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Special Supplemental Nutrition Program for Women, Infants and Children

For other uses, see WIC (disambiguation).

The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) is a federal assistance program of the Food and Nutrition Service (FNS) of the United States Department of Agriculture (USDA) for healthcare and nutrition of low-income pregnant women, breastfeeding women, and infants and children under the age of five. (See Child nutrition programs.) The eligibility requirement is a family income below 185% of the U.S. Poverty Income Guidelines. If a person participates in other benefit programs, or has family members who participate in the Supplemental Nutrition Assistance Program, Medicaid, or Temporary Assistance for Needy Families, they automatically meet the eligibility requirements. This program is unrelated to the USDA's Supplemental Nutrition Assistance Program. Currently, WIC serves 53 percent of all infants born in the United States.[1]

History

In 1969 [2], a group of physicians described to the Department of Health, Education and Welfare and the USDA that young women, often pregnant, came to their clinics with various ailments that were caused by a lack of food. The doctors would prescribe needed foods, with the prescription acting as a sort of food voucher. WIC’s program beginnings surface in 1969, when the White House Conference on Food, Nutrition, and Health recommended that special attention be given to the nutritional needs of low-income pregnant women and preschool children.[3]

WIC was formally created by an amendment to section 17 of the Child Nutrition Act of 1966 on September 26, 1972.[4] The legislation (P.L. 92-433, sponsored by Senator Hubert Humphrey (D) of Minnesota) established the Special Supplemental Food Program for Women, Infants, and Children (WIC) as a 2-year pilot program. Eligibility was limited to children up to age 4 and excluded non-breastfeeding postpartum women. By the end of 1974, WIC was operating in 45 states. On October 7, 1975, WIC was established as a permanent program (P.L. 94-105). Eligibility was extended to non-breastfeeding women (up to 6 months postpartum) and children up to 5 years of age. However, all participants must be deemed to be at nutrition risk and with inadequate income (however, what constituted inadequate income was not defined). In 1978, P.L. 95-627 defined nutrition risk and established income eligibility standards that were linked to the income standards associated with reduced price school meals. Another income standard change took place in 1989, when P.L. 101-147 established similar income eligibility for Food Stamp, Medicaid, and AFDC participation, thus lowering the WIC income standard and simplifying the application process. WIC began to promote and support breastfeeding women in the late 1980s, and in 1989 Congress mandated $8 million be used specifically for that purpose. Also in 1999, the WIC program standardized nutrition risk criteria for program eligibility and began assigning individual nutrition risk priority levels.

Eligibility

In order to apply for the WIC assistance program, one must be a pregnant woman, breastfeeding for up to one year, postpartum for up to six months, or have young infants (0–1 years old) and children (under 5 years old) with specific nutritional needs.[5]

After meeting these basic eligibility requirements, applicants must also satisfy the following criteria to receive assistance:[6]

Income
State income requirements may be between 100% and 185% of Federal poverty guidelines,[5] though most states use the maximum guideline. This is approximately $43k annually for a family of four in the 48 contiguous states in 2013.[7]
Residence
Must be a resident of the county to which they are applying for assistance.
Nutrition risk
Must have a nutritional risk assessment by a qualified health professional. The Nutritional evaluation is based on height, weight, and growth assessment; hematocrit or hemoglobin levels; general health history; and a diet assessment.

Services

General services

Once applicants meet the eligibility requirements, they can expect to receive WIC assistance in the following four areas:[8]

Supplemental food
Food checks or an EBT card are issued to program participants that allow them to buy nutritious food that meets their needs at stores that have contracted with the government to accept these checks in exchange for merchandise.
Formula
WIC Laws and Regulations state, infant formula can only be changed from a non-contracted brand by medical documentation. It should be noted that the formula vouchers provided to the participant are not selected based upon nutritional or health benefits but upon lowest bidder status:

“Competitive bidding means a procurement process under which FNS or the state agency selects a single source (such as a single infant formula manufacturer offering the lowest price), as determined by the submission of sealed bids, for a product for which bids are sought for use in the Program.” [9]

Nutrition education
WIC participants are offered free health and nutrition education classes which help them understand their specific nutrition needs and learn about health prevention and improvement strategies.
Access to healthcare and other social services
Program participants receive guidance and assistance in accessing other important services such as prenatal programs, immunizations and child clinics, and drug and alcohol treatment programs.
Breastfeeding support
Program participants also receive guidance and support materials from Certified Lactation Educators about the benefit of breastfeeding and proper breastfeeding techniques.

