Special Supplemental Food Program for Women, Infants and Children (WIC): Accommodation of Cultural Food Preferences in the WIC Program

DEPARTMENT OF AGRICULTURE

Food and Nutrition Service

Special Supplemental Food Program for Women, Infants and Children

(WIC): Accommodation of Cultural Food Preferences in the WIC Program

AGENCY: Food and Nutrition Service, USDA.

ACTION: Notice of solicitation of comments.

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SUMMARY: Recently, cultural food preferences among participants in the

WIC Program have received considerable attention. There has been

concern expressed that some WIC participants may not take full

advantage of Program benefits (e.g., the food packages and nutrition

education) for cultural reasons. In this Notice, the Department is

soliciting public comments regarding the issues surrounding the

accommodation of cultural food preferences in the WIC Program.

DATES: To be assured of consideration, comments must be received on or

before December 20, 1994.

ADDRESSES: Comments should be sent to Stanley C. Garnett, Director,

Supplemental Food Programs Division, Food and Nutrition Service, USDA,

3101 Park Center Drive, Room 540, Alexandria, Virginia 22302. Comments

on this notice should be clearly labeled ``Accommodation of Cultural

Food Habits In the WIC Program Notice.'' Comments which are not within

the scope of this Notice should not be included. All written comments

will be available for public inspection during regular business hours

(8:30 a.m. to 5:00 p.m., Monday through Friday) at this office of the

Food and Nutrition Service (FNS).

FOR FURTHER INFORMATION CONTACT: Barbara Hallman, Chief, Program and

Policy Development Branch, Supplemental Food Programs Division, Food

and Nutrition Service, USDA, 3101 Park Center Drive, Room 540,

Alexandria, Virginia 22302, (703) 305-2730.

SUPPLEMENTARY INFORMATION:

Executive Order 12866

This Notice has been determined to be not significant for purposes

of Executive Order 12866 and therefore has not been reviewed by the

Office of Management and Budget.

Regulatory Flexibility Act

This action is not a rule as defined by the Regulatory Flexibility

Act (5 U.S.C. 601-612) and thus is exempt from the provisions of that

Act.

Paperwork Reduction Act

The Notice imposes no new reporting or recordkeeping provisions

that are subject to review by the Office of Management and Budget in

accordance with the Paperwork Reduction Act of 1980 (44 U.S.C. 3507).

Executive Order 12372

The WIC Program is listed in the Catalog of Federal Domestic

Assistance Programs under No. 10.557 and is subject to the provisions

of Executive Order 12372, which requires intergovernmental consultation

with State and local officials (7 CFR part 3015, subpart V, and 48 FR

29114 (June 24, 1983).

References

(1) Study of WIC Participant and Program Characteristics, 1988, was

funded by the Food and Nutrition Service (FNS), United States

Department of Agriculture (USDA), and conducted by the Research

Triangle Institute, Research Triangle Park, North Carolina. This two-

volume report published in April 1990, and referred to as PC88, is the

first of the biennial Congressional reports required by Section 343(a)

of Public Law 99-500, 42 U.S.C. Sec. 1786(d)(4).

(2) National Advisory Council on Maternal, Infant and Fetal

Nutrition--1992 Biennial Report on the Special Supplemental Food

Program for Women, Infants and Children and on the Commodity

Supplemental Food Program. This report contains recommendations to the

Congress on ways to improve the administration of the WIC Program.

(3) Technical Papers--Review of WIC Food Packages, published by the

USDA, November 1991. These papers were developed by a team of faculty

members of the Pennsylvania State University, The Department of

Nutrition, College of Health and Human Development, under a Cooperative

Agreement with USDA's Food and Nutrition Service during the spring and

summer of 1991. This was in response to Section 123(c) of Public Law

101-147 which required USDA to conduct a review of the appropriateness

of foods made available to WIC participants.

General Background

Recently, the ability of the WIC Program to accommodate cultural

food habits has received considerable attention. This is due in part to

significant demographic changes in the United States. The current

racial/ethnic participation rate in WIC is approximately: 45 percent

White, 27 percent Black, 24 percent Hispanic, 2 percent Asian/Pacific

Islander, and 2 percent American Indian.

