Caregiver Perspectives on Underutilization of WIC: A Qualitative Study.

OBJECTIVES: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is a federal program that improves the health of low-income women (pregnant and postpartum) and children up to 5 years of age in the United States. However, participation is suboptimal. We explored reasons for incomplete redemption of benefits and early dropout from WIC. METHODS: In 2020-2021, we conducted semistructured interviews to explore factors that influenced WIC program utilization among current WIC caregivers (n = 20) and caregivers choosing to leave while still eligible (n = 17) in Massachusetts. By using a deductive analytic approach, we developed a codebook grounded in the Consolidated Framework for Implementation Research. RESULTS: Themes across both current and early-leaving participants included positive feelings about social support from the WIC clinic staff and savings offered through the food package. Participants described reduced satisfaction related to insufficient funds for fruits and vegetables, food benefits inflexibility, concerns about in-clinic health tests, and in-store item mislabeling. Participants described how electronic benefit transfer cards and smartphone apps eased the use of benefits and reduced stigma during shopping. Some participants attributed leaving early to a belief that they were taking benefits from others. CONCLUSIONS: Current and early-leaving participants shared positive WIC experiences, but barriers to full participation exist. Food package modification may lead to improved redemption and retention, including increasing the cash value benefit for fruits and vegetables and diversifying food options. Research is needed regarding the misperception that participation means "taking" benefits away from someone else in need.

The Revised WIC Food Package and Child Development: A Quasi-Experimental Study.

BACKGROUND AND OBJECTIVES: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), one of the largest US safety net programs, was revised in 2009 to be more congruent with dietary guidelines. We hypothesize that this revision led to improvements in child development. METHODS: Data were drawn from a cohort of women and children enrolled in the Conditions Affecting Neurocognitive Development and Learning in Early Childhood study from 2006 to 2011 (Shelby County, TN; N = 1222). Using quasi-experimental difference-in-differences analysis, we compared measures of growth, cognitive, and socioemotional development between WIC recipients and nonrecipients before and after the policy revision. RESULTS: The revised WIC food package led to increased length-for-age z scores at 12 months among infants whose mothers received the revised food package during pregnancy (ß = .33, 95% confidence interval: 0.05 to 0.61) and improved Bayley Scales of Infant Development cognitive composite scores at 24 months (ß = 4.34, 95% confidence interval: 1.11 to 7.57). We observed no effects on growth at age 24 months or age 4 to 6 years or cognitive development at age 4 to 6 years. CONCLUSIONS: This study provides some of the first evidence that children of mothers who received the revised WIC food package during pregnancy had improved developmental outcomes in the first 2 years of life. These findings highlight the value of WIC in improving early developmental outcomes among vulnerable children. The need to implement and expand policies supporting the health of marginalized groups has never been more salient, particularly given the nation's rising economic and social disparities.

Household Food Security and Infant Adiposity.

OBJECTIVES: Food insecurity has been associated with obesity, but previous studies are inconsistent and few included infants. We examined associations between household food security and infant adiposity and assessed the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and Supplemental Nutrition Assistance Program (SNAP) as effect modifiers. We hypothesized that infants from food-insecure households would have greater adiposity, with attenuation by WIC and SNAP. METHODS: We repeatedly measured 666 infants from the southeastern United States in 2013-2017. We categorized households as high, marginal, low, or very low using the US Household Food Security Survey Module. Outcomes were BMI z score, subscapular and triceps skinfold-for-age z score, the sum of subscapular and triceps skinfolds, the ratio of subscapular and triceps skinfolds, and BMI z score ≥1 (at risk for overweight). We used covariate-adjusted repeated-measures linear and logistic regressions. RESULTS: Of infants, 68.6% were Black and 60.5% had household incomes <$20 000. Interactions between food security and WIC and/or SNAP were not significant. Compared with infants from high food security households, infants from very low food security households had higher BMI z scores (0.18 U; 95% confidence interval [CI] 0.01 to 0.35), higher subscapular skinfold-for-age z scores (0.31 U; 95% CI 0.04 to 0.59), a higher sum of subscapular and triceps skinfolds (0.53 mm; 95% CI 0.002 to 1.07), and greater odds of being at risk for overweight (odds ratio 1.55; 95% CI 1.14 to 2.10). Infants from low food security households had greater odds of being at risk for overweight (odds ratio 1.72; 95% CI 1.17 to 2.10). CONCLUSIONS: In larger and longer studies, researchers should examine food security and adiposity in young children.

