

The Supplemental Nutrition Assistance Program (SNAP) is critical to alleviating food insecurity, but low diet quality among program participants is a concern. Nutrition-related interventions have focused on SNAP-authorized food retailers, but the perspectives of small food store owners and managers have not been represented in national policy discussions. This study aimed to explore the opinions of store owners/managers of SNAP-authorized small food stores about their overall perceptions of the program and the stricter stocking standards previously proposed in 2016. We conducted in-depth, semi-structured interviews with 33 small food store owners and managers in San Francisco and Oakland, California in 2016. Interviews were analyzed for thematic content using the general inductive approach. Four themes emerged from owners/managers’ discussion of their overall perceptions of SNAP: the beneficial impact of SNAP on their business, how SNAP enables them to connect with the broader community, the importance of SNAP in preventing hunger, and the nutrition-related struggles that SNAP participants face. Store owners/managers had a generally favorable response towards the proposed stricter stocking standards. Additional themes discussed pertained to the concern about whether stocking changes would lead SNAP participants to purchase more healthful food and some logistical challenges related to sourcing and storing perishable foods.

The Revised WIC Food Package and Child Development: A Quasi-Experimental Study

BACKGROUND AND OBJECTIVES

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), one of the largest US safety net programs, was revised in 2009 to be more congruent with dietary guidelines. We hypothesize that this revision led to improvements in child development.

METHODS

Data were drawn from a cohort of women and children enrolled in the Conditions Affecting Neurocognitive Development and Learning in Early Childhood study from 2006 to 2011 (Shelby County, TN; N = 1222). Using quasi-experimental difference-in-differences analysis, we compared measures of growth, cognitive, and socioemotional development between WIC recipients and nonrecipients before and after the policy revision.

RESULTS

The revised WIC food package led to increased length-for-age z scores at 12 months among infants whose mothers received the revised food package during pregnancy (β = .33, 95% confidence interval: 0.05 to 0.61) and improved Bayley Scales of Infant Development cognitive composite scores at 24 months (β = 4.34, 95% confidence interval: 1.11 to 7.57). We observed no effects on growth at age 24 months or age 4 to 6 years or cognitive development at age 4 to 6 years.

CONCLUSIONS

This study provides some of the first evidence that children of mothers who received the revised WIC food package during pregnancy had improved developmental outcomes in the first 2 years of life. These findings highlight the value of WIC in improving early developmental outcomes among vulnerable children. The need to implement and expand policies supporting the health of marginalized groups has never been more salient, particularly given the nation's rising economic and social disparities.

Alignment of California WIC Participant Preferences With Proposed WIC Food Package Recommendations

OBJECTIVE

Assess alignment of Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participant preferences with the National Academies of Sciences, Engineering, and Medicine WIC child food package recommendations and compare differences by race/ethnicity.

METHODS

Cross-sectional examination of survey responses collected between January and May 2019 from 2,993 California WIC families with children aged 1-4 years.

RESULTS

Over half of WIC participants (56.1%) wanted an increase in the amount allocated for fruits and vegetables. Many WIC participants (69.6%) thought the amount of juice offered by WIC was just right. Overall, the majority (91.0%) wanted to substitute more fruits and vegetables for juice. Most were satisfied with the amount of beans (78.4%), peanut butter (78.7%), and milk (88.3%). Preferences differed by race/ethnicity.

CONCLUSIONS AND IMPLICATIONS

Preferences of California WIC participants are highly aligned with the proposed National Academies of Sciences, Engineering, and Medicine changes for increasing fruits and vegetables. Notable differences by race/ethnicity suggest the need for more flexibility.