Nutrition education and anemia screening


Nutrition education ranges various topics including healthy eating, appropriate infant feeding, and breastfeeding. Additionally, the WIC program also screens for anemia in participants over 12 months old. Depending on the state, nutrition education is provided via a Registered Dietitian, an individual with a bachelors degree in nutrition or related field, or another certified professional authority. WIC agencies are required to stress the long-term benefits of nutrition education, although participating in this education is not compulsory for WIC recipients.[10]

Check/voucher and EBT card

WIC participants often receive a monthly check or voucher, or more recently an EBT card. The USDA implemented new rules in 2006 that required foods to be more price-competitive. This has resulted in the closure of many "WIC Only Stores". Formerly, these stores charged the maximum permitted under the program, charging up to 16% more than regular stores for the same food.[11] However, the WIC program is one of the most cost-effective government programs. A study of birth outcomes showed benefit-to-cost ratios ranging from $1.77 to $3.13 in Medicaid costs saved for each $1 spent on WIC.[12]

The WIC check/voucher is a specially designed check that is compatible with retail point-of-sale check readers and printers. The front of the check displays the recipient’s name and recipient number, a begin use- and an end-use date, a list of allowable items to be purchased with the check/voucher, including the quantity and/or maximum weight of the allowed items listed. The WIC recipient can choose if they want only some or all of the items listed on the check. The check also has an area for the cashier to enter the sale total, and an area for the recipient to sign the check/voucher at the time of use. The checks make use of MICR for enhanced security and ease of processing.

Alternately, many States (notably Texas and Nevada) have moved away from a paper system of checks and vouchers. The conversion of the WIC program to EBT cards has automated a great deal of the process and provides better care for the children and mothers currently using WIC. The cards are similar to consumer credit/debit cards but are exclusively used for purchasing WIC-approved items.

Items provided

The food items provided by WIC are juice (single strength), milk, breakfast cereal, cheese, eggs, fruits and vegetables, whole wheat bread, whole grain items including brown rice and tortillas, fish (canned)(for Exclusively Breastfed Mothers), legumes (dry/canned), and peanut butter. The program also provides tofu, soy milk, and medical foods for children and women with various metabolic or other diseases. Since the white potato was deemed less nutritious than other produce, the WIC commission banned white potatoes from the list, causing protests.[13] Organic fruits, vegetables, legumes and grains are covered under WIC while organic milk, cheese, juice, peanut butter and eggs are not covered under the program.

Responsibilities of recipients

The usual responsibilities of a WIC recipient are:

  • Being responsible for the WIC check/voucher and the recipient's WIC identification card. In many cases, a WIC check/voucher cannot be replaced if the check is damaged or lost.
  • Using the WIC check/voucher within the specified date range.
  • Selecting only the specified items on the check/voucher. The items also must be WIC-allowed items. For instance, a WIC check/voucher holder purchasing a gallon of milk may be asked to select the lowest cost product (usually store brand and not the premium brand) and must get a gallon container, not two half-gallon containers. In the case of a check stating "Two Quarts {2%, 1%...}," however, one can get a half gallon container instead of two quart-sized containers. This varies from state to state.
  • Must not exceed a certain sale amount (this is not used for all WIC checks/vouchers, depending on local/state regulations).
  • Being courteous with retail personnel during a WIC transaction.