Data from the FNS/USDA study entitled, Study of WIC Participant and

Program Characteristics, 1988, indicate that the WIC State and local

agency workforce has changed to reflect the cultural diversity of

participants being served. The study showed that staff members were

bilingual in many local agencies serving non- English speaking clients.

Although Spanish was spoken fluently by a significant number of these

staff members, some personnel also exhibited proficiency in other

languages such as Cambodian/Khmer, Vietnamese, Thai, Chinese, French,

Portuguese and Haitian/Creole.

In addition, in response to demographic changes in the WIC Program

participation, various Federal, State and local agency publications and

materials have been developed which target a wide variety of culturally

diverse groups. These culturally sensitive materials may be the only

understandable source of nutrition information that a WIC participant

receives. Such resources link WIC participants not only to food

assistance and nutrition education but also to a much needed health

care system.

Low-income populations, including WIC participants, are faced with

numerous barriers to assistance and many difficulties in their lives.

For populations in need of assistance who are of different cultures,

especially those who have recently arrived in the United States and who

lack orientation to service delivery here, the barriers to assistance

can be of such magnitude as to adversely affect their health and well-

being. The WIC community must give special consideration to its

approach in delivering quality benefits to this growing subpopulation.

In its 1992 report to Congress, the National Advisory Council on

Maternal, Infant, and Fetal Nutrition recommended that the Department

develop policy and guidance to better accommodate WIC participants of

culturally diverse backgrounds. In recognition of this need, and in

response to the increased emphasis on accommodating the needs of

culturally diverse populations, the 1993 National Association of WIC

Directors Conference featured a session which presented various issues

concerning service delivery to culturally diverse populations and the

WIC food packages. In addition, the theme of the 1993 National WIC

Nutrition Services Conference, sponsored by the Food and Nutrition

Service, was ``Meeting the Needs of a Diverse Population.''

Approximately 800 persons attended, and over 60 speakers addressed

topics pertinent to the conference theme.

Workshops on cultural accommodation in WIC food packages were also

conducted at this conference.

With this Notice, the Department is seeking guidance on issues/

questions concerning the accommodation of cultural food preferences in

the WIC Program. The Department would like information on how the

current WIC food packages can be efficiently and effectively used by

culturally diverse populations. It is not the intention of this Notice

to solicit comments that only identify possible WIC food substitutions.

The intent is to gather information concerning some basic questions

regarding the food preferences of culturally diverse WIC participants

and ways to improve culturally sensitive service delivery. This in turn

will help the Department to identify issues of importance for further

consideration and policy formulation.

Definitions of Terms

Concepts and terminology that we are using in this Notice correlate

with terms defined below. The first four--Culture, Cultural Diversity,

Cultural Sensitivity and Ethnicity--reflect definitions established by

the U.S. Department of Health and Human Services for the same or

related terms.

Culture: The shared values, mores, traditions, norms, customs,

arts, history, folklore, and institutions of a group of people that are

unified by race, ethnicity, language, nationality, or religion.

Cultural Diversity: Differences in race, ethnicity, language,

nationality or religion among various groups within a community,

organization, or nation. A community is said to be culturally diverse

if its residents include members of different groups.

Cultural Sensitivity: An awareness of the nuances of one's own and

other cultures.

Ethnicity: Characteristics associated with a common group--often

linked by race, nationality, and language--that shares a common

cultural heritage.

Food Preferences: The characteristic and repetitive acts that

members of an ethnic group undertake in order to secure food and

nourishment in a culturally significant manner.

Program Background

The authorizing legislation, Section 17 of the Child Nutrition Act

of 1966 (CNA), as amended (42 U.S.C. 1786), established the WIC Program

to provide supplemental foods, nutrition education, and access to

related health and social services for low-income pregnant,

breastfeeding and postpartum women, infants, and children up to age 5

who are at nutritional risk. Nutritional risk is determined by a

competent professional authority and includes conditions such as

inadequate weight gain during pregnancy; history of high-risk

pregnancies; growth problems in infants and children; anemia; and

inadequate dietary patterns.