Fruit and Vegetable Purchases and Consumption among WIC Participants after the 2009 WIC Food Package Revision: A Systematic Review

To promote fruit and vegetable (FV) intake among participants, the USDA Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) implemented a comprehensive food package revision in 2009. However, to our knowledge, no studies have systematically explored the factors related to FV purchases and/or consumption among WIC participants in the post-2009 revision era. To fill this knowledge gap, we conducted a systematic literature review using PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Central Register of Controlled Trials, and Web of Science using key search terms. Studies published from January 1, 2007, through February 28, 2019, were included, since an interim rule for the WIC food package revision was issued in 2007. This review followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses format. The articles were grouped based on main themes or factors, settings, design, study years, and sample size. Thirty-nine articles met the inclusion criteria. Seven main themes or factors related to FV purchases and/or consumption in WIC participants were identified in these articles. The 2009 WIC food package revision was the most-studied factor (n = 9). National and state-level studies showed a consistently positive relation between the 2009 revision and FV purchases and/or consumption. However, some studies did not find a positive relation. State-level policy variations can be exploited as natural experiments to assess the causality of state-level factors in WIC participants' FV purchases or consumption. The majority of the included studies were limited in being local (n = 26, 66.7%), cross-sectional (n = 29, 74.4%), or having sample sizes <1000 (n = 25, 64.1%), which could explain the diverse results regarding the relation between FV purchases and/or consumption and various factors, including individual, store, and program characteristics.

Associations between Governmental Policies to Improve the Nutritional Quality of Supermarket Purchases and Individual, Retailer, and Community Health Outcomes: An Integrative Review

Supermarkets are natural and important settings for implementing environmental interventions to improve healthy eating, and governmental policies could help improve the nutritional quality of purchases in this setting. This review aimed to: (1) identify governmental policies in the United States (U.S.), including regulatory and legislative actions of federal, tribal, state, and local governments, designed to promote healthy choices in supermarkets; and (2) synthesize evidence of these policies' effects on retailers, consumers, and community health. We searched five policy databases and developed a list of seven policy actions that meet our inclusion criteria: calorie labeling of prepared foods in supermarkets; increasing U.S. Department of Agriculture (USDA) Supplemental Nutrition Assistance Program (SNAP) benefits; financial incentives for the purchase of fruit and vegetables; sweetened beverage taxes; revisions to the USDA Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food package; financial assistance for supermarkets to open in underserved areas; and allowing online purchases with SNAP. We searched PubMed, Econlit, PsycINFO, Web of Science, and Business Source Ultimate to identify peer-reviewed, academic, English-language literature published at any time until January 2020; 147 studies were included in the review. Sweetened beverage taxes, revisions to the WIC food package, and financial incentives for fruits and vegetables were associated with improvements in dietary behaviors (food purchases and/or consumption). Providing financial incentives to supermarkets to open in underserved areas and increases in SNAP benefits were not associated with changes in food purchasing or diet quality but may improve food security. More research is needed to understand the effects of calorie labeling in supermarkets and online SNAP purchasing.

Association Between Usage of an App to Redeem Prescribed Food Benefits and Redemption Behaviors Among the Special Supplemental Nutrition Program for Women, Infants, and Children Participants: Cross-Sectional Study

Background

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is one of the most important food assistance programs in the United States, serving 6.4 million low-income, eligible women, infants, and children under 5 years of age in 2019. In the program, participants are prescribed a list of food benefits, which can be redeemed in WIC-authorized stores. However, there are multiple behavioral barriers in the program and the stores that prevent participants from redeeming the benefits fully.

Objective

This study aims to examine the relationship between the use of a widely used mobile phone app, WICShopper, and the redemption of the prescribed food packages.

Methods

WIC administrative data were obtained from West Virginia for the period January 2019 to January 2020 and included 30,440 WIC households that had received food benefits in that period. The redemption rates of 18 WIC food benefits were compared between app users and nonapp users, that is, those who never used the app in the study period. The use behaviors were defined for the app users, including the number of active use benefit cycles, active benefit cycle rates, number of active use days in the cycle, and proportion rates of daytime use. Panel linear regressions were applied to examine how the redemption rates were related to these behaviors over time.

