Insights in Public Health

Abstract

The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) is a proven, cost-effective investment in strengthening families. As part of the United States Department of Agriculture's (USDA) 15 federal nutrition assistance programs for the past 40 years, WIC has grown to be the nation's leading public health nutrition program. WIC serves as an important first access point to health care and social service systems for many limited resource families, serving approximately half the births in the nation as well as locally. By providing nutrition education, breastfeeding promotion and foods in addition to referrals, WIC plays a crucial role in promoting lifetime health for women, infants and children. WIC helps achieve national public health goals such as reducing premature births and infant mortality, increasing breastfeeding, and reducing maternal and childhood overweight. Though individuals and families can self-refer into WIC, physicians and allied health professionals have the opportunity and are encouraged to promote awareness of WIC and refer families in their care.

Introduction

The Special Supplemental Nutrition Program for Women, Infants and Children (WIC) is a proven, cost-effective investment in strengthening families.^1–4 The program is a short-term intervention program designed for low to moderate-income pregnant and postpartum women, infants, and children. Its mission is to safeguard the health of income-eligible, nutritionally at-risk women, infants, and children up to age five. WIC celebrates 40 years of strengthening families in 2014. WIC works to combat food insecurity with sister United States Department of Agriculture (USDA) programs in the state such as Supplemental Nutritional Assistance Programs (SNAP), Child Nutrition Programs including School Breakfast and School Lunch, the Senior Farmers' Market Nutrition Program, and the Emergency Food Assistance Program.

Designed to influence lifetime nutrition and lifestyle behaviors, WIC provides nutrition education, nutritious foods, breastfeeding support, and referrals. The nutrition education and specific healthy foods provided enable young families to make lifelong healthy eating and lifestyle choices. WIC clients are generally 25% women, 25% infants up to age one, and 50% children age two to five. Approximately half of births in the state and nationally are enrolled in WIC. In Federal Fiscal Year (FFY) 2013, Hawai‘i WIC served an average of 36,370 women, infants and children monthly, each receiving an average monthly food benefit of $70.07. Last year, WIC check redemptions totaled approximately $30.6 million.

WIC has evolved from the initial infant formula give-away pilot project to decrease infant mortality to the largest public health breastfeeding promotion program in the nation. WIC promotes breastfeeding as the optimal infant feeding choice and supports national efforts to improve breastfeeding initiation, duration, and exclusivity. WIC supports two major Healthy People 2020 goals to (1) promote health and reduce chronic disease risk through the consumption of healthful diets, and achievement and maintenance of healthy body weights, and (2) improve the health and well-being of women, infants, children, and families. Numerous Healthy People 2020 objectives related to WIC are summarized in Table 1. WIC provides anticipatory guidance to families, connects them to community resources, and promotes medical and dental homes. Findings demonstrate that WIC improves birth outcomes,^5–7 diets and diet-related outcomes,^8,9 infant feeding practices,¹⁰ and immunization rates.¹¹

Table 1.

