Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)

Kiersten McMahon

APRIL 19, 2015

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The Special Supplemental Program for Women, Infants, and Children (WIC) effectively

fulfills its purpose to provide millions of women in America with education and healthy and

nutritious foods. It is one of the largest food assistance programs in the United States of

America. The federal WIC program is not an entitlement program, therefore, it is efficient in

providing WIC benefits to those willing to take the initiative to participate in the nutrition

education classes as well as to those who need the program the most. Nationwide, the

program can be improved through greater outreach into particularly affected low-income

communities, reform of the education classes, and more consideration for the greater demands

placed on health care workers. The WIC program serves many women and children of the

Fargo-Moorhead area. The Women, Infants, and Children federal program is a sustainable

program that will only serve to benefit many more women with expansion and continuing

reforms.

The United States Department of Agriculture (USDA) defines WIC as a program that:

“provides Federal grants to States for supplemental foods, health care referrals, and nutrition

education for low-income pregnant, breastfeeding, and non-breastfeeding postpartum women,

and to infants and children up to age five who are found to be at nutritional risk”.1 WIC began

as a two year pilot program that was voted into the Child Nutrition Act of 1966 on September

26, 1972. During this time, the program only served children up to age four and excluded non-

breastfeeding postpartum women. However, in 1975 WIC was established as a permanent

program. The program now served non-breastfeeding women, up to 6 months after childbirth,

and children up to 5 years of age. All participants had to be deemed at nutrition risk and with

1 "Women, Infants, and Children (WIC)." Women, Infants, and Children (WIC). Accessed February 3, 2015. http://www.fns.usda.gov/wic/women-infants-and-children-wic.

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inadequate income. However, the legal definitions of “nutrition risk” and “inadequate income”

were not defined, which allowed women to be turned away who may have benefited from

participation in the program.2 Then, the U.S. poverty threshold was established to determine

the minimum income necessary to support a household with food, housing, and basic

necessities and is adjusted for inflation every year. A household’s income does not include

welfare benefits and the Census Bureau measurement of poverty status is not a measurement

of whether an individual or family is actually living in poverty. It is calculated this way because

welfare benefits boost most low-income Americans over the poverty threshold.3 Finally, in

1978, the program adopted the national income standard laid down by the standards for the

reduced-price school lunch program. This action officially connected the standards for the WIC

program and the National School Lunch Program under the USDA. Now in order to qualify for

and participate in WIC, the household’s income had to be 195% or lower based on the federal

poverty guidelines. Nutrition education was also required for all WIC program participants.

Then, in 1981, the income level standard for WIC was lowered to having a household income of

185% or lower by federal poverty guidelines along with the reduced-price school lunch

program.4

As mentioned in the USDA definition, the WIC program aims to help: pregnant women

throughout their pregnancy and up to six weeks after childbirth or after the end of pregnancy,

breastfeeding women up to the child’s first birthday, non-breastfeeding postpartum women up

to six months after childbirth or after the end of pregnancy, infants up to their first birthday,

and children up to their fifth birthday. The program only serves children up to their fifth

2 "WIC." Federal Safety Net. Accessed February 3, 2015. http://federalsafetynet.com/wic.html.3 "U.S. Poverty Threshold." Federal Safety Net. http://federalsafetynet.com/us-poverty-threshold.html. 4 "WIC." Federal Safety Net. Accessed February 3, 2015. http://federalsafetynet.com/wic.html.

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birthday because then the child would be attending school and have eligibility for reduced-price

lunches. The WIC program currently serves 53% of all infants born in the United States. In

order to receive WIC’s benefits; which include supplemental and nutritious foods, nutrition

education and counseling at WIC clinics, and screenings and referrals to other health, welfare,

and social services; the mother must take the initiative to ask about and register for the

program. The WIC program is not based on entitlement, therefore, Congress does not set aside

funds for every eligible person each year. Instead it authorizes a specific amount of money to

be administered at the federal level by the USDA Food and Nutrition Service (FNS) and by 90

WIC state agencies, through approximately 47,000 authorized retailers. WIC also operates

through 1,900 local agencies in 10,000 clinic sites, in 50 State health departments, 34 Indian

Tribal Organizations, the District of Columbia, and five territories (Northern Mariana, American

Samoa, Guam, Puerto Rico, and the Virgin Islands). WIC services can be found in county health

departments, hospitals, mobile clinics, community centers, schools, public housing sites,

migrant health centers and camps, and Indian Health Service facilities.5 Participants receive

checks or vouchers every month to buy specific foods designed to supplement their diets.

