Comments from Richard Besser, MD, on Proposed Rule to Update WIC Food Packages

The following comments were submitted by Richard Besser, MD, Robert Wood Johnson Foundation (RWJF) president and CEO, to the U.S. Department of Agriculture Food and Nutrition Service, on the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC): Revisions in the WIC Food Packages proposed rule.

RWJF is committed to improving health and health equity for all in the United States. In partnership with others, we are working to develop a Culture of Health rooted in equity that provides every individual with a fair and just opportunity to thrive, no matter who they are, where they live, or how much money they have.

Health is more than an absence of disease. It is a state of physical, mental, and emotional wellbeing. It reflects what takes place in our communities, where we live and work, where our children learn and play, and where we gather to worship. That is why RWJF focuses on identifying, illuminating, and addressing the barriers to health caused by structural racism and other forms of discrimination, including sexism, ableism, and prejudice based on sexual orientation.

We rely on evidence to advance health equity. We cultivate leaders who work individually and collectively across sectors to address health equity. We promote policies, practices, and systems change to dismantle the structural barriers to wellbeing created by racism. We work to amplify voices to shift national conversations and attitudes about health and health equity. Our comments are grounded in the perspectives and expertise of our grantees, who include academic researchers, policy experts, advocates, and organizers with deep expertise in supporting health in early childhood.

Of note, RWJF has consistently invested in research demonstrating WIC’s role in reducing food insecurity, improving nutritional intake, and reducing childhood obesity, while identifying ways to further improve the impact of the program. We have also supported and worked with the National WIC Association to expand access by streamlining enrollment in the WIC program, particularly during the COVID-19 pandemic. Many of the lessons learned by RWJF and our grantees and partners are relevant to this proposed rule.

For example, research funded by our national program Healthy Eating Research (HER) has repeatedly demonstrated that increasing flexibility and options available to families improves healthy consumption. In a HER-funded study published in July 2022, WIC participants reported that increased cash vouchers allowed their families to eat a wider variety of fruits and vegetables. Likewise, HER-funded research in Washington State during the COVID-19 pandemic and published in the Journal of the Academy of Nutrition and Dietetics in December 2022, showed that expanding the number of options on the approved list of WIC food items immediately increased participant benefit redemption. HER-funded research suggests additional ways to increase consumption of fruits and vegetables, such as better labeling of WIC-authorized produce and use of mobile apps, permitting purchase of frozen fruits and vegetables, and allowing online shopping.

RWJF is pleased to offer comments on the proposed rule as outlined here and detailed below:

I.     Background on the Importance of WIC and the Proposed Rule;
II.    Promoting the Agency of WIC Participants
III.    Increasing the Cash-Value Voucher (CVV);
IV.    Allowing Juice Only as a Substitution;
V.    Expanding Access to Whole Grains;
VI.    Increasing the Overall Value of the WIC Benefit; and
VII.    Going Further: Recommendations for Future USDA Updates to WIC.

    I.    Background on the Importance of WIC and the Proposed Rule

For decades, WIC has provided food and critical resources to millions of families in need. In 2022, more than 6.2 million people participated in WIC, including almost half of infants born in the U.S. The WIC program plays a key role as a nutrition safety net for these families, including many families of color, who, due to longstanding systemic and structural inequities, experience food insecurity at rates that exceed the national average. Further, WIC helps to keep families with low incomes out of poverty; a comprehensive analysis by researchers at Child Trends estimates that WIC contributed a two percent reduction in the child poverty rate by 2019 compared to what the rate would have been without the existence of the program.

The COVID-19 pandemic hit families hard. Feeding America estimates that 45 million people, including 15 million children, may have experienced food insecurity in 2020. While food insecurity stabilized in 2021, rates remained highest among families of color. WIC participation increased during the pandemic, as well, partly because flexibilities provided by USDA allowed the WIC program to innovate in how it delivers services to meet children’s and families’ needs while keeping them safe. Throughout the pandemic and our nation’s recovery, WIC has been and will continue to be an essential tool for ensuring children have enough nutritious food and the opportunity for a healthy start in life.

The proposed changes to the WIC food package are likely to have a significant impact on the health and nutrition of U.S. families. The WIC food package was last updated in 2009 to better align with dietary guidelines. Research has found that those changes increased access to and availability of healthy foods and improved diet quality and variety among participants. The changes have also been associated with declines in childhood obesity rates among participating children. Those declines have been among the most widespread progress in reducing obesity rates among any population group; rates have declined among all racial and ethnic groups and in 28 of 56 states and territories. WIC also has a proven track record of public health success that is attributable to its science-based structure, including the following achievements: improved pregnancy and birth outcomes, reduced risk of infant mortality, improved breastfeeding rates, increased consumption of under-consumed food groups, including fruits, vegetables, whole-grain food, and lower-fat milk, and higher dietary quality.

Moreover, WIC changes have spillover effects for the broader population. For example, manufacturers reformulated infant formula and breakfast cereals in the 1980s to meet iron-fortification requirements set forth in the initial food packages. Retailers also reported increased stocking of fresh produce after minimum stock requirements were implemented in 2009, especially in low-income neighborhoods. USDA’s proposed rule would result in similar effects, for example, with new requirements for WIC retailers to increase the minimum number of vegetables they stock.

