The neighborhood food environment modifies the association between infant feeding and childhood obesity.

BACKGROUND: The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) issues infant formula to infants who are not fully breastfed, and prior research found elevated obesity risk among children receiving lactose-reduced infant formula with corn syrup solids (CSSF) issued by WIC. This study was conducted to evaluate associations between a broader set of specialty infant formulas issued by WIC and child obesity risk, whether neighborhood context (e.g. neighborhood food environment) modifies associations, and whether racial/ethnic disparities in obesity are partly explained by infant formula exposure and neighborhood context. METHODS: WIC administrative data, collected from 2013-2020 on issued amount (categorical: fully formula fed, mostly formula fed, mostly breastfed, fully breastfed) and type of infant formula (standard cow's milk formula, and three specialty formulas: any CSSF, any soy-based formula, and any cow's milk-based formula with added rice starch) and obesity at ages 2-4 years (defined as a Body Mass Index z-score ≥ 95th percentile according to World Health Organization growth standard) were used to construct a cohort (n = 59,132). Associations of infant formula exposures and race/ethnicity with obesity risk were assessed in Poisson regression models, and modification of infant feeding associations with obesity by neighborhood context was assessed with interaction terms. RESULTS: Any infant formula exposure was associated with significantly higher obesity risk relative to fully breastfeeding. Receipt of a CSSF was associated with 5% higher obesity risk relative to the standard and other specialty infant formulas (risk ratio 1.05, 95% confidence interval 1.02, 1.08) independent of breastfeeding duration and receipt of other specialty infant formulas. The association between CSSF and obesity risk was stronger in neighborhoods with healthier food environments (10% higher risk) compared to less healthy food environments (null). Racial/ethnic disparities in obesity risk were robust to adjustment for infant formula exposure and neighborhood environment. CONCLUSIONS: Among specialty infant formulas issued by WIC, only CSSFs were associated with elevated obesity risk, and this association was stronger in healthier food environments. Future research is needed to isolate the mechanism underlying this association.

Associations of Increased WIC Benefits for Fruits and Vegetables With Food Security and Satisfaction by Race and Ethnicity.

Introduction: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides nutrition support for racially and ethnically diverse populations. In 2021, the monthly cash value benefit (CVB) for the purchase of fruits and vegetables increased from $9 to $35 and was later adjusted to $24. This study investigated, by racial and ethnic groups, whether CVB increases were associated with increases in CVB redemption, household food security, child fruit and vegetable intake, satisfaction with CVB amount, and likelihood of continued participation in WIC if the CVB returned to $9 per month. Methods: We conducted a longitudinal study of WIC participants (N = 1,770) in southern California at 3 time points, from April 2021 through May 2022; the CVB amount was $9 at baseline, $35 at Survey 2, and $24 at Survey 3. Racial and ethnic groups were Hispanic English-speakers, Hispanic Spanish-speakers, non-Hispanic Asian, non-Hispanic Black, non-Hispanic Other, and non-Hispanic White. We used mixed-effect and modified Poisson regressions to evaluate outcomes by group. Results: At baseline, groups differed significantly in dollars of CVB redeemed, percentage of CVB redeemed, household food security, and satisfaction with CVB amount. After the increase in CVB, we found increases in all groups in CVB redemption, household food security, and satisfaction. Non-Hispanic Black and Hispanic English-speaking groups, who had low levels of satisfaction at baseline, had larger increases in satisfaction than other groups. Reported likelihood of continued WIC participation if the monthly CVB returned to $9 also differed significantly by group, ranging from 62.5% to 90.0%. Conclusion: The increase in CVB for children receiving WIC benefited all racial and ethnic groups. Continued investment in an augmented CVB could improve health outcomes for a racially and ethnically diverse WIC population.

Lower redemption of monthly Special Supplemental Nutrition Program for Women, Infants and Children benefits associated with higher risk of program discontinuation.