Results

App users consistently had higher average redemption rates than nonapp users; the difference ranged from 3.6% (4.8% relative) for infant formula to 14.3% (40.7% relative) for fish. After controlling for sociodemographics, the coefficients of app use were significantly positive for all benefit categories except for WIC-eligible nutritionals. More active cycles and active days in the cycle were significantly related to redemption rates for all categories, except for frozen juice (coefficient=−0.002, P=.09). Daytime app access was positively associated with redemption rates for most food benefits except only a few, such as infant formula (coefficient=−0.03, P<.001).

Conclusions

Use of the WIC app was significantly related to higher redemption rates across food benefits, although the association varied across benefit categories. More active days were positively related to benefit redemptions across food categories, and the app’s daytime use was positively associated with the redemption of most benefit categories. These findings suggest that the WIC app can be an important tool for the promotion of benefit redemption among WIC participants.

Knowledge Translation and WIC Food Package Regulation Change

OBJECTIVE

Knowledge Translation (KT) is the exchange, synthesis, and ethically-sound application of knowledge. A case study methodology is used to examine KT at the organizational level of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) program.

METHOD

The study used purposeful sampling to select WIC informants from state WIC agencies to participate in semi-structured interviews about their individual experiences during the 2009 WIC regulation change process. Thematic coding of retrospective semi-structured interviews with key informants from WIC state agencies revealed key components of the state-level WIC regulation implementation process, and key constructs of Organizational Readiness for Knowledge Translation in the WIC program.

RESULTS

WIC informants highlight that decisions made by WIC state agencies regarding how to appraise, synthesize, and adapt evidence or regulation change are constrained by the KT decisions made by federal agencies. WIC state agencies should assess their level of readiness for KT in terms of 1) innovation readiness; 2) personal readiness; and 3) institutional readiness.

CONCLUSIONS

This WIC case study can help decision-makers to understand the KT process of implementing evidence-informed regulation changes, identify factors that could influence states' ability to be prepared for implementing changes, and gauge "practicality" of future WIC regulation changes.

Main Factors Influencing Whole Grain Consumption in Children and Adults-A Narrative Review

Despite their recognized health benefits, intakes of whole grains (WG) are below recommended levels in almost all countries worldwide. This observation highlights the need to increase WG consumption by understanding factors influencing this consumption and how they could be favorably impacted. This review focused on facilitators of and barriers to WG consumption and how to improve the effectiveness of programs aiming at increasing WG consumption. The main methods to facilitate WG intakes in both adults and children seem to be to (i) increase the availability and the variety of foods containing WG, (ii) improve their sensory appeal, (iii) reduce their purchase cost, (iv) use a familiarization period to introduce them to consumers (with a gradual increase in consumed amounts and repeated exposure), and (v) improve communication and labeling to enhance consumers’ ability to identify products with WG. These strategies may be used to improve the effectiveness of programs aiming at promoting WG consumption, with a further emphasis on the need to apply them over a long period of time, and potentially to include tasting sessions of new foods containing WG. Finally, these strategies should involve broad partnerships between multiple stakeholders at the regulatory, institutional and industrial levels.

Dietary policies and programs in the United States: A narrative review

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School-based and youth targeted programs and policies were most frequently studied.

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Research has rather neglected older adult, Asian, Native Hawaiian and American Indian populations.

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Despite existing research indicating effectiveness, faith-based were understudied.

Prior reviews describing approach, methodological quality and effectiveness of dietary policies and programs may be limited in use for practitioners seeking to introduce innovative programming, or academic researchers hoping to understand and address gaps in the current literature. This review is novel, assessing the “where, who, and in whom” of dietary policies and programs research in the United States over the past decade – with results intended to serve as a practical guide and foundation for innovation. This study was conducted from October 2018 to March 2019. Papers were selected through a tailored search strategy on PubMed as well as citation searches, to identify grey literature. A total of 489 papers were relevant to our research objective. The largest proportion of papers described school-based strategies (31%) or included economic incentives (19%). In papers that specified demographics, the study populations most often included children, adults and adolescents (54%, 46%, and 42% respectively); and White, Black and Hispanic populations (77%, 76% and 70%, respectively). Results highlight opportunities for future research within workplace and faith-based settings, among racial/ethnic minorities, and older adults.

