Increased WIC Benefits for Fruits and Vegetables Increases Food Security and Satisfaction Among California Households with Young Children

Electronic Survey Methodology for Data Collection and Analysis in Nutrition and Dietetics Research

BACKGROUND

This article is part of a series of articles in the Journal of the Academy of Nutrition and Dietetics exploring the importance of research design, epidemiological methods, and statistical analysis as applied to nutrition and dietetics research. The purpose of this ongoing statistical portfolio is to assist Registered Dietitian Nutritionists (RDN) and Nutrition and Dietetic Technicians, Registered (NDTR) in interpreting nutrition research and applying scientific principles to produce high-quality data analysis. Advances in technology are promoting faster, easier, and often more diverse data collection and analysis. Consumers and practitioners alike are rapidly adopting electronic communication preferences (ie, telehealth, mobile applications, social media). This article, which accompanies the companion article on basic survey research, is an overview of electronic internet-mediated survey methodology for data collection and analysis in nutrition and dietetics research. Its purpose is to highlight the unique requirements in electronic planning and administration for surveys that builds on basic survey principles. This includes the effect of internet-mediated data methodology on an array of research parameters, including evaluation of software functions for the investigator and survey navigation issues for the participant. A Checklist for Reporting Electronic Survey Statistics (CRESS) is provided as a guide for data dissemination in nutrition and dietetics research.

A Systematic Review: The Impact of COVID-19 Policy Flexibilities on SNAP and WIC Programmatic Outcomes

In response to the coronavirus disease 2019 (COVID-19) public health emergency (PHE), the federal government deployed policy flexibilities in food and nutrition assistance programs including the Supplemental Nutrition Assistance Program (SNAP) and Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) to meet the needs those experiencing economic hardship. Emergent literature evaluates the impact of these flexibilities on program outcomes. The objective of this study was to explore the impact of policy flexibilities deployed during the COVID-19 PHE on access, enrollment/retention, benefit utilization, and perceptions of SNAP and WIC. Keyword searches were performed in November 2023, February 2024, and August 2024. The search included peer-reviewed literature from 2020 to 2024, following Johanna Briggs Institute (JBI) and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, resulting in 37 eligible articles. Twelve studies evaluated policy flexibilities in SNAP only, 21 in WIC only, and 4 in both programs. Across these, 12 studies explored program access, 7 enrollment/retention, 13 benefit utilization, and 15 program perceptions. JBI critical appraisal tools were used to assess risk of bias. The reviewed articles show that although SNAP and WIC participants identified challenges to access, there were increases in enrollment/retention due to policy flexibilities enabling remote services and reducing administrative burden in both programs. Benefit increases led to greater purchase of preferred foods in SNAP and greater access to fruit and vegetables in WIC. Overall, participants were satisfied with the flexibilities and reported most were beneficial for their households. Some implementation challenges were identified by participants and staff. A few studies showed potential risks of bias, including selection bias and confounding bias. COVID-19-related policy flexibilities in SNAP and WIC demonstrated significant improvements in selected program outcomes; however, challenges communicating policy flexibilities to authorized vendors and participants created difficulties to benefiting from the flexibilities. Findings from the evaluations of these flexibilities can inform future program enhancements and long-term regulatory changes. This study was registered in PROSPERO (CRD42023493302).

Household WIC Benefit Redemption Varies by Participant and Household Characteristics in Southern California

BACKGROUND

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides benefits redeemable for select healthy foods, aligned with the 2020-2025 Dietary Guidelines for Americans, to support healthy diets among pregnant and postpartum women, and their children to age 5 years, living in low-income households. WIC benefits are often not fully redeemed, limiting nutritional benefits of participation.

OBJECTIVE

The objective of this study was to assess the associations of WIC participant, caregiver, and household characteristics with WIC food benefit redemption.

DESIGN

This was a longitudinal study using WIC administrative data.

PARTICIPANTS/SETTING

WIC participants served by a program in Southern California from November 2019 to June 2023 (n = 501 527 certification periods; n = 271 116 individuals) were included in this study.

MAIN OUTCOME MEASURES

Mean WIC benefit redemption percentage in certification periods in benefit categories (ie, cheese/tofu, eggs, breakfast cereal, legumes, canned fish, fruits and vegetables, infant foods [cereal, fruits and vegetables, meats, contract and therapeutic formula], whole grains/bread, yogurt, whole and reduced-fat milk, and 100% juice) and across all categories, continuous and interval-scaled in 10% increments was measured.