We support that the proposed rule is grounded in the latest nutritional science, including the 2020–2025 Dietary Guidelines for Americans, as recommended by the National Academies of Sciences, Engineering and Medicine (NASEM) in its 2017 report, ‘‘Review of WIC Food Packages: Improving Balance and Choice.”’ Ensuring that WIC is aligned with the most current nutritional guidance is essential to supporting health and health equity for all WIC participants.

    II.    Promoting the Agency of WIC Participants

A core principle of RWJF’s efforts to build a national Culture of Health is that communities, regardless of income or geography, have the power, agency, and resources to create and implement their own solutions to the unique health issues facing them. Thus, as an overarching principle, RWJF encourages changes to the WIC food package that promote flexibility and autonomy, including by expanding the allowable food items and facilitating easy substitutions. Several of the proposals for which USDA has specifically sought comment would expand access to a broader array of food items and substitutions, including:

- Allowing use of the Cash-Value Voucher to purchase frozen, canned, or dried fruits and vegetables in addition to fresh;
- Adding soy-yogurts and soy-cheeses as substitutes;
- Adding canned fish to the infant food package;
- Adding canned legumes;
- Adding tofu and other nut butters as substitutes; and
- Increasing flexibility on food package sizes.

As USDA has acknowledged, substitutions and nutritional tailoring are important to accommodate the needs of individuals with disabilities and those with allergies and cultural preferences. Beyond that, RWJF believes that all WIC families deserve to have the power, agency, and autonomy to respond to their own unique needs and circumstances, which they know best.

    III.    Increasing the Cash-Value Voucher

We support that the proposed rule makes permanent the increased Cash-Value Voucher (CVV) that allows for the purchase of fruits and vegetables. Enacted during the pandemic, the CVV benefit was temporarily raised from $9–11 per person per month to $25 per child and $44–49 for adults per month. Making this increase permanent more than doubles the previous CVV benefit for children and quadruples it for adults.

According to research funded in part by RWJF national program office Healthy Eating Research (HER), WIC participants reported that the increased CVV benefit better met their household needs and was the most valued part of the WIC food package. In fact, they would often spend the fruits and vegetable benefit before other WIC food package components each month. The research also found that the increased CVV benefit facilitated healthier eating habits and allowed families to eat more culturally appropriate diets, particularly for those on plant-based diets. Families also had more opportunity to introduce new fruits and vegetables to their children—a practice that is critical to forming healthy eating habits in childhood.

USDA should keep this increased CVV benefit throughout implementation of the new rule to ensure there is no lapse in benefit for families. USDA’s proposed rule outlines an implementation timeline of 18 months, allowing states to adjust complex computer systems to account for the new food packages. This window is critical to ensure that states are positioned to appropriately program in new products, issuance levels, and substitution patterns. However, the proposed rule suggests that changes cannot be made on a food category basis; instead, an entire food package (e.g., the food package for children) must be adjusted at the same time. For example, the proposed rule suggests that canned fish could not be added to the child food package until the entire child food package is updated. This limitation is of particular concern for the food packages with elevated CVV, as a narrow reading of that limitation would suggest that benefits must be reduced to $9 or $11 for fruits and vegetables unless all changes are included across the individual food package. USDA should avoid this result and explicitly exempt CVV from this limitation in implementation to assure equitable treatment of WIC participants as states adjust their systems and program in the new food packages.

    IV.    Allowing Juice Only as a Substitution

Increasing fruit and vegetable consumption is critical for improving health outcomes and closing intake disparities. Whole fruit is higher in fiber than 100 percent fruit juice. In its 2017 report, “Review of WIC Food Packages: Improving Balance and Choice,” NASEM prioritized fiber intake across all child and adult food packages. USDA’s proposed rule takes important steps towards encouraging whole fruit and vegetable consumption. Echoing NASEM’s recommendation, the proposed rule would reduce overall issuance of 100 percent fruit juice and permit substitution of the remaining juice benefit for additional CVV.

RWJF recommends that USDA go one step further and flip the substitution pattern: eliminate default juice issuance, add an additional $3 (adjusted for inflation) to the CVV, and permit juice only as a substitution option. By eliminating default juice issuance, WIC can better align participant perceptions and nutrition education messages with medical advice.

    V.    Expanding Access to Whole Grains

RWJF strongly supports the ways in which the proposed rule would increase WIC participants’ access to whole grains through new cultural options and stronger cereal standards.

NASEM identified that 100 percent of adults and 93 percent of children do not meet their whole grain intake as recommended by the Dietary Guidelines for Americans. Further, children exceed the recommended refined grain intake. Black and Hispanic families face the greatest intake disparities, with the average Hispanic toddler consuming only 26 percent of recommended whole grain intake. NASEM recognized that breakfast cereals are well positioned to drive increased whole grain intake for young children, leveraging limited WIC resources to deliver whole grains and key nutrients like iron and folate through the same food category. NASEM identified that multiple whole grain cereals—including gluten-free varieties—are already on the marketplace.

