September 14, 2016
Kathleen Rasmussen, Chair
Shannon Whaley, Vice Chair
Review of the WIC Food Packages
Institute of Medicine
Food and Nutrition Board
Food and Nutrition; Health and Medicine
Dear Ms. Rasmussen and Ms. Whaley:
The Academy of Nutrition and Dietetics (the "Academy") appreciates the opportunity to submit written comments in addition to our oral testimony provided on June 29, 2016 as the National Academies of Sciences, Engineering, and Medicine Health and Medicine Division (HMD), formerly the Institute of Medicine (IOM), completes the review of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food package. Representing over 100,000 registered dietitian nutritionists (RDNs)1 nutrition dietetic technicians, registered (NDTRs), and advanced-degree nutritionists, the Academy is the largest association of food and nutrition professionals in the United States. The Academy is committed to improving the nation's health, and we believe that WIC is a critical component of that objective. Every day Academy members work with Americans in all walks of life — from prenatal care through end of life care — providing nutrition care services and conducting nutrition research.
The Academy supported the last review of the food package in 2006, and the significant changes made to the food packages, specifically additional fruits, vegetables, and whole grain bread and cereal products; reduction in saturated fat and cholesterol; and options for milk and meats and legumes consistent with the 2010-2015 Dietary Guidelines for Americans2 that largely reflected the IOM's recommendations in WIC Food Packages: Time for a Change3.
As nutritional science continues to evolve, public health officials can more accurately identify and recommend foods to fill gaps in diet quality. The long lasting impacts of pre-and inter-conception and prenatal nutrition status positions WIC as the most effective program to improve population health during these critical lifecycle stages of growth and development for children and increased nutritional need for pregnant and breastfeeding women.
Modifications to the Food Package
The Academy supports modifications to the food package to help fill nutritional gaps, while providing flexibility to meet the unique needs of communities. Our recommendations include:
- Evaluation and monitoring of the nutrition, lifestyle risk factors, such as anthropometric risk, biochemical risk, medical risk, and other predisposing factors (e.g., homelessness) for the WIC-eligible population. The inclusion of foods that supplement specific nutrients in the packages should remain a pillar of the WIC program. Continued expansion of nutrition status monitoring, data collection, and funding for evaluation at the national and state level will lead to more effective studies and result in improved participant and vendor satisfaction.
- Allowance for two separate food packages to meet the differing developmental needs of the infant over age 6 months: 1) age 6-8 months and 2) age 9-11 months. This targeted approach will provide WIC nutritionists, RDNs and paraprofessionals with the ability to tailor nutrition education for parents and facilitate proper introduction of healthful foods based on developmental milestones. A second infant food package for older infants is necessary, because the current package is designed for infants 6-8 months of age and development, focuses on pureed foods, and does not account for older infants' ability and willingness to "finger-feed" and for the progression to nutrient rich foods with texture and fiber appropriate for infants as they grow and develop.4 Alignment with the 2015-2020 Dietary Guidelines for Americans5 recommendations for mothers and children over 2 years old and ultimately incorporating the recommendations from the anticipated Birth to 24 months' guidelines currently under development. We encourage the committee to work with and align as much as possible with the Birth to 24-month committee's early findings and allow for timely implementation and integration when the first Birth to 24-month guidelines are released.
- Identification of ways to increase dairy or WIC allowable dairy-alternatives consumption in children and women, with special attention to children transitioning from whole milk to 1% milk. The 2015-2020 Dietary Guidelines for Americans calls for low-fat or non-fat dairy or dairy alternatives, and has been implemented in the WIC food package as such. The HMD committee’s recent interim report found that children and women do not get enough Vitamin E, potassium, or calcium, all of which are found in dairy6.
Cash Value Voucher Redemption
Research on cash value voucher (CVV) redemption finds that individuals that utilize CVV find them extremely useful, but also that certain communities do not utilize CVV to its full value.7,8 We urge the HMD to invest time in understanding the barriers and preferences associated with full utilization of CVV and encourage all states to monitor redemption. In particular, we recommend:
- Examination of state policies detailing CVV implementation and monitoring corresponding CVV redemption. States have different methods of implementing CVV, creating natural policy experiments.
- Provide education and technical assistance to participants and retailers on the redemption of CVV, with a particular focus on states and/or communities with low CVV redemption.
- Examination, through statistical modeling:
- If CVV can be used as a tool to promote and incentivize breastfeeding by increasing the CVV for exclusively breastfeeding women above that for non- or partially-breastfeeding women; and
- The potential nutritional impact of full or partial CVV replacement for juice in the child food package in communities with high CVV redemption to allow more options for families.
Impact of the Food Environment
The Academy requests that the HMD takes into consideration flexibility of the food package that focuses on the nutritional health of WIC mothers and their children as well as appreciation of modern day strains on family life and structure.
The food packages should allow for cultural and religious preferences, continue to accommodate variations in living situations, including the lack of a permanent night-time dwelling, and little to no use of modern cooking and storing appliances. Although WIC participants are under economic strain, it is important to recognize they face similar challenges to society in general with regard to balancing work and family.