The neighborhood food environment modifies the effect of the 2009 WIC food package change on childhood obesity in Los Angeles County, California

Background

Food packages provided by the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) were revised in 2009 to better align them with the Dietary Guidelines for Americans. This study was conducted to evaluate whether the effect of the food package change on childhood obesity varied by the food environment in the neighborhoods where WIC-participating children live.

Methods

Administrative data from participating children in Los Angeles County, California (2003–2016) were merged with geocoded food vendor information by neighborhood of residence. Obesity risk at age 4 was compared between children receiving old (2003–2009) and new (2010–2016) WIC food packages using sex-stratified Poisson regression models, with interaction terms between WIC package and neighborhood density (number per square mile) of healthy and unhealthy food outlets.

Results

The new food package was associated with a significant decrease in obesity risk. Among boys, the new food package was associated with 8 to 18% lower obesity risk at all healthy and unhealthy food outlet densities, and the association was not modified by neighborhood food outlet density. Among girls, the association of the new food package with obesity risk was protective in neighborhoods with high healthy and low unhealthy food outlet densities, and adverse in neighborhoods with high unhealthy and low healthy food outlet densities. The effect of the new food package among girls was modified by unhealthy food outlet density, with significantly smaller (p-value = 0.004) decreases in obesity risk observed in neighborhoods with higher unhealthy food outlet density.

Conclusions

The impact of the food package change was modified by the neighborhood food environment among girls only. Future policy changes should incorporate consideration of ways to mitigate potentially inequitable geographic distribution of the health benefits of policy changes.

Retirement and Healthy Eating

This paper investigates the effect of retirement on healthy eating using data drawn from the Survey of Health, Ageing and Retirement in Europe (SHARE). We estimate the causal effect of retiring from work on daily fruit or vegetable consumption by exploiting policy changes in eligibility rules for early and statutory retirement. Our results show that changes in eating behaviour upon retirement are gender-specific: retirement induces men to reduce healthy eating; it has no effect on women. We further show that, for men, retirement increases the probability of becoming obese.

Association of WIC Participation and Growth and Developmental Outcomes in High-Risk Infants

The objective of this study was to describe the association of enrollment in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC), the Supplemental Nutrition Assistance Program (SNAP), and infant growth and neurodevelopmental outcomes. Z scores and Bayley Scales of Infant and Toddler Development-Third Edition (Bayley-III) and Vineland Adaptive/Behavior Scale-II (VABS-II) scores represented primary outcomes. We conducted bivariate analyses and linear regression. Children who were enrolled in WIC or WIC/SNAP had weight z scores U (95% confidence interval [CI]) that were 1.32 (0.42-2.21) or 1.19 (0.16-2.23) units higher. Enrollment in WIC or WIC/SNAP was associated with a higher score (95% CI) of 11.7 U (1.2-22.2 U) or 11.5 (0.1-22.9) for Bayley-III cognitive score and 10.1 U (1.9-19.1 U) or 10.3 (0.9-19.7) for the VABS-II composite score. These findings support increased advocacy for participation in WIC or WIC/SNAP for families with high-risk infants.

The Impact of the Revised WIC Food Package on Maternal Nutrition During Pregnancy and Postpartum

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides nutritional support for pregnant and postpartum women and young children. The typical food package provided to recipient families was revised in October 2009 to include more whole grains, fruits, vegetables, and low-fat milk. Little is known about whether these revisions improved nutrition among women during this critical period of the life course. We conducted a quasiexperimental difference-in-differences analysis, comparing WIC recipients ("treatment" group) before and after the WIC policy change, while accounting for temporal trends among nonrecipients ("control" group). We examined nutritional outcomes among a cohort of 1,454 women recruited during pregnancy in 2006-2011 in Memphis and surrounding Shelby County, Tennessee. We found improvements in several measures of dietary quality and nutrient intake during pregnancy, although these did not persist into the postpartum period. Results were robust to numerous sensitivity analyses. At a time when federal WIC funding is threatened, this study provides some of the first evidence of the benefits of recent WIC revisions among low-income women.