STATISTICAL ANALYSIS

Multivariable quantile regression and generalized estimating equation ordinal logistic regression models were used to assess associations of WIC participant, caregiver, and household characteristics with median and interval-scaled redemption percentage, respectively, in each and across all categories.

RESULTS

Redemption ranged from very low (infant meats, 5.4%) to very high (infant formula, 96.2%). Median redemption across all categories was 70.6%. Significantly lower redemption was observed for households of Black, White, and other race/ethnicity-language preference individuals (compared with households of Hispanic English-speaking individuals); households with caregivers with lower educational attainment; and households with at least 1 month without food benefits issued, participating in the Supplemental Nutrition Assistance Program, income <100% of the federal poverty level, ≤5 individuals, or only 1 WIC participant.

CONCLUSIONS

WIC benefits are used at different rates by WIC participant, caregiver, and household characteristics. Groups with lower redemption may need additional support in using benefits. Maximizing redemption might help all WIC participants derive the full positive nutritional impact of program participation.

Examining the 2021 Cash Value Benefit Increase and WIC Participant Food Purchases

INTRODUCTION

The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) provides nutritious foods to more than six million low-income families. In June 2021, WIC increased the amount of money provided for fruits and vegetables (FV), but studies have not investigated whether this increase changed WIC participant FV purchases. The objective was to estimate the association between the FV funding increase and WIC shopper FV purchases.

METHODS

This evaluation uses longitudinal food transaction data from 496 stores in a grocery store chain in North Carolina between June 2020 and April 2022 and a propensity score weighted difference-in-differences (DID) approach to estimate the association between the FV funding increase and FV and other food group purchases. Analyses were conducted in 2023 and 2024.

RESULTS

WIC shoppers' WIC-eligible FV purchases increased by $12.4 per shopper per month (adjusted confidence interval [ACI], $12.0-$12.9) after the FV benefit increase, which was $9.3 (ACI, $8.7-$10.0) more than non-WIC shoppers. The monthly volume and unique varieties of FV purchased also increased more among WIC shoppers relative to non-WIC shoppers (DID 67.1 ounces [ACI, 61.9-72.3] and DID 2.1 varieties [ACI, 2.0-2.3]). There were also increases in the volume of processed foods (DID 22.0 ounces [ACI, 17.2, 26.9]) and sugar-sweetened beverages (DID 49.1 ounces [ACI, 33.4, 64.9]) purchased among WIC shoppers relative to non-WIC shoppers.

CONCLUSIONS

Increased WIC FV funding was associated with greater FV purchases. Research is needed to understand the effects of this policy on total dietary intake.

Longer WIC Participation Is Associated With Higher Diet Quality and Consumption of WIC-Eligible Foods Among Children 2-5 Years Old

BACKGROUND

Few studies have evaluated trends in diet quality across early childhood, including the extent to which foods and beverages available in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) Food Package contribute to children's diets.

OBJECTIVE

The objective of this study was to examine the following across ages 2 through 5 years: (1) trends in Healthy Eating Index-2020 (HEI-2020) total and component scores; (2) differences in mean HEI-2020 scores by WIC participation duration; and (3) contributions of the top 5 foods or beverages to HEI-2020 component scores by WIC duration.

DESIGN

This was a secondary analysis of a nationally representative sample of the WIC Infant and Toddler Feeding Practices Study-2 conducted between 2013 and 2019.

PARTICIPANTS/SETTING

WIC Infant and Toddler Feeding Practices Study-2 participants (n = 980; weighted n = 403 726) were included.

MAIN OUTCOME MEASURES

The outcomes were HEI-2020 scores and top contributing foods to HEI-2020 components.

STATISTICAL ANALYSES

Multivariate regression was conducted to examine HEI-2020 scores by WIC duration (high, intermediate, and low groups). The top 5 contributors to HEI-2020 components were averaged across ages 2 through 5 years and compared across WIC duration groups.

RESULTS

For all participants combined, the mean HEI-2020 total scores were similar across ages 2 through 5 years. Children with high WIC duration had higher total HEI-2020 scores compared with children with low WIC duration from ages 2 through 5 years (mean [SE], 58.1 [0.7] vs 55.6 [1.1]; P = .03). The percentage contributions of many of the WIC-eligible foods to HEI-2020 components were higher in the high WIC duration group compared with low WIC duration group, including higher intake of dried beans, unsweetened breakfast cereals, whole-grain breads, and 1% milk; the high WIC duration group also had lower intake of sweetened breakfast cereals and 2% milk.