Section 17(a) of the CNA, 42 U.S.C. 1786(a), clearly established

the WIC Program as ``supplemental'' in nature; that is, the WIC food

packages are not intended to provide a complete diet but are designed

to provide specific nutrients--iron, calcium, protein, and vitamins A

and C--historically lacking in the diets of the WIC population. WIC was

never intended to be a primary source of general food assistance.

Rather, WIC was intended to provide nutritional services as an

integrated adjunct to public health delivery.

However, along with WIC, the Department administers a variety of

other complementary food assistance programs that work together to

provide a more complete diet to needy persons. The largest of these

programs, the Food Stamp Program, provides general food assistance

intended to increase the food buying power of low-income households.

The Food Stamp Program is the Federal Government's primary means to

provide needed food assistance to ensure adequate nutrition for low-

income households. The National School Lunch and the School Breakfast

Programs provide free and reduced price meals to low-income children

and low-cost meals to non-needy children in school. Also, the Child and

Adult Care Food Program provides meals to persons in child and adult

day care centers and children in family day care homes. A variety of

commodity donation programs are also available to low-income persons.

Through the Food and Nutrition Services' domestic food assistance

programs, over $40 billion in food help is provided to one in six

people living in the United States.

In addition to supplemental food assistance, WIC provides nutrition

education, including information about the dangers of alcohol, tobacco

and other drug use to participants. The nutrition education provided by

WIC enables participants to make informed decisions in choosing foods

which, together with the supplemental foods contained in the WIC food

packages, can meet their total dietary needs. Such learned behavior

assists participants to continue healthful dietary practices after

leaving the Program.

Again, WIC is a unique food assistance program in that it also

serves as an adjunct to good health care during critical times of

growth and development to prevent the occurrence of health problems and

to improve the health status of Program participants. WIC participants

are screened and referred to other necessary health and social

services, such as prenatal care, well-baby care and immunizations.

Numerous studies have shown that WIC is extremely cost-effective

and highly successful in improving the health and nutritional status of

its clients. Given this proven track record, the President and

Congressional leaders have publicly stated that they intend to fully

fund the WIC Program; that is, they wish to provide enough funding so

that those who are eligible for the Program can be served by the end of

Fiscal Year 1996.

WIC Food Packages

Early legislation for the WIC Program, Pub. L. 92-433 (1972)

through Pub. L. 94-105 (1975), specifically identified protein, iron,

calcium and vitamins A and C as the target nutrients for WIC

participants. However, Pub. L. 95-627, enacted in November 1978,

deleted the reference to specific target nutrients. Instead, it defined

supplemental foods as those foods containing nutrients determined by

nutritional research to be lacking in the diets of pregnant,

breastfeeding, and postpartum women, infants, and children, as

prescribed by the Secretary of Agriculture. The Program direction

announced by that law remains in effect today, Section 17(b)(14) of the

CNA, 42 U.S.C. 1786(b)(14), and the law also directs the Secretary in

Section 17(f)(12) of the CNA, 42 U.S.C. 1786(f)(12), to assure that, to

the extent possible, the fat, sugar, and salt content of WIC foods is

minimal.

The law provides substantial latitude to the Department in

designing WIC food packages, but obligates the Department to prescribe

foods which effectively and economically supply those nutrients

critical to growth and development and which are specifically lacking

in the diets of the WIC eligible population.

In anticipation of the passage of Public Law 95-627, the

Department, in October 1978, assembled a WIC Food Package Advisory

Panel composed of State health officials, representatives of the

nutrition community and advocacy groups, to review the original food

packages and recommend changes. Panel recommendations included

retaining high-quality protein, iron, calcium, and vitamins A and C as

the targeted nutrients in the WIC Program and expanding the number of

available packages. Based on the Panel's recommendations, an evaluation

by the Department of the fat, sugar and salt content of the WIC foods,

and public response to proposed rules in 1979, new WIC food package

regulations were published in 1980 which are consistent with Public Law

95-627.