Economic evaluation of California prenatal participation in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) to prevent preterm birth

There is growing evidence that prenatal participation in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) reduces the risk of adverse birth outcomes. With recent changes in health care, rising health care costs, and increasing rates of prematurity in the U.S., there is urgency to estimate the potential cost savings associated with prenatal WIC participation. A cost-benefit analysis from a societal perspective with a time horizon over the newborn's life course for a hypothetical cohort of 500,000 Californian pregnant women was conducted in 2017. A universal coverage, a status quo ('business as usual') and a reference scenario (absence of WIC) were compared. Total societal costs, incremental cost savings, return on investment, number of preterm births prevented, and incremental net monetary benefits were reported. WIC resulted in cost-savings of about $349 million and the prevention of 7575 preterm births and would save more if it were universal. Spending $1 on prenatal WIC resulted in mean savings of $2.48 (range: $1.24 to $6.83). Decreasing prenatal WIC enrollment by 10% would incur additional costs (i.e. loss) of about $45.3 million to treat the resulting 981 preterm babies. In contrast, a 10% increase in prenatal WIC enrollment would prevent 141 preterm births and achieve additional cost-savings of $6.5 million. The findings confirm evaluations from the early 1990s that prenatal WIC participation is cost-saving and cost-effective. Further savings could be achieved if all eligible women were enrolled in WIC. Substantial preterm birth-related costs would result from reductions in WIC participation.

Interpretation and Understanding of the Dietary Guidelines for Americans Consumer Messages Among Low-Income Adults

Objective: The objective of this study was to determine the interpretation, understanding, and implementation of the Dietary Guidelines for Americans (DGA) consumer messages among low-income adults and compare findings to perceptions of the messages for consumers by community nutrition educators.Methods: In this mixed methods, cross-sectional study, a convenience sample of low-income adults (n = 98) with a child between the ages of 3 and 10 years old and nutrition educators (n = 9) were interviewed individually about the DGA messages, food-related behaviors, and barriers related to consuming fruits, vegetables, and whole grains. Interviews were audio-taped, transcribed verbatim, and analyzed using the inductive approach. Interpretation and ranking of the clarity and ease of the DGA messages by low-income adults and nutrition educators and perceptions about the messages were assessed. Descriptive statistics were conducted for demographic data and Fisher's exact tests were used to examine differences regarding the clarity and ease of the messages among low-income adults and nutrition educators.Results: According to the interview results, messages that tended to be misinterpreted most frequently were on topics such as sodium, fruit and vegetables, portions, and whole grain intake. Low-income adults and nutrition educators also differed in perceptions for the message clarity addressing whole grain servings (p = .001), avoiding oversized portions (p = .002), and comparing sodium (p < .001).Conclusions: Improvements in the DGA consumer messages are warranted to improve clarity and feasibility for low-income adults through new communication tools or strategies that complement the DGA.

Engaging Fathers in Early Obesity Prevention During the First 1,000 Days: Policy, Systems, and Environmental Change Strategies

OBJECTIVE

Fathers are critical stakeholders in childhood obesity prevention but are difficult to engage. This review presents a new approach to engaging fathers in obesity prevention during the first 1,000 days.

METHODS

The review focuses on five existing health and social service programs, including prenatal care, pediatric care, the Special Supplemental Nutrition Program for Women, Infants, and Children, home visiting, and Early Head Start. For each program, the obesity prevention services provided, evidence of father engagement, and barriers thereto are outlined. Subsequently, policy, systems, and environmental strategies are outlined to address the noted barriers and promote father engagement.

