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Review of WIC Food Packages: Improving Balance and Choice: Final Report (2017)

Chapter:8 Sensitivity Analysis for Food Package Nutrient, Food Group, and Cost Models

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Suggested Citation:"8 Sensitivity Analysis for Food Package Nutrient, Food Group, and Cost Models." National Academies of Sciences, Engineering, and Medicine. 2017. Review of WIC Food Packages: Improving Balance and Choice: Final Report. Washington, DC: The National Academies Press. doi: 10.17226/23655.
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8

Sensitivity Analysis for Food Package Nutrient, Food Group, and Cost Models

The committee was tasked with conducting a sensitivity analysis to evaluate the sensitivity of recommended changes to the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) food packages to assumptions used to develop the revised food packages. Specifically, the analysis tested the effects of changes in the food packages on the nutrient level in the packages, availability of the Dietary Guidelines for Americans (DGA) food groups and subgroups, and cost of the food packages. This type of analysis will provide the U.S. Department of Agriculture’s Food and Nutrition Service (USDA-FNS) with a tool to estimate the relative effect of various assumptions used in developing the food package recommendations, as well as to evaluate the potential effects of additional changes on the food packages.

In carrying out the sensitivity analysis, the committee chose a comprehensive approach and first examined the effects of the proposed revisions on the food packages, followed by tests of the effects of selected variations to these revisions. Changes in food quantities, as well as changes in assumptions regarding redemption rates, substitutions within food categories, and shifts in participation were tested. Including sensitivity analyses of the revised food packages adds to the analyses discussed in Chapters 6 and 7 (the rationale for the revised food packages and the cost analysis) by allowing a more detailed examination of the effects of specific changes on the provision of nutrients and food groups, and costs.

In the discussion below, a description of the analytic methods used is presented, followed by the results for the selected changes. Results related to food categories are described first, followed by results related to shifts in

Suggested Citation:"8 Sensitivity Analysis for Food Package Nutrient, Food Group, and Cost Models." National Academies of Sciences, Engineering, and Medicine. 2017. Review of WIC Food Packages: Improving Balance and Choice: Final Report. Washington, DC: The National Academies Press. doi: 10.17226/23655.
×

participation. A summary of the projected impact of food package changes on the nutrient and food group profiles of the packages, as well as package costs, is presented. In contrast to the Regulatory Impact Analysis (see Chapter 10) which projects cost effects of the revised food packages for fiscal years 2018 through 2022, the cost effects presented in this chapter reflect the effects of individual food category changes to specific food packages, one at a time, based on 2015 costs only.

PURPOSE, GOALS, AND LIMITATIONS OF SENSITIVITY TESTING

In the analyses presented below, the sensitivity of the predicted outcomes (nutrient and food group profiles of the food packages as well as costs) to various changes in the food packages, as well as to assumptions regarding food item substitutions within a food category (i.e. yogurt in place of milk), redemption rates, and participation rates, are examined. USDA-FNS will be able to use the sensitivity analysis results as a way to evaluate effects of various food package options on the specified outcomes, should different regulatory choices be made, or should participants behave in ways that are different than those that were assumed for the revised package (e.g., what would be the cost implications if the actual redemption rates differ from the calculated redemption rates in particular ways).

The initial task for the committee in conducting its sensitivity analysis included assessing the effects of food package item changes on the nutrient and food group profiles of the different packages and on assumed participant intake. Critical to assessing the effects of package changes on intake is information about how much of the prescribed foods in the individual’s package are redeemed and consumed. However, information on consumption of specific WIC foods by package was not available to the committee. It was also clear from the intake analysis (see Chapter 4) that the foods and nutrients available in the packages do not coincide with nutrient intakes reported by WIC participants in the National Health and Nutrition Examination Survey (NHANES), the only source of nationally representative population-wide intake data available. In addition, small sample sizes for pregnant, breastfeeding, or postpartum women necessitated collapsing the NHANES data for the years 2005–2012. As a result, it was not possible to focus on the most recent data for subgroups of women. For children, intake data were more robust for 2011–2012.

Given the difficulty of obtaining data as well as limitations in the available data, as described above, the committee devised a method that was applied in the sensitivity tests to estimate the effects of the food package changes on the nutrients and food groups available in the packages, but not on intakes of the participants. In the case of children only, where the sample size from NHANES was sufficient, the committee used

Suggested Citation:"8 Sensitivity Analysis for Food Package Nutrient, Food Group, and Cost Models." National Academies of Sciences, Engineering, and Medicine. 2017. Review of WIC Food Packages: Improving Balance and Choice: Final Report. Washington, DC: The National Academies Press. doi: 10.17226/23655.
×

estimates of intake changes to calculate projected Healthy Eating Index–2010 (HEI–2010) scores.

METHODOLOGICAL APPROACH TO SENSITIVITY ANALYSIS

Overview of the Approach

The starting point for the committee’s sensitivity analysis was the nutrient profile and cost estimates for the current food packages, and redemption data for WIC foods (see Chapter 7 for a description of the methodology and all assumptions applied). Holding all other components constant in the current food package, the effects of a single change to a given component (e.g., food items and/or amount and/or redemption rate, or participation) on the level of nutrients and food groups, and the cost at the food package level were determined. This approach enabled the committee to estimate how various food package changes might potentially affect recipients’ intakes within each package type. In addition, effects of package component changes on the average food cost per person were estimated. All tests in the sensitivity analysis evaluated not only the effect of a change to a given food category in the revised food package, but also included one to three alternatives as additional sensitivity tests. The development of the set of tests that were conducted is described briefly below.

The results of the sensitivity test outcomes were examined for each WIC food category in the following order: dairy; breakfast cereal; the cash value voucher (CVV), separately and combined with juice; fish; the rotation of peanut butter, legumes, and fish; and infant food vegetables and fruits. Several of the food categories (e.g., dairy) examined represent a composite of different substitution options (i.e., fluid milk, which can be substituted with yogurt and cheese). As described in Appendix R, the committee assumed that all participants selected a substitution option for dairy. This was because no information was available regarding the frequency of WIC participant selection of cheese or yogurt in place of milk, and because it was assumed that participants would choose the most valuable (highest cost) food item, if given the option.

When the options for food substitutions are changed in the revised food package, the nutrients provided in that package will likely change as well. For example, in the current food package IV-B for children ages 2 to less than 5 years, the assumption used for the dairy food category was that 1 pound of cheese and 1 quart of yogurt are substituted for 4 quarts of milk. In the revised food packages, children have two options: the option described for the current package, and also an option to substitute 2 quarts of yogurt in place of 2 quarts of milk. These two options were accounted for by allotting one of the two substitution options to half of the children,

Suggested Citation:"8 Sensitivity Analysis for Food Package Nutrient, Food Group, and Cost Models." National Academies of Sciences, Engineering, and Medicine. 2017. Review of WIC Food Packages: Improving Balance and Choice: Final Report. Washington, DC: The National Academies Press. doi: 10.17226/23655.
×

and the other substitution option to the remaining children. Furthermore, the overall amount of milk available in the children’s revised package decreased. Thus, there was a decrease in saturated fat in the revised package compared to the current package because, on average, less cheese was included, and also because the overall quantity of dairy was reduced. This change might result in a decrease in dairy provided, but an increase in the HEI–2010 score due to the reduction in saturated fat.

