WIC Research Update

1. WIC Research Update Melissa Abelev, PhD Assistant Deputy Administrator USDA Food and Nutrition Service Office of Policy Support

2. WIC’s Mission: • To safeguard the health of low-income women, infants, and children up to age 5 who are at nutrition risk by providing nutritious foods to supplement diets, information on healthy eating, and referrals to health care.

3. History of WIC: What does “supplemental” mean? • Growing concern in the 1960s about malnutrition among poor • In 1968, group of physicians met with Dept. HEW and USDA to describe ailments of patients caused by lack of food • First plan: build commissaries that could stock foods to distribute based on health providers’ prescriptions • Simultaneously: Dr. Paige established voucher program in Baltimore • WIC formally authorized as pilot in 1972 • Link between health care and nutrition through prescriptions and assessment of nutritional risk

4. WIC’s legislative mandate: • 1975: P.L. 94-105 established WIC as a permanent program: • Congressfinds that substantial numbers of pregnant women, infants and young children are at special risk in respect to their physical and mental health by reason of poor or inadequate nutrition or health care, or both. It is, therefore, the purpose of the program…to provide supplemental nutritious food as an adjunct to good health during such critical times of growth and development in order to prevent the occurrence of health problems.”

5. “Supplemental Foods” • Child Nutrition Act of 1966, • Section 17(b)(14), as amended: • Foods containing nutrients determined by nutritional research to be lacking in the diets of the program’s target population • Section 17(f)(11) • “To the extent possible” prescribed foods should assure that fat, sugar, and salt content is appropriate

6. Background: Food Packages • Supplemental Foods – meet specific needs of low-income pregnant, postpartum women (not/breastfeeding), infants and children who are at nutritional risk • Food Package & Nutrition Education are the chief means by which WIC affects dietary quality • Science-based: Dietary Guidelines and American Academy of Pediatrics • Last Revisions to WIC food packages (2009/2014); • first since 1980, • now required every 10 years (HHFKA)

7. Background: Food Packages Examining Nutritional Risk • Supplemental Foods – meet specific needs of low-income pregnant, postpartum women (not/breastfeeding), infants and children who are at nutritional risk • Food Package & Nutrition Education are the chief means by which WIC affects dietary quality • Last Revisions to WIC food packages (2009/2014); • first since 1980, • now required every 10 years

8. IFTPS Cohort

9. Nutritional Risk(NHANES Diet Quality Study) • Analysis of 2005-08 NHANES data: • WIC children more likely than income-eligible non-participants or higher-income children to drink whole milk • Consumed less whole fruit and more juice • Less likely to consume vegetables as discrete items • All groups had low whole grain consumption

10. Food Package: 2014 Final Rule • 30 percent increase in the dollar amount for children's fruits and vegetables purchases • Allow parents of older infants to purchase fresh fruits and vegetables instead of jarred infant food • Expand whole grain options • Provide yogurt as a partial milk substitute • More flexibility to meet nutritional and cultural needs • Three breastfeeding-related packages: full, partial, formula

11. Food Package: 2014 Final Rule • 30 percent increase in the dollar amount for children's fruits and vegetables purchases • Expand whole grain options • Provide yogurt as a partial milk substitute • Allow parents of older infants to purchase fresh fruits and vegetables instead of jarred infant food • More flexibility to meet nutritional and cultural needs • Three breastfeeding-related packages: full, partial, formula

12. How did States use their flexibility?(WIC PC – Food Package Options Report) • Federal regulations: minimum requirements and maximum monthly allowances (MMA) • Vary by participant group and food category • Within regs, State flexibility for substitutions in types and forms of foods • E.g. MMA child whole grains 2 lbs.  States can offer up to five whole-grain alternatives beyond whole-grain bread

13. Flexibility, Whole Grains With the Final Rule, 29% of SAs offered whole-wheat pasta.

14. Flexibility, CVV

15. State Policy Choice Differences between Interim and Final Rules(WIC Food Packages Policy Options Study II) • 29% of SAs added whole-grain pasta • 39% provided fresh fruits and vegetables as an alternative to jarred infant food • The proportion of SAs offering frozen, canned, and dried FV increased by 9, 8, and 5pp • Proportion of SAs offering soy-based bev and tofu as milk alternatives increased by 21 and 23 pp

16. Differences between Interim and Final (cont.) • More low-sodium canned beans, peanut butter, and canned veg • 72% of SAs adopted option for CPA to prescribe fat-reduced milk to 12-24 month at risk of overweight or obesity • Cost-containment, least-cost brand • Milk, 43% of SAs • Cheese, 35% • Eggs, 38% • No organics except FV, 67%