- We recommend adopting ranges of container/package sizes to accommodate marketplace variations so as not to limit participant access or choice and undue to undue manufacturing cost. For example, allowing a range of oatmeal container size in the WIC food package that is appropriate to family size. Offering different packaging provides families with more healthy options.
Special Dietary Concerns
In addition, the Academy asks the HMD to consider expanding substitutions for special dietary concerns.
- WIC nutritionist have the ability to tailor WIC food package substitutions to accommodate food allergies, like gluten. We ask for more support for WIC nutritionists to prescribe food allergy substitutions.
It is the position of the Academy of Nutrition and Dietetics that "well-planned vegetarian diets are appropriate for individuals during all stages of the lifecycle, including pregnancy, lactation, infancy, childhood, and adolescence9." The 2015-2020 Dietary Guidelines for Americans notes that the Healthy Vegetarian Eating Pattern is similar to the Healthy U.S.-Style Eating Pattern but "is somewhat higher in calcium and dietary fiber and lower in vitamin D, due to differences in the foods included in the protein foods group." We ask you to consider:
- Vegetarian substitutions for baby food meats for fully breastfed infants with consideration for protein, iron, zinc, vitamin D and omega-3 fatty acids
- Vegan substitutions for eggs and canned fish, with prudent consideration for the nutrients listed above and vitamin B12 and possibly choline intake, and high risk patients, seen by Registered Dietitian Nutritionist.
Nutrition Education and Counseling
The Academy continues to support tailored nutrition counseling to help families meet their unique cultural preferences and nutrition needs. The Academy agrees that nutrition education is "pivotal to WIC's success in achieving its mission to safeguard the health of low-income women, infants, and children."10 Prenatal nutrition of the mother and benefits of breastfeeding are the top two topics discussed in nutrition counseling sessions prior to birth, but after birth that focus shifts to the nutritional needs of the baby11. The Academy notes the opportunity for nutrition counseling sessions to address chronic disease prevention, including oral health, by focusing on the postpartum nutrition of the mother, while still addressing the needs of the baby and be more collaborative with the CDC's interconception care concepts including communicating with mothers at specific time points to encourage health.
Academy members who administer and lead WIC programs stand ready to help WIC recipients maximize the health of themselves and their families. The Academy appreciates the opportunity to comment on this important review and hopes to discuss these recommendations in greater detail in the near future. Please contact Jeanne Blankenship, MS, RDN at 202/775-8277 or by email at email@example.com with any questions or requests for additional information.
Jeanne Blankenship, MS, RDN
Vice President, Policy Initiatives & Advocacy
Academy of Nutrition and Dietetics
Jennifer Noll Folliard, MPH, RDN
Director, USDA Legislation and Policy
Academy of Nutrition and Dietetics
1 The Academy recently approved the optional use of the credential "registered dietitian nutritionist (RDN)" by "registered dietitians (RDs)" to more accurately convey who they are and what they do as the nation's food and nutrition experts. The RD and RDN credentials have identical meanings and legal trademark definitions.
2 U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2010. 7th Edition, Washington, DC: U.S. Government Printing Office, December 2010
3 WIC food packages: time for a change / Committee to Review the WIC Food Packages, Food and Nutrition Board
4 Pediatric Nutrition, 7th Edition. Chapter 6: Complimentary Foods. American Academy of Pediatrics Committee on Nutrition; Editor in chief: Ronald E. Kleinman, MD, FAAP; Associate editor: Frank R. Greer, MD, FAAP. October 22, 2013
5 U.S. Department of Health and Human Services and U.S. Department of Agriculture. 2015–2020 Dietary Guidelines for Americans. 8th Edition. December 2015.
6 National Academies of Sciences, Engineering, and Medicine. 2016. Review of WIC food packages: Proposed framework for revisions: Interim report. Washington, DC: The National Academies Press. doi: 10.17226/21832.
7 Women, Infants, and Children Cash Value Voucher (CVV) Use in Arizona: A Qualitative Exploration of Barriers and Strategies Related to Fruit and Vegetable Purchases Journal of Nutrition Education and Behavior Volume 46, Issue 3, Supplement, May–June 2014, Pages S53–S58
8 National WIC Association. Fruit and Vegetable CVV Redemption Survey.
9 Position of the American Dietetic Association: Vegetarian Diets. Volume 109, Issue 7, Pages 1266-1282 (July 2009)
10 CFR 246.2
11 U.S. Department of Agriculture, Food and Nutrition Service, Office of Policy Support. WIC Nutrition Education Study: Phase I Report, by Sheryl Cates, Kristen Capogrossi, Linnea Sallack, Karen Deehy Celia Eicheldinger, Shawn Karns, Samantha Bradley, Katherine Kosa, and Jenna Brophy. Project Officer: Karen Castellanos-Brown. Alexandria, VA: May 2016