Food Insecurity and Mental Distress Among WIC-Eligible Women in the United States: A Cross-Sectional Study.

BACKGROUND: Women living in Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)-eligible households may be pregnant or breastfeeding. Stress during pregnancy and breastfeeding may influence women's mental health making them more vulnerable to higher rates of food insecurity (FI). OBJECTIVE: Determine whether or not FI is associated with moderate-to-severe mental distress among women living in WIC-eligible households, and whether or not the strength of the association differs among WIC participants compared with eligible nonparticipants with low income. DESIGN: Cross-sectional data from the 2011-2018 National Health Interview Survey were utilized. PARTICIPANTS/SETTING: A total of 7,700 women living in WIC-eligible households with at least one child were analyzed. MAIN OUTCOME MEASURES: Moderate-to-severe mental distress was measured using the validated K6 nonspecific psychological distress scale. FI was measured using the 10-item, US Adult Food Security Survey Module. STATISTICAL ANALYSES PERFORMED: Multivariate logistic regression was used to examine the association between FI and mental distress. The conditional effects of WIC participation were examined by including interaction terms for FI and WIC participation as well as by stratifying the sample by WIC participation. RESULTS: Among women in WIC-eligible households, FI was associated with moderate-to-severe mental distress in a dose-response fashion: compared with those who were food secure, the adjusted odds of moderate-to-severe mental distress were 1.8 times higher among those with marginal food security (adjusted odds ratio [AOR] 1.83, 95% CI 1.50 to 2.23), 2.1 times higher among those with low food security (AOR 2.14, 95% CI 1.76 to 2.60), and 3.7 times higher among those with very low food security (AOR 3.73, 95% CI 2.95 to 4.71). The interaction between FI and WIC participation was not significant, with similar associations between FI and mental distress among WIC participants and nonparticipants. CONCLUSIONS: Among this nationally representative sample of women in WIC-eligible households, increasing severity of food insecurity was associated with poor mental health among WIC participants and nonparticipants. WIC participation was not observed to moderate the association between FI and mental distress. More research should consider including mental health screening at WIC clinic visits to enable early identification and referral for care.

Women, Infants, and Children enrollment and pregnancy-related behaviors and outcomes among Medicaid recipients in the United States.

BACKGROUND: Nearly 40% of pregnant women in 2016 were enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Prior studies have investigated nutritional behaviors among WIC participants and access to WIC breastfeeding counseling services. However, there are no (few?) nationally representative, large-scale analyses of WIC users and pregnancy behaviors. Thus, the present study aims to examine associations between WIC use and select pregnancy outcomes among Medicaid enrollees. METHODS: We examined pregnancy-related behaviors and outcomes using 2018 U.S. Birth Certificates for Medicaid patients aged 18-45 years (N = 1 159 263). Outcomes included prenatal care (PNC) adequacy, breastfeeding initiation, cigarette use, and gestational weight gain. Standard binary and multinomial logistic regressions were used to estimate odds ratios (OR) and 95% confidence intervals (CIs). RESULTS: After adjustment, WIC users had statistically significant increased odds of adequate PNC (adjusted OR [AOR] = 1.31 [95% CI 1.30, 1.32]), cigarette use (quit smoking during pregnancy 1.09 [1.07, 1.11]; smoked throughout pregnancy 1.16 [1.14, 1.18], and exceeding recommendations of weight gain 1.07 [1.06, 1.08]) compared with non-WIC users. WIC enrollees also experienced decreased odds of breastfeeding initiation (0.85 [0.85, 0.86]) compared with non-WIC users. CONCLUSIONS: The study underscores the value of the WIC program in improving access to PNC. Yet, low-income women remain at risk for smoking during pregnancy and exceeding the recommended amount of weight gain. Breastfeeding initiation is lower than anticipated among WIC participants. Additional studies are needed to investigate WIC program efficacy.

The effect of the 2009 WIC revision on maternal and child health: A quasi-experimental study.

