TABLE 2.
Thematic summary of all included studies related to fruit and vegetable (FV) purchases and consumption among WIC participants1
| Main themes or hypothesis | Study setting | Study population | Comparison group | Outcome (FV purchases or FV intake) | Results | Rank, author(s), year, quality2 |
|---|---|---|---|---|---|---|
| I. 2009 WIC food package revision | National | WIC children aged 2–4 y | Self (post-revision) and income-eligible nonparticipants’ children aged 2–4 y | Dietary intake3 (HEI-2010 component scores of FV) | 1. WIC children had significant ↑ of 3.7 HEI-2010 points (95% CI: 0.6, 6.9) after the 2009 revision compared with income-eligible nonparticipating children2. WIC children had significant 3.4-fold ↑ (95% CI: 1.3, 9.4) in greens and beans compared with income-eligible nonparticipating children3. No significant change in HEI-2010 component scores of total fruit (including 100% fruit juice), whole fruit (not including 100% fruit juice), (P = 0.73), and total vegetables comparing WIC children and income-eligible nonparticipating children (P = 0.47) | 1. Tester et al., 2016 (25)*** |
| National | All WIC participants | Self (post-revision) and income-eligible nonparticipants | FV per capita purchase4 (g/d) [100% fruit juice assessed separately] | 1. Significant ↑ in purchase of FV without additions (e.g., sugar, fat, and salt) over time in both WIC and income-eligible nonparticipants | 2. Ng et al., 2018 (24)*** | |
| State (California) | Pregnant or postpartum women and/or caregivers of children enrolled in WIC | Self (post-revision) | FV intake3 (frequency: times/d; daily servings) [100% fruit juice assessed separately] | 1. Proportion of families eating more vegetables compared with 6 mo ago significantly ↑ by 7.2% after WIC revision; no significant changes on fruits (P = 0.11)2. Mean frequency of fruit intake for respondents ↑ significantly by 0.1 servings/d after WIC revision; no change on vegetable (P = 0.12) | 3. Whaley et al., 2012 (27)*** | |
| State (Connecticut and Massachusetts) | WIC participants | Self (post-revision) | FV purchased amount4 (g/mo) and FV expenditure4 ($/mo) | 1. Significant ↑ in FV (fresh vegetable, frozen vegetable, and fresh fruit) purchased amount and expenditure per household | 4. Andreyeva and Luedicke, 2015 (26)*** | |
| Local (Head Start centers in rural communities in New Mexico) | Preschool children from WIC-participating households | Self (post-revision) | FV intake3 (cups/d) [fruit measurement excluding fruit juice] | 1. Significant ↓ vegetable without potatoes intake for preschool children after the 2009 revision; decrease not significant if including potatoes as vegetables (P > 0.05)2. No change in fruit intake for preschool children (P > 0.05) | 5. Morshed et al., 2015 (28)*** | |
| Local (local agencies in Texas) | WIC participants with a child aged 2–5 y | Self (post-revision) | FV consumption frequency3 (times/d) [100% fruit juice assessed separately] | No significant difference in FV intake for children before and after the 2009 WIC food package revision (P > 0.003) | 6. Diep et al., 2015 (29)*** | |
| Local (12 WIC clinics in Chicago, IL) | WIC-participating mothers and children | Self (post-revision) | FV intake3 (fruit: % participants with >0 servings/d; vegetable: % participants with >0.5 servings/d) [100% fruit juice assessed separately] | Nonsignificant ↑ % of black and Hispanic children and mothers with >0 servings/d of fruits (P > 0.05); nonsignificant ↑ % of black and Hispanic children and black mothers with >0.5 servings/d of vegetables (P > 0.05); nonsignificant ↓ % of Hispanic mothers with >0.5 servings/d of vegetables (P > 0.05) | 7. Kong et al., 2014 (30)*** | |
| Local (12 WIC clinics in Chicago, IL) | WIC-participating mother/child (2–3 y) dyads | Self (post-revision) | Dietary intake3 (servings/d) [100% fruit juice assessed separately] | 1. Significant ↑ fruit intake among Hispanic mothers2. No significant change in fruit or vegetable intake in any African mothers (P = 0.15 and 0.53, respectively), and children (P = 0.95 and 0.28, respectively), and in Hispanic children (P = 0.47 and 0.09, respectively) | 8. Odoms-Young et al., 2014 (31)** | |
