Feasibility and acceptability of a personalized, pre-filled online grocery cart to improve benefit redemption and diet quality of grocery purchases among participants of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).

Most participants in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) do not fully redeem their benefits due to barriers like transportation, confusing product eligibility, and unclear labeling. Online food shopping enables choice architecture to promote benefit redemption and maximize diet quality. We conducted a mixed-methods pilot randomized-controlled trial to assess the feasibility and acceptability of a pre-filled online grocery shopping cart to improve WIC benefit redemption and diet quality of grocery purchases. Rhode Island WIC participants (n = 24, mean age 29.4 ± 1.1 years, 75% Hispanic, 54% had never grocery shopped online) completed a baseline questionnaire and a simulated shopping episode (SSE), buying WIC and non-WIC items. After a week, we randomized participants into the intervention (personalized, modifiable carts pre-filled with 100% of the 2022 proposed WIC packages) or control (selected their items individually) groups before the second SSE. Both groups had WIC labels. We assessed feasibility using process data and percent agreement to feasibility questions, and acceptability via percent agreement to acceptability questions and post-intervention qualitative interviews. We conducted exploratory analyses to examine differences within and between groups at each timepoint for percent WIC benefit redemption and diet quality of grocery purchases, evaluated using the Grocery Purchase Quality Index-2016 (GPQI-2016) scores. Quantitative study measures suggest that the intervention was feasible and that the personalized, modifiable pre-filled cart was acceptable. These findings were supported during qualitative interviews, where participants highlighted time-savings, flexibility, and WIC labels as facilitators of WIC online shopping. Exploratory results showed significant increases in mean percent redemption of most WIC food categories and non-significant moderate increases in most GPQI-2016 scores. These measures are vital for the future adaptation of a full-scale efficacy trial in real-life settings.

Associations Between Infant Formula Exposure, Housing Instability and Postneonatal Mortality Among Participants in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC).

OBJECTIVES: To quantify infant mortality rates (IMR) using expanded racial categories, and to examine associations between infant formula exposure, housing instability and postneonatal mortality among Minnesota WIC Participants. METHODS: Births in Minnesota from 2014 through 2019 (n = 404,102) and associated infant death records (n = 2034) were used to calculate neonatal and postneonatal rates using expanded racial categories. Those births that participated in the WIC program (n = 170,011) and their linked death records (n = 853) were analyzed using logistic regression to examine associations between formula exposure, housing instability, and postneonatal death. RESULTS: Postneonatal IMR was more than twice as prevalent among Black (African American) as East African immigrant infants (IMR = 3.9 vs 1.5). After adjustment for confounding (term status and nativity of mother (U.S. vs foreign born), infants exposed to formula by 28 days were four times as likely to die in the postneonatal period as those without formula exposure (aOR = 4.0; 95% CI 3.2-4.9). WIC participants who experienced housing instability at birth were 1.7 times as likely to lose an infant in the postneonatal period (28 to 364 days of age) as those in stable housing (aOR = 1.7; 95% CI 1.2, 2.4). CONCLUSIONS FOR PRACTICE: Disaggregating Black mortality rates revealed inequities in infant mortality among Black families of varied backgrounds. Formula exposure and housing instability are modifiable risk factors associated with postneonatal mortality. Appropriate interventions to reduce barriers to breastfeeding and provide housing stability for vulnerable families could reduce disparities in postneonatal mortality.

Long COVID and the Higher Risk of Food Insecurity Among Participants and Nonparticipants of Food Assistance Programs in the United States.