Healthy People 2020 Objectives Related to WIC

Topic Area		Objective
Early & Middle Childhood (EMC)	EMC-1	Increase the proportion of children who are ready for school in all five domains of healthy development, physical development, social-emotional development, approaches to learning, language and cognitive development
Maternal, Infant & Child Health (MICH)	Morbidity & Mortality
	MICH-1	Reduce the rate of fetal and infant deaths
	MICH-3	Reduce the rate of child deaths
	MICH-5	Reduce the rate of maternal mortality
	MICH-6	Reduce maternal illness and complications due to pregnancy
	MICH-8	Reduce low birth weight (LBW) and very low birth weight (VLBW)
	MICH-9	Reduce preterm births
	Pregnancy Health & Behaviors
	MICH-10	Increase the proportion of pregnant women who receive early and adequate prenatal care
	MICH-11	Increase abstinence from alcohol, cigarettes and illicit drugs among pregnant women
	MICH-13	Increase the proportion of mothers who achieve recommended weight gain during pregnancies
	Preconception Health & Behaviors
	MICH-14	Increase the proportion of women of childbearing potential with intake of at least 400 micrograms of folic acid from fortified foods or dietary supplements
	MICH-15	Reduce the proportion of women of childbearing potential who have low red blood cell folate concentrations
	MICH-16	Increase the proportion of women delivering a live birth who received preconception care services and practiced key recommended preconception health behaviors
	Infant Care
	MICH-21	Increase the proportion of infants who are breastfed
	Health Services
	MICH-30	Increase the proportion of children, including those with special health care needs, who have access to a medical home
Nutrition & Weight Status (NWS)	Weight Status
	NWS-8	Increase the proportion of adults who are at a healthy weight
	NWS-9	Reduce the proportion of adults who are obese
	NWS-10	Reduce the proportion of children and adolescents who are considered obese
	NWS-11	Prevent inappropriate weight gain in youth and adults
	Food Security
	NWS-12	Eliminate very low food security among children
	NWS-13	Reduce household food insecurity and in doing so reduce hunger
	Food & Nutrient Consumption
	NWS-14	Increase the contribution of fruits to the diets of the population aged two years and older
	NWS-15	Increase the variety and contribution of vegetables to the diets of the population aged two years and older
	NWS-16	Increase the contribution of whole grains to the diets of the population aged two years and older
	NWS-17	Reduce consumption of calories from solid fats and added sugars in the population aged two years and older
	NWS-18	Reduce consumption of saturated fats in the population aged two years and older
	NWS-19	Reduce consumption of sodium population aged two years and older
	NWS-20	Increase consumption of calcium population aged two years and older
	Iron Deficiency
	NWS-21	Reduce iron deficiency anemia among young children and females of childbearing age
	NWS-22	Reduce iron deficiency anemia among pregnant females
Oral Health (OH)	Oral Health of Children & Adolescents
	OH-1	Reduce the proportion of children and adolescents who have dental caries experience in their primary or permanent teeth
	Access to Preventive Services
	OH-8	Increase the proportion of low-income children and adolescents who received any preventive dental services during the past year

WIC Funding

WIC is a domestic discretionary program funded annually through Congressional appropriations. WIC was established by Congress as part of the Child Nutrition Act of 1966, and is currently reauthorized through 2015. Grants are provided to the states, which in turn provide funding at local levels. The Hawai‘i State Department of Health (DOH) is the designated State Agency which administers funds from the USDA, Food and Nutrition Services (FNS). WIC Services Branch within the Hawai‘i DOH is responsible for administering the 100% federally funded Program. Seventy-five percent (75%) of funds are generally spent on food benefits, with 25% spent on nutrition education, breastfeeding promotion, other client services and administration.

WIC Eligibility Requirements

WIC recipients must have income at or below 185 percent of the poverty income guidelines or be adjunctively income-eligible through enrollment in SNAP, Temporary Assistance to Needy Families (TANF) or MedQUEST. In addition to meeting income eligibility, the WIC applicant must be a pregnant woman, a breastfeeding woman up until one year postpartum, a non-breastfeeding woman up until six months postpartum, or an infant or child up to age five living in Hawai‘i. Postpartum women include those who miscarry. Finally, applicants must also be at risk medically or nutritionally (eg, anemia, underweight, overweight).

WIC Availability in Hawai‘i

WIC services are available on all major islands statewide. A family is free to access WIC services at the agency of their choice and does not depend on where they live (except for Kokua Kalihi Valley Comprehensive Family Services, which only serves those residing in Kalihi Valley). In addition to their main clinic site, several of the agencies provide satellite clinic services to ensure accessibility. Contracted services are available at seven community health centers (CHCs), one social service agency and one hospital. State employees provide services at an additional seven local agencies. This variation is related to funding and women, infants and children receive the same services regardless of type of agency or location. Table 2 lists the agency, type of agency, caseload achieved for the period October 1, 2012 through September 30, 2013 (FFY 2013), and the general service area. The caseload across the state was nearly half a million in 2013.

Table 2.