OBJECTIVE: To determine whether Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food benefit redemption is associated with discontinuing WIC participation, failure to recertify, overall and by race/ethnicity-language preference and participant category. DESIGN: Retrospective cohort study, using multivariable modified Poisson regression to determine risk ratios (RR) and 95 % CI for associations between household-level food benefit redemption (interval-scaled benefit redemption percent, averaged across WIC benefit subcategories, for the final 3, 6 and 12 months of certification) and failure to recertify in WIC, overall and within strata of race/ethnicity-language preference and participant category. SETTING: WIC administrative data collected November 2019-July 2021 in Southern California. PARTICIPANTS: WIC-participating children ages 0-3 years at initial certification from November 2019 to May 2020 (n 41 263). RESULTS: In all time periods, and for all subgroups, every 10 % lower food benefit redemption was associated with increased risk of failure to recertify. Among households without missing food benefit data, failure to recertify risk peaked at 505 % higher (RR = 6·05, 95 % CI (5·63, 6·51)) in households with average 12-month redemption <10 % compared with households with ≥70 % redemption. CONCLUSIONS: Lower WIC benefit redemption was associated with higher risk of failing to recertify among participants. Focused nutrition education around benefit redemption may improve WIC retention and child health through incremental increases in food benefit redemption.

Association of Playground "Playability" With Physical Activity and Energy Expenditure.

INTRODUCTION: Children's physical activity, especially play, is important for healthy physical, social, and psychological development. Playgrounds are public spaces for children, but not all playgrounds are conducive to play and physical activity. We examined "playability," the ability of a space to promote active play, and associations with moderate-to-vigorous physical activity (MVPA) and energy expenditure. METHODS: This cross-sectional study assessed playground features with the Play Space Audit Tool; we calculated playability scores from audit data, overall and by domain (general amenities, surface, path, and play structure), from playgrounds in 70 parks in Chicago, Illinois, in 2017. We observed 2,712 individuals during the audits and used the System for Observing Play and Recreation in Communities tool to assess MVPA and energy expenditure. We used generalized estimating equation negative binomial regression to calculate incidence rate ratios for MVPA and mixed effects models to calculate energy expenditure (in kcal/kg/min) associated with playability scores. RESULTS: General amenities and play structure scores were associated with 1.28 (95% CI, 1.08-1.52) and 1.15 (95% CI, 1.00-1.31) times as many individuals (any age) engaged in MVPA, respectively. The general amenities score was significantly associated with 0.51 (95% CI, 0.24-0.79) and 0.42 (95% CI, 0.15-0.68) higher energy expenditure in renovated playgrounds and in all playgrounds, respectively. CONCLUSION: Overall, general amenities and play structure scores were associated with MVPA and were robust to adjustment for weather, neighborhood socioeconomic characteristics, and crime. These playground playability indices may strengthen future evaluations of community infrastructure for children's physical activity.

Breastfeeding moderates childhood obesity risk associated with prenatal exposure to excessive gestational weight gain.

Gaining excessive gestational weight may increase obesity risk in the offspring, while breastfeeding lowers that risk. Using data from the Special Supplemental Nutrition Programme for Women, Infants and Children (WIC) in Southern California, we examined the associations between gestational weight gain (GWG), breastfeeding during infancy and childhood obesity at 2-4 years, and determined whether breastfeeding moderated the association between GWG and childhood obesity. GWG was based on weight measurements collected during the first trimester and within a month before delivery. GWG values were standardized by gestational age (GWG z-scores), per maternal prepregnancy body mass index (BMI) and categorized into tertiles. Fully breastfeeding duration was determined by WIC infant package data indicating the amount of infant formula received monthly. Children's length (or height) and weight measurements were used to calculate BMI-for-age z-scores and identify obesity (z-score ≥ 95th percentile). Multivariable linear and modified Poisson regression analyses were conducted. Fully breastfeeding moderated the association between GWG z-scores tertile and obesity in the offspring. Each additional month of fully breastfeeding was associated with 3%-5% obesity risk reduction for each age group and GWG z-scores tertile, except at age 4 years for children whose mothers had low GWG z-scores (tertile 1). Shorter fully breastfeeding duration was associated with greater obesity risk among children of mothers with high GWG z-scores (tertile 3), but not for those whose mothers had low GWG z-scores. Longer fully breastfeeding duration may provide greater protection against obesity among children at higher risk due to intrauterine exposure to high gestational weight gain.

Longer Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Participation Duration Is Associated with Higher Diet Quality at Age 5 Years.

