Food-package assignments and breastfeeding initiation before and after a change in the Special Supplemental Nutrition Program for Women, Infants, and Children

Community-based diet and obesity-related policy, system, and environmental interventions for obesity prevention during the first 1000 days: A scoping review

Community-based policy, systems, and environmental interventions have the potential to reduce modifiable risk factors for obesity early in life. The purpose of this scoping review was to characterize the breadth, generalizability, and methodological quality of community-based diet and obesity-related policy, system, and environmental interventions during the first 1000 days of life, from pregnancy to 24 months of age. Eight databases were searched, and 83 studies (122 references) were included. Data were extracted for breadth (intervention characteristics), generalizability (reach, effectiveness, adoption, implementation, and maintenance), and study quality (Downs and Black Checklist). Systems and environmental approaches were common (> 80%), relative to policy approaches (39%). The majority (60-69%) occurred in the prenatal period and early infancy (0-3 months), assessed breastfeeding or child growth/obesity (53% for both), and included people with lower income (80%) or racial and/or ethnic minority groups (63%). Many interventions reported positive outcomes (i.e., in the expected direction) for child diet, breastfeeding, and feeding practices (> 62%). Few reported intervention maintenance or spanned the full 1000 days. Most studies were classified as good (32%) or fair (56%) methodological quality. The interventions mainly addressed pregnancy and early infancy. Rigorous and representative investigation is needed to improve intervention reach, sustainability, and application in toddlerhood.

The neighborhood food environment modifies the association between infant feeding and childhood obesity

BACKGROUND

The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) issues infant formula to infants who are not fully breastfed, and prior research found elevated obesity risk among children receiving lactose-reduced infant formula with corn syrup solids (CSSF) issued by WIC. This study was conducted to evaluate associations between a broader set of specialty infant formulas issued by WIC and child obesity risk, whether neighborhood context (e.g. neighborhood food environment) modifies associations, and whether racial/ethnic disparities in obesity are partly explained by infant formula exposure and neighborhood context.

METHODS

WIC administrative data, collected from 2013-2020 on issued amount (categorical: fully formula fed, mostly formula fed, mostly breastfed, fully breastfed) and type of infant formula (standard cow's milk formula, and three specialty formulas: any CSSF, any soy-based formula, and any cow's milk-based formula with added rice starch) and obesity at ages 2-4 years (defined as a Body Mass Index z-score ≥ 95th percentile according to World Health Organization growth standard) were used to construct a cohort (n = 59,132). Associations of infant formula exposures and race/ethnicity with obesity risk were assessed in Poisson regression models, and modification of infant feeding associations with obesity by neighborhood context was assessed with interaction terms.

RESULTS

Any infant formula exposure was associated with significantly higher obesity risk relative to fully breastfeeding. Receipt of a CSSF was associated with 5% higher obesity risk relative to the standard and other specialty infant formulas (risk ratio 1.05, 95% confidence interval 1.02, 1.08) independent of breastfeeding duration and receipt of other specialty infant formulas. The association between CSSF and obesity risk was stronger in neighborhoods with healthier food environments (10% higher risk) compared to less healthy food environments (null). Racial/ethnic disparities in obesity risk were robust to adjustment for infant formula exposure and neighborhood environment.

CONCLUSIONS

Among specialty infant formulas issued by WIC, only CSSFs were associated with elevated obesity risk, and this association was stronger in healthier food environments. Future research is needed to isolate the mechanism underlying this association.

Any Infant Formula Amount, but Not Infant Formula Type, Is Associated with Less Healthful Subsequent Beverage Intake among Special Supplemental Nutrition Program for Women, Infants, and Children-Participating Children

Background

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides nutrition assistance to low-income households, including infant formula for infants not fully breastfeeding. Issuance of lactose-reduced infant formula made with corn syrup solids (CSSF) is associated with elevated risk of obesity in early life, but associations between formula type and dietary intake have not been examined.

Objectives

To evaluate associations between infant formula (amount and type) issued by WIC with subsequent child diet at ages 12-59 mo.

Methods

Dietary data from 2014, 2017, and 2020 Los Angeles County WIC Survey respondents (n = 1339 children, 12-59 mo of age) were merged with WIC administrative data on infant feeding (amount and type of infant formula at ages 0-12 mo). Intake frequencies were available for sweetened beverages, sweets, juice, fast food, water, fruit, vegetables, and milk. Infant feeding was categorized by amount of WIC-issued formula (descending: fully formula fed, mostly formula fed, mostly breastfed, fully breastfed) and issuance of a CSSF (any, none). Associations between infant feeding (infant formula amount and type) and child diet were evaluated in multivariable generalized estimating equation negative binomial regression models, stratified by child age (12 to <24 mo, 24 to <60 mo).