BACKGROUND: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is the largest U.S. nutrition program for low-income pregnant women. It was revised in 2009, with the goal of improving nutritional content of food packages, enhancing nutrition education, and strengthening breast feeding support. Few studies have assessed the effects of this revision on perinatal health. OBJECTIVES: To investigate the impact of the revised WIC program on maternal and child health in a large, multi-state data set. METHODS: We conducted a quasi-experimental difference-in-differences analysis, comparing the pre/post changes among WIC recipients to changes among non-recipients. We adjusted for key sociodemographic covariates in multivariable linear models. We used data from the Pregnancy Risk Assessment Monitoring System (PRAMS) for 18 states from 2004 to 2017. 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. CONCLUSIONS: The revised WIC program was associated with improvements in women's gestational weight gain and infant breast feeding.

Longer Family Participation in WIC is Associated With Lower Childhood Sugar-Sweetened Beverage Intake.

OBJECTIVE: To evaluate if children of families with a longer duration of participation in the Special Supplementation Nutrition Program for Women, Infants, and Children (WIC) consume fewer sugar-sweetened beverages (SSB) and more water. DESIGN: A repeated cross-sectional study. SETTING: Conducted among representative samples of WIC-participating families in Los Angeles County, California, in 2014, 2017, and 2020. PARTICIPANTS: Children aged 4-59 months participating in WIC. MAIN OUTCOME MEASURES: Daily servings of total SSBs, daily servings of specific types of SSBs, and daily servings of water. ANALYSIS: Multivariable count regression models were used to estimate incidence rate ratios (IRR) and 95% confidence intervals (CI) for associations of the duration of family WIC participation with daily servings of total SSBs, water, and specific types of SSBs. Zero-inflated negative binomial regression models were used for total SSBs and specific types of SSBs, and Poisson regression was used for water. RESULTS: Children of families with 2 years of WIC participation consumed significantly fewer daily servings of total SSBs (IRR, 0.95; 95% CI, 0.93-0.98; P = 0.002), fruit-flavored SSBs (IRR, 0.95; 95% CI, 0.91-0.99; P = 0.02), soda (IRR, 0.86; 95% CI, 0.76-0.98; P = 0.02), and water (IRR, 0.99; 95% CI, 0.98 to < 1.00; P = 0.03) than children of families with 1 year of WIC participation. Protective associations for total SSBs, fruit-flavored SSBs, and soda remained statistically significant and increased in magnitude through 10 years of family WIC participation. CONCLUSIONS AND IMPLICATIONS: Duration of WIC participation was associated with decreased SSB intake by young children. Given the role that increasing water intake in lieu of SSBs plays in child obesity, improving the effectiveness of WIC nutrition education on parental perceptions and provision of fruit-flavored SSBs and water to their children merits detailed evaluation.

Women, Infants, and Children Cash Value Benefit Redemption Choices in the Electronic Benefit Transfer Era.

PURPOSE: This study aims to examine the relationship between cash value benefit (CVB) redemption outcomes in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) across food processing types and socio-demographics. DESIGN: Cross-sectional and panel analyses. SETTING: Virginia. SUBJECTS: 98,067 Virginia WIC households. MEASURES: CVB redemption rate. RESULTS: The predominant share of CVB redemption was for fresh produce (77.3%). Non-Hispanic whites and blacks redeemed a smaller share of fresh produce than Hispanic participants (P < .001). Non-Hispanic black WIC households have a significantly lower CVB redemption rate than non-Hispanic white WIC households (ß = -.008, P < .001). Households with a child participant tend to have a higher redemption rate (ß = .01, P < .001). The redemption rates of fruits and of vegetables were positively correlated with household size. CONCLUSIONS: Minority status and household size were significantly related to CVB redemptions among Virginia WIC participants.

Process Evaluation of a Farm-to-WIC Intervention.

