Longer Participation in the Special Supplemental Nutrition Program for Women, Infants, and Children Is Not Associated with Reduced Sugar-Sweetened Beverage Intake among Black Participants.

This study assessed relationships of duration of family Special Supplemental Nutrition Program for Women, Infants and Children (WIC) participation with racial/ethnic disparities in child sugar-sweetened beverage (SSB) and water intake. Child beverage intake and family duration on WIC were collected during three cross-sectional surveys of WIC-participating families in Los Angeles County, California (2014, 2017 and 2020; n = 11,482). The associations of family duration of WIC participation, a proxy for the amount of WIC services received, with daily intake of total SSBs, fruit-flavored SSBs and water were assessed in race/ethnicity strata with multivariable negative binomial and Poisson regression models. Among English-speaking Hispanic children, those of families reporting 10 years of WIC participation consumed 33% and 27% fewer servings of total and fruit-flavored SSBs compared to those of families reporting 1 year on WIC. Among Black children, those from families reporting 5 and 10 years of participation in WIC consumed 33% and 45% more daily servings of fruit-flavored SSBs than those from families reporting 1 year on WIC. Disparities in daily total and fruit-flavored SSB intake between Black and White children increased with longer family duration on WIC. Duration of family WIC participation is associated with healthier beverage choices for infants and children, but does not appear to be equally beneficial across racial/ethnic groups in Los Angeles County.

Alignment of California WIC Participant Preferences With Proposed WIC Food Package Recommendations.

OBJECTIVE: Assess alignment of Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participant preferences with the National Academies of Sciences, Engineering, and Medicine WIC child food package recommendations and compare differences by race/ethnicity. METHODS: Cross-sectional examination of survey responses collected between January and May 2019 from 2,993 California WIC families with children aged 1-4 years. RESULTS: Over half of WIC participants (56.1%) wanted an increase in the amount allocated for fruits and vegetables. Many WIC participants (69.6%) thought the amount of juice offered by WIC was just right. Overall, the majority (91.0%) wanted to substitute more fruits and vegetables for juice. Most were satisfied with the amount of beans (78.4%), peanut butter (78.7%), and milk (88.3%). Preferences differed by race/ethnicity. CONCLUSIONS AND IMPLICATIONS: Preferences of California WIC participants are highly aligned with the proposed National Academies of Sciences, Engineering, and Medicine changes for increasing fruits and vegetables. Notable differences by race/ethnicity suggest the need for more flexibility.

The role of income and neighbourhood poverty in the association between the 2009 Special Supplemental Nutrition Program for Women, Infants and Children (WIC) food package change and child obesity among WIC-participating children in Los Angeles County, 2003-2016.

OBJECTIVE: To determine whether a previously reported association between the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) food package change and reduced child obesity risk among WIC-participating children in Los Angeles County holds across levels of family income and neighbourhood poverty. DESIGN: Analysis of prospectively collected WIC administrative data. The outcome was obesity at age 4 years (BMI-for-age ≥ 95th percentile). Poisson regression was applied to a matched sample (n 79 502) to determine if the association between the WIC food package change and child obesity was modified by family income (<50 % federal poverty level (FPL), 50-100 % FPL, >100 % but <185 % FPL) and neighbourhood poverty. SETTING: Los Angeles County, California. PARTICIPANTS: Children who participated in WIC in Los Angeles County between 2003 and 2016; children were grouped as receiving the old WIC food package (2003-2009) or the new WIC food package (2010-2016). RESULTS: Receiving the new WIC food package (i.e., post-2009) was associated with 7-18 % lower obesity risk across all family income categories. Neither family income nor neighbourhood poverty significantly modified the association between the WIC food package and child obesity. However, certain sub-groups seemed to benefit more from the food package change than others. In particular, boys from families with income above poverty but residing in the poorest neighbourhoods experienced the greatest reductions in obesity risk (relative risk = 0·77; 95 % CI 0·66, 0·88). CONCLUSIONS: The WIC food package revisions were associated with reduced childhood obesity risk among all WIC-participating families in Los Angeles County, across levels of income eligibility and neighbourhood poverty.

Every month matters: longitudinal associations between exclusive breastfeeding duration, child growth and obesity among WIC-participating children.