BACKGROUND: In the aftermath of the COVID-19 public health emergency, it is important to understand the extent of socioeconomic burdens of long COVID, defined as continuation of symptoms after initial infection, including food insecurity. OBJECTIVE: This study aimed to assess the association between long COVID and family food insecurity among low-income individuals (or any of their family members living with them) who were participants and nonparticipants in public food assistance programs (Supplemental Nutrition Assistance Program [SNAP], Special Supplemental Nutrition Program for Women, Infants, and Children [WIC], and National School Lunch Program [NSLP]) in the United States. DESIGN: The study used an observational cross-sectional design. PARTICIPANTS/SETTING: Data on 7151 adults (aged 18+ years), with family income of < 200% of the Federal Poverty line, from the 2022 National Health Interview Survey, were analyzed. MAIN OUTCOME MEASURES: Level of family food security, based on responses to a set of 10 questions measuring family's food security during the past 30 days. STATISTICAL ANALYSES PERFORMED: Multinomial logistic regression models were estimated to obtain relative risk ratios of marginal and low/very low food security, relative to the base outcome of high food security, for long COVID status. Multivariable models were estimated separately for the full sample and for subgroups of food assistance participants and nonparticipants. A seemingly unrelated regression (SUR) specification was estimated to assess whether the estimates were different across the participant and nonparticipant subgroups. RESULTS: Compared with individuals who never had COVID-19, the adjusted relative risks of experiencing marginal and low/very low food security were 1.42 (95% CI, 1.00-2.02) and 1.43 (95% CI, 1.08-1.91) times higher, respectively, for individuals who had long COVID. Although the adjusted risks were not observed to be statistically significant in the participant subgroup, among nonparticipants, adjusted relative risk ratios were 2.34 (95% CI, 1.43-3.82) and 1.56 (95% CI, 1.02-2.39), respectively. SUR results showed that relationships between long COVID and food insecurity were only different for marginal and not low/very low levels of food security between food assistance participant and nonparticipant groups. CONCLUSIONS: Study findings highlight a significantly higher risk of marginal and low/very low- food security among low-income adults who had long COVID, especially those who were nonparticipants in public food assistance programs. Further research is warranted to explore the causal pathways of this relationship for informing policies to mitigate the burden of long COVID.

Experiences participating in federal nutrition assistance programs during the early months of the COVID-19 pandemic: an investigation in Vermont.

BACKGROUND: Federal nutrition assistance programs serve as safety nets for many American households, and participation has been linked to increased food security and, in some instances, improved diet quality and mental health outcomes. The COVID-19 pandemic brought new and increased economic, social, and psychological challenges, necessitating inquiry into how nutrition assistance programs are functioning and associated with public health outcomes. METHODS: Using data from a representative statewide survey administered in Vermont (n = 600) between July and September 2020, we examined participant experiences with major federal nutrition assistance programs: the Supplemental Nutrition Assistance Program (SNAP), the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), and school meal programs. We explored quantitative and qualitative responses regarding perceptions of program utility, and used nearest neighbors matching analyses in combination with bivariate statistical tests to assess associations between program participation and food insecurity, perceived stress, and fruit and vegetable intake as indicators of dietary quality. RESULTS: One in four respondents (27.3%) used at least one federal nutrition assistance program. As compared to non-participants, we found higher rates of food insecurity among program participants (57.5% vs. 18.1%; p < 0.001), an association that persisted even when we compared similar households using matching techniques (p ≤ 0.001). From matched analyses, we found that, compared to low-income non-participants, low-income program participants were less likely to meet fruit intake recommendations (p = 0.048) and that low-income SNAP and WIC participants were less likely to meet vegetable intake recommendations (p = 0.035). We also found lower rates of perceived stress among low-income school meal participant households compared to low-income non-participants (p = 0.039). Despite these mixed outcomes, participants broadly valued federal nutrition assistance programs, characterizing them as helpful or easy to use. CONCLUSIONS: We found that federal nutrition assistance programs as a group were not sufficient to address food insecurity and stress or increase fruit and vegetable intake in the state of Vermont during the early months of the COVID-19 pandemic. Nonetheless, participants perceived benefits from participation in these programs. Optimizing the utility of nutrition assistance programs depends on critical examination of their functioning under conditions of great stress.

Initial Feeding Method, WIC-Provided Lactation Support, and Breastfeeding Duration at an Urban Pediatric Primary Care Practice.