BACKGROUND: Despite the promise of farm-to-institution interventions for addressing limited vegetable access as a barrier to intake, programs designed for the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) are lacking. As such, little is known about the implementation of, and mechanisms of action through which, farm-to-WIC interventions affect vegetable intake and participant satisfaction with such programs. OBJECTIVE: To examine whether a farm-to-WIC intervention to promote vegetable intake was implemented as intended, differences between participants who received the intervention relative to those in a usual-care control group in intermediate outcomes of vegetable-related knowledge, attitudes, and behaviors, and secondary outcomes of physical activity and weight status; and participant satisfaction with the intervention. DESIGN: A process evaluation encompassing descriptive and comparative analyses of implementation fidelity logs and survey data collected as part of a pilot study was conducted. PARTICIPANTS/SETTING: The setting was a large, New Jersey-based, urban WIC agency. Recruited between June 3 and August 1, 2019 through 3 of the agency's 17 sites (1 intervention and 2 control sites), participants were 297 primarily Hispanic adults (160 enrolled at the intervention site and 137 at control sites). INTERVENTION: The intervention combined behaviorally focused instruction and handouts with the introduction of a WIC-based farmers' market, field trips to an area farmers' market, telephone coaching and support, and recipe demonstrations and tastings. MAIN OUTCOME MEASURES: Primary outcomes were vegetable intake (measured via self-report and objectively using dermal carotenoids as a biomarker of intake) and the redemption of vouchers provided by WIC for fruit and vegetable purchases at farmers' markets (measured objectively using data provided by WIC). For the process evaluation, logs were used to document program activities. Vegetable-related knowledge, attitudes, and behaviors, physical activity, and satisfaction with the intervention were assessed with participant questionnaires. Weight status was assessed with direct measures of height and weight. Data were collected at baseline and at mid- and post-intervention (3 and 6 months post-baseline, respectively). STATISTICAL ANALYSES PERFORMED: Descriptive statistics were used to characterize implementation fidelity. Associations between intermediate and secondary outcomes and vegetable intake were examined at baseline with Pearson correlations. Post-baseline between-group differences in the outcomes were examined with linear mixed-effects models adjusted for baseline values and covariates. Satisfaction with the intervention was assessed with inferential and thematic analyses. RESULTS: Post-intervention, measures of vegetable intake were higher in the intervention relative to the control study group. Receipt of the intervention was also associated with a greater likelihood of voucher redemption. Nearly all participants (≥94%) received the intervention as intended at the WIC-based farmers' market; smaller percentages completed 1 or more planned trips to the area farmers' market (28%) and telephone coaching and support calls (88%). Although most intermediate and secondary outcomes were associated with measures of vegetable intake at baseline, the variables did not differ between study groups post-intervention. Mean satisfaction ratings were ≥6.8 on a 7-point scale. Recipe demonstrations, learning about vegetables, field trips, and the rapport with staff were liked most about the program. Although adding days and times for field trips was suggested, limited market days and hours of operation limited the ability to do so. CONCLUSIONS: Preliminary data highlight the promise of this well-received intervention. Intermediate outcome findings suggest that other potential intervention mechanisms of action should be considered in future large-scale trials of this program. Broad-scale initiatives are needed to improve access to farmers' markets in underserved communities.

The Magnitude and Determinants of Partial Redemptions of Food Benefits in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC).

PURPOSE: WIC provides food assistance to low-income pregnant and postpartum women, infants, and children ages 1- 4. A partial redemption (PR) occurs when a participant redeems only a portion of the prescribed benefit, thereby not obtaining the full nutritional benefit. We study the magnitude and determinants of PRs using electronic benefit transfer data. DESIGN/SETTING: Statistical analysis of all WIC transactions from Feb 2016 to Nov 2018. SUBJECTS: Oklahoma WIC participants. MEASURES: The probability of a WIC household fully redeeming a food category. A random effects probit model is used to study determinants of PRs. ANALYSIS: Estimate the marginal effects of key variables on households' likelihood of full redemption: location-urban/rural, number of members in WIC, duration in the program, number of shopping trips, shopping venue, and prescribed foods. RESULTS: Overall 18.5% of $ value of benefits are unredeemed, 29.3% excluding formula. Some foods have PRs > 40%. Only 17.3% of households fully redeem benefits in a given month. PRs increase with number of household members in WIC and duration of participation. PRs are lower for participants in rural locations, who shop more frequently, and who shop at WIC-specialized stores. CONCLUSIONS: Food packages with high PRs fail to impart prescribed benefits. Results pinpoint products and household characteristics associated with PRs, enabling targeted nutritional counseling and suggest food package choices need to be made with participant acceptance in mind.