Results

Any infant formula issuance in the first year of life was adversely associated with subsequent dietary intake. This included 21%-23% higher 100% juice intake at 24 to <60 mo and 11%-13% (at 24 to <60 mo) or 20%-22% (at 12 to <24 mo) lower water intake. CSSF receipt compared with only other infant formula was not consistently associated with subsequent child diet.

Conclusions

Any infant formula amount, but not CSSF receipt compared with other formula types, was associated with less healthful beverage intake patterns among WIC-participating children. WIC nutrition education may have a stronger impact if tailored based on infant feeding practices.

Surveillance of Infant Formula Shortages Using Special Supplemental Nutrition Program for Women, Infants, and Children Administrative Data

OBJECTIVE

To quantify self-reported difficulty accessing Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)-issued infant formula among participants early in the coronavirus disease 2019 (COVID-19) pandemic, to determine if infant formula redemption was associated with self-reported difficulty accessing infant formula, and to quantify changes in formula redemption during the 2022-2023 US infant formula shortages.

DESIGN

A cross-sectional study and time series data.

SETTING

Families participating in the WIC program in the Los Angeles metropolitan area from November 2019 to June 2023.

PARTICIPANTS

Families with infants (aged 0-12 months) issued infant formula by WIC with a completed 2020 Los Angeles County WIC Survey (n = 1,897) or issued infant formula by a large WIC program in Southern California between November 2019 and June 2023 (n = 109,135).

MAIN OUTCOME MEASURES

Incidence of ≥ 30% reduction in infant formula redemption and interval-scaled infant formula redemption.

ANALYSIS

Special Supplemental Nutrition Program for Women, Infants, and Children formula redemption data were matched to 2020 Los Angeles County WIC Survey data to determine if self-reported difficulty accessing infant formula was associated with administrative infant formula redemption data using negative binomial regression and were used to quantify the prevalence and severity of incomplete formula redemption during 2020-2023 formula shortages using ordinal logistic regression (outcome: interval-scaled formula redemption).

RESULTS

Few (13.0%) caregivers reported difficulty accessing the WIC-issued formula early in the COVID-19 pandemic. The 2.8% who reported an unresolved shortage early in the COVID-19 pandemic had 201% higher rates of ≥ 30% declines in formula redemption (incidence rate ratio [IRR], 3.01; 95% confidence interval, 1.57-5.79, P < 0.001) than those with no difficulties. Incomplete formula redemption odds were significantly elevated throughout the COVID-19 pandemic from March 2020 to January 2022 and increased further during the 2022-2023 infant formula shortages from February 2022 to June 2023, reaching 342% higher in October 2022 than February 2020 (odds ratio, 4.42; 95% confidence interval, 4.14-4.72; P < 0.001).

CONCLUSIONS AND IMPLICATIONS

Special Supplemental Nutrition Program for Women, Infants, and Children redemption data are an adequate proxy for population-level infant formula access issues among households with low income but are insufficiently sensitive for screening at a household level. US formula shortages (2020-2023) demonstrate the need for improved coordination between nutrition assistance programs, regulatory bodies, and commercial food systems, particularly during acute supply crises.

Breastfeeding Outcomes Associated With the Special Supplemental Nutrition Program for Women, Infants, and Children: A Systematic Review

BACKGROUND

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) promotes and supports breastfeeding for low-income women and children. A prior review reported negative associations of WIC with breastfeeding outcomes. WIC food package changes in 2009 increased breastfeeding support.

OBJECTIVE

The objectives of this systematic review were to 1) evaluate evidence on WIC participation and breastfeeding outcomes and 2) evaluate breastfeeding outcomes of WIC participants before versus after the 2009 food package.

DATA SOURCES

PubMed, Embase®, CINAHL, ERIC, SCOPUS, PsycINFO, and the Cochrane Central Register of Controlled Trials for papers published January 2009 to April 2022.

ELIGIBILITY CRITERIA

Included studies compared breastfeeding outcomes (initiation, duration, exclusivity, early introduction of solid foods) of WIC participants with WIC-eligible nonparticipants, or among WIC participants before versus after the 2009 package change.

STUDY APPRAISAL METHODS

Two independent reviewers evaluated each study and assessed risk of bias using EHPHP assessment.

RESULTS

From 13 observational studies we found: 1) moderate strength of evidence (SOE) of no difference in initiation associated with WIC participation; 2) insufficient evidence regarding WIC participation and breastfeeding duration or exclusivity; 3) low SOE that the 2009 food package change is associated with greater breastfeeding exclusivity; 4) low SOE that WIC breastfeeding support services are positively associated with initiation and duration.