These food package requirements appear in 7 CFR 246.10 of the WIC

Program regulations. The final rule (45 FR 74854, November 12, 1980)

established six different monthly packages: Food Package I for infants

0-3 months; Food Package II for infants 4-12 months; Food Package III

for children and women with special dietary needs; Food Package IV for

children 1-5 years of age; Food Package V for pregnant and

breastfeeding women; and Food Package VI for nonbreastfeeding

postpartum women. The Department created an additional food package in

November, 1992 (57 FR 56231, November 27, 1992). This enhanced package,

Food Package VII, is designed for those breastfeeding women who elect

not to receive infant formula through WIC for their infants.

Authorized WIC foods include: iron-fortified infant formula, iron-

fortified cereals, vitamin C-rich 100 percent fruit and/or vegetable

juice, calcium/protein-rich milk and cheese, protein/iron-rich eggs,

protein-rich peanut-butter or dried beans/peas, and physician-

prescribed formula/medical foods for participants with certain special

dietary needs. The enhanced package for certain breastfeeding women

increases allowable amounts of juice, cheese, peanut butter and dry

beans/peas, and also allows protein-rich tuna fish and carrots which

provide beta carotene (precursor to vitamin A) and dietary fiber.

The seven WIC food packages are designed to help accomplish the

following: supplement participants' diets with nutritionally dense

foods that follow current medical and nutritional guidance; complement

the eating patterns of preschool children; and address the special

requirements of pregnant and breastfeeding women. As described in the

1980 final rule (45 FR 74854), the WIC food packages were initially

designed and adopted with several considerations in mind. These

considerations should also be taken into account when commenting on the

issues presented in this Notice. The factors to be considered are

discussed below, with particular emphasis on how they apply to

accommodating cultural food habits.

1. Nutritional Integrity

The nutritional integrity of the WIC food packages--the provision

of specific target nutrients typically lacking in the diets of the WIC

population--is the cornerstone of the Program. Nutrient requirements

are particularly high during times of rapid growth, development and

replenishment. Therefore, the WIC population, composed of pregnant,

breastfeeding and postpartum women, infants and children, represents

individuals whose nutritional needs are among the highest and most

critical for optimal growth and development. Insuring optimal nutrient

intakes during these vulnerable periods of life is paramount to prevent

both immediate and long-term adverse health outcomes. Consequently,

effort has been made to reflect current nutritional science and assure

that the various packages supplement the nutrition needs of WIC's at-

risk population with nutrient-dense economical foods. Each of the

allowable WIC foods is rich in at least one or more of the nutrients

iron, calcium, protein, and Vitamins A and C, enabling the WIC food

packages to make a significant nutritional contribution to the diets

and health of Program participants.

Preserving the nutritional integrity of the food packages is

imperative if WIC is to remain an effective health-related program.

Congressional intent as evidenced both in statutory and legislative

report language has continually emphasized that the Department should

not implement any rule which would decrease the nutritional

contribution of the WIC foods and that any future modification should

be based on comprehensive scientific evidence.

2. Fat, Sugar, and Salt Content

As discussed previously, consideration of the fat, sugar and salt

content of foods in the WIC food packages is required by Section

17(f)(12) of the CNA. Several changes made to the WIC food packages in

the 1980 rulemaking responded specifically to this mandate. For

example, the Department established a limit on the amount of sugar

allowable in WIC approved cereals.

Additionally, FNS policy guidance permits WIC State agencies to

issue low-fat, low-cholesterol and low-sodium forms of WIC cheeses, as

well as low-fat and skim milks. The Department encourages local program

administrators to tailor the WIC food packages to meet the individual

nutritional needs of participants and, when appropriate, to adjust the

types of WIC foods prescribed to help reduce the amount of fat,

cholesterol, sodium and sugar the WIC food packages contribute to the

diet. Through WIC nutrition education, participants also receive advice

on how to further moderate their intakes of fat, cholesterol, sodium

and sugar and how to include adequate amounts of vegetables, fruits and

whole grain products in their diets.