Association of Work Requirements With Supplemental Nutrition Assistance Program Participation by Race/Ethnicity and Disability Status, 2013-2017.

Importance: Increased work requirements have been proposed throughout federal safety net programs, including the Supplemental Nutrition Assistance Program (SNAP). Participation in SNAP is associated with reduced food insecurity and improved health. Objectives: To determine whether SNAP work requirements are associated with lower rates of program participation and to examine whether there are racial/ethnic disparities or spillover effects for people with disabilities, who are not intended to be affected by work requirements. Design, Setting, and Participants: This nationally representative, pooled cross-sectional study examined how changes in SNAP work requirements at state and local levels in the US are associated with changes in food voucher program participation. The study combined information on state and local SNAP work requirements with repeated cross-sections from the 2012 through 2017 American Community Survey (with outcomes covering 2013 to 2017). The analytical approaches were based on difference-in-difference and triple-difference methods, after controlling for other economic and social factors. The sample included low-income adults without dependents, stratified by racial/ethnic group and disability status. The study also included parents who would otherwise meet work requirement criteria as a comparison group to estimate triple-difference models. This accounted for otherwise unobserved factors affecting trends in SNAP participation within local areas. Data were analyzed from January 2019 through March 2020. Exposure: Residence in areas where SNAP work requirements apply. Main Outcomes and Measures: The primary outcome is SNAP participation measured by whether anyone in the household received food vouchers at any point over the prior 12 months. Results: The final analytical sample included 866 000 low-income adults (weighted mean [SE] age, 33.6 [0.01] years; 42.5% [SE, 0.07%] men). The racial/ethnic breakdown was 56.5% (SE, 0.07%) non-Hispanic white respondents, 19.4% (SE, 0.06%) non-Hispanic black respondents, 17.7% (SE, 0.06%) Hispanic respondents, 2.5% (SE, 0.02%) Asian respondents, and 3.9% (SE, 0.03%) respondents of other or multiple races. In final triple-difference models, work requirements were associated with a 4.0 percentage point decrease in participation (95% CI, -0.048 to -0.032; P < .001) for childless adults without disability, equivalent to a 21.2% reduction in SNAP participation (95% CI, -25.5% to -17.0%). For childless adults with disability, work requirements were associated with a 4.0 percentage point reduction (95% CI, -0.058 to -0.023; P < .001), equivalent to 7.8% fewer SNAP participants with disability (95% CI, -11.2% to -4.4%). When the final models were stratified by race/ethnicity, benefit reductions were larger for non-Hispanic black adults (7.2 percentage points; 95% CI, -0.092 to -0.051; P < .001) and Hispanic adults (5.5 percentage points; 95% CI, -0.072 to -0.038; P < .001) than for non-Hispanic white adults (2.6 percentage points; 95% CI, -0.035 to -0.016; P < .001). Conclusions and Relevance: Because of the association of SNAP with food security and health, work requirements that lead to benefit loss may create nutritional and health harm for low-income Americans. These findings suggest that there may be racially disparate consequences and unintended harm for those with disability.

Advancing Nutrition in the International Food Assistance Agenda: Progress and Future Directions Identified at the 2018 Food Assistance for Nutrition Evidence Summit.