LIMITATIONS

Only observational studies, with substantial risk of bias and heterogeneity in outcomes and exposures.

CONCLUSIONS AND IMPLICATIONS OF KEY FINDINGS

WIC participation is not associated with a difference in breastfeeding initiation compared to WIC-eligible nonparticipants, but the 2009 food package change may have improved breastfeeding exclusivity among WIC participants and receipt of breastfeeding support services may have improved breastfeeding initiation and duration.

Breastfeeding Initiation Trends by Special Supplemental Nutrition Program for Women, Infants, and Children Participation and Race/Ethnicity Among Medicaid Births

OBJECTIVE

Describe long-term breastfeeding initiation trends by prenatal Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participation and race/ethnicity.

DESIGN

Cross-sectional study of birth certificate data from 2009 to 2017 in 24 states that adopted the 2003 birth certificate revision by 2009.

PARTICIPANTS

Term births with hospital costs covered by Medicaid (N = 6,402,704).

MAIN OUTCOME MEASURES

Breastfeeding initiation.

ANALYSIS

The descriptive characteristics of WIC participants and WIC-eligible nonparticipants were compared by year and race/ethnicity using the chi-square test of independence or t tests. Adjusted breastfeeding initiation prevalence was estimated using linear regression models with county fixed effects, controlling for sociodemographic and obstetric/health factors. Trends were compared by WIC status overall and within racial/ethnic groups. Differences and P values were assessed using interaction terms between WIC and year.

RESULTS

Breastfeeding initiation increased for WIC participants and nonparticipants. Special Supplemental Nutrition Program for Women, Infants, and Children participants had lower adjusted breastfeeding initiation (2009: 69.0%; 2017: 78.5%) than nonparticipants (2009: 70.8%; 2017: 80.1%) (P < 0.001 per year). Breastfeeding initiation increased more rapidly in WIC participants than in nonparticipants for non-Hispanic Asian/Pacific Islander (21.4% and 8.6%, respectively; P < 0.001) and American Indian/Alaskan Native (13.6% and 8.1%, respectively; P = 0.02)-narrowing the gap between WIC participants and nonparticipants over time.

CONCLUSIONS AND IMPLICATIONS

Annual birth certificate data provide detailed information for monitoring trends and disparities in breastfeeding initiation by prenatal WIC status. These findings can inform WIC and maternal child health program efforts to improve breastfeeding promotion for populations with low-income and racial/ethnic groups.

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

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

Lactose-reduced infant formula with corn syrup solids and obesity risk among participants in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)

BACKGROUND

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), a federal nutrition assistance program supporting low-income families, serves half of United States-born infants, most of whom are issued infant formula by age 2 mo. Obesity prevalence is high among children of low-income households, particularly formula-fed children.

OBJECTIVES

This study was conducted to determine whether glucose-based lactose-reduced infant formula made with corn syrup solids (CSSF) is associated with increased obesity risk compared with non-CSSFs that are lactose based.

DESIGN

WIC administrative data on infant formula issuance and child weights and lengths were collected prospectively in Southern California between 2012 and 2020. Included children stopped breastfeeding by 3 mo, were issued cow's milk-based formula through 12 mo, and were enrolled through the final year of WIC eligibility at age 4 y ( n = 15,246). CSSF issuance was assessed continuously (range 0-13 mo) and dichotomously (any, none). Poisson and linear risk regression with robust SE estimates generated risk ratios (RRs), risk differences, and CIs for child obesity [BMI for age (in kg/m 2) ≥95th percentile].

RESULTS

Any CSSF was issued to 23% of children, and 25% were obese at age 4 y. Children with any CSSF issuance had 10% higher obesity risk (RR: 1.10; 95% CI: 1.02, 1.20) than children with no CSSF issuance at age 2 y. Associations remained significant through age 4 y (RR: 1.07; 95% CI: 1.01,1.14), independent of maternal weight status, total formula issued and breastfeeding duration, and were not modified by child race or sex. Obesity risk increased with additional mo of CSSF exposure, reaching 16% higher risk (RR: 1.16; 95% CI: 1.05, 1.28) at age 2 y for children with 12 mo of CSSF.

CONCLUSIONS

CSSF issuance is associated with increased obesity risk in the first 5 y life in a dose dependent manner, independently of maternal weight status, breastfeeding duration, and total formula issuance.