Analyses Conducted

Most of the sensitivity tests were applied to food packages IV-B (for children ages 2 to less than 5 years), V-A (for pregnant women), and VII (for fully breastfeeding women) because these food packages capture the breadth of possible outcomes. Food package IV-B represents the largest proportion of participants and therefore has the greatest proportional effect on cost. Food package V-A includes a CVV amount that falls within that of other food packages. Food package VII includes the largest CVV and the largest quantity of fish. One test is also included for food package II (infants ages 6 to less than 12 months) to evaluate the option to substitute a CVV in place of infant food vegetables and fruits.

The committee developed a list of sensitivity tests that took into consideration which changes to the revised food packages (or assumptions applied, such as those for redemption rates) might have the greatest effect on the outcomes of interest (i.e., nutrient or food group composition of the packages, HEI–2010 score, and cost). A complete list of the tests conducted is provided in Appendix S, Table S-1. Several tests included a combination of variables, for example, a simultaneous change in the amount of a food and the redemption rate, or a change to both juice amounts and the CVV. All tests were conducted using the revised package food composites and redemption rates, as described in Appendix R, except in cases where the objective of the test was specifically to evaluate changes to these assumptions.

The proposed changes with the greatest impact were hypothesized to be: (1) those in the quantities of foods (e.g., changes to milk amounts) or substitution options (including only fluid milk instead of yogurt and cheese substitutions) offered in the different food packages; (2) changes to assumptions about redemption that were linked to the changes in quantities of foods (i.e., the redemption rate increased as milk quantities decreased, following an algorithm developed by the committee and described in Appendix R); (3) changes to the ratio of vegetables to fruits that are purchased (i.e., assuming fewer fruits and more vegetables are purchased with the CVV); and, (4) changes to participation categories (i.e., population shifts from formula to breastfeeding). By testing shifts in these variables for a

Suggested Citation:"8 Sensitivity Analysis for Food Package Nutrient, Food Group, and Cost Models." National Academies of Sciences, Engineering, and Medicine. 2017. Review of WIC Food Packages: Improving Balance and Choice: Final Report. Washington, DC: The National Academies Press. doi: 10.17226/23655.
×

sample of food packages, the degree to which the assumptions applied affect outcomes was assessed.

Outcome Measures for the Analyses

As described above, to carry out the sensitivity analyses, the committee identified outcome measures that included changes in the nutrient profiles and food groups in the different food packages, costs, and HEI–2010 scores (only for children ages 2 to less than 5 years). For all analyses, the absolute change in the outcome and the percent change compared to the current food package were calculated.

Changes in food groups and subgroups provided by the packages were evaluated in comparison to the current DGA food groups or food subgroups, applying the redemption rates for WIC foods. To evaluate changes to food groups, the food group corresponding to the food to be tested was identified. If the food was categorized as a DGA food subgroup (e.g., peanut butter is categorized as nuts, seeds, and soy), the effect of a change to the food on the total food group (e.g., total protein foods) was also evaluated. The foods in the food package were then converted to serving-equivalents per day using the USDA Food Patterns Equivalents Database (FPED) 2011–2012 (USDA/ARS, 2014). As was done for the nutrient profiles of the current and revised food packages (initially described in Chapter 3), differences in nutrients provided by the food packages for each food tested were sourced from the USDA Standard Reference Database, Release 28 (USDA/ARS, 2016).

Lastly, changes in the per-participant cost of each of the food packages were evaluated using the price per unit for foods (see Appendix R for price details). In addition, the overall average per-participant cost for a WIC food package was calculated to illustrate the impact of the change in one of the packages on the overall WIC program costs for food. The overall cost is a weighted average that incorporates the relative number of participants that are prescribed each different type of package.

In the cases where the food was a composite of different items (e.g., dairy is a composite of milk, yogurt, and cheese), the price of the food was a composite of the prices for the various substitution options. For some of the sensitivity tests, the composite was revised to reflect a food substitution. For example, the additional yogurt option was removed in some tests. Thus, the dairy composite was changed to replace the quart of yogurt with a quart of milk. Parallel changes in the composite nutrients and prices are also reflected in the test result.

Suggested Citation:"8 Sensitivity Analysis for Food Package Nutrient, Food Group, and Cost Models." National Academies of Sciences, Engineering, and Medicine. 2017. Review of WIC Food Packages: Improving Balance and Choice: Final Report. Washington, DC: The National Academies Press. doi: 10.17226/23655.
×

Impact of Food Package Changes on HEI–2010 Scores for Children Ages 2 to Less Than 5 Years

To evaluate changes to HEI–2010 scores for children, the committee calculated the difference between the redeemed amounts of foods in the current food packages and the corresponding redeemed amounts in the revised food package. The test used the assumption that the median intake of participants estimated using NHANES data would increase or decrease by this difference. The resulting intake values were then used to estimate HEI–2010 scores for the given test parameters. Only food package IV-B (for children ages 2 to less than 5 years) is used as an example for the HEI–2010 sensitivity test outcome for several reasons. First, children are the largest population subgroup served by WIC (comprising over 35 percent of the WIC-participating population) so this analysis represents the estimated effect of the food packages on a large proportion of participants.1 Second, the DGA food patterns (which are used in the calculation of the HEI–2010) apply only to individuals 2 years of age and older and therefore are not applicable to younger children or infants. Finally, median intake estimates for women were generated using data from NHANES 2005–2012 and therefore are less representative of current (2011–2012) intakes, and sample sizes remain small.

Interpretation of the Sensitivity Test Results

The relevance of a sensitivity test to a target population group may depend upon the importance of a specific nutrient or food group to the population group under consideration. For example, a 2 percent change in folate provided in a food package may be more relevant to pregnant women than to children. Thus, it may be necessary to evaluate each sensitivity test and outcome on a case-by-case basis. As applied by USDA-FNS, interpretation of the sensitivity test results may differ depending upon the options available (e.g., budgetary changes) or the question that is asked (e.g., Can changes to a particular food alter provision of a particular nutrient?).

Given that the relevance of a proposed food package change depends on the particular question, the committee chose to highlight changes of plus or minus 8 percent in the outcomes of interest, and offer a qualitative interpretation. The 8 percent value represents a potentially relevant level of change, and served as a means of distinguishing very small changes from others that may be more meaningful. The priority nutrients or food groups (as identified in Chapter 5) for the target population that change by at least

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1 Calculation of the revised HEI–2010 is also carried out in Chapter 9 for food package IV-B to compare the current to the revised food package. The same rationale applies to that calculation. A description of how the HEI–2010 is calculated using NHANES data is available in Appendix J.