Literature review

Nutrition requirements

A woman, infant or child must meet two standards to be eligible to receive WIC benefits: (1) nutritional risk and (2) income disparity. Yet according to Peter Germanis and conservative AEI scholar Douglas J. Besharov in the SAGE Evaluations Review Journal, these two requirements often fall short in determining the real eligibility for WIC participants. They assert that the idea of “nutritional risk” is too broad of a concept. WIC’s current definition of nutritional risk includes different medical conditions such as anemia and low or overweightness. The definition also includes the mother’s history, age, past pregnancy complications, and inadequate diet [14]

While some of the nutritional risk standards are clear, Besharov and Germanis further point out that the majority of people on WIC do not clearly exhibit these symptoms or history. They still might have nutritional risk, but they do not meet the definition outlined in the policy. Despite the definition of nutrition risk, the Institute of Medicine’s Committee on Scientific Evaluation of WIC Nutrition Risk Criteria pointed out that many states have used “generous” cut-off points and “loosely defined risk criteria.” Their research concluded that because the judgment of nutritional risk is left up to the discretion of the doctor, many participants who only partly need WIC’s assistance often take the spots of those with greater need.

In Feeding the Poor: Assessing Federal Food Aid, P.H. Rossi (1988) states that these gaps are often a result of unreliable tools or methods to measure nutrition risk, along with a lack of clarity in the definition of risk. In the study, Rossi took what are called “street-level bureaucrats” and applied them for WIC. These people were either at marginal or no nutrition risk, yet they were accepted easily into the WIC program. This practice essentially turns eligibility into solely a matter of income.[15]

Income requirements

The second eligibility standard for participation in the WIC program—income level—also allows for much subjectivity. In theory, to qualify for WIC services, a family must have an income that meets or is less than 185% of the current federal poverty level. While this definition seems straight forward, Besharov and Germanis describe many instances in which WIC participants with incomes above this level still received services. This could be due to the rapid growth of WIC in the past 30 years. Many WIC staff members have reported that because of the rise in funding, local income testing procedures have become less thorough (2000).

Besharov and Germanis aren't the only ones who have noticed discrepancies in the WIC income eligibility requirement. A USDA study demonstrated that 5.7% of WIC participants were not eligible because their income was too high (see U.S. General Accounting Office 1999, 23). Because of this evidence, the USDA believes that WIC can reduce funding and still meet the needs of those who truly are in need of assistance [16]

Conversely, the same report explained that some members of the USDA have concluded that the current method for estimating eligibility is flawed and reports a much lower number of eligible citizens than actually exists. The method is flawed because it measures income on an annual basis instead of a monthly basis. When the researchers compared monthly income to annual income, they found that the number of income-eligible people increased dramatically a monthly evaluation level. (46-54% increase for infants, and 34-36% increase for older children. No mention of the effect on mothers was mentioned). They concluded that if income were measured monthly, then a larger number of families would be eligible to participate in WIC [16]

Other research suggests that instead of redefining WIC eligibility requirements, policymakers should better advertise how lenient the requirements are. In a study published in 2005, Craig Gundersen, a professor in the Department of Nutritional Science at the University of Illinois at Urbana-Champaign, found that many parents stop using WIC funds to care for their children after their children reach the age of one year. However, over 35% of these children are in families that are below the poverty line. Only one in nine non-participating children nationwide are ineligible for WIC aid. The research suggests that parents are unaware that children up to five years of age are still eligible for WIC services; consequently, their children are not getting necessary nutrition.[17]

To combat this phenomenon, Gundersen suggests that if policymakers want to reach those most in need, they need to target this group of people who were once on WIC and left, not new recipients. His research shows that families that have never received WIC assistance have monthly family incomes $797 higher than those who have left the program and $1215 higher than those currently on the program. Clearly, the people who were once on WIC and left have greater need than most of those who have never sought WIC aid.

Other programs' effect

Eligibility for participation in the WIC program has been affected by a number of federal programs and policy changes since the 1980s. The federal government has gradually increased its control over WIC program policies, which has resulted in a move away from state program control. For instance, the nutritional risk criteria which had previously been instituted by the state cutoffs were standardized by the federal government in 1999 [18]

In 1989, the Child Nutrition and WIC Reauthorization Act increased the amount of eligible program participants by allowing groups such as Medicaid, Aid to Families with Dependent Children (AFDC), Temporary Assistance for Needy Families (TANF), and those qualified for food stamps automatically became eligible for WIC assistance. Allowing these groups to be eligible, in effect, raised the income eligibility threshold for WIC services. Participants in the WIC program are now viewed as those that are inherently eligible because of an income at 185% below the poverty line, or adjunctively eligible through eligibility and participation in the aforementioned programs. Interestingly, research has identified an increase in health benefits among WIC program participants that could offset the additional costs of Medicaid in the future. Changes in welfare benefits are also estimated to increase the adjunctive eligibility rate.