Revisiting the Relationship between WIC Participation and Breastfeeding among Low-Income Children in the U.S. after the 2009 WIC Food Package Revision

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides breastfeeding support and free formula to low-income participating infants in the U.S. Literature has consistently documented worse breastfeeding outcomes in WIC infants and children than in non-participants, although self-selection bias poses a challenge in examining the relationship between WIC participation and breastfeeding in low-income mother-child dyads. The WIC program adopted a comprehensive food package revision in 2009, the first one in four decades. Since that time, few national studies have examined the relationship between WIC participation and breastfeeding while controlling for the endogeneity of WIC participation with the propensity score method. This paper applied an instrumental variable (IV) approach on a large, nationally representative survey sample of children, the National Immunization Surveys (NIS), to examine the relationship between WIC participation and breastfeeding among children born between 2005 and 2014. We identified state Supplemental Nutrition Assistance Program (SNAP) enrollment rates and SNAP Policy Indices as valid IVs to address WIC participation endogeneity. Without the IVs, WIC participation had a significantly negative relationship with breastfeeding. After addressing endogeneity using the IVs, the relationship became insignificant in the whole sample and in the subpopulations across race/ethnicity and child gender. The neutrality of WIC participation on breastfeeding is important for policy makers to understand in seeking to improve breastfeeding among WIC participants.

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.

Potential overfeeding among formula fed Special Supplemental Nutrition Program for Women, Infants and Children participants and associated factors

BACKGROUND

The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) provides enough formula to meet the known nutritional needs of infants up to 6 months of age whose mothers report not breastfeeding, but many mothers report WIC providing insufficient formula, indicating potential overfeeding.

OBJECTIVE

To estimate the prevalence of potential overfeeding among formula-feeding WIC participants and identify associated factors.

METHODS

Potential overfeeding was identified among participants of the longitudinal Infant and Toddler Feeding Practices Study-2 (ITFPS-2) receiving the fully formula-feeding WIC infant package at 1 month of age (n = 1235, weighted n = 197 079). Associations of potential overfeeding with caloric intake, weight and participant characteristics were assessed.

RESULTS

Potential overfeeding was identified among 37.41% (95% CI = 33.57-41.25%) of fully formula-feeding infants. Potentially overfed infants were 0.18 kg heavier (P-value = .01), consumed 26 more calories daily (P-value = .004) and were more likely Non-Hispanic White or English-speaking Hispanic (P-value = .007) and highly active at 5 months of age (P-value = .01). Mothers of potentially overfed infants were less likely to agree that breastfeeding is easier than bottle feeding, only mothers can feed breastfed infants, turning away from the bottle indicates satiation, and crying always indicates hunger (P-values .04, .002, .04 and .04 respectively), and more likely to report WIC provides insufficient formula early (1-5 months, P-value <.0001) and late (6-13 months, P-value = .007) in infancy.

CONCLUSIONS

Potential overfeeding occurs in 37% of fully formula-feeding infant WIC-participants <6 months old. Mothers of these infants may benefit from additional education about the formula needs of their infants and how to recognize infant satiation cues.

The new child food package is associated with reduced obesity risk among formula fed infants participating in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) in Los Angeles County, California, 2003-2016

BACKGROUND

The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) changed the food packages provided to its participants in 2009, to better align them with the Dietary Guidelines for Americans. Previous research found that the 2009 WIC food package change was associated with reduced obesity risk, particularly among breastfed infants but also among those who were never breastfed. The objective of this study was to determine if the new child food package introduced in 2009, including more produce and whole grains for 1-4-year old children, was associated with healthier growth trajectories and reduced obesity risk at age 4 years among children who were exclusively formula fed during infancy.

METHODS

Administrative data on WIC-participating children in Los Angeles County, 2003-2016, were used (N = 74,871), including repeated measures of weight and length (or height); child's age, gender, and race/ethnicity; maternal education and language; and family poverty. Gender-stratified spline mixed models were used to examine weight-for-height z-score (WHZ) growth trajectories from 0 to 4 years and Poisson regression models were used to assess obesity (BMI-for-age > 95th percentile) at age 4. The main independent variable was duration of receipt (dose) of the new child package, categorized as 0, > 0 to < 1, 1 to < 2, 2 to < 3, 3 to < 4, and 4 years.

RESULTS

WHZ growth trajectories were similar for children across new child package dose groups. Boys and girls who were fully formula fed during infancy but received the new child food package for 4 years had a 7% (RR = 0.93; 95%CI = 0.89-0.98) and a 6% (RR = 0.94; 95%CI = 0.89-0.99) lower obesity risk, respectively, compared to children who received the new child food package for 0 years. There were no differences in obesity risk for children receiving < 4 years of the new child package vs. 0 years.

