WIC Research Update

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WIC Research Update

• Melissa Abelev, PhD
• Assistant Deputy Administrator
• USDA Food and Nutrition Service
• Office of Policy Support

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WICs 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.

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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

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WICs legislative mandate

• 1975 P.L. 94-105 established WIC as a permanent
  program
• Congress finds 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.

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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 programs target population
• Section 17(f)(11)
• To the extent possible prescribed foods should
  assure that fat, sugar, and salt content is
  appropriate

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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)

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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

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IFTPS Cohort
Demographics of mothers Percent
Race White/Black 59 and 25
Ethnicity Hispanic/Latino 40
Unmarried 70
75 poverty threshold 63
Food security Low/Very low 31 and 17
History of breastfeeding 54
Weight Overweight/Obese 26 and 28
Enroll 1st-2nd trimester/1st child 67 and 40
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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

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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

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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

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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

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

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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

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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

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Staff receive ongoing training(WIC Breastfeeding
Policy Inventory)
  State Agencies () Local Agencies ()
Staff Who Receive Ongoing BF Promotion Training    
Clerical or support staff 58.2 59.5
Competent Professional Authorities 83.1 77.7
Peer counselors 100.0 97.3
WIC designated breastfeeding experts 52.9 67.1
Breastfeeding coordinators 94.2 92.8
Nutritionists 90.8 84.9
None of these 2.4 1.2
Staff Are Trained on Using Food Packages to Promote BF 92.7 96.4
Staff Are Trained on Using Food Packages to Promote Exclusive BF 91.8 91.2
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The prenatal visit is a key link for
breastfeeding promotion.(WIC BPI)
  Participants ()
Breastfeeding Promotion Practices During Prenatal WIC Enrollment  
Give her a breastfeeding promotion kit 42.2
Enroll her in peer counseling program 81.5
Include her in prenatal breastfeeding education classes 82.4
Offer her participation in a breastfeeding support group 62.5
Provide individual breastfeeding counseling 96.5
Give her information about the greater quantity and variety of foods in the fully breastfeeding food package 88.4
Other 11.9
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Formula Policies(WIC Breastfeeding Policy
Inventory)
  State Agencies Local Agencies
Formula Issuance to Fully Breastfeeding Participants in 1st Month    
When a doctor prescribes formula 36.6 47.4
When the mother no longer wants to exclusively breastfeed 49.1 60.9
Never 36.9 25.5
Other 12.8 9.3
Steps Clinic Staff Take when a Participant on a Fully Breastfeeding Food Package Requests Formula    
Formula is issued without any additional steps taken 7.5 1.5
Participant receives counseling about benefits of breastfeeding 84.8 91.1
Participant receives counseling about changing food packages 79.8 93.0
A minimum amount of formula is provided based on assessment 79.8 78.7
Other 7.5 9.2
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Proportion of breastfeeding women now exceed
proportion of non-breastfeeding post-partum women
in WIC.(WIC PC 2014)
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More Positive Beliefs about Breastfeeding(ITFPS
Prenatal Report)
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Less Negative Beliefs about Breastfeeding(ITFPS
Prenatal Report)
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Beliefs by Sociodemographics(ITFPS Prenatal
Report)

• Race African Americans least positive
• Ethnicity Hispanics most positive
• Education Less educated less positive

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Experience with Breastfeeding
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Advice about Infant Feeding
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Advice Important to Making a Decision
gt80
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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)

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Higher Intention to Breastfeed

• Hispanic
• Married
• gt75 of poverty guidelines
• Breastfed previously for gt3 months
• More education

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Lower Intention to Breastfeed

• African American
• Pregnant with a third or subsequent child
• Having been on WIC previously 
• Not living with the babys father
• Engaging in discussions about infant feeding
  plans with no more than one person

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No Impact on Intention to Breastfeed

• Food security
• Pregnancy trimester joined WIC
• Weight before pregnancy
• Born in the US

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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.

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SD Beliefs Advice Intention
Explanatory variable Coefficient sign Significance
SD Some BF history Positive Significant
SD gtHigh School education Positive Significant
SD Mother living with father of baby Positive Significant
SD Second/subsequent born Negative Significant
Belief Benefits Index Positive Significant
Belief Barriers Index Negative Significant
Advice Spoke with gt1 person about feeding plans Positive Significant
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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

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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 milk consumption increased.
• CDC noted possible association with reductions in
  preschool-aged childrens obesity rates in 19
  States and territories
• Rates of breastfeeding and appropriate age of
  introduction of solid foods also improved (NY).

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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 

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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

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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

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USDA FNS wants to recognize and remember the work
of Gail Harrison.
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Thank You!