BACKGROUND: Global food insecurity persists despite continued international attention, necessitating evidence-based food assistance interventions that adequately address nutritional concerns. In June 2018, the US Agency for International Development's Office of Food for Peace through the Food Aid Quality Review (FAQR) project sponsored a "Food Assistance for Nutrition Evidence Summit" to share evidence relevant to policy and programmatic decision-making and to identify critical evidence gaps. OBJECTIVE: This article presents 4 priority areas to advance nutrition in the international food assistance agenda generated through presentations and discussions with the food assistance community at the Evidence Summit. METHODS: Priority areas were identified after the Evidence Summit using a combination of FAQR team discussions, review of presentations and official notes, and supporting literature. RESULTS: Key priority areas to advance nutrition in the international food assistance agenda are as follows: (1) increase research funding for food assistance in all contexts, paying particular attention to emergency settings; (2) research and adopt innovative ingredients, technology, and delivery strategies in food assistance products and programs that encourage long-term well-being; (3) redefine and expand indicators of nutritional status to capture contextual information about the outcomes of food assistance interventions; and (4) augment communication and collaboration across the food assistance ecosystem. CONCLUSIONS: These priorities are critical in a time of increased humanitarian need and will be key to fostering long-term resilience among vulnerable groups.

Postpartum Depression Screening and Referrals in Special Supplemental Nutrition Program for Women, Infants, and Children Clinics.

OBJECTIVES: To examine the relationships among participants' demographic, social, and health characteristics and positive screening scores for symptoms of postpartum depression (PPD); to examine the feasibility of referring to a case management program women with symptoms of PPD who are accessing Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) services; and to identify barriers to screening and treatment programs for women with symptoms of PPD. DESIGN: Descriptive, cross-sectional study followed by a process evaluation. SETTING: Two WIC clinics in a large southeastern U.S. city. PARTICIPANTS: One group (n = 302) included women with infants younger than 12 months who were screened for symptoms of PPD. The second group (n = 31) included case managers (n = 7), nutritionists (n = 12), advisory board members (n = 7), and student volunteers (n = 5) who participated in focus groups. METHODS: We conducted an initial screening of women for symptoms of PPD using the two-item Patient Health Questionnaire (PHQ-2). Participants with scores of 2 or greater (n = 73) were asked to complete the nine-item PHQ (PHQ-9) and the Edinburgh Postnatal Depression Scale. Participants were referred for case management services if they scored 10 or greater on the PHQ-9 or Edinburgh Postnatal Depression Scale (n = 29) and agreed to the referral (n = 19). We transcribed and analyzed the qualitative data recorded during focus groups. RESULTS: Participants with no health insurance and limited support in caring for their infants were more likely to report symptoms of PPD. Overall, 302 women were screened for PPD, indicating the feasibility of PPD screening in WIC clinics. Of the 19 participants referred to case management, 47% (n = 9) accessed care. The results of focus groups illuminated barriers to screening and treatment programs for women at the individual, local, and macrosystem levels. CONCLUSION: Our findings show the feasibility of PPD screening in WIC clinics. However, some participants did not receive mental health services after referral because of various barriers, which highlights the need to integrate mental health providers into WIC clinics.

Effect of Change in the Supplemental Nutrition Assistance Program Guidelines on Vendor Participation and Availability of Fresh Produce.

INTRODUCTION: In January 2018, new vendor eligibility standards for the Supplemental Nutrition Assistance Program (SNAP) were fully implemented to increase availability of healthy staple and perishable foods. We examined changes in SNAP vendor participation and availability of fresh fruits and vegetables (FFV) both short-term (2015 vs 2018) and long term (2003 vs 2018) in an urban, low-income community. METHODS: We conducted food store assessments from late June through early September of 2003, 2009, 2012, 2015, and 2018 in Albany, New York. SNAP status was assessed by using the US Department of Agriculture's list of SNAP-authorized stores and in-store verification. RESULTS: Numbers of SNAP vendors were 77 in 2003, 92 in 2009, 103 in 2012, 115 in 2015, and 109 in 2018. We observed a marginally significant (P = .049) short-term (2015, 85.9% vs 2018, 73.9%) decline in SNAP participation among convenience stores but no significant short-term changes in FFV availability among either SNAP or non-SNAP vendors. In long-term (2003 through 2018) trends, we found significant (P < .01) increases in SNAP participation among farmers markets and nonprofit organizations. The proportion of SNAP vendors stocking only 1 type of FFV also significantly increased, which was likely related to a consumer trend of favoring bananas as a grab-and-go snack. CONCLUSION: Despite the decline of SNAP participation among convenience stores, which primarily came from increased program withdrawals, the new SNAP rule did not substantially alter FFV availability after 6 to 8 months of its full implementation. Long term, policy efforts increased SNAP participation among farmers markets.