CONCLUSIONS

Providing healthy foods during childhood to children who were exclusively formula fed as infants was associated with modest improvements in obesity outcomes. While breastfeeding promotion should still be prioritized among WIC participants, providing healthy foods during childhood may provide health benefits to formula fed children, who comprise a sizeable proportion of children served by WIC.

WIC Participation and Breastfeeding after the 2009 WIC Revision: A Propensity Score Approach

In this study, we examined the association between participation in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and breastfeeding outcomes before and after the 2009 revisions. Four-thousand-three-hundred-and-eight WIC-eligible children younger than 60 months were included from the 2005–2014 National Health and Nutrition Examination Survey (NHANES). We compared two birth cohorts with regard to their associations between WIC participation and being ever-breastfed and breastfed at 6 months. We estimated the average effect of the treatment for the treated to assess the causal effect of WIC participation on breastfeeding based on propensity score matching. The results showed that WIC-eligible participating children born between 2000 and 2008 were significantly less likely than WIC-eligible nonparticipating children to ever receive breastfeeding (p < 0.05) or to be breastfed at 6 months (p < 0.05). Among children born between 2009 and 2014, WIC-eligible participating children were no longer less likely to ever receive breastfeeding compared to WIC-eligible nonparticipating children; the gap remained in breastfeeding at 6-months (p < 0.05). The disparities in prevalence of ever breastfed between WIC-eligible participants and nonparticipants have been eliminated since the 2009 WIC revision. More efforts are needed to improve breastfeeding persistence among WIC-participating mother–infant dyads.

Trends in Breastfeeding Disparities in US Infants by WIC Eligibility and Participation

OBJECTIVE

To examine the trends in breastfeeding disparities across Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) eligibility and participation statuses in the last 2 decades.

DESIGN

Secondary analyses from multiple cross-sectional surveys.

SETTING

United States.

PARTICIPANTS

The National Health and Nutrition Examination Survey 1999-2014 included 10,696 children younger than 60 months. Birth cohorts in 4-year increments were created from 1994 to 2014.

MAIN OUTCOME MEASURES

Ever-breastfed status and breastfed-at-6-months status.

ANALYSIS

The prevalence rates of ever-breastfed and breastfed at 6 months were estimated between WIC-eligible vs non-eligible children and WIC-eligible participants vs eligible nonparticipants. Prevalence rates and their 95% confidence intervals were plotted across birth cohorts. Log-binomial regression was conducted to test the trends of breastfeeding in each subgroup.

RESULTS

Ever-breastfeeding rates increased from 52% (WIC participants) vs 57% (WIC-eligible nonparticipants) in the 1994-1997 birth cohort to 71% vs 77% in the 2010-2014 birth cohort-a 36% vs 34% relative increase for participants vs eligible nonparticipants, respectively (P < .001). Breastfeeding-at-6-month rates increased from 28% (participants) vs 30% (eligible nonparticipants) to 34% vs 49% in the same time period-a 21% vs 66% relative increase, respectively (P < .001).

CONCLUSION AND IMPLICATIONS

To meet the Healthy People 2020's goal for breastfeeding at 6 months, sustainable postpartum breastfeeding education and interventions may be needed among WIC participants. Future research focusing on identification of the causal relationship between WIC participation and breastfeeding outcomes is warranted.

WIC Participation and Breastfeeding at 3 Months Postpartum

Objectives Participation in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) has been associated with lower breastfeeding initiation and duration. This study examines breastfeeding-related factors among WIC participants and nonparticipants that might explain these previous findings. Methods Respondents to the 2007 Infant Feeding Practices Study II who were income-eligible for WIC were categorized as follows: no WIC participation (No-WIC); prenatal participation and infant entry while ≥60 % breastfeeding (WIC BF-high); prenatal participation and infant entry while <60 % breastfeeding (WIC BF-low). Percent breastfeeding was the number of breast milk feeds divided by the total number of liquid feeds. Using propensity scores, we matched WIC BF-high respondents to No-WIC respondents on demographic and breastfeeding factors. We used logistic regression to estimate the impact of WIC participation on breastfeeding at 3 months postpartum in the matched sample. Within-WIC differences were explored. Results Of 743 income-eligible respondents, 293 never enrolled in WIC, 230 were categorized as WIC BF-high, and 220 as WIC BF-low. Compared to matched No-WIC respondents, WIC BF-high respondents had increased odds of breastfeeding at 3 months, though this difference was not statistically significant (OR 1.92; 95 % CI 0.95-3.67; p value 0.07). WIC BF-high respondents were more similar on breastfeeding-related characteristics to No-WIC respondents than to WIC BF-low respondents. Conclusions for Practice Accounting for prenatal breastfeeding intentions and attitudes, we find no negative association between WIC participation and breastfeeding at 3 months postpartum. This is in contrast to prior studies, and highlights the importance of understanding within-WIC differences.