RESULTS

Although the programs hold great promise in bringing obesity prevention services to fathers, barriers to their engagement are present in the inner (e.g., limited hours of operation, lack of father-specific materials and programming) and outer (e.g., lack of model programs, best practice models, and consistent funding) settings of programs. Policy, systems, and environmental strategies to increase father engagement focus on earmarked funding, changes to national practice guidelines and practitioner training requirements, and the establishment of father-engagement performance metrics.

CONCLUSIONS

Increasing father involvement in the specified programs will likely increase their engagement in early obesity prevention in an efficient and sustainable manner.

Food and Beverage Intake From 12 to 23 Months by WIC Status

: media-1vid110.1542/5984243449001PEDS-VA_2018-2274Video Abstract BACKGROUND: In 2009, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) revised its food packages to align with updated nutrition science. Understanding how these revisions may impact current consumption patterns could be important.

METHODS

Dietary data from the 2011-2014 NHANES were used to estimate the percentage of children who were aged 12 to 23 months consuming selected food and beverage categories on any given day by age and WIC status (children who were on WIC, those who were eligible for but not receiving WIC benefits, and those who were not eligible for WIC).

RESULTS

Consumption of food and beverage categories differed by WIC status. On a given day, a lower percentage of children who were eligible for but did not receive WIC benefits consumed vegetables (excluding white potatoes; 42.3%) and grains (76.5%) compared with children who were participating in WIC (vegetables [excluding white potatoes]: 60.4%; grains: 85.5%) and those who were not eligible for WIC benefits (vegetables [excluding white potatoes]: 58.1%; grains: 87.2%; P < .05). A lower percentage of both children who were eligible for but not receiving WIC benefits and those who were participating in WIC consumed fruits (57.6% and 70.6%, respectively) and snacks (45.9% and 48.5%, respectively) than those who were not eligible for WIC (fruits: 86.4%; snacks: 69.1%; P < .05). A lower percentage of children who were receiving WIC consumed dairy than children who were not eligible for WIC (91.7% and 97.2%, respectively; P < .05). A higher percentage of those who were receiving WIC consumed 100% juice (70.6%) than children who were eligible for but not receiving WIC (51.6%) and children who were not eligible for WIC (50.8%; P < .05).

CONCLUSIONS

Improving early WIC participation and retention could positively impact some diet-related disparities among young children who are eligible for WIC.

Understanding the factors influencing low-income caregivers' perceived value of a federal nutrition programme, the Special Supplemental Nutrition Program for Women, Infants and Children (WIC)

OBJECTIVE

Retention of participants has been an issue in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). It has been suggested that the perceived value of WIC may affect whether participants remain in the programme. The present study aimed to explore this phenomenon.

DESIGN

Using a constructivist approach, thirty-one individual in-depth interviews were conducted. Transcripts were analysed using constant comparative analysis. Social, cultural and environmental factors that contribute to the value of WIC were explored as the phenomenon of interest.

SETTING

Eight WIC clinics across the State of Illinois, USA.ParticipantsThirty-one caregivers of children enrolled in WIC for at least 6 months.

RESULTS

Several factors influenced perceived value of WIC at the interpersonal (level of social support), clinic (value of WIC services v. programme administration issues), vendor (shopping difficulties), community and systems levels (other programme use, stigma and restrictions on food choice). Other themes existed along continua, which overlapped several levels (continuum of perceived need and perceived value of infant formula).

CONCLUSIONS

Many caregivers value WIC, especially before their child turns 1 year old. Improvements are needed at the clinic, during shopping and within the food packages themselves in order to increase perceived value of WIC.

Mobile Phone Apps for Low-Income Participants in a Public Health Nutrition Program for Women, Infants, and Children (WIC): Review and Analysis of Features

BACKGROUND

Since 1972, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) has been proven to improve the health of participating low-income women and children in the United States. Despite positive nutritional outcomes associated with WIC, the program needs updated tools to help future generations. Improving technology in federal nutrition programs is crucial for keeping nutrition resources accessible and easy for low-income families to use.