Some states even issue electronic benefit cards to participants instead of the paper checks or

vouchers. A few state agencies distribute WIC foods through warehouses or deliver the foods

to participants’ homes. Some of the approved foods include: infant cereal, iron-fortified adult

cereal, vitamin-C rich fruit or vegetable juice, eggs, milk, cheese, peanut butter, dried or canned

beans or peas, canned fish, soy-based beverages, tofu, fruits and vegetables, baby foods, whole

wheat bread. However, different food packages are provided for different categories

5 "Women, Infants and Children (WIC)." About WIC- WIC at a Glance. Accessed February 3, 2015. http://www.fns.usda.gov/wic/about-wic-wic-glance.

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of participants. WIC recognizes and promotes breastfeeding as the optimal source of nutrition

for infants, but for women who do not fully breastfeed, WIC provides iron-fortified infant

formula. Special infant formulas and medical foods may also be provided when they are

prescribed by a physician for a specified medical condition.6

Congress passed the WIC program with the intent of providing health benefits to

pregnant women, breast-feeding women, as well as infants and children at risk to improve the

overall health of the programs participants. However, as the program has been developing,

areas of improvement have been noticed by many. As the program expands, the demands on

WIC agencies increase and issues with the program itself become apparent when there are

those in need who struggle with eligibility or committing to the demands of the program itself.

The WIC program was placed under the administration of health agencies, which can be

problematic because of the added work requirements placed on the local health agencies who

have staff that provide both WIC and non-WIC services. In 1982, a local health department in

rural North Carolina showed that the total number of encounters in the Columbus County

Children’s Clinic greatly increased during a two-year period, which coincided with the growth of

the WIC program. Not only was there a growing number of WIC encounters, but the number of

infants and children who came to the clinic for WIC certification kept coming back. To the

benefit of local agencies such as this one, in 1979 there was a change in the reporting

requirements for the WIC program, which made it easier for health departments to request

funding for nurses or equivalent staff. Those funds can only be used for WIC related services

and the increasing number of children in WIC also receiving non-WIC services from the same

6 "WIC." Federal Safety Net. Accessed February 3, 2015. http://federalsafetynet.com/wic.html.

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nurses are contributing disproportionately to the increase in the total number of nursing

encounters. Therefore, consideration must be given to providing the resources necessary to

handle the total number of children using clinic services.7

In 2003, the WIC program was 25 years old. Yet, very little was known about the

program in comparison to the data and knowledge gathered from other antipoverty programs

such as AFDC/TANF, Medicaid, or food stamps. The Current Population Survey (CPS) and the

Survey of Income and Program Participation (SIPP) contains a degree of under-reporting for

most of the antipoverty programs in the United States, but the degree of under-reporting for

the WIC program is larger than the others. This may have been because there is a certain

stigma against receiving the program, even greater than food stamps, which makes people less

likely to respond that anyone in the household receives benefits from the WIC program.

Especially because they are required to purchase specific items. This can be seen in the

statistics from 1998. In that year, 58% of all infants were eligible, 57% of children years one

through four were eligible, and 54% of pregnant or postpartum women were eligible for the

WIC program. However, many of those eligible either did not participate or did not report

participation. They estimated that, out of those who were eligible, 73% of infants, and 38% of

children one through four, and 67% of pregnant or postpartum women participated. These

numbers could reflect state regulations because some states have stricter regulations than

others. States that required proof of income, before it was mandatory under federal law, and

that had stricter program rules had less participation. Interestingly, the surveys also found that

individuals in households with African American or Hispanic respondents were more likely to

7 Kotch, Jonathan B., and David Whiteman. "Effect of a WIC Program on Children's Clinic Activity in a Local Health Department." Medical Care 20, no. 7 (1982): 691-98.