Suggested Citation:"8 Sensitivity Analysis for Food Package Nutrient, Food Group, and Cost Models." National Academies of Sciences, Engineering, and Medicine. 2017. Review of WIC Food Packages: Improving Balance and Choice: Final Report. Washington, DC: The National Academies Press. doi: 10.17226/23655.
×

8 percent are identified. The complete results of the sensitivity analyses are given in Appendix S.

SENSTIVITY ANALYSIS RESULTS

Overview

A summary of the results of the committee’s sensitivity analysis is presented below, organized by WIC food category or food package category (e.g., CVV/juice or the revised rotation of peanut butter/legumes/fish), to which changes were made. The nutrient, food group, and HEI–2010 tests followed similar patterns for each. The summary also describes the rationale for each test, such as USDA-FNS may have less funding and needs to reduce a food quantity, or participants may behave differently than was assumed when food package changes were evaluated. For each WIC food category, a discussion of the test results that evaluate the effect of a revised food package change are presented first, followed by additional tests conducted for the same food category. The potential positive or negative consequences of each test result are described relative to the current food package.

Summary of Sensitivity Analysis Results

Dairy Adjustment

Changes to quantities of dairy and substitution options that are proposed for the revised packages were evaluated. The revised food package includes an option for substituting an additional quart of yogurt, therefore, a 5-percent increase in redemption for dairy was assumed based on the potential participant preference for yogurt (Fung et al., 2010). To test this assumption, another set of tests was conducted to evaluate the outcomes should the substitution options (yogurt and cheese) not be offered (only fluid milk is offered). Further reductions in dairy were also tested as an example of a possible food package change that could be implemented in the case of reduced funding. The latter tests retained the substitution options. As amounts of dairy were reduced, the redemption rate was increased, applying the committee’s algorithm explained in Appendix R.

Revised packages compared to the current packages When the quantity of dairy foods in the food packages is changed by including an additional yogurt substitution, levels of added sugars increase but levels of saturated fat decrease because milk amounts are reduced and, for some tests, there is less cheese in the average package (see Table 8-1). Both of these food components were priority nutrients to limit for all WIC population groups.

Suggested Citation:"8 Sensitivity Analysis for Food Package Nutrient, Food Group, and Cost Models." National Academies of Sciences, Engineering, and Medicine. 2017. Review of WIC Food Packages: Improving Balance and Choice: Final Report. Washington, DC: The National Academies Press. doi: 10.17226/23655.
×

TABLE 8-1 Impact of Dairy Changes on Nutrient and Food Group Food Package Profiles and on the HEI–2010 Scores Relative to the Current Food Packages for Children Ages 2 to Less Than 5 Years (IV-B), Pregnant Women (V-A), and Fully Breastfeeding Women (VII)a

Food Package Adjustments (Amount and Redemption Rate)b,c Nutrients Food Group(s)d HEI Scoree Package Per-Participant Cost WIC Average Per-Participant Cost Appendix S Table Reference
IV-B Revised: −2 quarts, 80%, additional substitutionsf (+) added sugars
(−) saturated fat
+$0.08 +$0.03 S-2
Test 1: −4 quarts, 86%, additional substitutionsf (−) calcium, potassium, riboflavin, vitamin D (−) dairy −$0.89 −$0.27 S-2
Test 2: −2 quarts, 76%, no substitutions (only fluid milk) (+) vitamin D
(−) added sugars, saturated fat
−$4.29 −$2.18 S-2
V-A Revised: −6 quarts, 66%, additional substitutionsf (+) added sugars
(−) calcium, vitamin A, vitamin D, saturated fat
(−) dairy NA −$1.11 −$0.11 S-3
Test 1: −10 quarts, 74%, additional substitutionsf (+) added sugars
(−) energy, protein, total fat, calcium, magnesium, phosphorus, potassium, sodium, zinc, selenium, riboflavin, vitamin B12, vitamin A, vitamin D, saturated fat
(−) dairy NA −$2.97 −$0.28 S-3
VII Revised: −8 quarts, 68%, additional substitutionsf (+) added sugars
(−) calcium, phosphorous, potassium, riboflavin, vitamin A, vitamin D, saturated fat
(−) dairy NA −$1.59 −$0.06 S-4
Suggested Citation:"8 Sensitivity Analysis for Food Package Nutrient, Food Group, and Cost Models." National Academies of Sciences, Engineering, and Medicine. 2017. Review of WIC Food Packages: Improving Balance and Choice: Final Report. Washington, DC: The National Academies Press. doi: 10.17226/23655.
×
Test 1: −12 quarts, 77%, additional substitutionsf (+) added sugars
(−) calcium, magnesium, phosphorus, potassium, sodium, zinc, thiamin, riboflavin, vitamin B12, vitamin A, vitamin D, saturated fat
(−) dairy NA −$2.49 −0.12 S-4
Test 2: −8 quarts, 65%, no substitutions (only fluid milk) (−) calcium, phosphorus, sodium, zinc, added sugars, saturated fat (−) dairy NA −$5.51 −$0.19 S-4

NOTES: — = indicates that no changes were in the range of more than approximately ± 8%; (+) = increased amount (an increased amount for saturated fat, added sugars, and sodium is undesirable); (−) = decreased amount (a decreased amount for saturated fat, added sugars, and sodium is desirable); HEI = Healthy Eating Index–2010; NA = unable to calculate change in HEI score for any but food package IV-B. Weighting of milk substitution options for alternative tests were the same as the weighting of milk substitution options for the revised packages. Nutrient and food group composition of the food packages were based on the assumptions outlined in Appendix R.

a Notations for nutrients and food groups in the table represent changes of 8% or greater. Not all nutrients or food groups listed were identified in Chapter 5 as a priority for the target population subgroup. See Appendix S for more details on changes in nutrients and food groups.

b The adjustment is in reference to the current food package amounts.

c For all quantities of milk tested, the maximum amounts of possible substitutions are assumed as the likely participant behavior (i.e. substitutions are of greater value than fluid milk). Therefore, changes to nutrients reflect changes in these substitutions. Particularly, added sugars and saturated fat in the food package are affected by the amounts of yogurt and cheese that may be substituted.

d Food group noted corresponds to the appropriate food group or subgroup from the Dietary Guidelines for Americans.

e The committee created a tool to estimate the HEI for children ages 2 to less than 5 years considering the revised package change or test. To do this, the difference between the redeemed amounts of the HEI components for the current food package and the redeemed amounts of the HEI components for the test food package were added to the median intake estimated using NHANES 2011–2012.

f The tests included the maximum substitutions allowable. The substitution options were allocated evenly, for example, 50 percent of children were allotted the 1 lb cheese, 1 qt yogurt substitution and 50% of children were allotted the 2 qt yogurt substitution option.