3. Cost

In addition to the criteria specified in legislation, cost was a

prime consideration in the design of the WIC food packages. The

Department is committed to serving as many eligible persons as possible

while maintaining the nutritional integrity of the Program. WIC is not

an entitlement program, and the number of potentially eligible

individuals who can be served is determined by the amount of funds

appropriated by Congress. Therefore, the total cost of the WIC food

packages influences the total number of participants that can be served

by the Program. State and local agencies have the flexibility, within

regulatory parameters (7 CFR 246.10 and supplemented by FNS Instruction

804-1 ``WIC Program--Food Package Design: Administrative Adjustments

and Nutrition Tailoring'') to specify lower cost food brands, physical

forms of foods, and types and sizes of food containers to help control

the cost of the WIC food packages. While changes in quantities of

allowable WIC foods can be made to accommodate nutritional needs of

individuals or categories of persons, they cannot be made solely for

cost-containment reasons.

4. Practicality

All WIC food packages are designed to address a number of practical

considerations which reflect participant and Program needs. For

example, the WIC foods are readily available in retail food stores,

offer variety and versatility to participants in the ways these foods

can be used in an overall diet, are nutrient-dense, can be easily

divisible into servings on a daily basis, and have broad appeal.

Additionally, all WIC food packages are individual food prescriptions

which, in order to have the full effect in improving a participant's

nutritional status, are intended to be consumed only by the participant

and not by other family members. Also, in selecting WIC foods,

consideration is given to whether, in fact, participants are likely to

have easy access to and routinely consume large quantities of a food

item even without the WIC Program. For example, certain ethnic groups

purchase a food in bulk and use it daily as a staple food item. In this

type of situation, providing a small amount of a routinely consumed

staple food item may not be a cost-effective way to use limited WIC

resources.

5. Domestic, Natural State

Foods offered in all WIC food packages are generally foods that are

of domestic origin and which have undergone minimal processing. The WIC

Program, along with other food assistance programs administered by the

Department, participates in a longstanding partnership with American

agriculture and endeavors to provide foods which support the nation's

agricultural economy.

6. Administrative Feasibility

WIC food packages are designed to strike a balance between

desirable, nutrient dense, shelf-stable, low-cost staple food items and

administrative feasibility. This means that although there are

certainly some foods that would be particularly beneficial for and

culturally appealing to WIC participants, the WIC Program is not always

capable within the limitations of its current structure of easily

delivering such foods. For example, fresh fruits and vegetables would

greatly enhance WIC food packages. However, the labor intensive

management needed to provide non-prepackaged produce items which widely

fluctuate in cost, require participant weighing and measuring, and are

highly perishable make them administratively prohibitive for the WIC

Program.

Also, WIC is limited in its ability to offer a wide range of food

options, since from a management standpoint choice options pose

considerable challenges to WIC participants and the vendor community.

Each food option added to the food package magnifies the difficulties

of program management and accountability.

These practical considerations and constraints pose serious and

real limitations to WIC's ability to offer a wide variety of desirable

foods. This was most recently demonstrated when USDA proposed to

enhance food packages for certain breastfeeding women (new Food Package

VII, 57 FR 9505, March 19, 1992). Commenters stressed the critical

importance of assuring that any new foods added would be

administratively feasible and practical. As such, after reviewing the

ability of the WIC food delivery system to provide fresh fruits and

vegetables, we concluded in a Final Rule published at 57 FR 56231,

November 27, 1992, that practicality and cost considerations limited

choices considerably. We ultimately decided (7 CFR 246.10(c)(7)(ix))

that fresh carrots in one pound prepackaged bags were one of the few

items that WIC had the capacity to provide without undue administrative

difficulty for managers, food vendors and participants, as well.

7. Food Package Flexibility

The WIC regulations (7 CFR 246.10) establish the maximum allowances

of all WIC foods available to Program participants. However, State and

local agencies have the authority to tailor these food quantities

according to the needs of individual participants or categories of

participants when based on a sound nutritional rationale. Tailoring

must also take into consideration: food preferences; food acceptance;

food use; household conditions; and food preparation abilities. These

tailoring provisions, established in Program regulations at 7 CFR

246.10 and supplemented by FNS Instruction 804-1, are designed to

permit State and local agencies to implement their own nutrition

policies and philosophies within the parameters of food package

requirements. As of August 1992 (57 FR 34504, August 4, 1992), Program

regulations at 7 CFR 246.10(e) also permit State agencies to tailor the

food packages to better accommodate WIC participants in homeless

situations.