| Local (WIC clinic in south central Texas) | WIC-participating infants and toddlers (4–24 mo) | Self (post-revision) | FV exposure3 (any consumption, regardless of portion size) [100% fruit juice assessed separately] | 1. Significant ↓ daily exposure of fresh vegetables among toddlers (12–24 mo) after the 2009 package revision2. No significant change in daily exposure to fresh fruits among toddlers (P > 0.05)3. Significant ↑ in % of toddlers who had zero exposures to FV after 2009 package revision | 9. Reat et al., 2015 (32)** | |
| II. WIC participation | National | WIC children aged 13 and 24 mo | Self (longitudinal) | HEI-2015 component scores3 | 1. Maximum on both total fruit (including 100% fruit juice) and whole fruit (excluding 100% fruit juice) scores, but low on total vegetable and greens and beans scores in children | 10. Au et al., 2018 (35)*** |
| National | WIC children aged 2–4 y | WIC income-eligible nonparticipants’ children aged 2–4 y | FV intake3 (cups/d) | 1. No difference in whole fruit or total vegetable intake between WIC children and income-eligible nonparticipants (P > 0.05)2. WIC children consumed significantly ↑ total fruit (including 100% fruit juice) compared with income-eligible nonparticipating children | 11. Vercammen et al., 2018 (34)*** | |
| Local (Los Angeles County, CA) | WIC-only children | Participating children in dual programs (SNAP and WIC) | FV intake3 (servings/d) | 1. Children who participated in dual programs (WIC + SNAP) consumed ↑ FVs than those who participated in WIC only | 12. Liu et al., 2017 (37)*** | |
| Local (2 supermarkets in 2 small urban areas in North Carolina—Wilson and Greenville, NC) | WIC adult grocery shoppers | WIC nonparticipants (eligible and noneligible) | FV consumption4 (skin carotenoids) | WIC participants had significant ↑ skin carotenoids score than nonparticipants | 13. McGuirt et al., 2018 (38)*** | |
| National | WIC children 12–23 mo | WIC income-eligible and high-income nonparticipants’ children 12–23 mo | FV intake3 (consumed on a given day) | 1. Significant ↑ % of fruit and vegetable (excluding white potatoes) intake among WIC-participating children compared with income-eligible nonparticipating children | 14. Hamner et al., 2019 (33)** | |
| National | WIC children 12–47.9 mo | WIC nonparticipating children 12–47.9 mo | Any FV consumed3 | 1. Significant ↓ % of WIC children consumed fruit compared with low- or high-income nonparticipating children aged 12–47.9 mo2. No significant difference in vegetable consumption across WIC participation (P > 0.05) | 15. Guthrie et al., 2018 (36)** | |
| Local (grocery stores in 7 low-income communities in the northern Great Plains region) | WIC grocery shoppers | WIC-eligible or ineligible nonparticipants | FV consumption3 (daily servings: scores from 1 = 0 serving to 10 = >8 servings) | Positive but nonsignificant relation between WIC participation and FV consumption (P > 0.05) | 16. Chang et al., 2015 (39)** | |
| III. Individual factors | Local (Los Angeles County, CA) | WIC children living in the USA <10 y (36–60 mo) | WIC children of Hispanic immigrants living in USA ≥10 y and Hispanic US-born parents | FV intake3 (servings/d) [fruit juice assessed separately] | 1. Children of Hispanic immigrants (living in the USA <10 y) consumed significant ↓ FV than children of Hispanic immigrants (living in USA ≥10 y)2. Children of Hispanic immigrants (living in the USA <10 y) consumed significant ↓ vegetables than children of Hispanic US-born parents | 17. Chaparro et al., 2015 (40)*** |
| Local (WIC clinic in Birmingham, AL) | WIC participants (women), regular CVV redeemers | Low CVV redeemers | FV intake3 (servings/d) [fruit juice assessed separately] | Regular CVV redeemers consumed significant ↑ daily servings of FVs compared with low CVV redeemers | 18. Singleton et al., 2018 (47)*** | |