OBJECTIVE

This review aimed to analyze the main features of publicly available mobile phone apps for WIC participants.

METHODS

Keyword searches were performed in the app stores for the 2 most commonly used mobile phone operating systems between December 2017 and June 2018. Apps were included if they were relevant to WIC and excluded if the target users were not WIC participants. App features were reviewed and classified according to type and function. User reviews from the app stores were examined, including ratings and categorization of user review comments.

RESULTS

A total of 17 apps met selection criteria. Most apps (n=12) contained features that required verified access available only to WIC participants. Apps features were classified into categories: (1) shopping management (eg, finding and redeeming food benefits), (2) clinic appointment management (eg, appointment reminders and scheduling), (3) informational resources (eg, recipes, general food list, tips about how to use WIC, links to other resources), (4) WIC-required nutrition education modules, and (5) other user input. Positive user reviews indicated that apps with shopping management features were very useful.

CONCLUSIONS

WIC apps are becoming increasingly prevalent, especially in states that have implemented electronic benefits transfer for WIC. This review offers new contributions to the literature and practice, as practitioners, software developers, and health researchers seek to improve and expand technology in the program.

Preferences and Perceived Value of WIC Foods Among WIC Caregivers

OBJECTIVE

To evaluate preferences for and values of Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) foods and packages and understand what factors may influence these preferences and values.

DESIGN

Using a mixed-methods approach, surveys and individual in-depth interviews were conducted to measure and understand preferences for specific WIC foods and how much WIC food packages are worth to participants.

SETTING

Eight WIC clinics across Illinois.

PARTICIPANTS

Caregivers of infants enrolled in WIC for at least 3-6 months.

PHENOMENON OF INTEREST

Preferences for WIC foods, WIC food package values, and factors that influence these categories.

ANALYSIS

Frequencies were gathered to analyze survey data and interview transcripts were analyzed using constant comparative analysis to identify emergent themes.

RESULTS

Survey (n = 150) and interview (n = 31) participants valued the food packages in WIC but they valued the infant packages more. The cash value fruit and vegetable voucher increased the perceived value of the program for many participants. Restrictions on food choice preferences (eg, type of milk) detracted value from the program.

CONCLUSIONS AND IMPLICATIONS

This study shows that providing more choice in the program could improve satisfaction with WIC overall. More research is warranted with a more representative sample to assess whether expanded food choice would improve value of and preference for WIC foods.

WIC Households' Bread and Cold Cereal Purchases: When They Use Benefits Versus Paying Out of Pocket

PURPOSE

The US Department of Agriculture's Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) seeks to improve the health of participating women and children by providing nutrition education and a monthly package of supplemental foods including whole grain bread and cereal. While some studies confirm that participants consume more whole grains, others find no effect. In this study, we hypothesize that the positive association between WIC and whole grains is being reduced in size and consistency by several factors.

DESIGN/SETTING/PARTICIPANTS

American households were surveyed about their food purchases. Overall response rate was 45.6%. A total of 4826 households completed the survey including 471 WIC households.

MEASURES

The survey recorded households' purchases of refined and whole grains in bread and cereal over 1 week.

ANALYSIS

T tests were used to compare the bread and cereal purchases of WIC and eligible, non-WIC households. Probit models were also estimated to assess a WIC household's likelihood to choose whole grain foods when using benefits versus other payment methods.

RESULTS

On average, WIC households acquired more whole grains in bread than eligible, non-WIC households (1.33 vs 0.72 ounce equivalents per household member aged 1 year or older; P < .05). No difference is found for cereal ( P > .10). Moreover, when using payment methods other than WIC benefits, WIC participants are 19% less likely than other households to choose whole grain bread ( P < .05) and 20% less likely to choose a whole grain cold cereal ( P < .05), which suggests that WIC-provided foods may replace some whole grains participants would otherwise buy for themselves.