Hawai‘i WIC Agencies by Name, Type, 2013 Caseload and Service Area

Agency Name	Type	Caseload	Service Area
Kalihi Palama Health Center (Hale Ho‘ola Hou)	CHC*	42,543	O‘ahu
Kapiolani Medical Center for Women and Children	Hospital	21,149	O‘ahu
Kokua Kalihi Valley (Comprehensive Family Services)	CHC	18,859	Kalihi Valley
Waimanalo Health Center	CHC	10,927	O‘ahu
Waianae Coast Comprehensive Health Center	CHC	56,390	O‘ahu
Leeward Unit	State	45,027	O‘ahu
Pearl City Unit	State	20,084	O‘ahu
Wahiawa Unit	State	43,868	O‘ahu
Windward Unit	State	34,799	O‘ahu
Bay Clinic	CHC	20,141	Hawai‘i Island
Hilo Unit	State	45,225	Hawai‘i Island
Kona Unit	State	18,737	Hawai‘i Island
Community Clinic of Maui (Malama I Ke Ola Health Center)	CHC	23,450	Maui
Maui Unit	State	19,942	Maui
Moloka‘i Community Health Center	CHC	5,241	Moloka‘i
Maui Family Support Services	Social Service	1,271	Lana‘i
Kaua‘i Unit	State	18,380	Kaua‘i
TOTAL		446,033

^*Denotes a Community Health Center Location

WIC Benefits

Once enrolled, WIC provides monthly support for specific supplemental foods to ensure health and development along with nutrition education, breastfeeding promotion/support, and referrals. The families then redeem checks at authorized retail grocery stores (and one approved pharmacy for specialty formulas).

WIC provides four major benefits discussed in more detail: (1) nutrition education; (2) specific healthy supplemental foods; (3) breastfeeding promotion/support; and (4) referrals to health and social services.

Nutrition Education

Core nutrition messages based on national recommendations endorsed by the USDA are promoted by WIC to encourage participants to eat more fruits, vegetables, whole grains, and fiber; consume less fat, cholesterol, juice, and sweetened beverages; and to breastfeed. Nutrition education may be provided one-on-one with a nutritionist, registered dietitian or trained staff, or in a group setting. Participant-centered services, theoretically based on stages of change, and drawing techniques from motivational interviewing and rapport building, are offered by direct service staff. Families are able to choose topics that they want to learn, such as what to eat for a healthy pregnancy, cooking on a budget, reading food labels, how and when to introduce solids to a baby, and how and when to wean a baby from a bottle to a cup.

Healthy Supplemental Foods

The WIC food packages (ie, foods covered by WIC dollars) are designed for nutritional value to supplement the needs of women, infants, and children to ensure good health, growth and development. The package was changed in 2009 based on an Institute of Medicine study to align with the Dietary Guidelines for Americans, including cash value vouchers (CVVs) for fruits and vegetables for the first time.¹² The food package currently includes fruits, vegetables, low-fat dairy, soy products, and whole grains. Table 3 lists the key nutrients provided by categories of WIC allowed foods.

Table 3.

WIC Foods and Key Nutrients Provided

WIC Foods & Alternatives	Key Nutrients Provided
Fruits & Vegetables	Vitamins A,C,E, Folate, Potassium, Fiber
Baby Food Fruits & Vegetables and Meats	Vitamins A,C,E, Folate, Potassium, Fiber (Iron & Zinc in baby food meat)
Milk, Soy Beverage, Tofu	Protein, Calcium, Vitamins A,D; Folate, Riboflavin
Whole Grain Cereals, Bread, Brown Rice, Soft Corn Tortillas	Iron, B Vitamins, Folate, Fiber, Zinc, Magnesium
Canned Fish (Tuna, Salmon, Sardines, Mackerel)	Protein, Folate
Dry Beans, Peanut Butter	Protein, Calcium, Vitamins A,D, Riboflavin
Cheese	Protein, Calcium, Vitamins A,D, Riboflavin
Eggs	Protein, Vitamins A&D

While WIC's prescribed food packages and allowed foods are limited and specific, SNAP benefits are more liberal. For example, WIC allowed cereals must contain a minimum of 28 mg of iron and a maximum of 21.2 g of sucrose and other sugars per 100 g of dry cereal but any cereal can be purchased with SNAP benefits. As another example, WIC allowed juices must contain at least 30 mg of vitamin C per 100 mL of juice whereas any drink can be purchased with SNAP benefits. Another difference is that WIC benefits expire in 30 days, but unused SNAP benefits carry over into the next month. SNAP allows families to buy fruits and vegetables at participating farmers' markets in Hawai‘i, but currently WIC CVVs are redeemable only at authorized grocery stores. WIC encourages families to apply for all eligible USDA programs, and use SNAP benefits to complement the WIC food package.

