California WIC Participants Report Favorable Impacts of the COVID-Related Increase to the WIC Cash Value Benefit.

The United States Department of Agriculture approved an increase to the Cash Value Benefit (CVB) for the purchase of fruits and vegetables issued to participants receiving an eligible Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food package. In order to understand satisfaction, perceptions, and the overall impact of additional benefits for fruits and vegetables at the household level, a qualitative study consisting of structured phone interviews was conducted with families served by WIC in Southern California from November to December 2021 (n = 30). Families were selected from a large longitudinal study sample (N = 2784); the sample was restricted by benefit redemption and stratified by language and race. WIC participants were highly satisfied with the CVB increase, reporting increased purchasing and consumption of a variety of fruits and vegetables. Respondents noted the improved quality and variety of fruits and vegetables purchased due to the increased amount. Findings are expected to inform policy makers to adjust the CVB offered in the WIC food package with the potential to improve participant satisfaction and increase participation and retention of eligible families with benefits from healthy diets supported by WIC.

A Qualitative Examination of California WIC Participants' and Local Agency Directors' Experiences during the Coronavirus Disease 2019 Pandemic.

BACKGROUND: The US Department of Agriculture granted waivers to allow flexibility in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) operations during the coronavirus disease 2019 (COVID-19) pandemic; however, research examining the associations between waiver introduction and changes in perceptions, practices, and challenges of WIC participants' and agency directors' experiences is limited. OBJECTIVE: The objective of this study was to assess California WIC participants' and agency directors' perceptions and practices of remote WIC services during the COVID-19 pandemic. A secondary aim was to understand other COVID-19 challenges related to maintaining access to healthy foods by WIC participants. DESIGN: A qualitative study that included semistructured interviews was conducted between June 2020 and March 2021. PARTICIPANTS AND SETTING: One hundred eighty-two WIC participants with a child aged 0 to 5 years from three regions of California (Southern, Central, and Northern) and 22 local WIC agency directors across the state were interviewed. MAIN OUTCOME MEASURES: WIC participants' and agency directors' perceptions, practices, and other challenges during COVID-19. STATISTICAL ANALYSES PERFORMED: Interviews were recorded, transcribed, and analyzed using a grounded theory approach. RESULTS: Participants shared that they valued the information received from WIC and were very satisfied with remote WIC services. Participants reported that enrolling in WIC remotely was easier than coming in person. All waivers and changes to WIC operations, namely the physical presence, remote benefit issuance, and separation of duties waivers, and remote work and remote delivery of nutrition education, were largely viewed by WIC agency directors as options that should be continued postpandemic. Further, a majority (63%) of households reported experiencing food insecurity, and half of respondents received food from a food bank or pantry during the pandemic. CONCLUSIONS: Findings suggest WIC will attract and retain the most families by offering a hybrid model of services, incorporating both onsite services and remote options to work more efficiently and effectively.

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.

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.

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

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

WIC Participants' Perceptions of COVID-19-Related Changes to WIC Recertification and Service Delivery.

Many Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) clinics implemented alternatives to in-person service delivery in response to the COVID-19 pandemic, including virtual visits and electronic document sharing. The objective of this cross-sectional study was to describe WIC participants' experiences with remote service delivery and recertification during the pandemic. Participants included mothers and infants who participated in a WIC-based intervention between June 2019-August 2020. All participants (N = 246) were invited to complete a follow-up survey between November 2020-February 2021; 185 mothers completed the survey. The survey assessed sociodemographics, employment, food security, experiences with remote WIC recertification and service delivery, and experiences with obtaining WIC foods during the pandemic. Average age for mothers was 29.2 ± 6.3 years and for infants was 17.7  ± .2 months; 80% (n = 147) identified as Hispanic. Approximately 34% (n = 62) of participants reported very low or low food security and 40% (n = 64) had difficulties buying WIC foods during the pandemic. Among participants who recalled providing documentation of income and address virtually, the majority felt comfortable providing information via email (60%) and text messaging (72%). Participants reported high levels of satisfaction with remote methods of service delivery, as well as overall satisfaction with the WIC program during the pandemic. While ~ 25% of study participants preferred for all WIC services to remain remote, 75% still desired at least some in-person contact with WIC staff after the pandemic. In conclusion, remote methods of WIC service delivery addressed existing barriers to WIC participation and were well-received by study participants.