National Trends in Food Insecurity and Congregation-Based Food Provision between 1998 and 2012.

Food insecurity has been a persistent problem in the U.S., and yet over the past three decades, federally funded food programs have become more restrictive. Scholars and policymakers have inquired whether the nonprofit sector is increasing its food provision activities to address this unmet need. This study analyzes data from the U.S. Census and a nationally representative survey of religious congregations in the U.S. to examine trends in food insecurity and congregation-based food provision between 1998 and 2012. The objective of the study is to investigate the extent to which congregation-based food provision fluctuated with national food insecurity prevalence for the overall population, and for subgroups vulnerable to this condition. Results show an over-time correspondence between the prevalence of food-insecure households and the prevalence of congregations that provide food. Parallel patterns are observed between food insecurity in disproportionately affected subpopulations (e.g., African-Americans and immigrants) and food provision in the congregations likely to serve those households. These findings indicate that congregations are helping meet the needs of food-insecure households. However, research suggests that congregations and nonprofits are not an adequate substitute for federally funded programs. Policy recommendations include expanding access to federally funded programs like the Supplemental Nutrition Assistance Program (SNAP) to more immigrants and other groups vulnerable to food insecurity, as well as providing more systematic financial or federal support and quality control of congregation-based efforts.

WIC Food Package Changes: Trends in Childhood Obesity Prevalence.

OBJECTIVES: To evaluate the association of the 2009 changes to the US Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food package and childhood obesity trends. We hypothesized that the food package change reduced obesity among children participating in WIC, a population that has been especially vulnerable to the childhood obesity epidemic. METHODS: We used an interrupted time-series design with repeated cross-sectional measurements of state-specific obesity prevalence among WIC-participating 2- to 4-year-old children from 2000 to 2014. We used multilevel linear regression models to estimate the trend in obesity prevalence for states before the WIC package revision and to test whether the trend in obesity prevalence changed after the 2009 WIC package revision, adjusting for changes in demographics. In a secondary analysis, we adjusted for changes in macrosomia and high prepregnancy BMI. RESULTS: Before the 2009 WIC food package change, the prevalence of obesity across states among 2- to 4-year-old WIC participants was increasing by 0.23 percentage points annually (95% confidence interval: 0.17 to 0.29; P < .001). After 2009, the trend was reversed (-0.34 percentage points per year; 95% confidence interval: -0.42 to -0.25; P < .001). Changes in sociodemographic and other obesity risk factors did not account for this change in the trend in obesity prevalence. CONCLUSIONS: The 2009 WIC food package change may have helped to reverse the rapid increase in obesity prevalence among WIC participants observed before the food package change.

Food and Beverage Intake From 12 to 23 Months by WIC Status.