BACKGROUND: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides supplemental healthy foods and nutrition education to children under age 5 y in low-income households. OBJECTIVES: We aimed to identify characteristics associated with duration of WIC participation and assess how participation duration relates to household food insecurity (HFI), child diet quality, and child weight status at age 60 mo. METHODS: This analysis of the WIC Infant and Toddler Feeding Practices Study-2, a prospective cohort of WIC-participating children enrolled in 2013, included children with complete baseline-60 mo data (n = 836). Outcomes assessed with WIC participation duration in multivariable regression were HFI (USDA 6-item Household Food Security Screener), child diet quality on a given day [Healthy Eating Index (HEI)-2015], and obesity (CDC BMI-for-age ≥95th percentile). RESULTS: Factors associated with longer WIC participation included male sex; lower household income; reported diet changes in response to WIC nutrition education; household Supplemental Nutrition Assistance Program participation; English-speaking Hispanic, Spanish-speaking Hispanic, and non-Hispanic other maternal race-ethnicity and language preference; an ever-married mother; lower maternal education; higher maternal age; earlier enrollment during pregnancy; and reporting a subsequent pregnancy. Longer WIC participation was associated with lower HFI odds (OR: 0.69; 95% CI: 0.51, 0.95), higher total HEI-2015 (ß: 0.73; 95% CI: 0.20, 1.25), and higher obesity odds (OR: 1.20; 95% CI: 1.05, 1.37) in multivariable-adjusted regression models. CONCLUSIONS: Longer WIC participation was associated with reduced HFI and higher diet quality, and unexpectedly with higher obesity odds, at 60 mo. Further research is needed to confirm and understand mechanisms underlying the unexpected associations identified with longer WIC participation (e.g., male sex, obesity). Groups with shorter participation durations may benefit from targeted WIC retention efforts to maximize nutrition security.

Differences in Early Childhood Dietary Behaviors by Infant Feeding Type and Sex.

BACKGROUND: Type of infant feeding has been linked to later nutritional outcomes, including dietary diversity and obesity in childhood. Little is known about how introduction to complementary feeding and diet quality in early childhood vary by infant feeding type and sex. OBJECTIVE: Our objective was to investigate whether early childhood dietary patterns vary by infant feeding type and sex. METHODS: Data from the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Infants and Toddler Feeding Practices Study 2 (ITFPS-2) was used, including children with complete information on the WIC infant food package received at ages 1, 7, and 11 mo (N = 2839). Based on this information, children were grouped as fully breastfed, mostly breastfed, mostly formula fed, and fully formula fed. Outcomes include introduction of complementary foods; caloric intake aged between 1 and 36 mo; and Healthy Eating Index (HEI)-2015 between 13 and 36 mo. Mixed models were used adjusting for child's, mother's, and family's sociodemographic characteristics. RESULTS: Across all infant feeding groups, the mean age of introduction to any solids was before the age of 6 mo; fully breastfed children were introduced to complementary foods closer to the recommended age (mean 5.1-5.2 mo) compared with other feeding groups (mean 4.6-4.8 mo). Fully formula fed infants consumed significantly more energy than fully breastfed infants at ages 1 mo (boys = 55 kcal/d, girls = 47 kcal/d), 12 mo (boys = 68 kcal/d, girls = 59 kcal/d), 24 mo (boys = 81 kcal/d, girls = 71 kcal/d), and 36 mo (boys = 95 kcal/d, girls = 83 kcal/d). No meaningful differences were observed for HEI-2015 between infant feeding groups or child sex, with average scores of HEI-2015 for all children being 61-63 out of 100. CONCLUSION: Early childhood dietary patterns were slightly better among children who were fully breastfed as infants, compared with children in other infant feeding groups. The diets of all WIC-participating children could be improved.

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.

Association of the Neighborhood Built Environment With Incident and Prevalent Depression in the Rural South.