| Local (WIC clinic in urban New Jersey) | WIC participants (Hispanic women) | WIC non-Hispanic and US-born Hispanic women | FV intake frequency3 (times/d) [100% fruit juice assessed separately] | 1. Race/ethnicity was significant predictor of vegetable intake (e.g., Hispanic women consumed ↑ orange-colored vegetables compared with non-Hispanic black women)2. Hispanic origin and birth place significant predictors of vegetable intake among Hispanics (e.g., foreign-born consumed ↑ orange-colored vegetables compared with US- born) | 19. Di Noia et al., 2015 (41)*** | |
| Local (2 WIC clinics in Atlanta, GA) | WIC mothers and their oldest children | Within-group comparison | FV intake3 (servings/d; indicator of >5 servings/d) [fruit juice assessed separately] | 1. “Already eat plenty of FV” significant ↓ FV consumption in mothers and oldest children2. “Knowing FV often spoil before eating” significant ↑ FV consumption among mothers3. “Not knowing how to prepare most FV” significant ↑ FV consumption in mothers4. “Concerned about money” significant ↑ FV consumption in oldest children | 20. Chen and Gazmararian, 2014 (43)** | |
| Local (WIC clinic in Milwaukee, WI) | WIC parents/caregivers | Within-group comparison | FV purchases3 (times/wk) and FV type consumed3 (type) [juice assessed separately] | 1. 89% of participants redeemed CVVs regularly and 39% of participants bought FVs less than once a week2. 96% of participants consumed raw, boiled, and steamed vegetables | 21. Kharofa et al., 2014 (48)** | |
| Local (WIC clinic in urban New Jersey) | WIC women | Within-group comparison | FV intake3 (cups/d) and consumption frequency3 (times/d) [100% fruit juice assessed separately] | 1. Significant positive association between social desirability trait and daily vegetable consumption frequency among nonbreastfeeding women | 22. Di Noia et al., 2016 (44)** | |
| Local (2 WIC clinics in Phoenix, AZ) | WIC women or mothers of WIC children | Within-group comparison | CVV redemption3 | Perceived facilitators and barriers for FV redemption:1. Positive experiences and facilitators:
|
23. Bertmann et al., 2014 (42)** | |
| Local (Hartford, CT) | WIC-eligible pregnant women | Within-group comparison | Prenatal FV intake3 | 10 factors related to prenatal FV intake (social support, family structure, FV access, FV preferences, FV knowledge, FV health outcome expectations, self-efficacy, intentions, FV action/coping planning strategies, maternal health status) | 24. Hromi-Fiedler et al., 2016 (45)** | |
| Local (Tulare, Alameda, and Riverside counties, CA) | WIC participants | Within-group comparison | FV purchase decision3 | Ranking of perceived factors affecting FV purchase decisions from most important to least important: highest quality produce; can see, smell, touch before buying; best bargains on produce; convenience; clearly displayed prices | 25. Kaiser et al., 2015 (46)* | |
| IV. Farmers’ markets | State (California) | WIC households | WIC households redeemed at a full-line grocery | CVV full redemption4 | Probability of CVV full redemption was 99.1% at farmers’ markets compared with 66.8% at a full-line grocery with 6–9 cash registers | 26. Saitone et al., 2018 (54)** |
| Local (WIC clinics in Birmingham, AL) | WIC women | Within-group comparison | FV intake3 (servings/d) | 1. Farmer-to-consumer (FTC) retail outlet usage associated with significant ↑ FV daily intake and significant ↑ odds of consuming ≥5 servings/d among WIC women | 27. Singleton et al., 2016 (49)*** | |
| Local (2 WIC clinics Atlanta, GA) | WIC FMNP participants (women and their children) | WIC non-FMNP participants (women and their children) | FV intake frequency3 (times/d) | 1. No significant difference on FV intake of mothers and children detected between FMNP groups and non-FMNP groups (P > 0.05) | 28. Stallings et al., 2016 (51)*** | |