Suggested Citation:"8 Sensitivity Analysis for Food Package Nutrient, Food Group, and Cost Models." National Academies of Sciences, Engineering, and Medicine. 2017. Review of WIC Food Packages: Improving Balance and Choice: Final Report. Washington, DC: The National Academies Press. doi: 10.17226/23655.
×

Overall, the revisions to food package IV-B (for children) will have a positive effect on the nutritional composition of the package for this group. The HEI–2010 dairy score for food package IV-B does not change appreciably. For women, however, increased redemption will not compensate for the reduced quantities of dairy in their revised food packages because calcium, potassium, phosphorus, riboflavin, vitamin A, and vitamin D all are lower in one or both of the tested packages. The relevance of these changes depends on the needs of target population group and on the foods selected from among the package options. Potassium was a priority nutrient to increase for all subgroups of women; whereas, vitamins A and D were priorities only for some subgroups of women. Fluid milk provides more potassium, but a substitution of cheese in place of milk provides more saturated fat. The monthly cost of the dairy changes to the revised packages ranged from −$1.59 to +$0.08 per-participant by package and from −$0.11 to +$0.03 per-participant overall.

Alternatives to the revised packages compared to the current packages When the quantities of dairy foods in food package IV-B (for children) were reduced further (to 12 quarts), decreases in the key dairy nutrients (calcium, potassium, vitamin D) were noted, along with riboflavin, and the HEI–2010 score for dairy was reduced. Changes in saturated fat and increases in added sugars are less than 8 percent because of the substitution assumptions applied. If all caretakers of children selected a cheese substitution instead of 2 quarts of yogurt, the changes to these nutrients (which are priorities to reduce) would be more substantial. However, the largest decreases in milk tested (−10 quart for food package V-A and −12 quart for food package VII) result in the reduction of additional nutrients beyond the 8 percent threshold, despite the increased redemption rate.

Removing all substitution options in the packages evaluated decreases the added sugars provided. In most cases the reduction of milk and reduced substitutions with yogurt decreased costs (see Table 8-1).

The cost effects of these tests per package ranged from −$5.51 to −$0.89. The effects on the overall average food cost per person are −$2.18 and −$0.09.

Evaluation Changes to dairy foods in the packages and the substitution options affected levels of calcium, potassium, vitamin A, vitamin D, saturated fat, and added sugars. Allowing for a variety of substitutions or additional substitution options for milk may promote greater consumption and improve level of essential nutrients from dairy foods in the packages; however, these substitutions can have a substantial impact on the cost of the food packages.

Suggested Citation:"8 Sensitivity Analysis for Food Package Nutrient, Food Group, and Cost Models." National Academies of Sciences, Engineering, and Medicine. 2017. Review of WIC Food Packages: Improving Balance and Choice: Final Report. Washington, DC: The National Academies Press. doi: 10.17226/23655.
×

Changing Breakfast Cereal to All Whole Grain-Rich

A sensitivity analysis was used to test the revised package requirement that all breakfast cereals meet the whole grain-rich specifications. The assumed redemption of ready-to-eat (RTE) breakfast cereals was decreased by 10 percent (to 54 percent) to account for participants’ potential preference for refined grain varieties and the potentially reduced number of choices. To evaluate this assumption, the first test assumed that no change to redemption would occur for breakfast cereals (i.e., 60 percent, based on the current food package redemption rate). A second test was conducted for the children’s food package (IV-B) using the highest (69 percent) of the state redemption rates made available to the committee (see Table 8-2).

Revised packages compared to the current packages Across all food packages that were evaluated, the revised package change to all whole grain-rich cereals resulted in higher levels of zinc. There were also lower levels of several B vitamins and iron. However changes in folic acid levels did not exceed the 8 percent threshold. This finding is in alignment with the information reviewed in Chapter 6, which indicates that most ready-to-eat cereals have similar levels of nutrient fortification. Therefore, nutrients in the food packages were unlikely to be greatly affected by this change in cereal specifications. Although whole grain cereals are more expensive than the refined grain options, this food package change results in a substantial increase in the amounts of whole grains offered across the food packages. The HEI–2010 score for whole grains (a priority food subgroup for all population groups evaluated) increases for all tests conducted on food package IV-B (for children). The change to all whole grain-rich cereals results in a savings of $0.08 (based on reduced redemption) per-participant.

Alternatives to the revised packages compared to the current packages If redemption continues at the current rate (60 percent), the change to whole grain-rich cereals will also provide additional fiber compared to the breakfast cereals in the current food packages, but they also provide less riboflavin and vitamin A. If redemption increases to 69 percent, fiber, iron, magnesium, phosphorus, zinc, and folate would all increase above the 8 percent threshold. The cost, if redemption remains at the current rate, is +$0.43 per food package. Increasing redemption rates further would increase the cost of the children’s package by $1.16. The overall average per-participant cost for the change to all whole grains if redemption remains at the current rate would range from +$0.01 to +$0.15 across the three packages tested (food package IV-B, V-A, and VII).

Suggested Citation:"8 Sensitivity Analysis for Food Package Nutrient, Food Group, and Cost Models." National Academies of Sciences, Engineering, and Medicine. 2017. Review of WIC Food Packages: Improving Balance and Choice: Final Report. Washington, DC: The National Academies Press. doi: 10.17226/23655.
×

TABLE 8-2 Impact of Changes to All Whole Grain-Rich Breakfast Cereals on Nutrient and Food Group Food Package Profiles and on the HEI–2010 Scores Relative to the Current Food Packages for Children Ages 2 to Less Than 5 Years (IV-B), Pregnant Women (V-A), and Fully Breastfeeding Women (VII)a

Food Category Food Package Adjustments (Amount and Redemption Rate)b Nutrients Food Group(s)c HEI Scored Package Per-Participant Cost WIC Average Per-Participant Cost Appendix S Table Reference
Breakfast cereal IV-B Revised: all WG, 54% (+) zinc
(−) iron, thiamin, riboflavin, niacin, vitamin B12, vitamin A, added sugars
(+) whole grains (+) whole grain score −$0.08 −$0.03 S-5
Test 1: all WG, 60% (+) fiber, zinc
(−) riboflavin, vitamin A
(+) whole grains (+) whole grain score +$0.43 +$0.15 S-5
Test 2: all WG, 69% (+) fiber, iron, magnesium, phosphorus, zinc, folate (+) total grains, whole grains (+) whole grain score +$1.16 +$0.42 S-5
V-A Revised: All WG, 54% (+) zinc
(−) iron, thiamin, riboflavin, niacin, vitamin B12, vitamin A, added sugars
(+) whole grains NA −$0.08 −$0.01 S-6
Suggested Citation:"8 Sensitivity Analysis for Food Package Nutrient, Food Group, and Cost Models." National Academies of Sciences, Engineering, and Medicine. 2017. Review of WIC Food Packages: Improving Balance and Choice: Final Report. Washington, DC: The National Academies Press. doi: 10.17226/23655.
×
Test: All WG, 60% (+) fiber, zinc
(−) riboflavin, vitamin A
(+) whole grains NA +$0.43 +$0.04 S-6
VII Revised: All WG, 54% (+) zinc
(−) iron, thiamin, riboflavin, vitamin A, added sugars
(+) whole grains NA −$0.08 −$0.01 S-7
Test: All WG, 60% (+) fiber, zinc (+) whole grains NA +$0.43 +$0.01 S-7