8. Ability To Meet Cultural Needs

In 1975 Congress directed the Department to consider cultural

patterns of diet in administering the WIC Program (Pub. L. 94-105).

Additionally, in subsequent legislation (Pub. L. 95-627), Congress

directed the Department to permit cultural food adjustments.

Consequently, since 1980, Program regulations have permitted WIC State

agencies to submit for Departmental consideration proposals for

substitutions or eliminations in the WIC food packages. As cited in 7

CFR 246.10(e), cultural adjustments must meet the following criteria:

the cultural food substitution must be nutritionally equivalent or

superior to the food which it is intended to replace; it must be widely

available to participants in the areas where the substitute is intended

to be used; and the substitution must be cost equivalent to or less

than the cost of the food it is intended to replace. Additionally,

these changes must be approved by the Department.

Since 1980, only three State agencies have submitted proposals to

the Department for approval. The first proposal, submitted in 1980, was

approved; it utilized the current WIC foods, substituting soy formula

or powdered milk for fluid whole milk for Southeast Asians. The second

proposal, submitted in 1988, requested rice and tofu to replace

portions of the milk and cereal allowances. The intent was to better

accommodate food preferences of Hispanics and Southeast Asians. The

Department requested additional information from the State agency since

it questioned the nutritional equivalency of the proposed substitutions

and also had various other concerns. The State agency did not respond,

presumably withdrawing the request. The third request, also in 1988,

was for the addition of potatoes as a WIC food. Potatoes were requested

to accommodate the needs of Eskimos who rely for food resources almost

wholly on fishing and hunting; their diets lack dairy products, fruits,

vegetables and grains. Potatoes are used in at least one Eskimo

staple--caribou soup. The request was not approved for several reasons:

1) program regulations allow substitutions, but not the addition of a

food item; 2) potatoes would not supply a comparable amount of target

nutrients--vitamins A and C, iron, calcium and protein--as would other

WIC foods; and 3) the WIC food package does provide juices which can

replace some servings of fruits and vegetables lacking in the Eskimo

diet.

The provisions of the WIC Program regulations which govern cultural

food substitutions (7 CFR 246.10(e)) have been criticized as being

difficult to conform with and inflexible. For example, the food for

food substitution requirement has been cited as difficult or impossible

to meet, given the requirements for nutritional and cost equivalency.

While the Department recognizes the limitations of these provisions, it

is the intent of the Department to maintain the nutritional integrity

of the WIC food packages. The itent is also to prescribe foods which

effectively and economically supply those nutrients critical to growth

and development and which are typically lacking in the diets of the

WIC-eligible population.

Some culturally appealing foods, such as tofu, yogurt and rice,

have often been formally and informally suggested for inclusion in the

WIC food packages either as additional foods or as food substitutes.

The following factors evoked concern about the appropriateness of these

foods for the WIC packages. As a calcium substitute, tofu is not

considered nutritionally equivalent to milk. Further, there is no Food

and Drug Administration Standard of Identity for tofu to establish

nutrient requirements and to guarantee product safety to the consumer.

For this reason, the calcium content of tofu may vary according to

brand and processing method and there is no assurance that tofu

products will be free from harmful bacteria.

Yogurt is nutritionally comparable to milk on a cup-by-cup basis.

However, unlike white fluid milk, flavored yogurts, which are likely to

be more acceptable, have added sugar.

Rice is frequently suggested as a cereal substitute, yet it does

not supply an equivalent quantity of iron. As one of the target

nutrients in the WIC food package, iron is a critical component of WIC-

approved cereals. A one-ounce serving of cereal is intended to supply

45 percent of the U.S. Recommended Daily Allowance of iron for adults

and children 4 or more years of age. Therefore, WIC cereals are a rich

source of this nutrient. In comparison, enriched rice is not highly

iron-fortified and, therefore, is not nutritionally equivalent to iron-

fortified cereals. Further, rice, while popular, is not a particularly

nutrient dense food product with respect to WIC's other target

nutrients.