INTRODUCTION: A neighborhood's built environment is associated with physical activity among its residents, and physical activity is associated with depression. Our study aimed to determine whether the built environment was associated with depression among residents of the rural South and whether observed associations were mediated by physical activity. METHODS: We selected 2,000 participants from the Bogalusa Heart Study who had a valid residential address, self-reported physical activity (minutes/week), and a complete Center for Epidemiologic Study-Depression (CES-D) scale assessment from 1 or more study visits between 1998 and 2013. We assessed the built environment with the Rural Active Living Assessment street segment audit tool and developed built environment scores. The association between built environment scores and depression (CES-D ≥16) in geographic buffers of various radii were evaluated by using modified Poisson regression, and mediation by physical activity was evaluated with mixed-effects models. RESULTS: Depression was observed in 37% of study participants at the first study visit. One-point higher physical security and aesthetic scores for the street segment of residence were associated with 1.07 times higher (95% CI, 1.02-1.11) and 0.96 times lower (95% CI, 0.92-1.00) baseline depression prevalence. One-point higher destination scores (ie, more commercial and civic facilities) in radius buffers of 0.25 miles or more were associated with 1.06 times (95% CI, 1.00-1.13) the risk of depression during follow-up. Neighborhood poverty (defined as percentage of residents with incomes below the federal poverty level and dichotomized at 28.3%) modified cross-sectional and longitudinal associations. Associations were not mediated by physical activity. CONCLUSION: The built environment was associated with prevalence and risk of depression, and associations were stronger in high-poverty neighborhoods. Built environment improvements to promote physical activity should take neighborhood context into consideration to minimize negative side effects on mental health in high-poverty communities.

The new child food package is associated with reduced obesity risk among formula fed infants participating in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) in Los Angeles County, California, 2003-2016.

BACKGROUND: The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) changed the food packages provided to its participants in 2009, to better align them with the Dietary Guidelines for Americans. Previous research found that the 2009 WIC food package change was associated with reduced obesity risk, particularly among breastfed infants but also among those who were never breastfed. The objective of this study was to determine if the new child food package introduced in 2009, including more produce and whole grains for 1-4-year old children, was associated with healthier growth trajectories and reduced obesity risk at age 4 years among children who were exclusively formula fed during infancy. METHODS: Administrative data on WIC-participating children in Los Angeles County, 2003-2016, were used (N = 74,871), including repeated measures of weight and length (or height); child's age, gender, and race/ethnicity; maternal education and language; and family poverty. Gender-stratified spline mixed models were used to examine weight-for-height z-score (WHZ) growth trajectories from 0 to 4 years and Poisson regression models were used to assess obesity (BMI-for-age > 95th percentile) at age 4. The main independent variable was duration of receipt (dose) of the new child package, categorized as 0, > 0 to < 1, 1 to < 2, 2 to < 3, 3 to < 4, and 4 years. RESULTS: WHZ growth trajectories were similar for children across new child package dose groups. Boys and girls who were fully formula fed during infancy but received the new child food package for 4 years had a 7% (RR = 0.93; 95%CI = 0.89-0.98) and a 6% (RR = 0.94; 95%CI = 0.89-0.99) lower obesity risk, respectively, compared to children who received the new child food package for 0 years. There were no differences in obesity risk for children receiving < 4 years of the new child package vs. 0 years. CONCLUSIONS: Providing healthy foods during childhood to children who were exclusively formula fed as infants was associated with modest improvements in obesity outcomes. While breastfeeding promotion should still be prioritized among WIC participants, providing healthy foods during childhood may provide health benefits to formula fed children, who comprise a sizeable proportion of children served by WIC.

The neighborhood food environment modifies the effect of the 2009 WIC food package change on childhood obesity in Los Angeles County, California.

BACKGROUND: Food packages provided by the Special Supplemental Nutrition Program for Women, Infants and Children (WIC) were revised in 2009 to better align them with the Dietary Guidelines for Americans. This study was conducted to evaluate whether the effect of the food package change on childhood obesity varied by the food environment in the neighborhoods where WIC-participating children live. METHODS: Administrative data from participating children in Los Angeles County, California (2003-2016) were merged with geocoded food vendor information by neighborhood of residence. Obesity risk at age 4 was compared between children receiving old (2003-2009) and new (2010-2016) WIC food packages using sex-stratified Poisson regression models, with interaction terms between WIC package and neighborhood density (number per square mile) of healthy and unhealthy food outlets. RESULTS: The new food package was associated with a significant decrease in obesity risk. Among boys, the new food package was associated with 8 to 18% lower obesity risk at all healthy and unhealthy food outlet densities, and the association was not modified by neighborhood food outlet density. Among girls, the association of the new food package with obesity risk was protective in neighborhoods with high healthy and low unhealthy food outlet densities, and adverse in neighborhoods with high unhealthy and low healthy food outlet densities. The effect of the new food package among girls was modified by unhealthy food outlet density, with significantly smaller (p-value = 0.004) decreases in obesity risk observed in neighborhoods with higher unhealthy food outlet density. CONCLUSIONS: The impact of the food package change was modified by the neighborhood food environment among girls only. Future policy changes should incorporate consideration of ways to mitigate potentially inequitable geographic distribution of the health benefits of policy changes.