BACKGROUND: Research has found breastfeeding to be protective of obesity; however, this link remains contentious. We examined longitudinal associations between exclusive breastfeeding duration, growth trajectories and obesity at 4 years among children participating in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC), and whether these associations differed in the context of the 2009 WIC food package change, implemented to improve alignment with dietary guidelines and promote breastfeeding. METHODS: Longitudinal data from 260 935 WIC-participating children in Los Angeles County, California, 2003-2016, were used to assess the relationship between duration of receipt of the fully breastfeeding package (an exclusive breastfeeding proxy) with childhood growth and obesity using mixed effects and Poisson regression models. RESULTS: Children exclusively breastfed for longer duration had healthier growth trajectories and lower obesity risk at age 4. Compared with infants with no fully breastfeeding package receipt, any receipt (a breastfeeding initiation proxy) was associated with reduced obesity risk. Obesity risk was lowest for boys and girls exclusively breastfed for 7 (risk ratio (RR)=0.73, 95% CI=0.64 to 0.82) and 13 months (RR=0.63, 95% CI=0.58 to 0.69), respectively. Exclusive breastfeeding duration increased, but associations between exclusive breastfeeding duration and growth and obesity were not modified, following the 2009 WIC food package change. CONCLUSION: Increased duration of exclusive breastfeeding was associated with reduced obesity risk. The greatest incremental benefit was observed going from none to any exclusive breastfeeding, and the maximum cumulative benefit was among children receiving the fully breastfeeding package for more than 6 months. Breastfeeding promotion in WIC remains important for obesity prevention.

Potential overfeeding among formula fed Special Supplemental Nutrition Program for Women, Infants and Children participants and associated factors.

BACKGROUND: The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) provides enough formula to meet the known nutritional needs of infants up to 6 months of age whose mothers report not breastfeeding, but many mothers report WIC providing insufficient formula, indicating potential overfeeding. OBJECTIVE: To estimate the prevalence of potential overfeeding among formula-feeding WIC participants and identify associated factors. METHODS: Potential overfeeding was identified among participants of the longitudinal Infant and Toddler Feeding Practices Study-2 (ITFPS-2) receiving the fully formula-feeding WIC infant package at 1 month of age (n = 1235, weighted n = 197 079). Associations of potential overfeeding with caloric intake, weight and participant characteristics were assessed. RESULTS: Potential overfeeding was identified among 37.41% (95% CI = 33.57-41.25%) of fully formula-feeding infants. Potentially overfed infants were 0.18 kg heavier (P-value = .01), consumed 26 more calories daily (P-value = .004) and were more likely Non-Hispanic White or English-speaking Hispanic (P-value = .007) and highly active at 5 months of age (P-value = .01). Mothers of potentially overfed infants were less likely to agree that breastfeeding is easier than bottle feeding, only mothers can feed breastfed infants, turning away from the bottle indicates satiation, and crying always indicates hunger (P-values .04, .002, .04 and .04 respectively), and more likely to report WIC provides insufficient formula early (1-5 months, P-value <.0001) and late (6-13 months, P-value = .007) in infancy. CONCLUSIONS: Potential overfeeding occurs in 37% of fully formula-feeding infant WIC-participants <6 months old. Mothers of these infants may benefit from additional education about the formula needs of their infants and how to recognize infant satiation cues.

Economic evaluation of California prenatal participation in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) to prevent preterm birth.

There is growing evidence that prenatal participation in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) reduces the risk of adverse birth outcomes. With recent changes in health care, rising health care costs, and increasing rates of prematurity in the U.S., there is urgency to estimate the potential cost savings associated with prenatal WIC participation. A cost-benefit analysis from a societal perspective with a time horizon over the newborn's life course for a hypothetical cohort of 500,000 Californian pregnant women was conducted in 2017. A universal coverage, a status quo ('business as usual') and a reference scenario (absence of WIC) were compared. Total societal costs, incremental cost savings, return on investment, number of preterm births prevented, and incremental net monetary benefits were reported. WIC resulted in cost-savings of about $349 million and the prevention of 7575 preterm births and would save more if it were universal. Spending $1 on prenatal WIC resulted in mean savings of $2.48 (range: $1.24 to $6.83). Decreasing prenatal WIC enrollment by 10% would incur additional costs (i.e. loss) of about $45.3 million to treat the resulting 981 preterm babies. In contrast, a 10% increase in prenatal WIC enrollment would prevent 141 preterm births and achieve additional cost-savings of $6.5 million. The findings confirm evaluations from the early 1990s that prenatal WIC participation is cost-saving and cost-effective. Further savings could be achieved if all eligible women were enrolled in WIC. Substantial preterm birth-related costs would result from reductions in WIC participation.

Contribution of WIC-Eligible Foods to the Overall Diet of 13- and 24-Month-Old Toddlers in the WIC Infant and Toddler Feeding Practices Study-2.