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participate and report participation than those in White or Asian households. It was also

interesting to note that low-income households headed by married respondents were more

likely to participate than single respondents. This could be because of the costs and demands

of participating in the WIC program. It was also noted that houses with more educated

respondents were less likely to participate than those with less education. Also, those who

lived in suburbs reported less participation than those households residing in urban areas. The

analysts of these surveys suggest that there needs to be more outreach to Asian and suburban

women and reductions in the transaction costs for single mothers and more educated mothers

to gain greater participation.8

Participation in the WIC program has been increasing since its implementation in 1974.

The WIC program had 88,000 participants in 1974 and grew to have around 8.1 million

participants in 2006. In 2006, about one-quarter of participants were pregnant or postpartum

women, about one-quarter were infants, and about half were children one to five years old.

However, despite the health benefits that can be gained from participation in the program,

many eligible households were not participating in WIC during pregnancy and many exited the

program after the child turned one year old. The Early Childhood Longitudinal Study found that

WIC participants in better economic health, over a variety dimensions, are more likely to wait to

enter the program or leave early. This was shown in the statistics from 2006. There were high

rates of participation among the eligible postpartum women, at 74%, and the eligible infants, at

83.1%. The low participation rates came from eligible pregnant women, at 69.6%, and eligible

children ages one to five at 43.5%. The study suggests that pregnant women and children are

8 Bitler, Marianne P., Janet Currie, and John Karl Scholz. "WIC Eligibility and Participation." The Journal of Human Resources 38, no. Special Issue on Income Volatility and Implications for Food Assistance Programs, 1139-1179.

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less likely to participate in WIC because of the provision of infant formula and the participants

breast-feeding decisions. The mothers who breast-feed for six months or more are less likely to

leave the program than those who choose not to breast-feed or only breast-fed for less than six

months.9 The WIC program encourages breast-feeding because it has benefits for both the

mother and the child. Human milk is associated with lower rates of urinary-tract infections,

lower and upper respiratory-tract infections, diarrhea, allergic diseases, otitis media, bacterial

meningitis, botulism, bacteremia, and necrotizing entero-colitis in infants and children. It also

improves their cognitive and educational abilities. The health benefits for mothers who breast-

feed are: a lower risk for breast and ovarian cancers, a decreased chance for long-term

osteoporosis and pregnancy-induced obesity, a more rapid return to the prepartum state, and a

reduction in menstrual blood loss. On the more mental side, there are reports of an increase in

self-esteem, greater bonding with the child, and greater success with mothering. Research has

also suggested that employment negatively effects the percentages of women who breast-feed.

In 1996, the Personal Responsibility and Work opportunity Reconciliation Act (PRWORA) was

passed. The PRWORA required all states to adopt work requirements for its federal welfare

population, but it also allowed states to exempt mothers of young children from the work

requirements. However, the states put strict regulations on the exemptions and, therefore,

many women did not receive exemption. The PRWORA also required the states to set a

number of minimum hours a new mother must work. Across the nation, the minimum number

of hours ranged from zero to thirty-two or more. Lastly, the PRWORA required each state to

set penalties for those who do not fulfill the previous two work requirements. When analyzing

9 Jacknowitz, Alison, and Laura Tiehen. "Transitions into and out of the WIC Program: A Cause for Concern?" Social Service Review 83, no. 2 (2009): 151-183.

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the number of women breast-feeding from 1990 to 2000, it was evident that the work

requirements significantly reduced the rates of breast-feeding. In the states with the strictest

work requirement laws, breast-feeding reduced by about 22%. Those states in the middle saw

a reduction of about 20%.10 These work requirements are counterproductive to the goals of the

WIC program.

The findings, from the previously mentioned Early Childhood Longitudinal Study,

indicated that the program was working effectively and sufficiently to provide what the

mothers and children needed. There was some evidence that those exiting the program early

were those who were no longer eligible for the program. However, the findings also suggested

that the women and children still exhibited need. The study suggested that the WIC program

be reformed to allow participation for a longer duration for greater exposure to WIC services.