: media-1vid110.1542/5984243449001PEDS-VA_2018-2274Video Abstract BACKGROUND: In 2009, the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) revised its food packages to align with updated nutrition science. Understanding how these revisions may impact current consumption patterns could be important. METHODS: Dietary data from the 2011-2014 NHANES were used to estimate the percentage of children who were aged 12 to 23 months consuming selected food and beverage categories on any given day by age and WIC status (children who were on WIC, those who were eligible for but not receiving WIC benefits, and those who were not eligible for WIC). RESULTS: Consumption of food and beverage categories differed by WIC status. On a given day, a lower percentage of children who were eligible for but did not receive WIC benefits consumed vegetables (excluding white potatoes; 42.3%) and grains (76.5%) compared with children who were participating in WIC (vegetables [excluding white potatoes]: 60.4%; grains: 85.5%) and those who were not eligible for WIC benefits (vegetables [excluding white potatoes]: 58.1%; grains: 87.2%; P < .05). A lower percentage of both children who were eligible for but not receiving WIC benefits and those who were participating in WIC consumed fruits (57.6% and 70.6%, respectively) and snacks (45.9% and 48.5%, respectively) than those who were not eligible for WIC (fruits: 86.4%; snacks: 69.1%; P < .05). A lower percentage of children who were receiving WIC consumed dairy than children who were not eligible for WIC (91.7% and 97.2%, respectively; P < .05). A higher percentage of those who were receiving WIC consumed 100% juice (70.6%) than children who were eligible for but not receiving WIC (51.6%) and children who were not eligible for WIC (50.8%; P < .05). CONCLUSIONS: Improving early WIC participation and retention could positively impact some diet-related disparities among young children who are eligible for WIC.

School Mid-day Meal Programme in India: Past, Present, and Future.

The National Programme for Nutrition Support for Primary Education was initiated in 1995 with two major objectives: universalisation of primary education and improvement in nutritional status of primary school children. The Central Government provided 100 g of wheat /rice per day free of cost to children studying in classes I-V in all Government, local body and Government aided primary schools. Kerala, Orissa, Tamil Nadu, Chattisgarh and MP provided hot cooked meals using the cereals provided but all other states and UTs provided 3 kg cereals/month to children with 80% attendance. By 2001, over 100 million students in 7,92,000 schools were covered under the programme. There was some improvement in enrolment but the programme had no impact on classroom hunger. In 2001 the Supreme Court of India ruled that Mid-day meal (MDM) is a legal entitlement for all school children and that the government should provide a hot cooked mid-day meal for 200 d to all primary school children. In the last decade, universal primary education and MDM have been achieved. MDM is providing hot cooked meals every day to about 100 million children. Cereal content of MDM is adequate but pulse and vegetable content of MDM are inadequate; these lacunae have to be addressed. School health services in co-ordination with MDM can identify under-nourished, normal and over-nourished children by using Body mass index (BMI) for age, and provide appropriate counseling and care. If this practice is institutionalized and routinely followed, there can be substantial improvement in nutritional status of children.

Evolución de los programas de ayuda alimentaria en México a través de información de la Ensanut MC 2016 / Evolution of social food assistance programs in Mexico through Ensanut MC 2016 data

Resumen: Objetivo: Describir la cobertura y focalización de los Programas de Ayuda Alimentaria (PAA) en México. Material y métodos: Se obtuvo información de 9137 hogares de la Encuesta Nacional de Salud y Nutrición Medio Camino (Ensanut MC) 2016 sobre los PAA que reciben. Se analizó la distribución de los PAA por lugar de residencia, índice de nivel socioeconómico y pertinencia los PAA. Resultados: El 44% de los hogares recibe algún PAA, con mayor concentración en hogares indígenas (70%), de muy bajo nivel socioeconómico (70%) y en inseguridad alimentaria moderada y severa. Los PAA con mayor cobertura fueron Prospera (21%), Liconsa (9%), Programa de Desayunos Escolares (17%) y el Programa de Adultos Mayores; de éstos, el programa mejor focalizado fue Prospera. Conclusiones: Es necesario revisar los recursos de los programas y dirigirlos a la población con mayores carencias y mayor vulnerabilidad nutricional.