WIC program participation can be affected by an introduction of new programs or changes to existing policy of programs that affect women, infants and children. The WIC program assists 73 percent of eligible infants, 38 percent of eligible children, and 67 percent of eligible pregnant and postpartum women (Bitler & Scholz, 2002). Where services increase under the TANF program, a specific segment of participants in the WIC program, such as infants, have shown a decrease in participation. Implementation of the TANF program accounts for a 9.8 percent reduction in WIC program participation.

In addition to current programs that affect eligibility and participation in the WIC program, many states distribute waivers that extend program rules, change work requirements, and extend program timelines that affect eligibility and participation in WIC.[18]

Internal programs' effect

WIC’s impact is affected by internal programs. Some scholars assert that the spending structure needs to be adjusted so a greater number of eligible individuals can receive WIC services. Transferring some spending to other parts of the program is under consideration.

Besharov and Germanis argue that a sustained effort to make the program more effective should begin with a policy debate about WIC’s role and impacts. “WIC’s rigid spending rules, for example, prevent local programs from spending more than about 30 minutes for nutritional education every 6 months with clients." In the article “WIC Reauthorization: Opportunities for improving the Nutritional Status of Women, Infants, and Children (2002), authors Fox, McManus, and Schmidt from the George Washington University, say local WIC agencies are required to make nutrition education available to participants at least twice in each six-month certification period. The initial nutritional session is usually conducted during the intake appointment with the individual, and subsequent sessions are typically offered in a group format lasting about 10 to 15 minutes. These education sessions are optional than mandatory (2003). This practice raises questions about the efficiency of WIC spending. People doubt the legitimacy of the 30-minute nutritional education since it’s too short to play a part in improving the participant’s nutritional status. Therefore, it’s reasonable to ask: Would it be more effective and efficient if the spending for this session is transferred to other useful areas?

Based on the data mentioned by Alison Jacknowitz from American University and Laura Tiehen from the U.S. Department of Agriculture in their article “Transitions into and out of the WIC Program: A Cause for Concern?”,[19] in 2002 the average retail value of the WIC food benefit for infants ages 4–12 months was $100.37 per month; the average retail value of the child food benefit was $39.29 per month (Institute of Medicine, 2006). The higher retail value of the WIC food benefit for infants is due to the inclusion of infant formula. Since the WIC program encourages breast feeding, it raises a question similar to the foregoing: Would it be more effective and efficient if some of the spending on infant formula is transferred to drawing more participation of WIC, making more people eligible for this program?

Food package

Participants of WIC receive checks, vouchers, or electronic cards to purchase food at participating retail markets each month to supplement their diets. The program food package is designed to address the specific needs of low-income pregnant, breastfeeding, and postpartum non-breastfeeding women; infants; and children up to five years of age who are nutritionally at risk.

The food purchased with WIC vouchers must be on the approved list of approved foods. Up until 2005, the list of approved foods was meant to help supplement participant’s diets to contain the following priority nutrients: protein, calcium, iron, and Vitamins A and C.[20] The literature stated that from the initiation of WIC in 1972 until 2005, the monthly food packages provided by WIC remained largely unchanged despite advances in nutrition knowledge, changes in dietary patterns, increased cultural diversity among WIC participants, and a nationwide epidemic of obesity.[21]

Nationwide data showed that WIC participants had inadequate intake of vitamin E, magnesium, calcium, potassium, and fiber while using the original food packages. Participants also had an excessive intake of saturated fats, sodium, zinc, and preformed Vitamin A.[21] Despite the huge expenditures each month to supplement millions of diets in the country, the program was not delivering the necessary nutrients to this important population made up of women, infants, and children during the most critical time in their lives, drastically affecting future health.