Breastfeeding (BF) is associated with improved maternal and infant health outcomes. However, underserved populations have limited access to lactation support. Our urban pediatric primary care practice partnered with WIC to integrate a BF peer counselor (BFPC) into newborn visits. To study the association of BF duration with (1) BFPC integration, (2) initial infant feeding methods (IFM). This is a retrospective cohort study of patients receiving BFPC support matched with those that did not based on race, ethnicity, and insurance. IFM were compared using chi-square. BF duration was compared using a t-test. These variables were compared across IFM using ANOVA. A cohort of 111 infant-mother dyads received BFPC support and 222 dyads did not (7/09/2019-4/25/2022). There was no significant difference in feeding methods between these groups. Compared to infants whose IFM was exclusive BF, fewer infants who initially used formula or both formula and breastmilk were exclusively BF at 2-month (55.8%, 8.2%, 10.9%), 4-month (54.8%, 6.3%, 14.5%), and 6-month visits (54.8%, 4.3%, 14.1%) (p < 0.001). There was a significant association between IFM and duration of any and exclusive BF (Formula only: 1 week; BF and Formula: 3 weeks; Exclusive BF: 14 weeks; p < 0.001). A significant association was found between IFM and duration of BF. Early formula introduction was negatively associated with BF duration. The prenatal period may therefore be optimal for initiating BF support. Although there was no association between BFPC and BF duration, additional benefits of this intervention should be explored.

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.

Breastfeeding Perceptions and Decisions among Hispanic Participants in the Special Supplemental Nutrition Program for Women, Infants, and Children: A Qualitative Study.

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) is a nutrition assistance program in the U.S. WIC served 2.5 million eligible Hispanic women, infants, and children under the age of five in 2021, which is WIC's largest racial/ethnic group. However, limited research has been conducted to understand Hispanic WIC participants' perceptions of WIC breastfeeding recommendations and their breastfeeding decisions. For this qualitative study, we interviewed 18 of these pregnant and postpartum WIC participants on their experiences and decision-making processes related to breastfeeding. Hispanic cultures and home country norms were identified as prominent influences on breastfeeding decisions, along with perceptions of WIC's breastfeeding support. These results can help the WIC program to refine its breastfeeding education to better meet the needs of Hispanic participants.

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.

Infant Feeding Support for Pregnant and Postpartum Parents With Intellectual and Developmental Disabilities: Perspectives of WIC Staff.

OBJECTIVE: To describe the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) staff experiences, perceptions, and training needs surrounding the provision of infant feeding support for parents with intellectual and developmental disabilities (IDD). METHODS: We conducted in-depth semistructured interviews between October and November 2021 with Maryland WIC staff (N = 10) who provide infant feeding counseling and support. We analyzed interviews using conventional content analysis. RESULTS: Three themes were identified: identifying and documenting IDD, facilitating effective communication and infant feeding education, and assessing WIC staff competence and readiness. CONCLUSIONS AND IMPLICATIONS: The interviews suggested the need to explore the risks and benefits of routine and compassionate processes for identifying and documenting disability, create accessible teaching materials that facilitate understanding and engagement, and educate and train staff to provide tailored support in WIC. Engaging parents with IDD to better understand their perspectives and experiences should guide future efforts to improve inclusivity and accessibility.

WIC Peer Counselors Support Breastfeeding Among WIC Participants.

BACKGROUND: The Special Supplemental Nutrition Program for Women, Infants, and Children, also known as WIC, is associated with improved health outcomes for participants. The role of WIC Peer Counselors was created to support breastfeeding among WIC participants. OBJECTIVE: This Naturalistic Inquiry study explored the perceptions and experiences of 9 WIC Peer Counselors located in Southeast Texas. METHODS: The WIC Peer Counselors were recruited via purposive and snowball sampling and participated in semi-structured face-to-face interviews. Data collection, analysis, and trustworthiness adhered to established guidelines. RESULTS: Study findings revealed the novel approaches the WIC Peer Counselors used to encourage, initiate, support, and sustain WIC participants' breastfeeding, including using tools of their craft, involving and educating family members, making themselves accessible 24/7, and identifying the need for equipment and supplies. CONCLUSIONS: The WIC Peer Counselors' understanding of the breastfeeding culture of their WIC clients and their unique ability to establish and maintain rapport with them make WIC Peer Counselors ideally suited resources to meet the WIC goal of increasing breastfeeding and thereby improving the health of the nation. Health care providers should recognize the valuable, yet unrecognized and underutilized, contributions of WIC Peer Counselors and consider referring pregnant and postpartum dyads to WIC for breastfeeding education and support.