Cross-sectional associations between the neighborhood built environment and physical activity in a rural setting: the Bogalusa Heart Study.

BACKGROUND: Insufficient physical activity (PA) is a common health risk and more prevalent in rural populations. Few studies have assessed relationships between the built environment and PA in rural settings, and community policy guidance to promote PA through built environment interventions is primarily based on evidence from urban studies. METHODS: Participants in the Bogalusa Heart Study, a longitudinal study in rural Louisiana, with International Physical Activity Questionnaire data from 2012 to 2013 and a valid residential address (N = 1245) were included. PA was summarized as the number of weekly metabolic equivalent (MET)-minutes of total, transportation, and leisure time PA. The Rural Active Living Assessment street segment audit tool and Google Street View were used to assess features of the built environment overall and in six categories (path features, pedestrian safety features, aesthetics, physical security, destinations and land use) that influence PA. Scores for street segment built environment (overall and in categories) were calculated, for segments and buffers of 0.25, 0.50, 1.00 and 1.50 miles. Associations between built environment scores and PA were assessed with generalized estimating equations. RESULTS: Participants reported little weekly total, leisure time, and transportation PA (mean 470, 230 and 43 MET-minutes per week, respectively). A 1-point increase in the overall built environment score was associated with 10.30 additional weekly leisure time MET-minutes within a 1.50 mile buffer (p-value 0.05), with a similar magnitude observed for a 1.00-mile buffer. A 1-point increase in the aesthetic score was associated with significantly higher leisure time PA for all geographic units (from 22.21 to 38.75 MET-minutes weekly) when adjusted for individual covariates, but was attenuated and only significant for the segment of the residence after accounting for other neighborhood characteristics. CONCLUSIONS: Significant associations between features of the environment (overall and aesthetic scores) with leisure time PA were observed among adults in this rural population. Built environment interventions in rural settings face additional barriers of lower population density and greater distances for infrastructure projects, and it is important to identify approaches that are both feasible for rural communities and can promote PA.

The association of angiogenic factors and chronic kidney disease.

BACKGROUND: There are limited data on the associations of circulating angiogenic factors with chronic kidney disease (CKD). We investigate the associations of circulating vascular endothelial growth factor (VEGF)-A, angiopoietin-1, angiopoietin-1/VEGF-A ratio, VEGF receptor 1 (VEGFR-1), VEGFR-2, and pentraxin-3 with CKD. METHODS: We recruited 201 patients with CKD and 201 community controls without CKD from the greater New Orleans area. CKD was defined as estimated glomerular filtration rate (eGFR) < 60 mL/min/1.73 m2 or presence of albuminuria. Multivariable quantile and logistic regression models were used to examine the relationship between angiogenesis-related factors and CKD adjusting for confounding factors. RESULTS: After adjusting for covariables including traditional cardiovascular disease (CVD) risk factors, C-reactive protein, and history of CVD, the medians (interquartile range) were 133.08 (90.39, 204.15) in patients with CKD vs. 114.17 (72.45, 170.32) pg/mL in controls without CKD (p = 0.002 for group difference) for VEGF-A; 3951.2 (2471.9, 6656.6) vs. 4270.5 (2763.7, 6537.2) pg/mL (p = 0.70) for angiopoietin-1; 25.87 (18.09, 47.90) vs. 36.55 (25.71, 61.10) (p = 0.0001) for angiopoietin-1/VEGF-A ratio; 147.81 (122.94, 168.79) vs. 144.16 (123.74, 168.05) ng/mL (p = 0.25) for VEGFR-1; 26.20 (22.67, 29.92) vs. 26.28 (23.10, 29.69) ng/mL (p = 0.31) for VEGFR-2; and 1.01 (0.79, 1.49)vs. 0.89 (0.58, 1.18) ng/mL (p = 0.01) for pentraxin-3, respectively. In addition, an elevated VEGF-A level and decreased angiopoietin-1/VEGF-A ratio were associated with increased odds of CKD. CONCLUSIONS: These data indicate that plasma VEGF-A and pentraxin-3 levels were increased and the angiopoietin-1/VEGF-A ratio was decreased in patients with CKD. Future prospective studies are warranted to examine whether angiogenic factors play a role in progression of CKD.