For those who delayed entrance into the program, the study suggests that the WIC program

also be redesigned to allow for greater outreach. They understood that because WIC is not a

federal entitlement program and is based upon the mother’s willingness to participate, the

efforts for outreach need to be implemented into the program budget in the most efficient

way.11

The Survey of Income and Program Participation was used again to assess the changing

in the determinants of use for multiple food assistance (FA) programs by low-income children

from 1990 to 2009. The rate of children living in poverty has increased steadily since 2000 and,

in 2009, one in five children in the United States lived in poverty, which is a huge public

10 Haider, Steven J., Alison Jacknowitz, and Robert F. Schoeni. "Welfare Work Requirements and Child Well-Being: Evidence from the Effects on Breast-Feeding." Demography 40, no. 3 (2003): 479-497.11 Jacknowitz, Alison, and Laura Tiehen. "Transitions into and out of the WIC Program: A Cause for Concern?" Social Service Review 83, no. 2 (2009): 151-183.

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concern. The WIC program is one of the largest food assistance programs in the United Sates.

The others are the Supplemental Nutrition Assistance Program (SNAP), the National School

Lunch Program (NSLP), and the School Breakfast Program (SBP). The survey reported that

participation in WIC and the free and reduced-price school meal programs has increased among

the poorest households with children, but participation in SNAP, which is the largest program

for low-income households, has declined from 1990 to 2004. Participation in the WIC program

doubled from 4.5 million participants to 9.1 million participants from 1990 to 2009. As the

program gained more participants, more money has been allocated into their budget. With the

increases in the budget for the WIC program, statistics have shown that children ages one to

four have increased participation. There were also increases in immigration during this time,

which contributed to the greater demand for WIC services as well because requirements for

gaining WIC services are less strict than the requirements for participation in the SNAP

program. Immigrants are not required to provide legal documentation of their immigrant

status to participate in WIC and the school meal programs.12 In 1999, about one in ten families

with children in the United States were mixed-status families, which is a family that has one or

more children that are U.S. born citizens and where at least one parent is a non-citizen. U.S.

born children in these families are eligible for all social service programs. However, they may

have limited access because their non-citizen parents are often ineligible, or believe they are

ineligible, and do not apply for social services for their children.13 Between 1997 and 2006, it

was shown that almost all participants aged zero to four were native born United States

12 Newman, Constance, Jessica E. Todd, and Michele Ver Ploeg. "Children’s Participation in Multiple Food Assistance Programs: Changes from 1990 to 2009." Social Service Review 85, no. 4 (2011): 535-564.13 Fomby, Paula, and Andrew J. Cherlin. "Public Assistance Use among U.S.-Born Children of Immigrants." International Migration Review 38, no. 2, 584-610.

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citizens. On the other hand, the population of native born children of immigrants participating

in the WIC program was growing much faster than the native born U.S. citizens’ population in

participation between 1997 and 2006.14

The greater question in all of this is whether or not the WIC program works. A study

done by the Association for Public Policy Analysis and Management found that children

participating in the WIC program were more likely to have mothers who had smoked or drank

during pregnancy, were poorer, and scored lower on tests that measure their coping skills.

They also found that WIC participants were poorer and less educated than the other eligible

non-participating mothers. This suggests that eligible participating mothers are negatively

selected from the greater population of eligible participants. Therefore, the WIC program helps

these women have healthier infants. By assessing data from the Pregnancy Risk Assessment

Monitoring System they found that the benefits of WIC used by pregnant women far outweigh

the costs of the program and that WIC actually saves the government money by economizing

the costs of treating mothers and infants under Medicaid. They estimated that participation in

WIC reduces the probability of a low birth weight by 29% and also reduces the probability of an

extremely low birth weight by more than half. This is significant because lower birth rates

increase the risk of death and negative consequences for health and cognitive function if the

child survives. The analysts argue that the program does work, but that there are areas of

improvement. The WIC program could improve through the nutrition education component

and through targeting the neediest women for larger benefits.15 Below is a chart that shows

14 Newman, Constance, Jessica E. Todd, and Michele Ver Ploeg. "Children’s Participation in Multiple Food Assistance Programs: Changes from 1990 to 2009." Social Service Review 85, no. 4 (2011): 535-564.15 Bitler, Marianne P., Janet Currie, and John Karl Scholz. "WIC Eligibility and Participation." The Journal of Human Resources 38, no. Special Issue on Income Volatility and Implications for Food Assistance Programs, 1139-1179.

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how much the program costs today for the nation, the state of Minnesota, and the state of

North Dakota. The information is gathered from statistics found on the United States

Department of Agriculture website.

