The Special Supplemental Nutrition Program for Women,

Infants, and Children

(WIC)

Meta-Analysis

University of North Florida

Department of Sociology

Nicholas Jones

Table of Contents

Abstract…………………………………………………………...3

Program Processes…………………………………………..4

Program Impact/Outcome…………………………..…..7

Data/Literature………………………………………………..8

Shortcomings………………………………………………....13

Conclusions…………………………………………….……..14

Utilization and Synthesis……………………….….……16

References…………………………………………………….18

Abstract

The Special Supplemental Nutrition Program For Women, Infants, and Children (WIC) was established in

the early 70’s as a response to an increase in reported health issues surrounding pregnant and nursing

women and their children. The majority of these issues were found among low income mothers and

were the result of malnutrition and a lack of education regarding childcare and rearing, ultimately

leading to poor health outcomes for both the mother and child. Poorer health outcomes in poorer

communities creates a deficit in spending where the cost of health care which is normally paid for by

one’s insurance company must instead picked up by the state and/or federal government due to an

individual’s lack of coverage. WIC helps dramatically shrink this deficient by supplementing nutritionally

valuable foods for low income families, educating participants about healthy behaviors and lifestyle

choices, and providing a basis for regular medical examination that aids and reinforces the preventative

care needed by all individuals to maintain good health outcomes. Increased enrollment in WIC,

especially in the early stages fetal development, is associated with a decrease in low and very low

birthrates and fetal and infant mortality. Eligibility cut offs on the state level prevent a large population

of mothers, infants, and children at risk of malnutrition from receiving support. A strong outreach policy

to the entire population at risk would be more favorable than weak policy geared strictly to pregnant

women, but policy amendment must take into account the geographic clustering of poverty as income is

also strongly associated with enrollment.

Program Processes

Mission Statement and Program Theory

The USDA’s Food and Nutrition Service’s website states that WIC aims to “To safeguard the health of

low-income women, infants, and children up to age 5 who are at nutrition risk by providing nutritious

foods to supplement diets, information on healthy eating, and referrals to health care.”

Supplemental nutrition + nutrition education + health monitoring -> better health outcomes for

women, infants, and children at risk of malnutrition

Population

WIC assists nutritionally at risk women during and up to 6 weeks after pregnancy, breastfeeding

women up to their infants 1st birthday, and non-breastfeeding women up to 6 months postpartum. WIC

also assists infants up to their 1st birthday and children up to their 5th birthday. In 2014 there were a

reported 8,258,476 individuals participating in the WIC program consisting of 1,972,833 women,

1,964,393 infants and 4,432,290 children. (NSA 2014)

Eligibility

Must be pregnant and have a family income between 100 and 185% lower than the issued federal

poverty level. (Set by state agency)

Must live in the same state in which they apply

Must be examined by a health professional and evaluated for their risk of malnutrition

Can become eligible through enrollment in other assistance programs such as SNAP, TANF, and

Medicaid

Implementation

WIC is federally funded with a yearly congressional grant. In 1974 the total cost of WIC consisting of

the NSA and all their services along with the total cost of the supplemental food itself was 10 million

dollars. In 2014 that same total exceeded 6.2 billon (FNS yearly fiscal reports) and now funds the efforts

of 90 different state agencies in all 50 states 47,000 retailers 1,900 local agencies and over 10,000 clinic

sites. WIC’s annual budget is broken into 7 US regions, each representing a branch office of the NSA. By

far the largest spending is in the South-Eastern region which comprises of Alabama, Florida, Georgia,

Kentucky, Mississippi, North Carolina, South Carolina, Tennessee and the Choctaw MS and Eastern

Cherokee tribes. This is a result of denser populations and concentrated poverty. In 2014 the NSA

estimated that the average cost of supplemental nutrition per person per month was around 43 dollars

(NSA, Table 1)

NSA Regional Branches (NSA) % living in poverty based on 2007 US census (Mulbrandon)

*Any information not exclusively cited by author or study was published by the USDA’s NSA branch and can be found on WIC’s

national web page.