CONCLUSION

WIC is positively associated with whole grains. However, the association is stronger for bread than cereal. Moreover, foods provided through the program may partially replace whole grains that WIC households would otherwise buy for themselves.

Examining the Feasibility of Healthy Minimum Stocking Standards for Small Food Stores

OBJECTIVE

In response to recent national efforts to increase the availability of healthy food in small stores, we sought to understand the extent to which small food stores could implement the newly published Healthy Small Store Minimum Stocking Recommendations and reflect on the new US Department of Agriculture Food and Nutrition Service's final rule for stocking of staple foods for Supplemental Nutrition Assistance Program-approved retailers.

DESIGN

We collected qualitative and quantitative data from 57 small stores in four states (Arizona, Delaware, Minnesota, and North Carolina) that accepted Supplemental Nutrition Assistance Program but not Special Supplemental Nutrition Assistance Program for Women, Infants, and Children benefits. Data from semistructured, in-depth interviews with managers/owners were transcribed, coded, and analyzed. We collected quantitative store inventory data onsite and later performed descriptive analyses.

RESULTS

Store interviews revealed a reluctant willingness to stock healthy food and meet new recommendations. No stores met recommended fruit and vegetable stocking, although 79% carried at least one qualifying fruit and 74% carried at least one qualifying vegetable. Few stores met requirements for other food categories (ie, whole grains and low-fat dairy) with the exception of lean proteins, where stores carrying nuts or nut butter were more likely to meet the protein recommendation. Water and 100% juice were widely available and 68% met basic healthy beverage criteria.

CONCLUSIONS

In contrast to the inventory observed, most owners believed store stock met basic recommendations. Further, findings indicate that small stores are capable of stocking healthy products; however, technical and infrastructure support, as well as incentives, would facilitate shifts from staple to healthier staple foods. Retailers may need support to understand healthier product criteria and to drive consumer demand for new products.

Association between food insecurity and food intake

BACKGROUND

We aim to identify the prevalence of food insecurity and to ascertain the association between food insecurity and food intake.

METHOD

A cross-sectional survey.

SETTING

The study included users of a primary healthcare service in Belo Horizonte, Brazil, from 2013 to 2014. Socioeconomic, health, and food intake data were gathered using a questionnaire and the Brazilian Food Insecurity Scale.

SUBJECTS

Individuals 20 years old or older (n = 2817).

RESULTS

The prevalence of food insecurity among families with individuals under 18 years was 41.0%, and 26.4% in other households. After adjusting for potential confounders, the households in food insecurity with members under 18 years old, the consumption of fruits and vegetables (RP = 0.70, 95%IC: 0.58-0.84), and fruits (RP = 0.74, 95%IC: 0.59-0.93) was lower; and consumption of beans was higher (RP = 1.49, 95%IC: 1.06-2.09) compared to those with food security. In households without members under 18 years old, the consumption of fruits and vegetables (RP = 0.68, 95%IC: 0.58-0.79), fruits (RP = 0.61, 95%IC: 0.50-0.74), and beans (RP = 0.78, 95%IC: 0.63-0.97) was lower; and the consumption of tubers (RP = 1.36, 95%IC: 1.03-1.79) was higher. However, the state of food insecurity did not affect the consumption of ultra-processed foods, independently of age, sex, marital status, educational level, and employed status.

CONCLUSION

Food insecurity negatively affected the fruit and vegetable consumption in both types of families tested. The consumption of beans was higher in households with children and adolescents, and the consumption of tubers was higher in households without children and adolescents. However, food insecurity did not change the intake of ultraprocessed foods.

Getting a healthy start: The effectiveness of targeted benefits for improving dietary choices

There is growing policy interest in encouraging better dietary choices. We study a nationally-implemented policy - the UK Healthy Start scheme - that introduced vouchers for fruit, vegetables and milk. We show that the policy has increased spending on fruit and vegetables and has been more effective than an equivalent-value cash benefit. We also show that the policy improved the nutrient composition of households' shopping baskets, with no offsetting changes in spending on other foodstuffs.