CONCLUSIONS

Findings illustrate how WIC-eligible foods contribute to higher diet quality scores; when children participate in WIC longer, their diets are better aligned with national dietary guidelines.

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.

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 (β: 1.6 pts; 95% confidence interval [CI]: 1.4, 1.7), total vegetable (β: 3.6 pts; 95%CI: 3.4, 3.9), and total FV (β: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.

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.

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.

Food Insecurity and Mental Distress Among WIC-Eligible Women in the United States: A Cross-Sectional Study

BACKGROUND

Women living in Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)-eligible households may be pregnant or breastfeeding. Stress during pregnancy and breastfeeding may influence women's mental health making them more vulnerable to higher rates of food insecurity (FI).

OBJECTIVE

Determine whether or not FI is associated with moderate-to-severe mental distress among women living in WIC-eligible households, and whether or not the strength of the association differs among WIC participants compared with eligible nonparticipants with low income.

DESIGN

Cross-sectional data from the 2011-2018 National Health Interview Survey were utilized.

PARTICIPANTS/SETTING

A total of 7,700 women living in WIC-eligible households with at least one child were analyzed.

MAIN OUTCOME MEASURES

Moderate-to-severe mental distress was measured using the validated K6 nonspecific psychological distress scale. FI was measured using the 10-item, US Adult Food Security Survey Module.

STATISTICAL ANALYSES PERFORMED

Multivariate logistic regression was used to examine the association between FI and mental distress. The conditional effects of WIC participation were examined by including interaction terms for FI and WIC participation as well as by stratifying the sample by WIC participation.

RESULTS

Among women in WIC-eligible households, FI was associated with moderate-to-severe mental distress in a dose-response fashion: compared with those who were food secure, the adjusted odds of moderate-to-severe mental distress were 1.8 times higher among those with marginal food security (adjusted odds ratio [AOR] 1.83, 95% CI 1.50 to 2.23), 2.1 times higher among those with low food security (AOR 2.14, 95% CI 1.76 to 2.60), and 3.7 times higher among those with very low food security (AOR 3.73, 95% CI 2.95 to 4.71). The interaction between FI and WIC participation was not significant, with similar associations between FI and mental distress among WIC participants and nonparticipants.

CONCLUSIONS

Among this nationally representative sample of women in WIC-eligible households, increasing severity of food insecurity was associated with poor mental health among WIC participants and nonparticipants. WIC participation was not observed to moderate the association between FI and mental distress. More research should consider including mental health screening at WIC clinic visits to enable early identification and referral for care.

Increased WIC Cash Value Benefit is Associated with Greater Amount and Diversity of Redeemed Fruits and Vegetables among Participating Households

Background

Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food packages for children ages 1 to 4 y include a cash value benefit (CVB) redeemable for fruits and vegetables (FVs) with participating vendors. The CVB value was increased beginning in June 2021.

Objectives

This study evaluated associations of the augmented CVB with the amount and diversity of redeemed FVs.

Methods

Price look-up codes (PLUs) in redemption data determined outcomes including any redemption (any, none), amount redeemed (United States dollars [USD]/mo), and percent of total CVB redemption (percent) in 54 FV commodity groups among a cohort of 1770 WIC-participating children in Southern California. Outcomes across all commodity groups for fresh fruits, fresh vegetables, and all FVs were evaluated including dollar amount redeemed, percentage of redemption, and diversity of produce redeemed (variety and balance among items redeemed). Comparisons were made between augmented CVB periods (35 USD/mo in June-September 2021, 24 USD/mo October 2021-June 2022) and the preaugment period (9 USD/mo in June 2020-May 2021). Associations were tested in multivariable generalized estimating equation Poisson (any redemption) and linear (amount, percent, diversity) regression models.

Results

The augmented CVB was associated with higher any redemption prevalence and amount redeemed for 53 of 54 commodity groups at both 35 USD/mo and 24 USD/mo compared with 9 USD/mo. Redemption diversity increased for both fruits, vegetables, and all produce during both augment periods, and modestly greater increases in redeemed fruits relative to vegetables were observed at 35 USD/mo. The most commonly redeemed vegetables were tomatoes, onions, cucumbers, peppers, and avocados and the most commonly redeemed fruits were bananas, apples, grapes, limes, and melons.

Conclusions

The augmented CVB was associated with greater redeemed FV amount and greater redeemed FV diversity. Data on FV intake diversity among WIC-participating children are needed to understand dietary impacts of the CVB increase.