Nutrition Education

WIC nutrition education requirements are explained in 7 CFR 246.11.

Nutrition education is provided at no cost to participants and must be

designed to achieve two broad goals. First, it should stress the

relationship between proper nutrition and good health with special

emphasis on the identified nutritional needs of participants. Second,

it should assist the participant in achieving a positive change in

eating habits, resulting in improved nutritional status and in the

prevention of nutrition-related problems through optimal use of WIC

foods with other nutritious foods. Nutrition education is to be taught

in the context of the ethnic, cultural and geographic preferences of

the participants and with consideration for educational and

environmental limitations experienced by participants.

Nutrition education can assist culturally diverse participants to

adapt more readily to their environment. For example, through nutrition

education participants can learn the importance of selecting

inexpensive and nutritious foods which complement the supplemental

foods provided by WIC.

WIC State and local agencies have developed culturally sensitive

nutrition education resources targeting the specific populations found

in their areas. The resources include pamphlets, videos, food

demonstrations, field trips to a local WIC food vendor, audio tapes,

calendars, and much more.

Some agencies have provided participants with instructions on how

to use WIC foods to prepare traditional foods of importance to

different cultures. For example, soy beans available through WIC can be

used to make tofu; milk, another WIC food, can be used to make yogurt.

Some participants need only to be familiarized with certain WIC

supplemental foods. Those who are not familiar with peanut butter may

have no idea how it is used or its nutrient content. A food

demonstration about how to make peanut butter sandwiches or how to

incorporate this product into traditional recipes which utilize a

peanut sauce, common in some Southeast Asian dishes, would be helpful.

WIC agencies that have approached these issues with sensitivity have

done much to improve the acceptance of WIC foods as excellent low-cost

sources of nutrients lacking in participants' diets.

1991 Food Package Review

Section 123(c) of the Child Nutrition and WIC Reauthorization Act

of 1989 (Pub. L. 101-147) required the Secretary to conduct a review of

the appropriateness of WIC foods and food packages. The legislation

specifically directed the Secretary to consider the nutrient density of

such foods and how effectively needed nutrients are provided to WIC

participants. FNS entered into a Cooperative Agreement with

Pennsylvania State University to conduct this review. The findings,

Technical Papers--Review of WIC Food Packages, were published in

November 1991. The Pennsylvania State University researchers concluded,

based on a review of the scientific literature on the dietary adequacy

of women and children in the United States and associated nutritional/

health outcomes, that:

the nutritional quality of the current WIC food packages

is excellent as judged by the large contribution of target nutrients

relative to their contribution of energy (calories) to diets of various

categories of participants (as cited in Technical Paper #5);

the WIC food packages are nutrient-dense sources of the

five target nutrients--vitamins A and C, protein, calcium, and iron (as

cited in Technical Paper #3); and,

in general, the WIC foods provided enhance rather than

inhibit the bioavailability of these nutrients (as cited in Technical

Paper #3).

The issue of lactose intolerance among different ethnic groups was

also addressed in this review. The conclusion was that, although the

specific prevalence of lactose intolerance in the WIC population is not

known, there is ample evidence to indicate that the majority of adults

in the ethnic minority populations served by WIC are potentially

affected by this condition. However, it is essentially not a major

issue for WIC age-eligible children because the prevalence of lactose

intolerance in children under age 5 is very low. With respect to

adults, there is sufficient evidence that dairy products can be and are

consumed by many individuals who meet a clinical definition of lactose

intolerance. Therefore, and particularly in light of the numerous

options for improving tolerance to dairy products in individuals with

low lactase activity, dairy foods of some type may be acceptable to

most WIC participants. It was also pointed out that it may be difficult

to distinguish lactose intolerance as such from non-acceptance of some

or all dairy products for other reasons, because the diagnosis of

lactose intolerance requires a laboratory test.