NOTES: (+) = increased amount (an increased amount for saturated fat, added sugars, and sodium is undesirable); (−) = decreased amount (a decreased amount for saturated fat, added sugars, and sodium is desirable); HEI = Healthy Eating Index–2010; NA = unable to calculate change in HEI score for any but food package IV-B; WG = whole grain-rich. Nutrient and food group composition of the food packages were based on the assumptions outlined in Appendix R.

a Notations for nutrients and food groups in the table represent changes of 8% or greater. Not all nutrients or food groups listed were identified in Chapter 5 as a priority for the target population subgroup.

b The adjustment is in reference to the current food package amounts.

c Food group noted corresponds to the appropriate food group or subgroup from the Dietary Guidelines for Americans.

d The committee created a tool to estimate the HEI for children ages 2 to less than 5 years considering the revised package change or test. To do this, the difference between the redeemed amounts of the HEI components for the current food package and the redeemed amounts of the HEI components for the test food package were added to the median intake estimated using NHANES 2011–2012.

Suggested Citation:"8 Sensitivity Analysis for Food Package Nutrient, Food Group, and Cost Models." National Academies of Sciences, Engineering, and Medicine. 2017. Review of WIC Food Packages: Improving Balance and Choice: Final Report. Washington, DC: The National Academies Press. doi: 10.17226/23655.
×

Evaluation The change to all whole grain-rich breakfast cereals increases the level of zinc in all three packages even if redemption rates drop by 10 percent. If redemption continues at the current rate, whole grain rich cereals included in the food packages will also provide additional fiber. Even with a lower rate of redemption, the whole grain component of the food packages is increased. Whole grain-rich cereals are more expensive than refined grain cereals; therefore, costs increase with the change unless redemption is reduced from the current rate.

Adjusting the Cash Value Voucher

The sensitivity analysis tested the proposed increases to the cash value voucher (CVV) for the revised packages that were evaluated. The redemption rate for the CVV was decreased in the revised packages (from 77 to 75 percent), under the assumption that an increase in value may result in a slightly decreased overall rate of use. Higher redemption rates were also tested to evaluate the effects of increased redemption on the nutrients and food groups offered, as well as the cost effects. Finally, the effects of an increased CVV was tested for food package VII to evaluate the effect of moving the CVV value closer to one that would provide approximately 50 percent of fruit and vegetable recommendations for fully breastfeeding women (see Table 8-3).

Revised packages compared to the current packages Increasing the CVV generally increases the amount of fiber (a higher-priority nutrient for all population subgroups) and vitamin C (a lower-priority nutrient for some women) provided by the food packages. Total vegetables (higher-priority food group for all WIC participants), total fruit (a higher- or middle-priority food group for women), and whole fruit (a higher-priority food subgroup for all population subgroups) all increase under this assumption. For food package IV-B (for children), the HEI–2010 score for total vegetables increased at least 8 percent as long as the redemption rate was 75 percent or higher. Because median intake of total and whole fruit already achieves the maximum HEI–2010 scores for total and whole fruit, no change in these HEI components is expected. The cost for the revised food package CVV ranges from +$2.76 to +$17.76. The change in the overall average per-participant cost ranges from +$0.26 to +$1.03.

Alternatives to the revised packages compared to the current packages In addition to the nutrients noted above for the revised food package tests, magnesium, potassium, copper, vitamin B6, folate, and choline also increased as the dollar value of the CVV increased beyond that proposed for the revised food package. Increasing the redemption rate for food

Suggested Citation:"8 Sensitivity Analysis for Food Package Nutrient, Food Group, and Cost Models." National Academies of Sciences, Engineering, and Medicine. 2017. Review of WIC Food Packages: Improving Balance and Choice: Final Report. Washington, DC: The National Academies Press. doi: 10.17226/23655.
×

package IV-B (for children) by 5 percent, however, did not result in a large increase in nutrient level, although cost increased by $1.25 per participant. The results of sensitivity tests that adjust the amounts of the CVV are limited by the vegetables and fruits included in the model and the proportions of each that are selected. Participants who make different selections or choose, for example vegetables over fruits, will be provided with different nutrients and food groups than those indicated in the analysis. The cost change when redemption is increased to 85 percent ranged from +$4.02 to +$21.26, depending on the food package, but the range for the overall change in average per-participant food cost increased from +$0.70 to +$1.47. The set of tests described below evaluates a shift in the ratio of vegetables to fruits that were assumed for the revised package.

Evaluation The CVV in the revised packages increased the level of fiber and vitamin C in all packages tested, compared to the current food packages. Given that the CVV permits participants a large degree of flexibility in selecting vegetables and fruits, the specific nutrients and nutrient levels contributed by the CVV will vary. The effects on food package costs vary with the redemption rate because the total value of the CVV varies across packages. The substantially higher CVV in food package VII (fully breastfeeding women) has a much smaller proportional effect on the average per-participant food cost because only about 3 percent of participants receive food package VII.

Additional Tests on the CVV: Proportions of Vegetables to Fruits

The tests described above assumed a decreased redemption rate with no change in the ratio of vegetables and fruits with the higher CVV provided. Therefore, another set of tests was developed to evaluate the effect of changing the redemption rate, the dollar amounts of the CVV, and the ratio of vegetables to fruits purchased. In the revised packages, the proportion of vegetables to fruits was 33 to 67 percent, based on redemption data that was obtained from two states. For the purposes of the sensitivity analyses, this proportion was shifted to 50 percent vegetables and 50 percent fruits. The revised food package tests, although the same as those presented in Table 8-3, are included in Table 8-4 for reference but are not described.

Alternatives to the revised packages compared to the current packages Shifting the proportion of vegetables to fruits that are redeemed to 50 percent of each increased the copper in food packages IV-B (for children) and V-A (for pregnant women). In food package VII (for fully breastfeeding women), which includes a substantially higher revised CVV, the additional nutrients provided are similar to those provided in the revised package when shifting

Suggested Citation:"8 Sensitivity Analysis for Food Package Nutrient, Food Group, and Cost Models." National Academies of Sciences, Engineering, and Medicine. 2017. Review of WIC Food Packages: Improving Balance and Choice: Final Report. Washington, DC: The National Academies Press. doi: 10.17226/23655.
×

TABLE 8-3 Impact of Increasing the CVV on Nutrient and Food Group Food Package Profiles and on the HEI–2010 Scores Relative to the Current Food Packages for Children Ages 2 to Less Than 5 Years (IV-B), Pregnant Women (V-A), and Fully Breastfeeding Women (VII)a