WIC Program Costs per Fiscal Year

Self-Reported Impact and Measurement Criteria

The Food and Nutrition Services branch of the USDA provides extensive state level participation data

and finance reports in accordance with the Office of Policy Support (OPS) which frequently conducts

evaluative research to assess the program and amend policy. Using this collection of data they claim that

participation in the WIC program is associated with:

“Improved birth outcomes and savings in health care costs,” measured by premature births, low birth

weight (LBW) and very low birth weight (VLBW) rates, infant death, and total adverted expenditures.

“Improved diet and diet-related outcomes,” measured by prevalence of anemia and nutrition intake

vs overall caloric consumption.

“Improved infant feeding practices,” measured by breastfeeding rates and rates of use of iron fortified

formula in non-breast feeders.

“Immunization rates and regular source of medical care,” measured by childhood immunization rates

and regularity of medical care.

“Improved cognitive development,” measured by vocabulary scores and memory after 1st year of life.

“Improved preconception nutritional status,” measured by hemoglobin levels and maternal obesity at

onset of subsequent pregnancy.

*All self-reported impacts, criteria, funding and population information accessed through from NSA’s

WIC website.

Literature/Data

The following literature and data have been categorized according to what is addressed

Eligibility

The CPS and SIPP (Current Population Survey and Survey of Income and Program Participation) grossly

undercounts those individuals enrolled and eligible to be enrolled in WIC. Undercounting is due to the

complex matter of determining whether or not an individual is at nutritional risk, a basic criteria of

eligibility. Eligibility also wrestles with the fact that many low income individuals have unstable home

environments and will often live where they receive the most support which can further alter their

eligibility. “The National Survey of WIC Participants implies that over 94 percent of WIC recipients have

incomes below 185 percent of poverty, suggesting that most adjunctively-eligible WIC households would

also be income eligible. The CPS data imply that roughly 13 percent of WIC recipients have incomes

above 185 percent of poverty, while SIPP data imply that 23 percent have incomes above 185 percent of

poverty.” (Bitler 2003: 21) Expanding eligibility to larger populations and increasing participation by

eligible individuals would increase the measurable effectiveness of the program. WIC participant and

program characteristic surveys show that enrollment is higher among Hispanics, African Americans and

married women and lower among Asians and individuals living in metropolitan areas. A lack of reliable

data regarding the income, living, and health statuses of eligible non participants inhibits the program

from reaching a core population at risk.

Access to early prenatal care by WIC is greatly limited. (Ku 1989) There is a correlation between

beginning of enrollment and length during pregnancy with overall birth outcomes. Race, local policy,

and coordination between programs were found unassociated with early enrollment, the only

association being previous enrollment. There is the possibility of using previous participants to as

liaisons to eligible non participants. Overall the benefit of WIC not being fully met. Information collected

on 1,181 pregnant women from 356 clinics in 208 local programs from 28 different states as well as

National Center for Health Statistics data. Suggests strong outreach policy to woman infants and

children better than weak policy geared strictly to pregnant women. Special outreach policy on a local

level also had little effect on early enrollment.

In 2005 Bitler argued that due to limitations set by state agencies larger population of eligible

individuals were still not receiving WIC support. “73 percent of eligible infants, 67 percent of eligible

pregnant and postpartum women, and 38 percent of eligible children one to four receive benefits.”

(Bitler, 2005: 38) Participants who are enrolled in the program are on average economically worse off

than those who are eligible but who do not receive care. WIC is intended to reach the entire population

of women, infants, and children at risk of malnourishment and falling between 100% and 185% below

the poverty line but the majority of those accepted are closer to 185%. Eligibility must be adjusted to

increase the amount of enrollees who are still at risk but who do not reach the level of poverty that is

strongly associated with enrollment. There is an overall lack of data needed to establish a good control

group so comparisons are made to programs like SNAP and TANF on the basis that the alleviation of

food insecurity itself partially deals with malnutrition. Close to a third of eligible WIC recipients receive

food stamps and do not participate in WIC although they are still at risk of malnutrition due to spoilage

and improper diet. This association holds true only if participation in WIC has no effect on household

food insecurity. The CPS and SIPP also underestimate enrollment in these programs, but not to the

degree that they do with WIC.