In response to the lack of intended program outcomes, the U.S. Department of Agriculture’s Food and Nutrition Service assigned the Institute of Medicine’s Committee to assess the effectiveness of the food package content.[21] As part of the evaluation, they were to determine the special dietary needs of each subgroup of the WIC participants. This included prioritizing the targeted nutrient intake and offering recommendations for specific changes to the WIC food packages. To do this, the committee was charged with making recommendations that were “culturally suitable, non-burdensome to administration, efficient for nationwide distribution and vendor checkout, and cost-neutral.” [21] These recommendations were implemented in the form of supplemental foods that would counteract the deficiencies and excesses of the WIC food package within the bounds of cost and cultural requirements. This change to the food package was done again in 2009, which put the food package in compliance with the 2005 Dietary Guideline for Americans. This change introduced an inclusion of cash-value vouchers for fruits, vegetables, whole-wheat bread, corn or whole-wheat tortillas, brown rice, oats, bulgur, and barley. Milk purchase options were also altered to only include lower-fat milk for all women and all children over 2 years of age. The adjustment in the food package had a significant effect on participant nutrition.[22]

The literature suggested that there has been a significant increase in the overall nutrition of WIC participants as a result of these food package changes. Participants were surveyed before and after the new food package implementations. The data showed that there was a 17.3 percentage point increase in whole wheat consumption and a 7.2 percentage point increase in the amount of vegetables consumed.[22]

Currently, WIC food packages include infant cereal, iron-fortified adult cereal, fruit rich in vitamin C, vegetable juice, eggs, milk, cheese, peanut butter, beans, and fish. WIC has recently expanded this list to also include soy-based beverages, tofu, baby foods, whole-wheat bread, and a variety of fruits and vegetables.[20]

The literature painted a clear picture of the improvements that have been made and the effect the food package change has made in increasing the nutrition of WIC participants.[22] The literature was also helpful in giving a clear blueprint for future changes in the WIC program including specialty committees, data collection on health effects, food selection, implementation, surveying for effectiveness.[21] Future changes to the food package will be evaluated in the same ways and data will be compared.

Future challenges

According to Food & Nutrition Services (FNS), WIC is one of the nation’s most successful and cost-effective nutrition intervention programs. In spite of its success, the WIC program, just like any other program that involves coordinating and communicating with many people, faces some challenges which limits WIC’s effectiveness in providing its services. The WIC program has been facing challenges especially in delivering high-quality nutrition services, these challenges include: coordinating its nutrition services with health and welfare programs undergoing considerable change in the Health Care System and welfare reform also increases demands on WIC outreach and coordination, responding to new health challenges such as obesity epidemic and participant demographic changes in the low-income population that it serves, recruiting and keeping a skilled staff-WIC agencies rely on Paraprofessionals to deliver services and it is also difficult to allocate the limited resources to train staff who lack needed skills, improving the use of information technology to enhance service delivery and program management, assessing the effect of nutrition services, meeting increased program requirements without a corresponding increase in funding.

According to Food & Nutrition Services (FNS), WIC is one of the nation’s most successful and cost-effective nutrition intervention programs. In spite of its success, the WIC program, as with any program that involves coordination and communication between many people, faces challenges in delivering nutrition services, such as the coordination of its nutrition services with changing health and welfare programs. Welfare reform increases demands on WIC management in performing outreach and coordination. New health challenges include the "obesity epidemic". The demography of the low-income population that the WIC program serves is constantly changing. Retention of staff, employment of paraprofessionals, and the allocation of resources for staff training are additional challenges, along with the use of information technology to assess the effect of nutrition services and to enhance service delivery and program management within the limits of program funding.

In the light of the above challenges, the United States General Accounting Office (GAO) did research and made recommendations to USDA that would help it to identify strategies that will address WIC’s challenges in recruiting and retaining a skilled staff and assessing the effects of nutrition services. It was recommended that:

  • USDA should work with Economic Research Service and the National Association of WIC Directors to conduct an assessment of the staffing needs of state and local WIC agencies. This assessment should examine factors such as staffing patterns, vacancies, salaries, benefits, duties, turnover, and retention.
  • USDA should work with the Economic Research Service, the National Association of WIC Directors, and other stakeholders, including the CDC, to develop a strategic plan to evaluate the impacts of specific WIC nutrition services. This plan should include information on the types of research that could be done to evaluate the impacts of specific nutrition services as well as the data and the financial resources that are needed.

References

External links

  • National WIC Association, a non-profit organization is support of the WIC program
  • WIC programs

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