BACKGROUND: The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) provides supplemental foods to assist participants in meeting their dietary needs. Few studies have described the extent to which WIC-eligible foods contribute to the overall diet of children who were enrolled in WIC prenatally or in early infancy. OBJECTIVE: Our aims were to examine commonly consumed foods and estimate the proportion of dietary intake contributed by WIC-eligible foods among 13- and 24-month-old children, and to assess differences by WIC participation status at 24-months. DESIGN: This was a national observational study. PARTICIPANTS/SETTING: Children participating in the WIC Infant and Toddler Feeding Practices Study-2 were included (13 months old [n=2,777] and 24 months old [n=2,450]) from 2013 to 2016. MAIN OUTCOME MEASURES: Dietary intakes were assessed using 24-hour dietary recalls at 13 and 24 months. The 10 most commonly consumed foods were described using the What We Eat in America food category classification system. WIC-eligible foods were defined as meeting the WIC nutrient criteria set forth in the Federal regulation. STATISTICAL ANALYSES PERFORMED: The estimated proportion (mean±standard error) of WIC-eligible foods to total daily intake was calculated for energy, macronutrients, and select micronutrients. Multiple linear regression, adjusted for confounders, was conducted to compare the estimated proportion of nutrient intake from WIC-eligible foods by WIC participation at 24 months. RESULTS: At 13 and 24 months, most (60% and 63%, respectively) of the commonly consumed foods were eligible for purchase as part of the child WIC food package. WIC-eligible foods provided >40% of calories and close to 50% or more of other nutrients, and the contribution of WIC-eligible foods to overall micronutrient intake increased between 13 and 24 months. Children still on WIC at 24 months obtained a larger proportion of calories and most other nutrients from WIC-eligible foods than children no longer on WIC. CONCLUSIONS: WIC-eligible foods could contribute to the overall diet of toddlers who were enrolled in WIC prenatally or in early infancy. Further, there may be additional nutritional benefits of staying on the program through 24 months.

Diet Quality of US Infants and Toddlers 7-24 Months Old in the WIC Infant and Toddler Feeding Practices Study-2.

Background: Despite the important implications of childhood dietary intakes on lifelong eating habits and health, data are lacking on the diet quality of low-income infants and toddlers. Objective: The objective of this study was to characterize diet quality in low-income US infants and toddlers. Methods: A national observational study was conducted of 7- to 12-mo-old (n = 1261), 13-mo-old (n = 2515), and 24-mo-old (n = 2179) children enrolled in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) prenatally/at birth from 2013 to 2016. The study used a 24-h dietary recall and survey questions. For 7- to 12-mo-olds, an adapted Complementary Feeding Utility Index (CFUI) was used, and for 13- and 24-mo-olds, the Healthy Eating Index-2015 (HEI-2015) was used. Descriptive statistics were calculated for CFUI and HEI-2015 scores. Results: For 7- to 12-mo-olds, the CFUI score (mean ± SE) was 0.56 ± 0.003 (range: 0.34-0.90, maximum possible 1.0). Most children met CFUI standards for exposure to iron-rich cereal (86.7%), and low exposure to energy-dense nutrient-poor foods (72.2%) and teas/broths (67.5%). Conversely, at 7-12 mo of age, exposure was low for vegetables (7.0%), fruits (14.4%), any sugary drinks (14.0%), and 12-mo breastfeeding duration (23.8%). At 13 and 24 mo of age, the HEI-2015 total score (maximum possible 100), on average, was 64.0. At both 13 and 24 mo of age, participants achieved, on average, maximal HEI-2015 component scores for total and whole fruits and dairy; however, scores for total vegetables, greens and beans, whole grains, seafood and plant proteins, fatty acids, and saturated fats were relatively low. Scores for refined grains, sodium, and added sugar were lower at 24 than at 13 mo of age, representing higher consumption, on average, over time. Conclusions: Although findings demonstrate that young children are doing well on some dietary components, there is room for improvement, especially as children age. Findings may be used to inform the Pregnancy and Birth to 24-mo (P/B-24) Project. This trial was registered at clinicaltrials.gov as NCT02031978.

Reliability and Validity of Food Frequency Questions to Assess Beverage and Food Group Intakes among Low-Income 2- to 4-Year-Old Children.