Food Package Adjustments (Amount and Redemption Rate)b Nutrients Food Group(s)c HEI Scored Package Per-Participant Cost WIC Average Per-Participant Cost Appendix S Table Reference
IV-B Revised: +$4, 75% (+) fiber, vitamin C (+) total vegetables, total fruit, whole fruit (+) total vegetable +$2.82 +$1.03 S-8
Test 1: +$4, 65% (+) total fruit, whole fruit, total vegetables score — +$1.62 +$0.59 S-8
Test 2: +$4, 80% (+) fiber, copper, vitamin C (+) total vegetables, total fruit, whole fruit (+) total vegetable score +$3.24 +$1.25 S-8
Test 3: +$4, 85% (+) fiber, potassium, copper, vitamin C (+) total fruit, whole fruit, total vegetables (+) total vegetable score +$4.02 +$1.47 S-8
V-A Revised: +$4, 75% (+) fiber, vitamin C (+) total vegetables, total fruit, whole fruit NA +$2.76 +$0.26 S-9
Test 1: +$4, 65% (+) whole fruit, total vegetables NA +$1.26 +$0.12 S-9
Test 2: +$4, 80% (+) fiber, vitamin C (+) total vegetables, total fruit, whole fruit NA +$3.51 +$0.34 S-9
Test 3: +$4, 85% (+) fiber, copper, vitamin C (+) total fruit, whole fruit, total vegetables NA +$4.26 +$0.41 S-9
Suggested Citation:"8 Sensitivity Analysis for Food Package Nutrient, Food Group, and Cost Models." National Academies of Sciences, Engineering, and Medicine. 2017. Review of WIC Food Packages: Improving Balance and Choice: Final Report. Washington, DC: The National Academies Press. doi: 10.17226/23655.
×
VII Revised: +$24, 75% (+) fiber, magnesium, potassium, copper, vitamin C, thiamin, niacin, vitamin B6, folate, choline (+) total vegetables, total fruit, whole fruit NA +$17.76 +$0.58 S-10
Test 1: +$24, 85% (+) fiber, magnesium, potassium, copper, vitamin C, thiamin, niacin, vitamin B6, folate, choline (+) total fruit, whole fruit, total vegetables NA +$21.26 +$0.70 S-10
Test 2: +$9, 75% (+) fiber, potassium, copper, vitamin C, vitamin B6 (+) total vegetables, total fruit, whole fruit NA +$6.51 +$0.21 S-10
Test 3: +$34, 75% (+) fiber, magnesium, potassium, copper, vitamin C, thiamin, riboflavin, niacin, vitamin B6, folate, choline, vitamin A (+) total vegetables, total fruit, whole fruit NA +$25.26 +$0.83 S-10

NOTES: — = indicates that no changes were in the range of more than approximately ± 8%; (+) = increased amount (an increased amount for saturated fat, added sugars, and sodium is undesirable); CVV = cash value voucher; HEI = Healthy Eating Index–2010; NA = unable to calculate change in HEI score for any but food package IV-B. Changes to nutrients and vegetables/fruits are based on the committee’s assumptions applied about participant preferences for specific varieties of vegetables and fruits. Nutrient and food group composition of the food packages were based on the assumptions outlined in Appendix R.

a Notations for nutrients and food groups in the table represent changes of 8% or greater. Not all nutrients or food groups listed were identified in Chapter 5 as a priority for the target population subgroup.

b The adjustment is in reference to the current food package amounts.

c Food group noted corresponds to the appropriate food group or subgroup from the Dietary Guidelines for Americans.

d The committee created a tool to estimate the HEI for children ages 2 to less than 5 years considering the revised package change or test. To do this, the difference between the redeemed amounts of the HEI components for the current food package and the redeemed amounts of the HEI components for the test food package were added to the median intake estimated using NHANES 2011–2012.

Suggested Citation:"8 Sensitivity Analysis for Food Package Nutrient, Food Group, and Cost Models." National Academies of Sciences, Engineering, and Medicine. 2017. Review of WIC Food Packages: Improving Balance and Choice: Final Report. Washington, DC: The National Academies Press. doi: 10.17226/23655.
×

TABLE 8-4 Impact of Changes to Vegetable and Fruit Proportions on Nutrient and Food Group Food Package Profiles and on the HEI–2010 Scores Relative to the Current Food Packages for Children Ages 2 to Less Than 5 Years (IV-B), Pregnant Women (V-A), and Fully Breastfeeding Women (VII)a

Food Package Adjustments (Amount and Redemption Rate)b Nutrients Food Groupsc HEI Scored Package Per-Participant Cost WIC Average Per-Participant Cost Appendix S Table Reference
IV-B Revised: +$4, 75%, 33/67 vegetable/fruit (+) fiber, vitamin C (+) total fruit, whole fruit, total vegetables (+) total vegetable scoree +$2.82 +$1.03 S-11
Test 1: +$4, 75%, 50/50 vegetable/fruit (+) fiber, copper, vitamin C (+) whole fruit, total vegetables (+) total vegetable scoree +$2.82 +$1.03 S-11
V-A Revised: +$4, 75%, 33/67 vegetable/fruit (+) fiber, vitamin C (+) total fruit, whole fruit, total vegetables NA +$2.76 +$0.26 S-12
Test 1: +$4, 75%, 50/50 vegetable/fruit (+) fiber, copper, vitamin C (+) total vegetables NA +$2.76 +$0.26 S-12
Suggested Citation:"8 Sensitivity Analysis for Food Package Nutrient, Food Group, and Cost Models." National Academies of Sciences, Engineering, and Medicine. 2017. Review of WIC Food Packages: Improving Balance and Choice: Final Report. Washington, DC: The National Academies Press. doi: 10.17226/23655.
×
VII Revised: +$24, 75%, 33/67 vegetable/fruit (+) fiber, magnesium, potassium, copper, vitamin C, thiamin, niacin, vitamin B6, folate, choline (+) total fruit, whole fruit, total vegetables NA +$17.76 +$0.58 S-13
Test 1: +$24, 75%, 50/50 vegetable/fruit (+) fiber, magnesium, potassium, copper, vitamin C, thiamin, niacin, vitamin B6, folate, choline (+) total fruit, whole fruit, total vegetables NA +$17.76 +$0.58 S-13

NOTES: (+) = increased amount (an increased amount for saturated fat, added sugars, and sodium is undesirable); HEI = Healthy Eating Index–2010; NA = unable to calculate change in HEI score for any but food package IV-B. Nutrient and food group composition of the food packages were based on the assumptions outlined in Appendix R.

a Notations for nutrients and food groups in the table represent changes of 8% or greater. Not all nutrients or food groups listed were identified in Chapter 5 as a priority for the target population subgroup.

b The adjustment is in reference to the current food package amounts.

c Food group noted corresponds to the appropriate food group or subgroup from the Dietary Guidelines for Americans.

d The committee created a tool to estimate the HEI for children ages 2 to less than 5 years considering the revised package change or test. To do this, the difference between the redeemed amounts of the HEI components for the current food package and the redeemed amounts of the HEI components for the test food package were added to the median intake estimated using NHANES 2011–2012.

e No shifts in fruit scores were observed because the HEI scores for total and whole fruit are at the maximum level based on median intake.