Multi-Method Formative Evaluation of a Digital Online Grocery Shopping Assistant Among Special Supplemental Nutrition Program for Women, Infants, and Children Participants.

OBJECTIVE: Assess the acceptability of a digital grocery shopping assistant among rural women with low income. DESIGN: Simulated shopping experience, semistructured interviews, and a choice experiment. SETTING: Rural central North Carolina Special Supplemental Nutrition Program for Women, Infants, and Children clinic. PARTICIPANTS: Thirty adults (aged ≥18 years) recruited from a Special Supplemental Nutrition Program for Women, Infants, and Children clinic. PHENOMENON OF INTEREST: A simulated grocery shopping experience with the Retail Online Shopping Assistant (ROSA) and mixed-methods feedback on the experience. ANALYSIS: Deductive and inductive qualitative content analysis to independently code and identify themes and patterns among interview responses and quantitative analysis of simulated shopping experience and choice experiment. RESULTS: Most participants liked ROSA (28/30, 93%) and found it helpful and likely to change their purchase across various food categories and at checkout. Retail Online Shopping Assistant's reminders and suggestions could reduce less healthy shopping habits and diversify food options. Participants desired dynamic suggestions and help with various health conditions. Participants preferred a racially inclusive, approachable, cartoon-like, and clinically dressed character. CONCLUSIONS AND IMPLICATIONS: This formative study suggests ROSA could be a beneficial tool for facilitating healthy online grocery shopping among rural shoppers. Future research should investigate the impact of ROSA on dietary behaviors further.

Cyclic Formula Feeding Among Infants Participating in the Special Supplemental Nutrition Program for Women, Infants, and Children.

BACKGROUND: Low-income households often experience a cyclic pattern in food availability, with acute food shortages at month end. Variations in the monthly feeding of infant formula are understudied. OBJECTIVES: This study aimed to compare the amount and frequency of formula consumed at the beginning and end of the monthly Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) assistance cycle and test associations with total energy intake and other feeding practices among infants aged 7-11 mo. METHODS: This study was conducted between May 2020 and April 2021 in the southeastern United States and involved mothers of infants participating in WIC's fully formula package. Mothers were interviewed and 24-h feeding recalls were conducted at the beginning and end of the month. We defined month beginning as 5 d following the first WIC formula purchase and month end as 5 d before the next monthly cycle. Fifty mother-infant dyads participated in single or multiple monthly cycles, totaling 98 monthly cycles. Generalized linear mixed-effects modeling was used to test differences in formula feeding at month beginning and end. RESULTS: Most participants (84%) were African American or Latino and >90% purchased all formula within 2-3 d of the WIC issuance. The energy intake from formula at month beginning was significantly higher than at month end (67.63% and 57.85%, respectively; P = 0.002), with no differences in total energy intake. The odds of infants being fed cow milk and fruit juices/drinks increased from month beginning to end (P < 0.05). CONCLUSIONS: Infants in low-income households are at risk of experiencing a cyclic feeding pattern characterized by higher formula feeding at month beginning and an increase in feeding of nonrecommended drinks at month end. The WIC program policy could review educational and distribution options to reduce cyclic formula feeding and clarify caregivers' understanding of infants' formula needs. Household-level investigations into formula management and determinants of cyclic feeding are warranted.

E-health Dietary Interventions for Participants of SNAP and WIC: A Systematic Review.