Abstract: Objective: To describe the coverage and targeting of Social Food Assistance Programs (SFAP) in Mexico. Materials and methods: Data were obtained from 9137 households of the Halfway National Health and Nutrition Survey 2016 (Ensanut MC 2016) who receive SFAP. The distribution of the SFAP by place of residence, index of socioeconomic status and SFAP relevance were analyzed. Results: 44% of households receive some SFAP, with a higher concentration in indigenous households (70%), a very low socioeconomic level (70%), and moderate and severe food insecurity. The SFAP with the greatest coverage were Prospera (21%), Liconsa (9%), School Breakfasts Program (17%) and the Support Program for Older Adults; of these the best-focused program was Prospera. Conclusions: It is necessary to review the resources of the programs and direct them to the population with greater deficiencies and greater nutritional vulnerability.

[Evolution of social food assistance programs in Mexico through Ensanut MC 2016 data]. / Evolución de los Programas de Ayuda Alimentaria en México a través de información de Ensanut MC 2016.

OBJECTIVE: To describe the coverage and targeting of Social Food Assistance Programs (SFAP) in Mexico. MATERIALS AND METHODS: Data were obtained from 9 137 households of the Halfway National Health and Nutrition Survey 2016 (Ensanut MC 2016) who receive SFAP. The distribution of the SFAP by place of residence, index of socioeconomic status and SFAP relevance were analyzed. RESULTS: 44% of households receive some SFAP, with a higher concentration in indigenous households (70%), a very low socioeconomic level (70%), and moderate and severe food insecurity. The SFAP with the greatest coverage were Prospera (21%), Liconsa (9%), School Breakfasts Program (17%) and the Support Program for Older Adults; of these the best-focused program was Prospera. CONCLUSIONS: It is necessary to review the resources of the programs and direct them to the population with greater deficiencies and greater nutritional vulnerability.

OBJETIVO: Describir la cobertura y focalización de los Programas de Ayuda Alimentaria (PAA) en México. MATERIAL Y MÉTODOS: Se obtuvo información de 9 137 hogares de la Encuesta Nacional de Salud y Nutrición Medio Camino (Ensanut MC) 2016 sobre los PAA que reciben. Se analizó la distribución de los PAA por lugar de residencia, índice de nivel socioeconómico y pertinencia los PAA. RESULTADOS: El 44% de los hogares recibe algún PAA, con mayor concentración en hogares indígenas (70%), de muy bajo nivel socioeconómic (70%) y en inseguridad alimentaria moderada y severa. Los PAA con mayor cobertura fueron Prospera (21%), Liconsa (9%), Programa de Desayunos Escolares (17%) y el Programa de Adultos Mayores; de éstos, el programa mejor focalizado fue Prospera. CONCLUSIONES: Es necesario revisar los recursos de los programas y dirigirlos a la población con mayores carencias y mayor vulnerabilidad nutricional.

A Summer Nutrition Benefit Pilot Program and Low-income Children's Food Security.

BACKGROUND: Federal summer meals programs serve less than one-sixth of children that receive free or reduced-price meals during the school year. To address this gap in food assistance for school-aged children, the Summer Electronic Benefits Transfer for Children (SEBTC) Demonstrations provided summer food assistance in the form of electronic benefits transfer cards to households with school-aged children certified for free or reduced-price meals during the school year. METHODS: Over 2011-2013, the SEBTC demonstrations were evaluated by using a random assignment design. Households were randomly assigned a monthly $60-per-child benefit, a monthly $30-per-child benefit, or no benefit, depending on the study year. Key outcomes included children's food security and consumption of foods and food groups related to a healthful diet (diet quality). At baseline (in the spring) and again in the summer, the evaluation surveyed ∼52 000 households over the course of the 3 years of the impact study. RESULTS: SEBTC reduced the prevalence of very low food security among children by one-third. It also had positive impacts on 6 of the 8 child nutrition outcomes measured (amounts of fruits and vegetables; whole grains; dairy foods; and added sugars). CONCLUSIONS: SEBTC is a promising model to improve food security and the dietary quality of low-income school-aged children in the summer months.