Introducing whole grain consumption during childhood is critical for WIC participants’ health throughout the life course, as whole grain consumption boosts intake of priority nutrients like fiber and iron and is associated with reduced risk of cardiovascular disease, type 2 diabetes, and other chronic diseases. In addition, USDA has listened to WIC families and providers in going further than the NASEM report to offer a broader range of nutritionally appropriate whole grain options that align with cultural eating patterns, including quinoa, wild rice, millet, triticale, amaranth, kamut, sorghum, wheat berries, tortillas with folic acid-fortified corn masa flour, corn meal (including blue), teff, buckwheat, and whole wheat pita, English muffins, bagels, and naan. Additional cultural options will both reflect traditional diets honored by WIC families while making the program more accessible to new immigrants and refugees as they settle in the United States.

    VI.    Increasing the Overall Value of the WIC Benefit

We commend USDA’s approach that “prioritize[s] WIC participants’ supplemental nutrition needs over maintaining cost-neutrality.”

With the exception of the Cash-Value Voucher (CVV) for fruits and vegetables, WIC foods are issued by quantity to ensure that a participant can obtain the same level of nutrients regardless of market fluctuations, inflationary pressures, retail cost, and geographic price variations. This highlight of WIC’s program design has been undermined by the diminishing value of the WIC benefit over time. Even though the 2009 food package updates added new food groups like fruits and vegetables through the CVV and whole grains, that regulatory change was cost-neutral and came at the expense of access to other supplemental foods. When WIC was established in the 1970s, a monthly benefit would supply approximately $20 of supplemental foods. According to the Bureau of Labor Statistics, if the WIC food packages were adjusted for annual inflation to maintain the same purchasing power, the total value of the monthly food benefit would be over $100 today. Instead, the average monthly WIC benefit in 2021 was only $35.58.

Diminished purchasing power for the WIC shopper is not just a matter of numbers, but also of nutrients. As WIC promotes a balanced approach that provides more nutrient-dense foods to participating families, it is critical that the value of the benefit is sufficient to meet the needs of families. The Dietary Guidelines for Americans noted the body of research that shows that young children may need up to ten exposures to accept a new type of food, given the diversity of textures and flavors that can be introduced. With only $9 per month for fruits and vegetables, families did not have the resources to try a wide range of produce and instead opted for familiar staples. With the added value that USDA now proposes be made permanent, families have increased variety of fruits and vegetable purchases while also reporting a ¼ cup per day increase in fruits and vegetable consumption for WIC-enrolled children. Qualitative research from California, Delaware, and North Carolina confirmed that the enhanced WIC benefit is allowing families to buy additional varieties of fruits and vegetables for their children to try. By using the enhanced WIC benefit to introduce children to a wider variety of fruits and vegetables, children’s dietary preferences will be shaped throughout the life course. This change will lead to improved health outcomes not only during the course of WIC participation, but also likely reduce long-term diet-related chronic disease in adulthood.

    VII.    Going Further: Recommendations for Future USDA Updates to WIC

The proposed updates to the WIC food packages are a welcome step by USDA to support the health and wellbeing of children and families and advance health equity in the U.S. RWJF values the strengths of the WIC program, and we are proud to work with Healthy Eating Research, the National WIC Association, and others, to strengthen and extend the reach of WIC. In addition to the above comments on the proposed rule, RWJF offers the following additional recommendations for future updates by USDA to the WIC program to improve access to WIC’s vital services:

- Make permanent the current waivers that have enabled families to access WIC services during the pandemic. These include allowing certification via phone, video, or drive-through clinics, extending certification periods, and continuing telehealth appointments between certifications;

- Advance equity in WIC participation, including by providing targeted outreach and support based on health and access disparities and establishing a process for equitable beneficiary participation in program design, implementation, and evaluation; and

- Support state efforts to implement WIC Electronic Benefit Transfer, explore mobile payments, and expand online purchasing options.

Further research supporting these recommendations, and others, is available in our August 2021 issue brief, “WIC: Ensuring a Healthy Start for All Kids and Families.”

Thank you for the opportunity to comment on the proposed rule to revise the WIC food packages. We have included numerous citations to supporting research through direct links to the research. We direct USDA to each of the materials we have cited and made available through active links, and we request that the full text of each of the studies and articles cited, along with the full text of our comment, be considered part of the formal administrative record for purposes of the Administrative Procedure Act. If USDA is not planning to consider these materials part of the record as we have requested here, we ask that you notify and provide us an opportunity to submit copies of the studies and articles into the record.

We look forward to continuing to work with USDA and other partners to ensure that everyone has the opportunity for health and wellbeing.

About the Robert Wood Johnson Foundation

The Robert Wood Johnson Foundation (RWJF) is committed to improving health and health equity in the United States. In partnership with others, we are working to develop a Culture of Health rooted in equity that provides every individual with a fair and just opportunity to thrive, no matter who they are, where they live, or how much money they have.