The migration of federal assistance services to online platforms during the COVID-19 pandemic sparked interest in digital nutrition education for individuals participating in the Supplemental Nutrition Assistance Program (SNAP) and Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) programs. With federal government investing in the modernization of the nutrition education components of both programs, there is a need to identify science-backed electronic health (e-health) dietary interventions to improve health outcomes in this population. Therefore, the objective of this systematic literature review was to summarize the effectiveness, acceptability, and feasibility of e-health dietary interventions among individuals participating in WIC or SNAP. Keyword searches were performed in Google Scholar, PubMed, and Science Direct. The search included peer-reviewed literature from 2014 to 2023 and a few articles offering context about interventions used long-term by the nutrition assistance programs. PRISMA guidelines were followed to conduct this systematic literature review, which resulted in 36 articles eligible for extraction. The studies evaluated e-health (52.8%), short message service/text messaging (27.8%), and smartphone application interventions (19.4%) delivered to WIC or SNAP participants. The interventions identified aimed to modify food choice, eating behavior, and dietary intake among SNAP participants, SNAP-eligible adults, and WIC participants. Most interventions were developed using content delivery and health behavior theoretical frameworks (77.8%) and evidence-based nutritional recommendations (59.3%). Review findings show a high level of acceptability and feasibility for e-health and mobile health dietary interventions among WIC and SNAP participants but varying levels of effectiveness. Level of engagement, dosage, retention, and adherence were strong predictors of positive dietary behavior change regardless of the mode of intervention delivery. Future studies need to prioritize health equity by recruiting samples representative of food nutrition assistance participants and addressing digital health literacy as a potential barrier to intervention effectiveness, as none of the present studies measured literacy among participants.

Mixed methods evaluation of the COVID-19 changes to the WIC cash-value benefit for fruits and vegetables.

Introduction: Recent cash-value benefit (CVB) increases are a positive development to help increase WIC participant fruits and vegetables (FV) access. Little is known about the impacts of the CVB changes on FV redemptions or about implementation successes and challenges among WIC State and local agencies. This mixed method study aimed to evaluate (a) the CVB changes' impact on FV access among WIC child participants measured by CVB redemption rates, (b) facilitators and barriers to CVB changes' implementation, and (c) differences in FV redemption and facilitators and barriers by race/ethnicity. Methods: We requested redemption data from all 89 State agencies for April 2020 to September 2022 and utilized descriptive statistics, interrupted time series analysis (ITS), and generalized linear regression analysis. Additionally, we recruited State agencies, local agencies, and caregivers across the U.S. for interviews and used rapid qualitative analysis to find emerging themes anchored in policy evaluation and implementation science frameworks. Results: We received redemption data from 27 State agencies and interviewed 23 State agencies, 61 local agencies, and 76 caregivers of child WIC participants. CVB monthly redemptions increased at $35/child/month compared to $9/child/month; however, adjusted ITS analyses found a decrease in redemption rates at $35/child/month. The decrease was not significant when the transition/first implementation month was excluded with rates progressively increasing over time. Differences were found among racial/ethnic groups, with lower redemption rates observed for non-Hispanic Black caregivers. Overall, WIC caregivers reported high satisfaction and utilization at the $35/child/month. The frequent and quick turnaround CVB changes strained WIC agency resources with agencies serving higher caseloads of diverse racial and ethnic populations experiencing greater issues with implementing the CVB changes. Conclusion: Despite implementation challenges, the increased CVB shows promise to improve WIC participant FV access and satisfaction with WIC. WIC agencies need adequate lead time to update the CVB amounts, and resources and support to help ensure equitable distribution and utilization of the FV benefits.

New Evidence on the Cycle in the Women, Infants, and Children Program: What Happens When Benefits Expire.

We provide evidence of a benefit redemption cycle in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). Using novel administrative data on item-level redemptions, we show that unlike SNAP, WIC redemptions peak at both the beginning and end of the month. Beginning-of-the-month excess redemptions are concentrated among more popular items such as infant formula, while end-of-the-month excess redemptions are concentrated among less popular items such as infant meats. We document that a substantial share of beneficiaries go at least one month without redeeming anything and discuss how administrative burdens may drive the WIC cycle.

Enrollment and use of a peer counselor mHealth texting program to support breastfeeding in low-income people: A pilot study in the District of Columbia.