Surveillance of Infant Formula Shortages Using Special Supplemental Nutrition Program for Women, Infants, and Children Administrative Data.

OBJECTIVE: To quantify self-reported difficulty accessing Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)-issued infant formula among participants early in the coronavirus disease 2019 (COVID-19) pandemic, to determine if infant formula redemption was associated with self-reported difficulty accessing infant formula, and to quantify changes in formula redemption during the 2022-2023 US infant formula shortages. DESIGN: A cross-sectional study and time series data. SETTING: Families participating in the WIC program in the Los Angeles metropolitan area from November 2019 to June 2023. PARTICIPANTS: Families with infants (aged 0-12 months) issued infant formula by WIC with a completed 2020 Los Angeles County WIC Survey (n = 1,897) or issued infant formula by a large WIC program in Southern California between November 2019 and June 2023 (n = 109,135). MAIN OUTCOME MEASURES: Incidence of ≥ 30% reduction in infant formula redemption and interval-scaled infant formula redemption. ANALYSIS: Special Supplemental Nutrition Program for Women, Infants, and Children formula redemption data were matched to 2020 Los Angeles County WIC Survey data to determine if self-reported difficulty accessing infant formula was associated with administrative infant formula redemption data using negative binomial regression and were used to quantify the prevalence and severity of incomplete formula redemption during 2020-2023 formula shortages using ordinal logistic regression (outcome: interval-scaled formula redemption). RESULTS: Few (13.0%) caregivers reported difficulty accessing the WIC-issued formula early in the COVID-19 pandemic. The 2.8% who reported an unresolved shortage early in the COVID-19 pandemic had 201% higher rates of ≥ 30% declines in formula redemption (incidence rate ratio [IRR], 3.01; 95% confidence interval, 1.57-5.79, P < 0.001) than those with no difficulties. Incomplete formula redemption odds were significantly elevated throughout the COVID-19 pandemic from March 2020 to January 2022 and increased further during the 2022-2023 infant formula shortages from February 2022 to June 2023, reaching 342% higher in October 2022 than February 2020 (odds ratio, 4.42; 95% confidence interval, 4.14-4.72; P < 0.001). CONCLUSIONS AND IMPLICATIONS: Special Supplemental Nutrition Program for Women, Infants, and Children redemption data are an adequate proxy for population-level infant formula access issues among households with low income but are insufficiently sensitive for screening at a household level. US formula shortages (2020-2023) demonstrate the need for improved coordination between nutrition assistance programs, regulatory bodies, and commercial food systems, particularly during acute supply crises.

Cross-sectional associations of Special Supplemental Nutrition Program for Women, Infants, and Children benefit redemption and diet among children ages 1-4 years in California.

BACKGROUND: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides supplemental healthy foods to children aged <5 y in low-income households. OBJECTIVES: The objectives of this study were to characterize WIC benefit redemption, identify associations between benefit redemption and child dietary intake, and whether child age modifies these associations. METHODS: The cross-sectional 2023 California Statewide WIC Survey, conducted with caregivers of WIC-participating children aged 1-4 y, was analyzed for this study. Included children had complete benefit redemption data, a complete National Health and Nutrition Examination Survey Dietary Screener Questionnaire (DSQ), and complete covariate data (weighted n = 2244). Monthly household category-specific benefit redemption percentage was averaged across 6 and 3 mo preceding survey completion. Associations between household redemption and child dietary intake (servings or amount/day) were assessed with multivariable linear regression and expressed as estimates and 95% confidence intervals (CI). RESULTS: Twenty-five percent higher redemption of breakfast cereal, whole grain bread, yogurt and whole milk in the 6 mo prior to the survey were associated with higher child intake frequency for cereal (0.02 servings/d; 95% CI: 0.00, 0.04), whole grain bread (0.02 servings/d; 95% CI: 0.00, 0.03), yogurt (0.04 servings/d; 95% CI: 0.02, 0.06), and whole milk (0.09 servings/d; 95% CI: 0.01, 0.16). Significant effect modification by child age (12 to <24 mo, 24-59 mo) was found for redemption of cheese/tofu and 100% juice (P-interaction = 0.02 and 0.001, respectively), and 25% higher redemption of these benefits were associated with lower intake frequency for cheese (-0.05 servings/d; 95% CI: -0.09, -0.02) and higher intake frequency for juice (0.12 servings/d; 95% CI: 0.06, 0.18), but only among children ages 12 to <24 mo. CONCLUSIONS: Higher redemption was associated with higher child intake of select WIC foods. Pairing the promotion of benefit redemption among program participants with nutrition education efforts may enhance dietary impacts of WIC participation.