Breastfeeding Support

WIC strengthened breastfeeding policies and activities in the 1990s which included the introduction of an enhanced food package for exclusively breastfeeding mothers in 1992, followed by a breastfeeding campaign implemented in 1997. WIC promotes breastfeeding as the optimal infant feeding choice. Breastfeeding provides numerous health benefits to both mother and infant, and reduces healthcare costs. Breastfeeding lowers the risk of obesity, type 2 diabetes and asthma.¹³ WIC educates pregnant women on the benefits of breastfeeding and continues to provide support after they give birth. Support includes the provision of personal pumps, which may be manual pumps or hospital-grade breast pumps on loan, breastfeeding supports (eg, breastfeeding drapes), and providing a breastfeeding-friendly clinic environment.

The breastfeeding peer counselor (BFPC) project is an adjunct to basic core WIC breastfeeding support. In 2004, the national BFPC initiative started hiring peer counselors to support WIC women learning to breastfeed. BFPC trained paraprofessional peer counselors provide breastfeeding support in venues other than WIC clinics, and during hours when WIC clinics are closed. Studies among WIC participants in Texas and Maryland have shown that interaction with WIC BFPCs prenatally is associated with increased rates of breastfeeding initiation.^10,14 In Hawai‘i WIC, the BFPCs concentrate on pregnant women enrolled in their first trimester, but also support breastfeeding among all those that are interested regardless of entry into WIC.

Referrals

WIC also assists families to access social services (eg, Head Start, domestic violence resources, voter registration, and financial assistance) and healthcare services (eg, substance abuse treatment, immunizations, oral care, or prenatal care). Medical and dental homes are encouraged. Some WIC agencies also coordinate activities such as car seat safety inspections and fluoride varnish applications.

Improved Birth Outcomes

Preterm births are costly. Prenatal WIC participation is associated with lower infant mortality rates.⁶ USDA studies based on linked WIC and Medicaid data in five states found that prenatal WIC participation resulted in longer pregnancies; fewer premature births; lower incidence of moderately low birth weight (LBW, less than 2,500 grams) and very low birth weight (VLBW, less than 1,500 grams) infants; fewer infant deaths; a greater likelihood of receiving prenatal care; and, within the first 60 days after birth, a savings of $1.77 to $3.13 for every dollar spent.^1,16 Another study conducted in Virginia found a savings of up to $4.21 in Medicaid for every dollar spent on a WIC pregnancy.¹⁷ Prenatal WIC participation is associated with a positive impact of 6.6 ounces of birth weight in WIC babies compared to babies born to mothers who did not participate in WIC prenatally,⁷ and prenatal WIC participation reduced the rate of LBW babies by 25% and VLBW babies by 44%.⁵ To promote healthy birth outcomes, WIC women are monitored throughout their pregnancy for appropriate weight gain as well as health behaviors and advised to receive early prenatal care. WIC infants are also routinely monitored. A recent analysis of Hawai‘i WIC data on gestational weight gain (GWG) and birth weights for mother-infant pairs from 2003 to 2005 indicated 62% had excessive weight gain and 15% had inadequate weight gain.¹⁸ Those with excessive weight gain during pregnancy were more likely to have a high birth weight (HBW) infant. Those with inadequate weight gain during pregnancy were more likely to have a LBW infant if they were underweight or normal weight prior to pregnancy. Women gaining appropriate weight had better birth outcomes. These analyses demonstrate the impact of WIC and help guide the provision of services.

Improved Diet and Diet-Related Outcomes

WIC participation is associated with higher mean intakes of iron, vitamin C, thiamin, niacin, and vitamin B6 without an increase in food energy intake, indicating an increase in nutrient density.¹⁹ Studies have shown positive effects on nutrient intake without an increase in fat or cholesterol intake;²⁰ and that WIC is more effective than other cash or SNAP benefits in improving intake of key nutrients for preschoolers.²⁰ The CDC has attributed a national decline in the iron deficiency anemia rate from 7.8 percent in 1975 to 2.9 percent in 1985 partially to WIC.⁴ Low-income children enrolled in WIC have a lower prevalence rate of anemia than those who are not enrolled in WIC.⁹ Moreover, WIC enrollment is associated with improved growth rates among children.²¹ Infants on WIC are less likely to be underweight, but are not at greater risk of being overweight.²² Four and five-year olds whose mothers participated in WIC during pregnancy have better vocabulary test scores than children whose mothers did not receive WIC.¹⁸