OBJECTIVE: To describe the characteristics of postpartum people who did and did not enroll in a breastfeeding peer-counselor mobile health (mHealth) texting program as well as the issues raised through 2-way texting with peer counselors. DESIGN: Pilot intervention study involving two Special Supplemental Nutrition Programs for Women Infants and Children (WIC) sites in the District of Columbia over 1 year. SAMPLE: WIC recipients. MEASUREMENTS: Descriptive statistics, comparison of recipients who enrolled or not and qualitative content analysis of text messages. INTERVENTION: A breastfeeding peer counselor texting program entitled BfedDC involving routine 1-way programmed messages and 2-way texting capacity for recipients to engage with peer counselors. RESULTS: Among our sample (n = 1642), nearly 90% initiated breastfeeding. A total of 18.5% (n = 304) enrolled in the BfedDC texting program, of whom 19.7% (n = 60) utilized the 2-way texting feature. Message content covered seven content themes and included inquiries about expressing human milk, breastfeeding difficulties, breastfeeding frequency and duration, appointments and more. CONCLUSIONS: Although enrollment was relatively low in BfedDC, benefits included 1-way supportive texts for breastfeeding and the ability to 2-way text with peer counselors. This program aligns with the Surgeon General's Call to Action to Support Breastfeeding and promotes breastfeeding equity in low-income people.

Food, nutrition, and autism: from soil to fork.

Food and nutrition-related factors have the potential to impact development of autism spectrum disorder (ASD) and quality of life for people with ASD, but gaps in evidence exist. On 10 November 2022, Tufts University's Friedman School of Nutrition Science and Policy and Food and Nutrition Innovation Institute hosted a 1-d meeting to explore the evidence and evidence gaps regarding the relationships of food and nutrition with ASD. This meeting report summarizes the presentations and deliberations from the meeting. Topics addressed included prenatal and child dietary intake, the microbiome, obesity, food-related environmental exposures, mechanisms and biological processes linking these factors and ASD, food-related social factors, and data sources for future research. Presentations highlighted evidence for protective associations with prenatal folic acid supplementation and ASD development, increases in risk of ASD with maternal gestational obesity, and the potential for exposure to environmental contaminants in foods and food packaging to influence ASD development. The importance of the maternal and child microbiome in ASD development or ASD-related behaviors in the child was reviewed, as was the role of discrimination in leading to disparities in environmental exposures and psychosocial factors that may influence ASD. The role of child diet and high prevalence of food selectivity in children with ASD and its association with adverse outcomes were also discussed. Priority evidence gaps identified by participants include further clarifying ASD development, including biomarkers and key mechanisms; interactions among psychosocial, social, and biological determinants; interventions addressing diet, supplementation, and the microbiome to prevent and improve quality of life for people with ASD; and mechanisms of action of diet-related factors associated with ASD. Participants developed research proposals to address the priority evidence gaps. The workshop findings serve as a foundation for future prioritization of scientific research to address evidence gaps related to food, nutrition, and ASD.

A Qualitative Exploration of Spanish-Speaking Latina Women's Experiences Participating in WIC Before and During the COVID-19 Pandemic.

BACKGROUND: More than one-third of the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participants identify as Latino, but participation has been declining and individuals who speak predominantly Spanish face additional barriers to participation. During the COVID-19 pandemic, there were changes in WIC eligibility and benefits that may have been differentially accessible to Spanish-speaking Latina participants due to factors such as language barriers and lack of awareness of changes. Understanding Spanish-speaking Latinas' experiences with the WIC program generally and during the pandemic can inform efforts to equitably implement future emergency food response policies and improve the WIC program and Latina participant enrollment more broadly. OBJECTIVE: This study aimed to understand the perceptions and experiences of Spanish-speaking Latina WIC participants with the WIC program generally and with COVID-19 pandemic-related policy changes made to the WIC program. DESIGN: Qualitative in-depth interviews were conducted virtually in Spanish in August 2022 using a semi-structured guide. PARTICIPANTS/SETTING: Study participants were 18 Spanish-speaking Latina adult WIC participants living in North Carolina recruited using convenience sampling. ANALYSIS: All interviews were recorded, transcribed, and coded in Spanish. Thematic analysis with inductive coding was used to derive key themes. RESULTS: Perceptions about the WIC program in this sample were mixed. Participants felt positively about the healthfulness of foods included in the WIC food packages but expressed concern about the monthly benefit amounts being too low and the cultural appropriateness of food options. Pandemic policy changes, such as remote appointments and the Cash Value Benefit increase were perceived positively; however, barriers to using benefits during this time included limited communication from WIC agencies, food shortages, and concerns about not being granted US citizenship or permanent resident status due to use of WIC (ie, public charge rule). Social networks played an important role in learning about and enrolling in WIC and navigating food shortages during the pandemic. CONCLUSIONS: Concerns about the cultural appropriateness of foods provided, communication challenges, and the public charge rule emphasized the need for resources dedicated in the WIC program to improving Spanish-speaking Latina women's experiences with WIC.