Any Infant Formula Amount, but Not Infant Formula Type, Is Associated with Less Healthful Subsequent Beverage Intake among Special Supplemental Nutrition Program for Women, Infants, and Children-Participating Children.

Background: The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides nutrition assistance to low-income households, including infant formula for infants not fully breastfeeding. Issuance of lactose-reduced infant formula made with corn syrup solids (CSSF) is associated with elevated risk of obesity in early life, but associations between formula type and dietary intake have not been examined. Objectives: To evaluate associations between infant formula (amount and type) issued by WIC with subsequent child diet at ages 12-59 mo. Methods: Dietary data from 2014, 2017, and 2020 Los Angeles County WIC Survey respondents (n = 1339 children, 12-59 mo of age) were merged with WIC administrative data on infant feeding (amount and type of infant formula at ages 0-12 mo). Intake frequencies were available for sweetened beverages, sweets, juice, fast food, water, fruit, vegetables, and milk. Infant feeding was categorized by amount of WIC-issued formula (descending: fully formula fed, mostly formula fed, mostly breastfed, fully breastfed) and issuance of a CSSF (any, none). Associations between infant feeding (infant formula amount and type) and child diet were evaluated in multivariable generalized estimating equation negative binomial regression models, stratified by child age (12 to <24 mo, 24 to <60 mo). Results: Any infant formula issuance in the first year of life was adversely associated with subsequent dietary intake. This included 21%-23% higher 100% juice intake at 24 to <60 mo and 11%-13% (at 24 to <60 mo) or 20%-22% (at 12 to <24 mo) lower water intake. CSSF receipt compared with only other infant formula was not consistently associated with subsequent child diet. Conclusions: Any infant formula amount, but not CSSF receipt compared with other formula types, was associated with less healthful beverage intake patterns among WIC-participating children. WIC nutrition education may have a stronger impact if tailored based on infant feeding practices.

Sleep Duration Is Associated with Household Food Insecurity and Sugar-Sweetened Beverage Intake Among Women, Infants and Children Participating Children Ages 0-5.

PURPOSE: To determine associations between child and household characteristics and sleep duration among low-income children in Los Angeles County. DESIGN: Cross-sectional study. SETTING: Survey data collected in 2017 and 2020 in Los Angeles County, California. SAMPLE: Special Supplemental Nutrition Program for Women, Infants and Children (WIC) households with children ages 4-60 months. MEASURES: Sleep duration for children 4-60 months old (less than recommended (LTR), recommended range, more than recommended (MTR)), household food insecurity (HFI), sociodemographics, and daily servings of sugar-sweetened beverages (SSB). ANALYSIS: Multinomial logistic regression, stratified by child age, was used to calculate odds ratios (OR) and 95% confidence intervals (CI) for associations between household/child characteristics and LTR or MTR sleep compared to recommended duration among WIC participating children 4-60 months old. RESULTS: The final sample included 3512 children ages 4-23 months and 6035 children ages 24-60 months. In the study population, 32% (3-5 years old) to 44% (4-11months) of children under 5 did not meet the recommended hours of sleep per night. HFI was associated with higher odds of LTR (OR 1.27, CI 1.12-1.45) and MTR (OR 1.46, CI 1.15-1.87) sleep among 24-60 month-old children. Each additional daily SSB serving was associated with higher odds of LTR sleep (4-23 months: OR 1.10, CI 1.02-1.19; 24-59 months: OR 1.12, CI 1.08-1.17). CONCLUSIONS: HFI and SSB intake are associated with not getting the recommended amount of sleep among low-income WIC participating children. Nutrition assistance program participants may benefit from receiving information about recommended sleep duration for young children and how to establish sleep routines to optimize sleep duration.