Likelihood of Breastfeeding Within the USDA's Food and Nutrition Service Special Supplemental Nutrition Program for Women, Infants, and Children Population

BACKGROUND

Breastfeeding is an important public health initiative. Low-income women benefiting from the U.S. Department of Agriculture's Food and Nutrition Service Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) are a prime population for breastfeeding promotion efforts. Research aim: This study aims to determine factors associated with increased likelihood of breastfeeding for WIC participants.

METHODS

The Preferred Reporting Items for Systematic Reviews and Meta-Analysis statement guided the systematic review of literature. Database searches occurred in September and October 2014 and included studies limited to the previous 10 years. The following search terms were used: low-income; WIC; women, infants, and children; breastfeeding; breast milk; and maternal and child health. The criterion for inclusion was a study sample of women and children enrolled in the WIC program, thereby excluding non-United States-based research.

RESULTS

Factors that increased the likelihood of breastfeeding for WIC participants included sociodemographic and health characteristics ( n = 17); environmental and media support ( n = 4); government policy ( n = 2); intention to breastfeed, breastfeeding in hospital, or previous breastfeeding experience ( n = 9); attitudes toward and knowledge of breastfeeding benefits ( n = 6); health care provider or social support; and time exposure to WIC services ( n = 5).

CONCLUSION

The complexity of breastfeeding behaviors within this population is clear. Results provide multisectored insight for future research, policies, and practices in support of increasing breastfeeding rates among WIC participants.

Predictors of Obesity in a Cohort of Children Enrolled in WIC as Infants and Retained to 3 Years of Age

This longitudinal study of children enrolled as infants in the New York State (NYS) Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) examined predictors of obesity (body mass index ≥ 95th percentile) at 3 years of age. NYS WIC administrative data which included information from parent interviews and measured heights and weights for children were used. All 50,589 children enrolled as infants in WIC between July to December 2008 and July to December 2009 and retained in WIC through age three were included. At 3 years of age, 15.1% of children were obese. Multiple logistic regression analysis showed that children of mothers who received the Full Breastfeeding Food Package when their infant was enrolled in WIC (adjusted OR = 0.52) and children with ≤2 h screen time daily at age 3 (adjusted OR = 0.88) were significantly less likely to be obese (p < 0.001) controlling for race/ethnicity, birth weight, and birthplace. In this cohort of NYS WIC participants, maternal receipt of the Full Breastfeeding Food Package (a surrogate measure of exclusive breastfeeding) is associated with lower levels of obesity in their children at age 3. The relationships between participation in WIC, exclusive breastfeeding, and obesity prevention merit further study.

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

OBJECTIVE

In 2009, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) implemented new food packages to improve dietary intake among WIC participants. This paper examines how the healthfulness of food purchases among low-income households changed following this reform.

METHODS

Point-of-sale data for 2137 WIC-participating and 1303 comparison households were obtained from a regional supermarket chain. The healthfulness of purchased foods and beverages was determined per their saturated fat, sugar, and sodium content. A pre-post assessment (2009-2010) of the product basket healthfulness was completed using generalized estimating equation models. Data were analyzed in 2015.

RESULTS

At baseline, healthy products accounted for most of the food volume purchased by WIC participants, but beverages were dominated by moderation (less healthy) items. With new subsidies for fruit, vegetables and whole grains, the WIC revisions increased the volume of healthy food purchases of WIC-participating households by 3.9% and reduced moderation foods by 1.8%. The biggest improvements were reductions in moderation beverages (down by 24.7% in volume), driven by milk fat restrictions in the WIC food package revisions. The healthfulness of the product basket increased post-WIC revisions; mainly due to a reduction in the volume of moderation food and beverages purchased (down by 15.5%) rather than growth in healthy products (up by 1.9%). No similar improvements were seen in a comparison group of low-income nonparticipants.

CONCLUSIONS

After the WIC revisions, the healthfulness of participant purchases improved, particularly for beverages. Efforts to encourage healthy eating by people receiving federal food assistance are paying off.