BACKGROUND: Fruits, vegetables, sweetened foods, and beverages have been found to have positive and negative associations with obesity in early childhood, yet no rapid assessment tools are available to measure intake of these foods among preschoolers. OBJECTIVE: This study examines the test-retest reliability and validity of a 10-item Child Food and Beverage Intake Questionnaire designed to assess fruits, vegetables, and sweetened foods and beverages intake among 2- to 4-year-old children. METHODS: The Child Food and Beverage Intake Questionnaire was developed for use in periodic phone surveys conducted with low-income families with preschool-aged children. Seventy primary caregivers of 2- to 4-year-old children completed two Child Food and Beverage Intake Questionnaires within a 2-week period for test-retest reliability. Participants also completed three 24-hour recalls to allow assessment of validity. Intraclass correlations were used to examine test-retest reliability. Spearman rank correlation coefficients, Bland-Altman plots, and linear regression analyses were used to examine validity of the Child Food and Beverage Intake Questionnaire compared with three 24-hour recalls. RESULTS: Intraclass correlations between Child Food and Beverage Intake Questionnaire administrations ranged from 0.48 for sweetened drinks to 0.87 for regular sodas. Intraclass correlations for fruits, vegetables, and sweetened food were 0.56, 0.49, and 0.56, respectively. Spearman rank correlation coefficients ranged from 0.15 to 0.59 for beverages, with 0.46 for sugar-sweetened beverages. Spearman rank correlation coefficients for fruits, vegetables, and sweetened food were 0.30, 0.33, and 0.30, respectively. Although observation of the Bland-Altman plots and linear regression analyses showed a slight upward trend in mean differences, with increasing mean intake for five beverage groups, at least 90% of data plots fell within the limits of agreement for all food/beverage groups. CONCLUSIONS: The Child Food and Beverage Intake Questionnaire exhibited fair to substantial test-retest reliability and moderate to strong validity in ranking fruits, vegetables, sweetened food, and the majority of beverages consumed by children aged 2 to 4 years old. Although the Child Food and Beverage Intake Questionnaire might not be able to assess the absolute intake of foods and beverages, given the scarcity of an easily administered, valid, and reliable questionnaire to assess nutritional intake among 2- to 4-year-old low-income children, this tool is a useful means for measuring trends in dietary intake among low-income preschoolers.

If You Build It They Will Come: Satisfaction of WIC Participants With Online and Traditional In-Person Nutrition Education.

OBJECTIVE: To examine satisfaction with in-person group and online nutrition education and compare findings based on language preference by Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participants. METHODS: A total of 1,170 WIC participants were randomly assigned to 2 nutrition education modalities between March, 2014 and October, 2015 in Los Angeles, CA. Logistic regressions compared differences between groups in satisfaction outcomes. RESULTS: Participants in both education groups were highly satisfied regardless of modality of nutrition education (89% and 95%; P = .01). The online group reported a stronger preference for online education than did the in-person group (P < .001). In the in-person group, Spanish-speaking participants were less likely than were English-speaking participants to prefer online education (P < .001). A training video improved access to online education. CONCLUSIONS AND IMPLICATIONS: Online delivery of education can be an acceptable addition for WIC participants with online access. High-quality online education platforms represent an important avenue to promote continued satisfaction with nutrition education.

Associations between preterm birth, low birth weight, and postpartum health in a predominantly Hispanic WIC population.

OBJECTIVE: To describe the postpartum health of predominantly Hispanic participants in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and identify how health characteristics differ between mothers who delivered preterm or low birth weight infants and those who did not. DESIGN: Cross-sectional survey among postpartum WIC mothers. SETTING: Los Angeles and Orange Counties, CA. PARTICIPANTS: WIC participants within 1 year of delivery (n = 1,420). MAIN OUTCOME MEASURES: Postpartum health behaviors, health characteristics, and birth spacing intentions and behaviors. ANALYSIS: Frequencies of health characteristics were estimated using analyses with sample weights. Differences were assessed with chi-square and Fisher exact tests with Bonferroni correction for pairs of tests. RESULTS: Many women exhibited postpartum risk factors for future adverse health events, including overweight or obesity (62.3%), depressive symptoms (27.5%), and no folic acid supplementation (65.5%). Most characteristics did not differ significantly (P > .025) between mothers of preterm infants and full-term infants or between mothers of low birth weight and normal birth weight infants. CONCLUSIONS AND IMPLICATIONS: Despite few differences between postpartum characteristics of mothers who delivered preterm or low birth weight infants and those who did not, a high percentage of mothers had risk factors that need to be addressed. Current postpartum educational activities of WIC programs should be evaluated and shared.

Revised WIC food package improves diets of WIC families.