Suggested Citation:"8 Sensitivity Analysis for Food Package Nutrient, Food Group, and Cost Models." National Academies of Sciences, Engineering, and Medicine. 2017. Review of WIC Food Packages: Improving Balance and Choice: Final Report. Washington, DC: The National Academies Press. doi: 10.17226/23655.
×

from 67 percent to 50 percent fruit. With a smaller CVV (such as for food packages IV-B and V-A), whole fruit (a higher-priority food subgroup for most WIC participants) increased compared to the current food packages. Similar to the previous tests of the higher CVV, the HEI–2010 score for total vegetables increased for food package IV-B. The shift to 50 percent vegetables does not affect the cost of the food packages because the costs applied for vegetables and fruits are approximately the same.2 The actual cost, however, will vary if different varieties of vegetables and fruits are selected by participants than those assumed in the analysis.

Evaluation For the higher CVV, shifting CVV redemption to an equal proportion of vegetables and fruits does not result in large shifts in the level of essential nutrients in the revised food packages. However, the food groups contributed by the packages do shift from total fruits to total vegetables with a corresponding increase in the vegetable component of the HEI–2010. Ultimately, the cost difference in shifting from fruits to vegetables depends on the varieties of vegetables and fruits selected by participants.

Trade-offs Between Juice and the Cash Value Voucher

In the model applied to generate the revised food packages in this report, monies saved from reductions in juice were used to increase the CVV in all food packages. Sensitivity tests were designed to determine the effects of changes to the combination of juice and the CVV, because both of these WIC food categories contribute to the total fruit food group (the CVV also contributes to total vegetables), and may provide similar nutrients. Additional tests were applied to lower the redemption rate for juice and to evaluate a scenario of no juice plus a further increase in the CVV (see Table 8-5).

Revised food packages compared to the current packages The trade-off of juice for an increased CVV increases the level of fiber, but decreases vitamin C (a lower-priority nutrient for some women). Total vegetables and whole fruit increase (both are higher-priority food groups for most WIC participants). However, because juice is less expensive than vegetables and whole fruit on a per serving basis, transferring the savings from a reduction in juice to an increase in the CVV results in an overall decrease in the amount of total fruit in the packages, although within food package VII ($35, for fully breastfeeding women) both total fruit and whole fruit increase with

__________________

2 Vegetables and fruits were selected for the model based on commonly redeemed varieties. The cost per cup-equivalent was determined based on Economic Research Service price data. See Appendix R for details.

Suggested Citation:"8 Sensitivity Analysis for Food Package Nutrient, Food Group, and Cost Models." National Academies of Sciences, Engineering, and Medicine. 2017. Review of WIC Food Packages: Improving Balance and Choice: Final Report. Washington, DC: The National Academies Press. doi: 10.17226/23655.
×

this change. The change in cost per food package ranges from +$0.29 to +$15.29 because of variance in the total cost of the increased CVV in the revised packages. The effects on the overall average per-participant food cost are narrower, ranging from +$0.03 to +$0.50.

Alternatives to the revised packages compared to the current packages Increasing the value of the CVV further in the revised package may compensate for the reduced amounts of vitamin C from juice (a lower-priority nutrient for some women) and result in increased levels of several other micronutrients, including magnesium, potassium, copper, thiamin, niacin, vitamin B6, folate, and choline. As was the case for the previous tests applied to the increased CVV, the HEI–2010 score for total vegetables increased for food package IV-B (for children). Total fruit scores did not decrease beyond the 8 percent threshold with the tests for reductions in juice. The change in cost for these tests ranges from +$0.77 to +$17.29 per food package, and from +$0.22 to +$0.57 per-participant overall.

Evaluation A cost-neutral shift from juice to the CVV increases the level of fiber and whole fruit, but decreases the amount of vitamin C and total fruit in the food packages. A further increase in the CVV may compensate for reduced vitamin C from juice and increase the level of other nutrients as well as increase total vegetables, total fruit, and whole fruit. Although the costs per food package for both the revised packages and additional tests vary widely, the effects on the overall average per-participant food costs are smaller because the largest increases in the CVV are for a package that represents approximately 3 percent of participants (fully breastfeeding women).

The Addition of Fish to Food Packages or Changes in Amounts of Fish

Fish is included in all revised food packages for children and women. This is a new food for several of the food packages because fish is currently only included in food package VII (for fully breastfeeding women). Therefore, several sensitivity tests were developed to evaluate the effect of including fish, as well as the effect of potential increases or decreases in redemption from the rate assumed for the revised packages (see Table 8-6).

Revised packages compared to the current packages Providing 10 ounces of fish every 3 months in the rotation did not result in changes to essential nutrients above the threshold of 8 percent, based on the redemption rate applied. A key nutrient in allowed fish, omega-3 fatty acids, was not evaluated because there is only an adequate intake (AI) for alpha-linolenic acid, the precursor to synthesis of eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), and readily available data on fish composition

Suggested Citation:"8 Sensitivity Analysis for Food Package Nutrient, Food Group, and Cost Models." National Academies of Sciences, Engineering, and Medicine. 2017. Review of WIC Food Packages: Improving Balance and Choice: Final Report. Washington, DC: The National Academies Press. doi: 10.17226/23655.
×

TABLE 8-5 Impact of Changes to Juice and the CVV Combined on Nutrient and Food Group Food Package Profiles and on the HEI–2010 Scores Relative to the Current Food Packages for Children Ages 2 to Less Than 5 Years (IV-B), Pregnant Women (V-A), and Fully Breastfeeding Women (VII)a

Food Package Adjustments (Amount and Redemption Rate)b Nutrients Food Group(s)c HEI Scored Package Per-Participant Cost WIC Average Per-Participant Cost Appendix S Table Reference
IV-B Revised: −64 oz, 78%; +$4 CVV (+) fiber
(−) vitamin C
(+) total vegetables, whole fruit
(−) total fruit
(+) total vegetable scoree +$0.87 +$0.32 S-14
Test 1: −64 oz 75%; +$4 CVV (+) fiber
(−) vitamin C
(+) total vegetables, whole fruit
(−) total fruit
(+) total vegetable scoree +$0.77 +$0.28 S-14
Test 2: −128 oz, +$18 CVV (+) fiber, copper, vitamin B6, choline,
(−) vitamin C
(+) total vegetables, whole fruit
(−) total fruit
(+) total vegetable scoree +$2.91 +$0.32 S-14
V-A Revised: −80 oz, +$4 CVV (+) fiber
(−) vitamin C
(+) total vegetables, whole fruit
(−) total fruit
NA +$0.29 +$0.03 S-15
Suggested Citation:"8 Sensitivity Analysis for Food Package Nutrient, Food Group, and Cost Models." National Academies of Sciences, Engineering, and Medicine. 2017. Review of WIC Food Packages: Improving Balance and Choice: Final Report. Washington, DC: The National Academies Press. doi: 10.17226/23655.
×
Test 1: −144 oz, +$10 CVV (+) fiber, copper, choline
(−) vitamin C
(+) total vegetables, whole fruit
(−) total fruit
NA +$2.29 +$0.22 S-15
VII Revised: −80 oz, +$24 CVV (+) fiber, magnesium, potassium, copper, vitamin C, thiamin, niacin, vitamin B6, folate, choline (+) total vegetables, total fruit, whole fruit NA +$15.29 +$0.50 S-16
Test 1: −144 oz, +$41 CVV (+) fiber, magnesium, potassium, copper, vitamin C, thiamin, niacin, vitamin B6, folate, choline, vitamin A (+) total vegetables, total fruit, whole fruit NA +$17.29 +$0.57 S-16