| Local (WIC clinic in Urbana, IL) | WIC FMNP participants | WIC non-FMNP participants | FV intake3 (eaten as snacks and servings/d) | 1. Significant ↑ participants receiving FMNP vouchers eating vegetables as snacks and eating >1 vegetable daily compared with those not receiving the voucher2. No significant difference in fruit intake, citrus fruit, or juice, between the voucher and nonvoucher group (P > 0.05) | 29. Wheeler and Chapman-Novakofski, 2014 (52)** | |
| Local (WIC clinic in Birmingham, AL) | WIC FITC outlet women users | WIC non-FTC outlet women users | FV intake3 (≥5 servings/d) [fruit juice assessed separately] | Significant ↑ % of FTC outlet users consuming ≥5 servings FVs per day compared with nonusers | 30. Singleton et al., 2017 (50)** | |
| Local (WIC clinic in urban New Jersey) | WIC women | Within-group comparison | FV purchase at farmers’ markets3 | Usage1. Barriers:
|
31. Di Noia et al., 2017 (53)** | |
| V. Store- and clinic-level factors | State (New Jersey) | WIC participants | Within-group comparison | CVV complete redemption,4 defined as redemption rate ≥90% | Minimum stocking of FVs in stores; significant but small ↑ (10%) in the odds of complete CVV redemption after the policy change | 32. Okeke et al., 2017 (55)** |
| State (212 WIC clinics in Washington state) | WIC nontribal clinics | Tribal WIC clinics | CVV redemption4 | Nontribal WIC clinics had significant ↑ CVVs redeemed compared with tribal WIC clinics | 33. McLaury et al., 2016 (56)** | |
| Local (Chelsea, MA) | Corner store adult customers (WIC participants and nonparticipants) | Control stores | WIC CVV sale at store level4 ($/mo) and % of customer who purchased fresh FVs3 | 1. WIC CVV sales significantly ↑ in intervention stores with improved visibility and quality of FVs compared with control stores 2. Nonsignificant ↑ in the proportion of WIC participants who purchased fresh FVs in intervention stores compared with control stores (P = 0.11) | 34. Thorndike et al., 2017 (57)** | |
| VI. Program intervention | State (California) | WIC women or caregivers of children | Within-group comparison | FV intake frequency3 (times/d) and self-reporting eating more FVs3 [100% fruit juice assessed separately] | 1. ↑ % of participants reported their family having more fruit intake after nutrition education curriculum state-wide implementation, but no significant difference in eating more vegetables (P = 0.31)2. Significant ↓ in vegetable mean frequency intake for respondents after education, but not significant for fruit (P = 0.97) | 35. Ritchie et al., 2010 (61)*** |
| Local (rural, Mexican heritage households in California's Central Valley) | Prior or current WIC participants | Within-group comparison | FV expenditure4 and frequency share by FV food groups4 | With an additional FV voucher ($25/mo/household):1. Fruit expenditure constitutes 55% of the spending but 45% of the frequency share2. Low % of mean expenditure share on dark-green and/or red and orange vegetables | 36. Hanbury et al., 2017 (60)*** | |
| National (school food authorities in Cherokee Nation and Chickasaw Nation and 8 states) | WIC children | Respondents in SNAP benefit model | FV intake3 (cup-equivalent/d) including fruit juice and vegetable juice | FV consumption among respondents in WIC benefit model 2 times ↑ compared with that in SNAP benefit model | 37. Briefel et al., 2018 (58)** | |
| Local (WIC clinic in urban New Jersey) | WIC Fresh Start (WFS) women | WFS nonparticipant women | FV intake3 (cups/d) [fruit juice included] | WFS participating women consumed significantly ↑ fruit and ↓ vegetables compared with WIC participants nationwide | 38. Di Noia et al., 2016 (59)** | |
| VII. FV prices | National | WIC participants | Within-group comparison | Purchasing power of CVV4 | Purchasing power of CVV varied across regions | 39. Çakır et al., 2018 (62)*** |
1CVV, cash value voucher; FMNP, Farmers’ Market Nutrition Program; FTC, farm-to-consumer; FV, fruit and vegetables; HEI, Healthy Eating Index; SNAP, Supplemental Nutrition Assistance Program; WFS, WIC Fresh Start; WIC, Special Supplemental Nutrition Program for Women, Infants, and Children.
2*** = good quality; ** = fair quality; * = poor quality.
3Self-reported outcome variable.
4Measured outcome variable.