Impact

Children who participate in WIC program are 5-11 % more likely to be in “excellent health” than those

who do not. (Carlson, 2003: 489) If the income of a family at poverty line level were to double it is

speculated that the likeliness of the children in that same family being in ”excellent health” would only

increase 3-10%. This not only confirms the value of supplemental nutrition and but illustrates its

importance weighed against income alone, though income possesses positive health associations

through indirect effects such as the availability of resources in a particular time of need. Research

indicates that the most substantial positive health benefit associated with participation in WIC is found

among the population with the lowest income, but findings such as these may be erroneous as low

income mothers have lower than average health outcomes when it comes to pregnancy, birthing, and

child rearing.

The relationship between reported enrollment in WIC and birth outcomes in New York City between

1988 and 2001 has been found to be modest at best (Joyce 2005) Using a sample of over 800,000 births

reported by the New York City Department of Health and Mental Hygiene research was aimed at

determining WIC’s association with fetal growth rather than preterm delivery. This was done in an

attempt to separate the perceived and actual effects of the program and New York City was chosen to

better grasp the outcome of WIC in densely populated urban areas, particularly in the northeast region

where enrollment rates are typically higher. Limiting the sample population to women who were

currently receiving Medicade, who had no previous live births, and who had enrolled in prenatal care

within first 4 months of pregnancy greatly reduced the heterogeneity of WIC and non WIC “highly

motivated” mothers. Multiple fetus pregnancies were also taken into account as they were more

commonly associated with a higher risk of mental retardation and anemia. Overall it was concluded that

participation in WIC during the prenatal stages of pregnancy had little effect on birth outcomes in New

York City. The use of such a large data set solidifies these claims but it can never be assumed that what

works in one area will work in another. The overall implication of policy advisors suggesting WIC’s

benefit in regard to fetal development is repeatedly undermined by clinical studies showing that “WIC is

unrelated to fetal growth among singleton births across race and ethnicity…” and that any “…association

between WIC and other less clinically supportable birth outcomes diminished over time and varied by

race and ethnicity.” (Joyce, 2005: 681)

There is a significant association between WIC participation and smoking, weight gain during

pregnancy, birth outcomes and likelihood of breastfeeding. (Joyce 2008) Overall it was found that WIC

possessed lower effects on and associations with health than previously suggested by researchers.

Effects are subject to age gestational biases and while evidence supports the notion that WIC works its

effect is often overestimated. Addressing lifestyle choices and behavior like smoking, diet, breastfeeding,

and immunization is known benefit mothers and children and it is suggested that more resources be

used to emphasis their role in WIC

Meta-Analysis

Avruch (1995) analyzes WIC using 13 studies ranging from 1981-1988 and suggests that the program

reduces low birth rates by 25 percent and very low birth rates by up to 44%. There is an association

between decreased levels of low birth weight in infants and mothers who were enrolled in the program.

LBW averages among WIC and non WIC recipients were totaled, LBW due to VLBW ruled out, and the

proportional average between the two used to calculate probable number of VLBW across each of the

13 studies. Infant survival rates, birth rates and population data including income were compared with

proportional average calculations to estimate whether or not WIC was cost effective. Using this data she

suggests that “prenatal WIC enrollment is estimated to have reduced first year medical costs for U.S.

infants by $1.19 billion in 1992.” (Avruch, 1995: 27) The federal government saves an estimated $.93

and State $.73 on every dollar spent on preventative care through WIC and it is suggested that savings

could reach $804,653,673

Selection bias was found to have an impact on past research and attempts at removing it have been

made, notably that of Yunwei Gai (2012) who examined a birth cohort of 14,000 adolescents in a

longitudinal study started in 2001. “WIC does not affect average birth weight and average gestational

week after correcting for selection bias using the instrumental variable method. However, WIC

participation has significantly reduced the probability of very premature birth and (very) low birth

weight after controlling selection bias by bivariate probit models.” (Gai, 2012: 61) (Table 2)

BIVARIATE) PROBIT: (VERY) LOW BIRTH

Graph Courtesy of Yunwei Gai, Economics Professor at Babson College

Shortcomings

Impact

Larger differences in health outcomes have been found between WIC and non WIC individuals in

communities with lower than average BWs.