Pilot Study of a Farm-to-Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Intervention Promoting Vegetable Consumption.

BACKGROUND: Vegetable intake is below recommended levels among adults served by the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). OBJECTIVE: The aim of this study was to determine whether a novel, theory-driven, farm-to-WIC intervention to promote vegetable intake showed promise of being successful and is therefore appropriate for efficacy testing. DESIGN: From June 2019 to January 2020, the intervention was piloted in three WIC agency sites (one randomized to the intervention study group and two to the control group) selected based on similarity in size and the demographics of participants served. PARTICIPANTS/SETTING: Recruited between June 3, 2019 and August 1, 2019, participants were 297 primarily Hispanic adults served by a large WIC agency located in a densely populated urban area in New Jersey (160 were enrolled at the intervention site and 137 at control sites). INTERVENTION: The intervention combined behaviorally focused instruction and handouts with the introduction of a WIC-based farmers' market, field trips to an area farmers' market, telephone coaching and support before and after trips, and recipe demonstrations and tastings. MAIN OUTCOME MEASURES: The primary outcomes were vegetable intake (measured objectively using dermal carotenoids as a biomarker of intake and via self-report) and the redemption of vouchers provided through the WIC Farmers' Market Nutrition Program (FMNP) for fruit and vegetable purchases at farmers' markets (objectively assessed using data provided by WIC). STATISTICAL ANALYSES PERFORMED: Between-group differences in vegetable intake were examined at mid- and post-intervention (3 and 6 months post-baseline, respectively) with linear mixed-effects models adjusted for baseline vegetable intake and covariates. Logistic regression analysis was used to relate FMNP voucher redemption to study group and covariates. RESULTS: At mid-intervention, objectively measured vegetable intake was higher among participants in the control group as compared with the intervention group; self-reported intake did not differ by group. Post-intervention, objectively measured and self-reported vegetable intake were higher among participants in the intervention group as compared with the control group. Receipt of the intervention was associated with a greater likelihood of FMNP voucher redemption. Voucher redemption rates were 87% in the intervention group and 28% in the control group (odds ratio = 17.39, 95% confidence interval [8.64, 35.02]). CONCLUSIONS: Meaningful associations found between the intervention, vegetable intake, and FMNP voucher redemption suggest that the program is appropriate for efficacy testing.

Recruitment and retention of WIC participants in a longitudinal dietary intervention trial.

BACKGROUND: This paper describes strategies and outcomes of techniques to recruit and retain low-income women served by the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in a longitudinal dietary intervention trial. METHODS: Community engagement strategies, methods to recruit and retain participants, and recruitment and retention rates are reported. Demographic and lifestyle predictors of loss to follow-up, contacts required to reach participants at each data collection point, participant reactions to the recruitment and retention strategies used, and reasons for drop out (assessed among those who discontinued their study involvement) also were examined. RESULTS: Of 1281 eligible women, 744 were enrolled (58% recruitment rate); retention rates were 87%, 70%, and 55%, respectively, 2 weeks and 3 and 6 months post-intervention. Being unmarried, younger, and having low baseline vegetable intake predicted loss to follow-up. Between 4 and 5 contact attempts and 1 and 2 completed contacts were required to reach participants at each data collection point. Participants endorsed recruiting women while waiting for WIC appointments (as they were accessible, perceived the information provided as informative, and wanted to pass the time) and by word of mouth. Lacking time and loss of interest were commonly reported reasons for not completing assessments and dropout. To improve retention, shortening telephone assessments, conducting the assessments in person, and increasing the amount of incentives were recommended. CONCLUSION: Despite using recommended strategies, recruitment and retention rates were modest. Research is needed to identify and test approaches to effectively engage WIC-enrolled adults in health intervention trials.