Evaluating the Association of the Increase in the WIC Cash Value Benefit on the Diversity of MyPlate Fruits and Vegetables Redeemed and Consumed By Children in Low-Income Households.

Background: Fruits and vegetables (FV) are a critical source of nutrients, yet children in the United States are not meeting the Dietary Guidelines for Americans (DGA). The monthly FV cash value benefit (CVB) included in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)'s food package to support child FV intake (FVI) received a substantial increase for economic relief during the COVID-19 pandemic. Objectives: To evaluate how an expansion of the monthly WIC CVB to purchase FV for WIC children ages 1-4 y is associated with diversity in FV redeemed, and how changes in redeemed FV are related to FVI. Methods: Caregivers representing 1463 WIC-participating children recruited from Los Angeles County, California, completed surveys during the CVB augmentation (T1: CVB = $9/mo; T2 = $35/mo; T3 = $24/mo). Redeemed price look-up codes (PLUs), corresponding to a food item, were assigned to its corresponding MyPlate FV group. Multivariable generalized estimating equation regression models assessed changes in amount and diversity of FV redemption across MyPlate groups and associations between changes in FV diversity and changes in FVI. Results: Slightly over half of all households were food insecure (55%), half of the children were female (52%), and most were Hispanic (78%). Compared with T1, significant increases in the number of PLUs and dollars redeemed were observed in most MyPlate FV groups. From T1 to T2, significant increases in diversity scores were observed for total fruit (ß: 1.6 pts; 95% confidence interval [CI]: 1.4, 1.7), total vegetable (ß: 3.6 pts; 95%CI: 3.4, 3.9), and total FV (ß:7.8 pts; 95%CI: 7.4, 8.2). Similarly, increases in diversity score were observed at T3 compared with T1. Changes in FV diversity redeemed were not associated with changes in FVI. Conclusions: During the CVB augmentation, WIC participants redeemed a greater amount and variety of FV according to DGA MyPlate recommendations, supporting its permanent increase.

Use of Interactive Texting Is Associated With Higher Odds of Continued WIC Participation During the COVID-19 Pandemic.

BACKGROUND: In Los Angeles County (LAC), California, the demand for Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) services increased during the COVID-19 pandemic, concurrent with the shift to fully remote WIC service delivery in March 2020. Technologies for facilitating remote services were critical for accommodating increases in participation during the COVID-19 pandemic. OBJECTIVE: The objective of this study was to quantify patterns of remote-service utilization and to determine whether use of remote services (phone, interactive texting, e-mail, online education, video appointments) was associated with higher rates of recertification among WIC participants early in the COVID-19 pandemic. DESIGN: Cross-sectional survey with administrative data for follow-up PARTICIPANTS AND SETTING: This study used data from the 2020 LAC WIC Survey and WIC administrative data to evaluate remote service utilization across LAC WIC agencies (unweighted n = 3,510; weighted n = 3,540). MAIN OUTCOME MEASURES: Recertification on WIC, determined by the issuance of a food package in the first 2 months after the end-date of the prior certification period. STATISTICAL ANALYSIS: Survey data were merged to WIC administrative data to determine whether participants completed a recertification; the association of utilization of each remote service with the odds of recertification among WIC-participating children 0 to 3 years of age was assessed with multivariable logistic regression. RESULTS: Most survey respondents reported using phone appointments (95.5%), interactive texting (77.3%), e-mail (60.1%), and online education (71.2%) to access WIC services during 2020, and over 82% of children successfully recertified. Interactive texting utilization was associated with 27% higher recertification odds (95% confidence interval, 1%-59%); associations between all other remote services and odds of recertification were not statistically significant. CONCLUSIONS: These results suggest that WIC investment in interactive texting technological infrastructure, and appropriate staff training, can help local WIC agencies successfully reach and provide high-quality services to WIC participants.