OBJECTIVE: To explore the impact of the new Special Supplemental Nutrition Program for Women, Infants and Children (WIC) food package on WIC participant consumption of fruit, vegetables, whole-grain food, and lower-fat milk. DESIGN: Telephone surveys of cross-sectional samples of California WIC families before and after the changes to the food package. PARTICIPANTS: Random samples of pregnant or postpartum women and/or caregivers of children enrolled in WIC: 3,004 in September, 2009; 2,996 in March, 2010. MAIN OUTCOME MEASURES: Consumption of fruit, vegetables, whole-grain food, and lower-fat milk. ANALYSIS: Comparisons of outcome variables were made by examining the differences by time point, adjusted for sociodemographic variables, using ANOVA (for means) or logistic regression (for percentages). RESULTS: Following the changes to the WIC food package, consumption of whole-grain food increased by 17.3 percentage points, a 51% increase over baseline. Caregivers and children who usually consumed whole milk decreased by 15.7 and 19.7 percentage points, respectively, a 60%-63% reduction over baseline. Accompanying increases in lower-fat milk consumption were demonstrated. Small but significant increases in consumption of fruits and vegetables were also observed. CONCLUSIONS AND IMPLICATIONS: Federal policy changes to the WIC program had the intended effect of increasing consumption of the prescribed food items.

Validity of child anthropometric measurements in the Special Supplemental Nutrition Program for Women, Infants, and Children.

INTRODUCTION: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) serves 50% of infants and 25% of preschool-aged children in the United States and collects height and weight measurements from eligible children every 6 mo, making WIC data a valuable resource for studying childhood growth and obesity. We assessed the accuracy of measurements collected by WIC staff by comparing them to "gold standard" measurements collected by trained research staff. RESULTS: Intraclass correlation coefficients (ICCs) measuring agreement between WIC and research protocol measurements for height, weight, and BMI were 0.96, 0.99, and 0.93, respectively. Although WIC measurements overestimated height by 0.6 cm and weight by 0.05 kg on average, BMI was underestimated by only 0.15 kg/m(2) on average. WIC BMI percentiles classified children as overweight/obese vs. underweight/normal with 86% sensitivity and 92% specificity. DISCUSSION: We conclude that height, weight, and BMI measurements of children aged 2-5 y collected by trained WIC staff are sufficiently accurate for monitoring and research purposes. METHODS: At seven WIC clinics in southern California, 287 children aged 2-5 y measured for height and weight by WIC staff using WIC standard protocol were remeasured by research staff using a research protocol (duplicate measurements with shoes and outerwear removed were taken by trained personnel).

Dietary micronutrients are associated with higher cognitive function gains among primary school children in rural Kenya.

With the exception of iodine and Fe, there is still very limited information on the effect of micronutrients on cognitive function, especially among school-age children. The present analysis evaluates the relationship between dietary Fe, Zn and B vitamins (B12, B6, folate and riboflavin) and gains in cognitive test scores among school children in rural Kenya. Data for the present study were obtained from The Child Nutrition Kenya Project, a 2-year longitudinal, randomised controlled feeding intervention study using animal source foods. Dietary nutrient values were based on monthly and bimonthly 24 h recall data collected during the study period. In longitudinal regression analyses, available Fe, available Zn, vitamin B12 and riboflavin showed significant relationships with improved cognitive test scores, after controlling for confounders such as energy intake, school, socio-economic status and morbidity. Available Fe intake was associated with significantly higher gains in Raven's Coloured Progressive Matrices test scores over time. Available Zn intake was associated with significantly higher gains in digit span-total test scores over time, while vitamin B12 and riboflavin intakes were each associated with significantly higher gains in digit span-forward test scores over time. This analysis demonstrates the influence of improved dietary micronutrient status on school children's cognitive function.

The impact of dietary intervention on the cognitive development of Kenyan school children.

Previous observational studies in developing countries have suggested that diet quality, particularly increased animal source food (ASF) consumption, is positively associated with child cognitive development. This report presents findings from a study in rural Kenya, designed to test the impact of three different diets on the cognitive development of school children. Twelve schools with a total of 555 Standard 1 children (equivalent to U.S. Grade 1) were randomized to one of four feeding interventions: Meat, Milk, Energy or Control (no feeding). Feeding continued for seven school terms (21 mo), and cognitive tests were administered before the commencement of feeding and during every other term of feeding. Hierarchical linear random effects models and associated methods were used to examine the effects of treatment group on changes in cognitive performance over time. Analyses revealed that children receiving supplemental food with meat significantly outperformed all other children on the Raven's Progressive Matrices. Children supplemented with meat, and children supplemented with energy, outperformed children in the Control group on tests of arithmetic ability. There were no group differences on tests of verbal comprehension. Results suggest that supplementation with animal source food has positive effects on Kenyan children's cognitive performance. However, these effects are not equivalent across all domains of cognitive functioning, nor did different forms of animal source foods produce the same beneficial effects. Implications of these findings for supplementation programs in developing countries are discussed.