17. Background: Food Packages • Supplemental Foods – meet specific needs of low-income pregnant, postpartum women (not/breastfeeding), infants and children who are at nutritional risk • Food Package & Nutrition Education are the chief means by which WIC affects dietary quality • Last Revisions to WIC food packages (2009/2014); • first since 1980, • now required every 10 years

18. Staff receive ongoing training(WIC Breastfeeding Policy Inventory)

19. The prenatal visit is a key link for breastfeeding promotion.(WIC BPI)

20. Formula Policies(WIC Breastfeeding Policy Inventory)

21. Proportion of breastfeeding women now exceed proportion of non-breastfeeding post-partum women in WIC.(WIC PC 2014)

22. More Positive Beliefs about Breastfeeding(ITFPS – Prenatal Report)

23. Less Negative Beliefs about Breastfeeding(ITFPS – Prenatal Report)

24. Beliefs by Sociodemographics(ITFPS – Prenatal Report) • Race: African Americans least positive • Ethnicity: Hispanics most positive • Education: Less educated less positive

25. Experience with Breastfeeding

26. Advice about Infant Feeding 78% • Husband/boyfriend • WIC staff 68% • Mothers 62% • Doctor 51% • Friends 40% • Other relative 39%

27. Advice Important to Making a Decision >80%

28. Infant Feeding Intentions (IFI) SCALE* • I am planning to only formula feed my baby and do not plan to breastfeed at all. • I am planning to breastfeed my baby or at least try. • When my baby is 1 month old, I will be breastfeeding without using any formula or other milk. • When my baby is 3 months old, I will be breastfeeding my baby without using any formula or other milk. • When my baby is 6 months old, I will be breastfeeding my baby without using any formula or other milk. *developed by Nommsen-Rivers (2010)

29. Higher Intention to Breastfeed • Hispanic • Married • >75% of poverty guidelines • Breastfed previously for >3 months • More education

30. Lower Intention to Breastfeed • African American • Pregnant with a third or subsequent child • Having been on WIC previously  • Not living with the baby’s father • Engaging in discussions about infant feeding plans with no more than one person

31. No Impact on Intention to Breastfeed • Food security • Pregnancy trimester joined WIC • Weight before pregnancy • Born in the US

32. Intention to Breastfeed Regression Model Socio-demographics (SD) + Beliefs + Advice/experiences → Intentions to Breastfeed Regression model explains nearly 34% of the variability in IFI scores.

33. SD + Beliefs + Advice = Intention

34. Summary • Breastfeeding viewed much more favorably than 20 years ago • Views on Benefits drive intention to breastfeed; vary by race, ethnicity and education level • Advice from more than one person impacts intention

35. Impact of Food Package Changes • Increased consumption of whole grains, fruits, and vegetables among WIC participants (LA). • Consumption of whole milk decreased; low- and reduced-fat milkconsumption increased. • CDC noted possible association with reductions in preschool-aged children’s obesity rates in 19 States and territories • Rates of breastfeeding and appropriate age of introduction of solid foods also improved (NY).

36. Impacts, continued • Increased availability of healthful foods, especially whole grains, fruits, and vegetables in smaller markets and convenience stores; especially important in food deserts; spillover effects for all consumers • Postpartum WIC participation associated with better subsequent maternal and infant birth outcomes – higher average birthweights and lengths; lower risk of maternal obesity 

37. Ongoing studies • National Survey of WIC Participants (NSWP) III • WIC Nutrition Education Study • Phase I, near publication • Phase II, in progress, expected 2018 • Infant-Toddler Feeding Practices Study • WIC Food Package Cost & Cost Containment Report, 2019 • WIC Medicaid Cost Study • WIC Eligibles Annual Update • WIC Participant Characteristics Biennial Report • WIC Nutrition Services and Administrative Cost Study • WIC Peer Grouping Study (“Indicators of High-Risk”) • WIC Vendor Management Report • Baylor Center for WIC Nutrition Education Innovations • UCLA Periconceptional Study Grants • WIC Special Project Grants

38. New Studies to begin in FY16 • Participant Research to Enhance WIC Services • EBT Database Exploration • Online Ordering of WIC Foods • Aligning Food Package Prescriptions to Breastfeeding Practices

39. USDA FNS wants to recognize and remember the work of Gail Harrison.

40. Thank You!