Comparison of Food Intake Among Infants and Toddlers Participating in a South Central Texas WIC Program Reveals Some Improvements After WIC Package Changes

In 2009, WIC began issuing revised food packages with the intent of improving dietary practices such as breastfeeding, delaying the introduction of complementary foods until about 6 months, limiting juice intake, and increasing intake of fruits, vegetables, whole grains, and baby food meats as appropriate for age. This observational study investigated whether dietary intake and feeding practices of a sample of majority-Hispanic infants and toddlers participating in a WIC clinic in south central Texas improved after the package changes. Feeding practices data and 24-h recalls were collected during telephone interviews with 84 caregivers of infants (4-12 months) and toddlers (1-2 years) in 2009 before the package change and with 112 caregivers in 2011 after the package change. The Nutrition Data System for Research was used to collect 24-h recalls. Outcomes for the two study years were compared using Chi square analysis for categorical and Mann-Whitney U analysis for continuous variables. Breastfeeding initiation, breastfeeding duration, age of introduction of complementary foods, and exposures to baby food fruits, vegetables, and meats among infants did not improve after the package changes. Significantly fewer infants received cereal in their bottles and fewer toddlers consumed vegetables and eggs after the package changes. The observed feeding practices of infants and toddlers among this sample did not reflect the WIC package changes. Strategic and comprehensive breastfeeding and nutrition education are recommended. Package modifications such as adding eggs back to the toddler package and allowing more flexibility for purchasing fresh produce and baby foods may be warranted.

Barriers and Contributors to Breastfeeding in WIC Mothers: A Social Ecological Perspective

BACKGROUND

In response to the Surgeon General's Call to Action to Support Breastfeeding, the goal of this research was to assess the barriers and positive contributors to breastfeeding initiation and duration in Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participants using the social ecological model (SEM).

MATERIALS AND METHODS

A cross-sectional design was used to survey WIC mothers (n = 283) in southern New Hampshire. Analysis of breastfeeding initiation and duration revealed statistically significant results primarily at the individual level of the SEM. Findings also showed influences at the interpersonal, community, and organizational levels. There were significant differences in beliefs toward breastfeeding between women who ever breastfed and women who never breastfed. Women who ever breastfed were more likely to agree that breastfeeding assists with losing baby weight (89% versus 77%; p = 0.03), babies fed breastmilk are less likely to get sick (86% versus 74%; p = 0.04), and breastfeeding helps mothers bond with their babies more quickly than formula feeding (88% versus 72%; p < 0.01). Breastfeeding duration was significantly related to employment status; among women who breastfed for 6 months or longer, 15% were employed full-time, 30% worked part-time, and 55% indicated "other" such as unemployed or stay-at-home mother (p = 0.01). Logistic regression revealed that maternal age was the most significant predictor of breastfeeding duration (odds ratio = 1.11; 95% confidence interval, 1.03, 1.19; p < 0.004).

CONCLUSIONS

Results indicate opportunities to inform and support women in the prenatal and postpartum period, improve the social and built environment, and develop and advocate for policies in an effort to support breastfeeding.

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

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

Intended And Unintended Effects Of The War On Poverty: What Research Tells Us And Implications For Policy

During the mid-1960s, the United States adopted a series of cash and in-kind transfer programs, as well as human capital investment strategies, as part of the War on Poverty. A number of other programs were first proposed as part of this "war" but were not implemented until the mid-1970s. These programs had noble goals: to increase incomes at the bottom of the income distribution, reduce poverty, and improve nutrition, heath, and human capital. However, various features of the programs also had the potential to produce unintended consequences: for example, means-tested programs can discourage work. In this paper, we comprehensively evaluate the main War on Poverty programs that were aimed at the low-income nonelderly population along with several follow-on programs. We focus on both intended and unintended consequences, drawing on the most compelling causal evidence. We conclude with a series of lessons learned and questions that are outstanding.

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

BACKGROUND

Beginning in 2009, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) revised its food packages and provided more whole grains, fruits, and vegetables and fewer foods with high saturated fat content. However, knowledge of the impact of this policy shift on the diets of WIC participants remains limited.

PURPOSE

To examine the longer-term impact of the 2009 WIC food package change on nutrient and food group intake and overall diet quality among African American and Hispanic WIC child participants and their mothers/caregivers.

METHODS

In this natural experiment, 24-hour dietary recalls were collected in the summer of 2009, immediately before WIC food package revisions occurred in Chicago IL and at 18 months following the food package change (winter/spring 2011). Generalized estimating equation models were used to compare dietary intake at these two time points. Data were analyzed in July 2013.

RESULTS

Eighteen months following the WIC food package revisions, significant decreases in total fat (p=0.002) and saturated fat (p=0.0004) and increases in dietary fiber (p=0.03) and overall diet quality (p=0.02) were observed among Hispanic children only. No significant changes in nutrient intake or diet quality were observed for any other group. The prevalence of reduced-fat milk intake significantly increased for African American and Hispanic children, whereas the prevalence of whole milk intake significantly decreased for all groups.