Fiscal Year 2014 Nation Minnesota North Dakota

Total Participation 8,258,922 121,755 12,814

Food Costs $4,325,820,173 $63,972,574 $7,272,648

Average Monthly

Food Cost per

Person

$43.65 $43.79 $47.30

Nutrition Services

and Administrative

Costs

$1,903,652,290 $30,395,455 $4,827,314

16

In November 2013, the Fargo-Moorhead Metropolitan Council of Governments (Metro

COG) created a Metropolitan Food Systems Plan and released a report identifying the existing

conditions and issues of the Fargo-Moorhead area in regards to people’s access to healthy and

sustainable food. The Metro COG, in collaboration with the North Dakota State University

(NDSU) Center for Social Research and the Cass Clay Food Systems Initiative, called attention to

the local food movement. The idea of the ability to produce and consume locally-sourced foods

as an important part of community connectivity, long-term livability, self-reliance, and local

food security is the main focus of the report. The report also indicates that increasing access to

healthy food can improve the health of large segments of the F-M Metro. The report defines

the “local food system” as “those growers, producers, distributors, and consumers of food

16 "WIC Program." WIC Program. Accessed February 3, 2015. http://www.fns.usda.gov/pd/wic-program.

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product which deal in the sale of food directly from producer/grower to consumer, or via a

retail/services establishment”. Over the past few years, the number of people living in the F-M

area using local food shelves and participating in the federal SNAP, also known as “food

stamps”, program has increased significantly. There are neighborhoods isolated from grocery

stores, community gardens, and other markets that sell healthy foods. Metro COG sees these

facts as problems that need to be addressed and they wish to develop policies that increase

access to safe, nutritious, and affordable foods by strengthening the local food system. The

new system will benefit the F-M area as a whole, but it will also target many issues particularly

affecting more vulnerable or low-income populations in the area as well. It has been proven

that local foods contain higher nutrient values than non-local ones. By increasing the

availability of local healthier foods, the health and well-being of many people will improve.

There will also be a greater sense of food security in the area. By creating a larger market,

healthier foods will be present in or close to areas that are currently isolated from healthy

foods.

The report also created a geographic profile of the food system in place in the F-M area.

In 2013, there were 11 community gardens, but only half were available to the public; the rest

were available through involvement in religious, housing, or other local service organizations. A

total of 7,536 households were located within a half a mile of a community garden. Community

gardens are beneficial to the community because they provide plots of land for growing

produce. The land can be owned publicly or privately, but it is typically gardened by the

residents of the area. As well as community gardens, 8,806 households were located within

half a mile from farmers markets. There is a total of eighteen grocery stores or supercenters in

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the FM area, and all but one are accessible by MATBUS or within ¼ of a mile of the MATBUS

Route. The one that is not accessible is the Costco on I-94 and Veterans Boulevard. A few

health food stores and ethnic grocery stores have opened up in the area. This is beneficial

because they provide a more diversified selection of food for the community and they are

another source of local food in the greater food system.

Metro COG is required to acknowledge and include Environmental Justice areas in its

planning programs under Executive Order 12898. An environmental justice area is an area that

has a concentration of low-income individuals with a median household income of less than

1.25% of poverty. However, Metro COG defines an environmental justice area as an area with a

population that is over 25% non-white as well. In the list of strategic issues for the Food

Systems Plan, Metro COG addresses the issues of food access in environmental justice areas. In

these areas they wish to increase access to locally grown foods for those facing mobility

limitations; such as low income, minority, and senior populations. They also want to further

develop strategies for bringing healthy and local foods closer to those who do not have the

ability to buy and eat it. They aim to do this by creating a food system that entwines with the

current transportation system. They hope this will increase the likelihood that residents will

use public transit, walk, or bike for food related trips. Not only will all of these efforts benefit

the community as a whole, but they will especially benefit the children of the community.

Fruits and vegetables are an important part of a healthy diet. They help with growth, weight

management, and chronic disease prevention. Obesity is a costly health issue of concern for all

communities and nations in the United States. Below is a chart that shows the weight patterns

of children in the Fargo-Moorhead area.