Outcome Evaluation of the You Can Do It Initiative to Promote Exclusive Breastfeeding Among Women Enrolled in the New York State WIC Program by Race/Ethnicity.

OBJECTIVE: To evaluate the effectiveness of You Can Do It at improving exclusive breastfeeding (BF) among New York State women enrolled in Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). DESIGN: Quasi-experimental study, September, 2013 through February, 2016. SETTING: Multicomponent intervention paired with a yearlong learning community in 12 clinics. PARTICIPANTS: Women who were enrolled in WIC during the first trimester, intended to breastfeed or were undecided, and continued in WIC after delivery, comprised 1 baseline cohort (n = 688) and 2 intervention cohorts: Breastfeeding Attrition Prediction Tool (BAPT) (consented, n = 362) and non-BAPT (declined, n = 408). INTERVENTION: The BAPT was offered to all eligible women in the intervention enrollment period. Consenting women received multiple counseling sessions tailored to individual BAPT results throughout pregnancy and were contacted promptly after delivery. MAIN OUTCOME MEASURE(S): Prevalence of exclusive BF at 7, 30, and 60 days. ANALYSIS: Multivariate logistic regression, stratified by race/ethnicity. Statistical significance set at P < .05. RESULTS: Prevalence of exclusive BF at 7 and 30 days was significantly higher among BAPT women compared with non-BAPT or baseline cohorts. Non-Hispanic black and Hispanic women in the BAPT cohort achieved significantly higher exclusive BF rates at 30 and 60 days compared with those in non-BAPT and baseline cohorts. CONCLUSIONS AND IMPLICATION: The initiative seems to be effective at increasing exclusive BF, particularly among non-Hispanic black and Hispanic women in the New York State WIC program.

Outcomes of a randomized controlled trial of nutrition education to promote farmers' market fruit and vegetable purchases and consumption among women enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).

BACKGROUND: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides participants seasonal Farmers' Market Nutrition Program (FMNP) vouchers to purchase fruits and vegetables (FV) at farmers' markets and monthly cash value vouchers (CVV) redeemable at farmers' markets. Despite the promise of FMNP vouchers and CVV for improving FV access among WIC participants, voucher redemption rates are low. This study evaluated WIC Fresh Start (WFS), a theory-driven, web-based lesson to promote FV intake, the redemption of CVV at farmers' markets, FMNP voucher redemption, and farmers' market-related knowledge, attitudes, and skills among women enrolled in WIC. METHODS: The lesson was evaluated in a four-arm randomized controlled trial. The setting was a large New Jersey-based WIC agency located in a densely populated, urban area. Participants (N = 744) were stratified based on FMNP voucher receipt and randomized to receive the WFS lesson or WIC online existing health education. Lesson effects on targeted outcomes were examined at posttest (2 weeks after the lesson) and 3 and 6 months after posttesting. RESULTS: Receipt of the WFS lesson was associated with FMNP voucher redemption (in the subset of participants preferring to speak Spanish); improvements in knowledge of the FMNP, locally grown seasonal items, seasonal items found at farmers' markets in July, WIC-authorized farmers' markets and food- and farmers' market-specific knowledge; ever having purchased and intentions to purchase FV at a farmers' market; FV food safety and preparation skills; and modest gains in the redemption of CVV at farmers' markets. FV intake did not differ over time by trial arm. CONCLUSIONS: Findings aid understanding of effective approaches to promote farmers' market use and farmers' market-related knowledge and skills among WIC participants. Further research is needed to explore factors that may explain the lack of lesson effects on FV intake. TRIAL REGISTRATION: NCT02565706.