Promoting Responsive Bottle-Feeding Within WIC: Evaluation of a Policy, Systems, and Environmental Change Approach.

BACKGROUND: Bottle-fed infants are at greater risk for overfeeding and rapid weight gain (RWG); evidence-based strategies for promoting healthy bottle-feeding practices are needed. OBJECTIVE: Our aim was to assess whether policy, systems, and environmental (PSE) strategies for promoting responsive bottle-feeding practices within the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) were associated with lower risk for RWG. DESIGN: We conducted a matched-pair cluster randomized trial. PSE strategies were implemented at 3 WIC clinics in Los Angeles County. PSE clinics were compared with 3 matched control clinics. Mothers and infants were assessed when infants were newborn and 3 months and 6 months of age. PARTICIPANTS/SETTING: Participants were mothers (n = 246) who enrolled their newborn infants (younger than 60 days) into WIC between May and August 2019. MAIN OUTCOME MEASURES: Infant weight was assessed and standardized to sex- and age-specific z scores. RWG was defined as weight-for-age z score change > 0.67. Mothers completed questionnaires assessing responsive and pressuring feeding styles, breast- and bottle-feeding patterns, and perceptions of WIC experiences. STATISTICAL ANALYSES PERFORMED: Logistic regression with estimation via generalized estimating equations and linear mixed models with repeated measures assessed effects of PSE strategies on categorical and continuous outcomes, respectively. RESULTS: Infants in PSE clinics had significantly lower likelihood of exhibiting RWG (P = .014) than infants in control clinics. Mothers in PSE and control clinics reported similar levels of responsive and pressuring feeding style and similar prevalence of breastfeeding and bottle-feeding. Mothers in PSE clinics trended toward feeling better supported with respect to their decision to bottle-feed (P = .098) and had more stable intentions to stay in the WIC program (P = .002) compared with mothers in control clinics. CONCLUSIONS: PSE strategies focused on promoting more inclusive assessment of infant feeding, tailored bottle-feeding counseling, and increased education and support for responsive bottle-feeding were associated with lower risk for RWG among WIC infants.

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.

Predictors of WIC Participation Through 2 Years of Age.

OBJECTIVE: To examine factors associated with Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) participation through 2 years of age. DESIGN: Longitudinal data from the WIC Infant and Toddler Feeding Practices Study-2. SETTING: Eighty WIC sites. PARTICIPANTS: The WIC Infant and Toddler Feeding Practices Study-2 participants interviewed through 2 years of age (n = 1,250). MAIN OUTCOME MEASURE: WIC participation through 2 years of age. ANALYSIS: Multivariate logistic regression and odds ratios. RESULTS: Infants in households with incomes ≤100% of the federal poverty level (FPL) were more than twice as likely as those with incomes above 100% FPL to continue WIC participation through 2 years (odds ratio = 2.22; 95% confidence interval [CI], 1.34-3.66). The odds of WIC participation through 2 years were 2.84 times higher for infants fully breastfed for 6 months or longer compared with infants breastfed for less than 6 months (95% CI, 1.43-5.66). Infants in households in which caregivers reported they made a change in how they fed their family on the basis of something they learned from WIC had 2.60 higher odds of continued WIC participation than infants in households in which caregivers did not report making a change (95% CI, 1.67-4.07). CONCLUSIONS AND IMPLICATIONS: In addition to lower household income, longer breastfeeding duration and application of WIC nutrition education are important predictors of WIC participation through 2 years of age.