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Percentage of overweight and obese children in clinic service area by age groupAge in Years Overweight

(>85th percentile and <95th

percentile BMI)

Obese (≥95th

percentile of BMI)

Total Overweight and

Obese

2-5 years 16.3 11.6 27.96-8 years 14.1 18.4 32.5

9-12 years 15.0 20.3 35.313-18 years 14.2 19.0 33.2

*Source: 2009 local clinic data for patients within service area, includes Cass and Clay Counties

In fact, the World Health Organization (WHO) says food insecurity rests on three factors;

they are food availability, food access, and food use. The report then cites the American

Journal of Clinical Nutrition in saying that: “the rates of obesity and type 2 diabetes in the

United States follow a socioeconomic gradient, such that the burden of disease falls

disproportionately on people with limited resources, racial-ethnic minorities, and the poor.

Among women, higher obesity rates tend to be associated with low income and low education

levels”. The report then states that the number of WIC participants in both Clay and Cass

counties has risen steadily since 2005, which is shown in the chart below.17

Total number of WIC participants by year and countyCounty 2005 2006 2007 2008 2009 2010 2011 2012Clay 16,103 15,336 15,927 16,103 16,175 17,024 17357 17,099Cass 22,584 25,548^ 30,000 32,472 35,184 36,156 36,444 37,584

*Source: Clay County Public Health WIC Department and Fargo Cass Public Health WIC Department

17 Fargo-Moorhead Metropolitan Council of Governments. “Metropolitan Food Systems Plan: Existing Conditions and Issues Identifications Report”. March 11, 2013.

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^Computer software conversion – incomplete data

The WIC program, effectively fulfills its purpose to provide millions of women in America

and the Fargo-Moorhead area with education and healthy and nutritious foods. It also provides

services that other federal food assistance programs do not. The federal WIC program is not an

entitlement program, therefore, it is efficient in providing WIC benefits to those willing to take

responsibility for their own health the health of their families. Nationwide, the program can be

improved through greater outreach into particularly affected low-income communities, reform

of the education classes, and more consideration for the greater demands placed on health

care workers. It is essential to the nation that Congress provides the funds necessary for the

continuation of the WIC program because it is a sustainable program that provides relief from

hunger and food insecurity as well as promoting living a healthy life.

Works Cited

Bitler, Marianne P., and Janet Currie. "Does WIC Work? The Effects of WIC on Pregnancy and Birth Outcomes." Journal of Policy Analysis and Management 24, no. 1, 73-91.

Bitler, Marianne P., Janet Currie, and John Karl Scholz. "WIC Eligibility and Participation." The Journal of Human Resources 38, no. Special Issue on Income Volatility and Implications for Food Assistance Programs, 1139-1179.

Fargo-Moorhead Metropolitan Council of Governments. “Metropolitan Food Systems Plan: Existing Conditions and Issues Identifications Report”. March 11, 2013.

Fomby, Paula, and Andrew J. Cherlin. "Public Assistance Use among U.S.-Born Children of Immigrants." International Migration Review 38, no. 2, 584-610.

Haider, Steven J., Alison Jacknowitz, and Robert F. Schoeni. "Welfare Work Requirements and Child Well-Being: Evidence from the Effects on Breast-Feeding." Demography 40, no. 3 (2003): 479-497.

Page 16 of 17

Jacknowitz, Alison, and Laura Tiehen. "Transitions into and out of the WIC Program: A Cause for Concern?" Social Service Review 83, no. 2 (2009): 151-183.

Kotch, Jonathan B., and David Whiteman. "Effect of a WIC Program on Children's Clinic Activity in a Local Health Department." Medical Care 20, no. 7 (1982): 691-98.

Newman, Constance, Jessica E. Todd, and Michele Ver Ploeg. "Children’s Participation in Multiple Food Assistance Programs: Changes from 1990 to 2009." Social Service Review 85, no. 4 (2011): 535-564.

"WIC." Federal Safety Net. Accessed February 3, 2015. http://federalsafetynet.com/wic.html.

"WIC Program." WIC Program. Accessed February 3, 2015. http://www.fns.usda.gov/pd/wic-program.

"Women, Infants and Children (WIC)." About WIC- WIC at a Glance. Accessed February 3, 2015. http://www.fns.usda.gov/wic/about-wic-wic-glance.

"Women, Infants, and Children (WIC)." Women, Infants, and Children (WIC). Accessed February 3, 2015. http://www.fns.usda.gov/wic/women-infants-and-children-wic.