Sleep Duration, Sedentary Behaviors, and Physical Activity across Weight Status in Hispanic Toddlers' Participants of the WIC Program.

OBJECTIVE: To describe physical activity, sedentary behaviors and sleep duration in toddlers' participants of the WIC program in Puerto Rico and assess its association with excessive weight. METHODS: This was a cross-sectional analysis of data gathered in the follow-up visit (12 months later) of a longitudinal study among toddlers 12-36 months old participants of the WIC program. In this follow-up visit, a Sleep, Sedentary Behaviors and Physical Activity Questionnaire was included. RESULTS: From the 213 eligible participants for the follow-up visit, 76 completed the follow-up visit. Most were girls (52.6%), with median age 21 months and most were categorized as healthy weight (76.3%). In general, toddlers spent a total median of 142 min/d in sedentary behaviors, 300 min/d in physical activities and 690 min/d sleeping. There was a higher duration of physical activities among overweight/obese compared to healthy weights (p<0.05) but similar duration of sedentary behaviors and sleep by weight status (p>0.05). There was a greater proportion of overweight/obese toddlers meeting the screen time recommendation (88.9%) compared to healthy weight toddlers (62.1%; p<0.05). Also, there was a significant positive age-adjusted correlation between time spent in unstructured physical activity (R=0.23, p<0.05) with weight-for-length z-score. Infant weight status was not significantly correlated to parent's perception or knowledge of physical activity or sleep in toddlers (p>0.05). CONCLUSION: Most toddlers studied met the recommendations for duration of sleep, sedentary behaviors, and physical activity. Overweight/obese toddlers engage in more physical activities than those with a healthy weight status. These findings could be due to educational interventions by the WIC program to promote physical activities, as these toddlers are active WIC participants.

A Critical Review of the Marketing Claims of Infant Formula Products in the United States.

A highly competitive infant formula market has resulted in direct-to-consumer marketing intended to promote the sale of modified formulas that claim to ameliorate common infant feeding problems. The claims associated with these marketing campaigns are not evaluated with reference to clinical evidence by the Food and Drug Administration. We aimed to describe the language of claims made on formula labels and compare it with the evidence in systematic reviews. Of the 22 product labels we identified, 13 product labels included claims about colic and gastrointestinal symptoms. There is insufficient evidence to support the claims that removing or reducing lactose, using hydrolyzed or soy protein or adding pre-/probiotics to formula benefits infants with fussiness, gas, or colic yet claims like "soy for fussiness and gas" encourage parents who perceive their infants to be fussy to purchase modified formula. Increased regulation of infant formula claims is warranted.

Women Infant and Children program participants' beliefs and consumption of soy milk : Application of the Theory of Planned Behavior.

The purpose of this study was to determine if Theory of Planned Behavior (TPB) variables predict soy milk intake in a sample of WIC participants in 2 Illinois counties (n = 380). A cross-sectional survey was used, which examined soy foods intake, behavioral beliefs, subjective norms, motivation, and intention. Soy product intake was low at both sites, and many participants (40%) did not know that soy milk was WIC approved. Most (> 70%) wanted to comply with their health care providers, but didn't know their opinions about soy milk (50-66%). Intention was significantly correlated with intake (0.507, P ≤ 0.01; 0.308, P ≤ 0.05). Environmental beliefs (0.282 and 0.410, P ≤ 0.01) and expectancy beliefs (0.490 and 0.636, P ≤ 0.01) were correlated with intention. At site 1, 30% of the variance in intention to consume soy milk was explained by expectancy beliefs and subjective norm beliefs (P < 0.0001); at site 2, 40% of the variance in intention was explained by expectancy beliefs. The TPB variables of expectancy beliefs predicted intention to consume soy milk in WIC participants. Therefore, knowing more about the health benefits of soy and how to cook with soy milk would increase WIC participants' intention to consume soy milk. Positive messages about soy milk from health care providers could influence intake.