Special Supplemental Nutrition Program for Women, Infants, and Children Participant Grocery Store Purchases during the COVID-19 Pandemic in North Carolina.

Background: Families participating in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) experienced barriers to accessing healthy food during the COVID-19 pandemic, but we do not yet understand how WIC participant food purchases shifted during the pandemic. Objectives: We aimed to describe the association between the initial shock of the pandemic in March 2020 and WIC shoppers' food purchases and changes in purchases before and during the pandemic at a top grocery chain and examine differences in these relationships by duration of WIC use. Methods: We used longitudinal food transaction data from WIC shoppers (n = 2,989,116 shopper-month observations from 175,081 unique WIC shoppers) from 496 stores in a top grocery store chain in North Carolina between October 2019 and May 2021. We used an interrupted time series design to describe the following: 1) the relationship between the initial shock of the pandemic and WIC shopper food purchases and 2) differences in purchases before and during the pandemic. To assess differences in purchases between shoppers consistently using WIC electronic benefit transfer (EBT) cards and shoppers starting or stopping WIC EBT use during the pandemic, we used models stratified by WIC group. Primary outcomes were share (%) of total calories purchased from fruits, vegetables, nuts, and legumes (FV), processed foods, and sugar-sweetened beverages (SSBs). Results: We observed small decreases in the share of total calories from FV (-0.4%) and small increases in the share of calories from processed food (1.1%) and SSBs (0.5%) purchased at this retailer when comparing the pre and post March 2020 periods. Compared with shoppers that started or stopped using WIC benefits during the pandemic, shoppers that used WIC benefits consistently had slightly higher FV and lower processed food and SSB purchases at this retailer. Conclusions: Future studies should examine whether additional supports for nutrient-dense food choices may be needed for families with low incomes in public health emergencies.

WIC staff and healthcare professional perceptions of an EHR intervention to facilitate referrals to and improve communication and coordination with WIC: A qualitative study.

Objectives: Participation in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) has numerous benefits, yet many eligible children remain unenrolled. This qualitative study sought to explore perceptions of a novel electronic health record (EHR) intervention to facilitate referrals to WIC and improve communication/coordination between WIC staff and healthcare professionals. Methods: WIC staff in three counties were provided EHR access and recruited to participate. An automated, EHR-embedded WIC participation screening and referral tool was implemented within 8 healthcare clinics; healthcare professionals within these clinics were eligible to participate. The interview guide was developed using the Consolidated Framework for Implementation Research to elicit perceptions of this novel EHR-based intervention. Semi-structured interviews were conducted via telephone. Interviews were recorded, transcribed, coded, and analyzed using thematic analysis. Results: Twenty semi-structured interviews were conducted with eight WIC staff, seven pediatricians, four medical assistants, and one registered nurse. Most participants self-identified as female (95%) and White (55%). We identified four primary themes: (1) healthcare professionals had a positive view of WIC but communication and coordination between WIC and healthcare professionals was limited prior to WIC having EHR access; (2) healthcare professionals favored WIC screening using the EHR but workflow challenges existed; (3) EHR connections between WIC and the healthcare system can streamline referrals to and enrollment in WIC; and (4) WIC staff and healthcare professionals recommended that WIC have EHR access. Conclusions: A novel EHR-based intervention has potential to facilitate healthcare referrals to WIC and improve communication/coordination between WIC and healthcare systems.