Improved Infant Feeding Practices Including Breastfeeding Rates

Women who reported having received breastfeeding advice at WIC are more likely to breastfeed than other WIC women or women not in WIC.³⁰ BFPC participants have an increased rate of initiation.¹⁰ For infants on formula, 90 percent received iron-fortified formula.²⁵ Data from Hawai‘i has shown an impact on breastfeeding initiation in WIC with closing the gap between those on WIC prenatally and those not on WIC. For example in 2000, an estimated 14.1% of WIC moms who were enrolled prenatally did not attempt to breastfeed compared to 7.8% of non-WIC moms; by 2011 5.9% of WIC moms did not attempt to breastfeed compared to 3.3% of non-WIC moms. Similarly, there has been a narrowing of this gap in breastfeeding at 8 weeks with an estimated 60.7% of WIC moms who were enrolled prenatally were breastfeeding compared to 74.7% of non-WIC moms in 2000, but by 2011 this increased to 73.4% of WIC Moms who were enrolled prenatally compared to 82.3% of non-WIC Moms.²⁶ Additionally, a recent analysis of Hawai‘i WIC mother-child pairs of two-year olds born between 2005 and 2009 showed children breastfed for at least six months had a lower childhood obesity risk compared to those who were never breastfed.²⁷ As a result of information such as this, WIC provides breastfeeding training to all staff, uses BFPCs, and incentivizes with a more robust food packages for nursing mothers and breastfed infants.

Improved Oral Health

Early childhood caries (ECC) is the most prevalent infectious and transmittable disease among children in America.²⁸ An estimated 80 percent of ECC in low-income children aged two to five remain untreated.²⁹ Children whose mothers participated in WIC for a full year were approximately 1.7 times more likely to have two or more dental visits per year than children who never participated in WIC.³⁰ WIC does not have trained staff to meet oral health care needs, but feeding practice recommendations and referrals can prevent ECC. WIC promotes dental homes for families, and encourages caregivers to plan a child's first dental visit by age one. Kona WIC and the West Hawai‘i Community Health Center have collaborated to provide “Keiki Dental Days” where the parent (with child in lap) and provider sit knee-to-knee to administer a child oral health assessment, fluoride varnish application, toothbrush prophylaxis, anticipatory guidance, and necessary referral to care and case management; services are provided on-site at WIC by the CHC dental staff. Many other CHCs with WIC services also offer co-located dental services.

Improved Immunization Rates & Regular Source of Medical Care

WIC participation is associated with improved rates of childhood immunization as well as having a regular source of medical care.³¹ Children in WIC are more likely to be immunized than those who drop out of WIC.¹¹ Many CHCs which offer WIC also offer co-located immunization and medical services. National studies show WIC infants are in better health than eligible infants not participating in WIC.²²

Collaborative efforts

In addition to providing direct support of clients, WIC staff also participates in collaborative efforts that promote health in the State. For example, WIC staff are participants in the Governor's Early Childhood Action Strategies to assure a comprehensive early childhood system.³² In this collaborative, specific focus areas of WIC interest include healthy and welcomed births, safe and nurturing families, on-track health and development, and equitable access to programs and services. Another example, would be supporting the work of the Family Health Services Division in State Priorities through participation in workgroups such as promoting healthy weight among children, improving access to children oral health care, promoting developmental screening, as well as participating in efforts such as reducing prenatal smoking and alcohol use. WIC staff also collaborates across divisions in the Hawai‘i DOH. For example, WIC staff support efforts of the Healthy Hawai‘i Initiative to reduce child obesity and improve breastfeeding education and initiations in birthing hospitals.

Conclusion

For the last 40 years, WIC has been improving the health of nutritionally at-risk women, infants and children by providing healthful supplemental foods accompanied by nutrition education, breastfeeding support and referrals, and through collaborative efforts with partners. WIC is cost effective in safeguarding the health status of the target population, with recent studies showing $4.21 in Medicaid savings for every dollar spent on a WIC pregnant woman. Interdepartmental and interagency cooperation help alleviate childhood hunger and food insecurity. Physicians and allied health care professionals can help promote WIC, by reaching out to potentially eligible families and encouraging them to apply.

Disclaimer

The opinions, findings, and conclusions in this article are those of the author and do not represent the official position of the Hawai‘i Department of Health.

Conflict of Interest

None of the authors identify a conflict of interest.