Established Evidence Results

Intervention Components (click on component to see a list of all articles that use that intervention): STATE/NATIONAL, WIC Food Package Change, POPULATION-BASED SYSTEMS, STATE

Intervention Description: 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.

Intervention Results: Significant increase in breastfeeding initiation between JulyDec 2008 (72.2%) and July-Dec 2011 (77.5%) (p<.05)

Conclusion: 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.

Study Design: Time trend analysis

Setting: New York State (NYS)

Population of Focus: Mothers of infants and children through 4 years enrolled in the NYS WIC program between July 1, 2008-December 31, 2008

Data Source: New York State WIC Statewide Information System; Mother self-report

Sample Size: Pre-Implementation • July-Dec 2008 (n=179,929) During and Post-Implementation • Jan-Jun 2009 (n=186,451) • July-Dec 2009 (n=188,622) • Jan-Jun 2010 (n=186,663) • July-Dec 2010 (n=186,012) • Jan-Jun 2011 (n=184,262) • July-Dec 2011 (n=183,656)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): STATE/NATIONAL, WIC Food Package Change, POPULATION-BASED SYSTEMS, STATE

Intervention Description: We analyze changes in breastfeeding among WIC participants from the period before to period after implementation of the new food package.

Intervention Results: No statistically significant trends in breastfeeding after implementation of the new WIC food package

Conclusion: Rates of ever breastfed children are rising nationally but the increase is not associated with changes in WIC's new food package as evidenced in national and state surveys of postpartum women.

Study Design: Time trend analysis

Setting: National

Population of Focus: Intervention: women who participated in WIC during pregnancy Control: women not on WIC during pregnancy of similar socioeconomic status

Data Source: PRAMS, National Immunization Survey and the Pediatric Nutrition Surveillance System

Sample Size: N/A8

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): WIC Food Package Change, STATE-BASED, Policy/Guideline (National), NATIONALLY-BASED,

Intervention Description: 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.

Intervention Results: 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.

Conclusion: Our study did not find evidence that the 2009 WIC food package revisions had an effect on ever breastfeeding, breastfeeding through 6 months, or exclusively breastfeeding through 6 months among a sample of infants eligible for WIC based on household income. Any positive effects observed in this study and prior studies that assessed this relationship may be reflections of the upward trends in breastfeeding rates that occurred in the U.S. before and after the implementation of the revisions.

Intervention Components (click on component to see a list of all articles that use that intervention): STATE/NATIONAL, POPULATION-BASED SYSTEMS, STATE, WIC Food Package Change

Intervention Description: 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.

Intervention Results: 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.

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

Study Design: QE: pretest-posttest

Setting: Los Angeles County, CA

Population of Focus: Mothers participating in WIC who spoke English or Spanish

Data Source: Mother self-report

Sample Size: 2005 (n=1772) 2008 (n=1598) 2011 (n=1650)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): WIC Food Package Change, STATE-BASED, Policy/Guideline (National), NATIONALLY-BASED,

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

Intervention 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.

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

Intervention Components (click on component to see a list of all articles that use that intervention): STATE/NATIONAL, WIC Food Package Change, POPULATION-BASED SYSTEMS, STATE

Intervention Description: 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 revised food package changes.

Intervention Results: 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.

Conclusion: 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.

Study Design: QE: pretest-posttest

Setting: WIC clinic in south central TX

Population of Focus: Spanish and English-speaking caregivers of infants and toddlers

Data Source: Mother self-report

Sample Size: 2009 (n=84) 2011 (n=112)

Age Range: Not specified

Intervention Components (click on component to see a list of all articles that use that intervention): WIC Food Package Change

Intervention Description: This final rule revises the WIC food packages based on public comments received on the interim rule published in 2007. The revisions aim to better align the food packages with current nutrition science, promote breastfeeding, provide more variety and choice for participants, and give state agencies more flexibility to accommodate cultural preferences. Key changes include increasing the cash-value voucher for fruits and vegetables for children, allowing yogurt and canned fish for certain food packages, providing more whole grain options, giving state agencies the option to allow cash-value vouchers for older infants, and eliminating certain medical documentation requirements.

Intervention Results: The final rule increases the cash-value voucher for children to $8 per month as recommended by the IOM. It allows state agencies to provide yogurt and canned jack mackerel as new options in certain food packages. For infants 9-11 months, it permits substituting a $4/$8 cash-value fruit/vegetable voucher along with jarred foods, rather than jarred foods alone. It eliminates the requirement for medical documentation for children to receive soy-based beverage/tofu and for women to receive more tofu. Overall, the changes aim to increase consumption of healthy foods like fruits, vegetables and whole grains while better accommodating dietary needs and personal preferences.

Conclusion: Despite overall smooth implementation of the interim rule changes, this final rule makes adjustments to improve clarity and address concerns raised during the public comment period. The revisions better fulfill the intent of following the IOM recommendations to update the WIC food packages to meet nutritional needs, increase breastfeeding support, expand food choices, and accommodate cultural preferences. The changes give state and local agencies more flexibility to tailor food packages to participants' needs while maintaining the nutritional integrity of the WIC program.

Study Design: N/A

Setting: N/A

Data Source: N/A

Sample Size: N/A

Age Range: N/A

Intervention Components (click on component to see a list of all articles that use that intervention): STATE/NATIONAL, WIC Food Package Change, POPULATION-BASED SYSTEMS, STATE

Intervention Description: The purpose of this study was to measure changes in the following 3 outcomes: WIC food-package assignments, WIC infant formula amounts, and breastfeeding initiation.

Intervention Results: There were changes in WIC food-package assignments and infant formula amounts but no change in breastfeeding initiation.

Conclusion: After the change, fewer WIC mothers of new infants received the partial breastfeeding package. More WIC mothers received the full breastfeeding package, but more mothers also received the full formula package.

Study Design: QE: pretest-posttest

Setting: 17 local WIC agencies in 10 states (CA, FL, GA, ID, IL, MN, RI, TN, TX & UT)

Population of Focus: All mothers with infants 0-5 months before and after intervention implementation

Data Source: Mother self-report

Sample Size: Months 1-2 – preintervention (n=17,597) Months 5-12 – postintervention (n=62,427)

Age Range: Not specified