CONCLUSIONS

Positive dietary changes were observed at 18 months post policy implementation, with the effects most pronounced among Hispanic children.

The new food package and breastfeeding outcomes among women, infants, and children participants in Los Angeles County

OBJECTIVES

We assessed the effect of the new Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food package, implemented in October 2009, on breastfeeding outcomes among a predominately Latina sample of WIC participants in Los Angeles County, California.

METHODS

We used data from 5020 WIC participants who were interviewed in a series of repeated cross-sectional surveys conducted in 2005, 2008, and 2011. Participants were randomly selected from Los Angeles County residents who received WIC services during those years.

RESULTS

Consistent with the WIC population in Los Angeles, participants were mostly Latina and had low levels of income and education; more than half were foreign-born. We found small but significant increases from pre- to postimplementation of the new WIC food package in prevalence of prenatal intention to breastfeed and breastfeeding initiation, but no changes in any breastfeeding at 3 and 6 months. The prevalence of exclusive breastfeeding at 3 and 6 months roughly doubled, an increase that remained large and significant after adjustment for other factors.

CONCLUSIONS

The new food package can improve breastfeeding outcomes in a population at high risk for negative breastfeeding outcomes.

Why WIC Women Stop Breastfeeding?

Women who receive benefits from Women, Infants, and Children (WIC) are not meeting the recommendations for breastfeeding duration. The purpose of this descriptive correlational study was to examine maternal sociodemographic and time factors related to the reason for discontinuing breastfeeding for 238 WIC participants who initiated breastfeeding. This study is a secondary data analysis of existing longitudinal survey and administrative data from a Chicago-area community health center and WIC clinic. The average length of breastfeeding within this sample was 16 weeks. Women in this sample reported a perception of insufficient milk (PIM; 46%), returning to work/school (13%), and other maternal problems (13%) as the main reasons for discontinuing breastfeeding. Within the first 16 weeks, 65% of the women who discontinued breastfeeding cited PIM as the main reason, with 2 distinct time points at 5 weeks and 13 weeks. Women of Hispanic descent were more likely than non-Hispanic women to report this perception (odds ratio 2.66, P = .01, 95% confidence interval = 1.21-5.83). Although these women initiated breastfeeding, the national recommendation for breastfeeding duration was not met in this population. Additionally, many women stopped breastfeeding early due to PIM. There are distinct time points where culturally tailored interventions may be most effective.

Changing WIC changes what children eat

OBJECTIVE

This study assessed the impact of revisions to the USDA Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food packages on nutritional behavior and obesity in children 0- to 4-years-old participating in the New York State (NYS) WIC program. In January 2009, NYS was the first to implement these revisions, which added fruits, vegetables, and whole grains and replaced whole milk with low(1%)-/nonfat milk for children 2- to 4-year-old.

DESIGN AND METHODS

In this cross-sectional study, >3.5 million administrative records in the NYS WIC Statewide Information System (WICSIS) were analyzed at 6-month intervals from July to December 2008 (pre-implementation) through July to December 2011. Behavioral data in WICSIS were obtained from parent interview by WIC staff at mandatory certification and recertification visits.

RESULTS

Comparing July to December in 2008 and 2011, increases were observed in breastfeeding initiation (72.2-77.5%); delaying introduction of solid foods until after 4 months of age (90.1-93.8%); daily fruit (87.0-91.6%), vegetable (78.1-80.8%), and whole grain consumption (59.0-64.4%) by children aged 1-4 years; and switches from whole milk to low-/nonfat milk by children aged 2-4 years (66.4-69.4%). In 1-year-old children, the proportion ≥95th percentile weight-for-recumbent length decreased from 15.1 to 14.2%; the proportion of children 2- to 4-year-old with body mass index (BMI) ≥95th percentile decreased from 14.6 to 14.2%.

CONCLUSIONS

These findings demonstrate that positive changes in dietary intake and reductions in obesity followed implementation of the USDA-mandated cost-neutral revisions to the WIC food package for the hundreds of thousands of young children participating in the NYS WIC program.

Establishing successful breastfeeding in the newborn period

The first days after delivery of a newborn infant are critical for breastfeeding establishment. Successful initiation and continuation-especially of exclusive breastfeeding-have become public health priorities, but it is fraught with many individual- and systems-level barriers. In this article, we review how hospital newborn services can be constructed or restructured to support the breastfeeding mother-infant dyad so that they can achieve high levels of breastfeeding success. Important positive and negative factors from the prenatal period, and the preparation for hospital discharge are also discussed.