WIC’s impact is exacerbated in poorer states like North Carolina and underestimated in wealthier

ones like Maryland.

WIC’s greatest impact is found among individuals enrolled in Medicaid as well as WIC, a sub-

population whose income is on average lower than those enrolled in WIC alone and is therefore not an

ideal representation of the program’s target population.

The effects of program greatly subject to gestation age

Data

A program intended to suit the needs of an exceptionally large and vulnerable population (8,258,476

individuals) will eventually find itself at the crossroads of available and pertinent data. Because of the

programs relative young age any analysis of WIC must make use of the former rather than the latter and

deeper understanding of its benefits and drawbacks are merely speculative.

The indirect but beneficial associations between income and health greatly underplay the importance

of nutrition

Much of the older state data regarding at risk population uses existing records of Medicare, Medicaid,

TANF, and Food Stamps recipients and must be evaluated differently than if recipients were enrolled

exclusively in WIC.

Using probit models helps eliminates variability which while necessary tends to hide the greater

distribution of participants and emphasize the effect of singled out variables

There is an inadequate amount of data comparing VLBWs of WIC and non WIC recipients and there

are few longitudinal studies that follow large enough populations while also extracting from them the

appropriate data needed to draw conclusions.

Theory/Implementation

By using such a broad theory WIC opens itself up to the possibility of helping a very large population in

need but closes the door to the possibility of reaching them all.

Frequent process evaluation and policy amendment may increase the efficiency of the program and

its ability to reach its target population but by leaving the overall target population relatively unaltered

and its parameters subject to state mandate WIC greatly reduces its ability to progress further.

Conclusion

1. Expanding eligibility further would help reach the larger population in need. An individual’s

eligibility to participate is determined by his or her state of residence and is very much dependent on

how far below the poverty line they fall. The population of eligible individuals has been estimated to be

close to 14 million and while there are already close to 6 million that would benefit from participation it

is suggested that imposing national cutoffs for eligibility at 100% below the poverty line rather than

state selected cutoffs anywhere between 100% and 185% would help reach the larger population at risk.

Supplemental programs like TANF and SNAP have been geared towards feeding lower income

individuals but data suggests that because WIC specifically targets nutrition it is better suited to meet

the needs of its target population. Needs are met through discounted nutritionally rich food items,

increased awareness of good health practices before, during, and after pregnancy, and continual

evaluation and preventative checkups that serve to monitor the well-being of participants whose

financial circumstance may not allow for the acquisition of the resources needed to keep their families

healthy. A balance must be struck between eligibility and financing as too few participants will reduce

the WIC’s beneficial impact and too many will reduce WIC’s perceived impact.

2. There is conclusive evidence that mothers, infant, and children who enroll in WIC have better

health outcomes than those who do not, but any supplemental service will likely aid those in need and

WIC’s true benefit is still up for debate. There is though supporting evidence of a positive association

between enrollment (especially in the early stages of fetal development) and birth weight,

breastfeeding, and immunization. This evidence is also up for debate as birth weight alone is not as

strongly associated with enrollment as very low birth weight, but coupled with definite negative

associations between enrollment and behavior that adversely effects health such as smoking and poor

diet WIC asserts its feasibility for aiding the larger population at risk of malnourishment. The majority of

WIC’s fiscal allotment from congress goes towards purchasing food for participants, each averaging each

close to 43 dollars a month. While this may not seem enough to impact one’s health we must keep in

mind that WIC also supplements formula and that the smaller portion of this allotment goes to the NSA

who help ensure that participants receive educational and medical resources they need as well as fund

frequent program evaluations guarantee impact.

3. The initial cost of WIC is made up for by the resulting savings in health care costs to federal and

state governments that are commonly associated with low birth weight. Regular medical

examinations, preventative care, and dietary education greatly impact the health of individuals and are

associated with better health outcomes. WIC was found to have similar health benefits to increased

income (assuming the income of a family at poverty line were to double) but lacked the secondary

benefits like monetary reserves, health insurance, and available transportation that often come with it.