However, the reviewers also found that there is ample evidence to

suggest that the traditional patterns of low or non-dairy product

consumption in some racial/ethnic groups might lead them to choose

relatively lower quantities of various dairy products or to choose non-

dairy sources of calcium not currently allowed by regulations (i.e.,

tofu or salmon/sardines with edible soft bones). The reviewers also

noted that there are valid scientific reasons for accommodating

cultural food preferences in general; these extend beyond clinical

intolerances to anthropological and sociological reasons. Foods not

accepted, regardless of the reason, will not be consumed.

The Department has had a long-standing policy in the WIC Program to

allow lactose-reduced milk for those participants who suffer from

lactose intolerance. A preliminary review of WIC State Plans of Program

operation and administration indicates that 55 of 84 WIC State agencies

(which include 32 Indian organizations serving as WIC State agencies)

specifically include lactose-reduced milk in their State-approved WIC

food lists.

Questions/Issues for Comment

The Department presents below broadly stated questions for comment.

Some questions are focused on ideas for regulatory or policy

redirection; others simply are seeking information on better ways to

meet needs within current requirements. Commenters are encouraged to

state their responses as specifically as possible. Commenters may also

address additional issues which are within the scope of this Notice.

Comments which are not within the scope of this Notice will not be

considered and therefore should not be included.

Each of the questions presented below is numbered. In order to

ensure full and appropriate consideration, commenters are asked to

precede each of their comments with the number of the question to which

it pertains. If comments are submitted on relevant issues which are not

listed in this Notice, the issues should be clearly defined.

Individual State and local agency comments are very important and

strongly encouraged, as are comments from the public health nutrition

community, industry, and the general public, including those

individuals who have been served or are being served by WIC.

Food Package Issues

1. Are the current food packages barriers to participation?

2. Are the current WIC foods culturally acceptable to diverse

populations?

3. Keeping in mind WIC's role as a nutrition/health program and

that WIC foods are intended to be supplementary to an overall diet, to

what extent should cultural food preferences or food traditions be

considered in designing the WIC food benefit?

4. Would the authorization/approval by all WIC State agencies of

lactose-reduced and/or lactose-free milks as WIC-eligible foods

adequately address the potential problem of lactose intolerance among

WIC participants? What other measures could be implemented to address

lactose intolerance (such as the substitution of other nutrient-dense,

low-cost calcium and/or protein rich foods for milk and cheese)?

5. Keeping in mind the below listed considerations, are there foods

that could be substituted or added to the WIC food packages that would

better accommodate cultural food preferences yet still result in the

WIC packages maintaining their nutritional integrity?

wide availability of the product;

participant appeal and acceptability;

domestic origin;

administrative feasibility (ability of participants,

vendor community, and WIC administrators to successfully manage a wider

variety or different types of WIC foods);

reasonable cost;

ease of daily apportionment;

rich in one or more of the target nutrients: calcium,

protein, iron, vitamins A and C; low in fat, sugar and salt content;

and

standardization and wholesomeness or safety of the

product.

6. What changes, if any, should be made in the current regulations

governing the Department's approval of cultural food substitutions

proposed by WIC State agencies?

Data/Information Issues

7. What data and/or information is available to help the Department

make informed decisions regarding this initiative (e.g., ethnic food

consumption data, scientific studies, acculturation practices,

participant surveys, etc.)?

The Department welcomes any data and/or information relevant to

this initiative.

Nutrition Education Issues

The nutrition education component of WIC can play a major role in

facilitating acceptance of WIC foods.

8. How are agencies currently introducing WIC foods to new

populations or suggesting ways to incorporate WIC foods into

traditional diets to increase their acceptability and to make optimal

use of current WIC food packages? How successful have these approaches

been in acceptability and use?

9. How could the nutrition education component of WIC play a more

effective role in meeting the nutritional needs of culturally diverse

populations?

10. What role do culturally sensitive nutrition education materials

from Federal, State and local agencies play in helping culturally

diverse populations accept and utilize the WIC foods in their

traditional diets?

11. Is there a need for USDA to produce more materials of this

nature, and, if so, what should be developed?

Dated: June 17, 1994.

William E. Ludwig,

Administrator, Food and Nutrition Service.

[FR Doc. 94-15233 Filed 6-22-94; 8:45 am]

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