Better health, regardless of income, means less government spending.

4. The greater a state’s overall poverty, the greater impact WIC will have on its inhabitants. Likewise

the poorer an individual, the greater the impact of WIC. This is primarily because the lower a states

average income the lower the states average birth weight. This holds true with individuals of any state,

but a larger part of the budget is used in regions that have densely populated areas with lower than

average earnings leaving eligible populations elsewhere vulnerable.

Utilization and Synthesis

It is strongly recommended that WIC reevaluate its target population to find an appropriate balance

between eligibility and impact. Decreasing the number of eligibles and moving the cutoff closer to 185%

lower than the poverty line would increase the impact overall but would leave a larger population

vulnerable. Increasing the number of eligibles and moving the cut off closer to 100% would address the

larger population at risk but decrease the impact overall and would lower the per dollar cost/benefit. By

directing more resources to the poorest populations WIC may increase savings to federal and state

governments but not without disadvantaging those who still fall below the poverty line and would

benefit from enrollment. State mandated cutoffs under address the larger population of eligibles, but

national mandate will never be appropriate as it cannot address the disparities in income between

states.

There is great potential for using past participants as liaisons to eligibles who are not enrolled. This

would not only be a cost effective solution as past participants have already received the kinds of

educational resources they need to maintain healthy lifestyle’s, but it would also allow the program to

impact a core population of at risk individuals that would be otherwise hard to reach while providing a

regenerative structure proven effective through facilitation in other social programs.

It is necessary for morality’s sake that a government secure the well-being of its people, but also

economically responsible to ensure that its people need not rely solely on the government. WIC seeks to

relieve those at risk of malnourishment with the nutritious resources they need to achieve healthy

outcomes, but also ensures that they receive the educational resources they need to maintain them. It is

therefore imperative that proper data continue to be collected in order to continue to adjust the

program to meet its maximum potential.

References

Avruch, S., and A.P. Cackley. 1995. "Savings Achieved by Giving WIC Benefits to Women

Prenatally." Public Health Reports 110(1):27-34.

Bitler, M., J. Currie and J. Scholz. 2003. " WIC Eligibility and Participation   "  Journal of Human

Resources 38(Volatility and Implications for Food Assistance Programs):1139-1179.

Bitler, M., C. Gunderson and G. Marquis. 2005. " Are WIC Nonrecipients at Less Nutritional Risk than

Recipients? an Application of the Food Security Measure." Review of Agricultural

Economics 27(3):433-438.

Carlson, A. and B. Senauer. 2003. "The Impact of the Special Supplemental Nutrition Program for

Women, Infants, and Children on Child Health." American Journal of Agricultural

Economics 85(2):479-491.

Food and Nutrition Services. 2015. "Women, Infants, Children (WIC)." USDA, Retrieved 11/29, 2015.

(http://www.fns.usda.gov/wic/women-infants-and-children-wic).

Gai, Y. and L. Feng. 2012. "Effects of Federal Nutrition Program on Birth Oucomes." Atlantic Economic

Journal 40(1):61-83.

Joyce, T., D. Gibson and S. Colman. 2005. "The Changing Association between Prenatal Participation in

WIC and Birth Outcomes in New York City."  Journal of Policy Analysis and Managment 24(4):661-

685.

Joyce, T., A. Racine and C. Yunzal-Butler. 2008. " Reassessing the WIC Effect: Evidence from the

Pregnancy Nutrition Surveillance System   "  Journal of Policy Analysis and Managment 27(2):277-

303.

Ku, L. 1989. "Factors Influencing Early Prenatal Enrollment in the WIC Program Leighton Ku Public

Health Reports." Public Health Reports 104(3):301-306.

Ludwig, J. and M. Miller. 2005. "Interpreting the WIC Debate Jens Ludwig and Matthew Miller Journal of

Policy Analysis and Management."  Journal of Policy Analysis and Managment 24(4):691-701.

Mulbrandon, C. 2007. "United States Poverty Map." VisualizingEconomics, Retrieved 12/7/14, 2014.

(http://visualizingeconomics.com/blog/2007/08/11/united-states-poverty-map).