NOTES: (+) = increased amount (an increased amount for saturated fat, added sugars, and sodium is undesirable); (−) = decreased amount (a decreased amount for saturated fat, added sugars, and sodium is desirable); CVV = cash value voucher; HEI = Healthy Eating Index–2010; NA = unable to calculate change in HEI score for any but food package IV-B. Changes to nutrients and vegetables/fruits are based on the committee’s assumptions applied about participant preferences for specific varieties of vegetables and fruits. Nutrient and food group composition of the food packages were based on the assumptions outlined in Appendix R.

a Notations for nutrients and food groups in the table represent changes of 8% or greater. Not all nutrients or food groups listed were identified in Chapter 5 as a priority for the target population subgroup.

b The adjustment is in reference to the current food package amounts.

c Food group noted corresponds to the appropriate food group or subgroup from the Dietary Guidelines for Americans.

d The committee created a tool to estimate the HEI for children ages 2 to less than 5 years considering the revised package change or test. To do this, the difference between the redeemed amounts of the HEI components for the current food package and the redeemed amounts of the HEI components for the test food package were added to the median intake estimated using NHANES 2011–2012.

e No shifts in fruit scores were observed because the HEI scores for total and whole fruit are at the maximum level based on median intake.

Suggested Citation:"8 Sensitivity Analysis for Food Package Nutrient, Food Group, and Cost Models." National Academies of Sciences, Engineering, and Medicine. 2017. Review of WIC Food Packages: Improving Balance and Choice: Final Report. Washington, DC: The National Academies Press. doi: 10.17226/23655.
×

TABLE 8-6 Impact of Changes to Fish Redemption on Nutrient and Food Group Food Package Profiles and on the HEI–2010 Scores Relative to the Current Food Packages for Children Ages 2 to Less Than 5 Years (IV-B), Pregnant Women (V-A), and Fully Breastfeeding Women (VII)a

Food Package Adjustments (Amount and Redemption Rate)b Nutrients Food Groupsc HEI Scored Package Per-Participant Cost WIC Average Per-Participan Cost Appendix S t Table Reference
IV-B Revised: +10 oz every 3 months, 68% e (+) total protein, seafood (+) seafood and plant protein score +$0.46 +$0.16 S-17
Test 1: +10 oz every 3 months, 59% e (+) total protein, seafood (+) seafood and plant protein score +$0.40 +$0.14 S-17
Test 2: +10 oz every 3 months, 79% e (+) total protein, seafood (+) seafood and plant protein score +$0.53 +$0.19 S-17
V-A Revised: +10 oz every 3 months, 68% e (+) total protein, seafood NA +$0.46 +$0.04 S-18
Test 1: +10 oz every 3 months, 59% e (+) seafood NA +$0.40 +$0.04 S-18
Test 2: +10 oz every 3 months, 79% (+) seleniume (+) total protein, seafood NA +$0.53 +$0.05 S-18
Suggested Citation:"8 Sensitivity Analysis for Food Package Nutrient, Food Group, and Cost Models." National Academies of Sciences, Engineering, and Medicine. 2017. Review of WIC Food Packages: Improving Balance and Choice: Final Report. Washington, DC: The National Academies Press. doi: 10.17226/23655.
×
VII Revised: −10 oz per month, 68% (−) selenium, niacine (−) total protein, seafood NA −$1.47 −$0.05 S-19
Test 1: −10 oz per month, 59% (−) selenium, niacine (−) total protein, seafood NA −$1.83 −$0.06 S-19
Test 2: −10 oz per month, 79% e (−) total protein, seafood NA −$1.02 −$0.04 S-19

NOTES: — = indicates that no changes were in the range of more than approximately ± 8%; (+) = increased amount (an increased amount for saturated fat, added sugars, and sodium is undesirable); (−) = decreased amount (a decreased amount for saturated fat, added sugars, and sodium is desirable); HEI = Healthy Eating Index–2010; NA = unable to calculate change in HEI score for any but food package IV-B. Nutrient and food group composition of the food packages were based on the assumptions outlined in Appendix R.

a Notations for nutrients and food groups in the table represent changes of 8% or greater. Not all nutrients or food groups listed were identified in Chapter 5 as a priority for the target population subgroup.

b The adjustment is in reference to the current food package amounts.

c Food group noted corresponds to the appropriate food group or subgroup from the Dietary Guidelines for Americans. For current food packages in which no fish is provided, the seafood food group is noted as increasing.

d The committee created a tool to estimate the HEI for children ages 2 to less than 5 years considering the revised package change or test. To do this, the difference between the redeemed amounts of the HEI components for the current food package and the redeemed amounts of the HEI components for the test food package were added to the median intake estimated using NHANES 2011–2012.

e Authoritative guidance recommends inclusion of fish in the diet as a source of omega-3 fatty acids. However, the quantity provided could not be assessed because omega-3 fatty acids are not included in the USDA Standard Reference Database for nutrient composition of foods.

Suggested Citation:"8 Sensitivity Analysis for Food Package Nutrient, Food Group, and Cost Models." National Academies of Sciences, Engineering, and Medicine. 2017. Review of WIC Food Packages: Improving Balance and Choice: Final Report. Washington, DC: The National Academies Press. doi: 10.17226/23655.
×

are limited. Fish also provides niacin, the quantities of which decrease in the revised food package VII (in which the quantity of fish provided was reduced). As intended, provision of fish (a higher-priority food group for all WIC participants) adds the seafood food group to the food packages where it was previously not included. The addition of fish to food packages IV-B (for children) and V-A (for pregnant women) increases the package cost by $0.46. The average per-participant food cost is increased from $0.04 to $0.16. The reduction in fish in food package VII saves $1.47 for that package, and $0.05 for the average package.

Alternatives to the revised packages compared to the current packages For the food packages evaluated, the redemption rate for fish was both increased and decreased. At a higher rate of redemption (79 percent), the amount of selenium provided becomes more apparent. The HEI–2010 scores for seafood and plant protein increased for all tests conducted on food package IV-B. Increasing the redemption rate of fish in food packages IV-B and V-A increases the package costs by $0.53, but cost savings remain in food package VII because of the reduction from the current food package amount. For these tests, the change in the average per-participant food cost ranges from −$0.06 to +$0.19.

Evaluation Inasmuch as the amounts of fish added to some food packages are small (3 ounces per month in some cases), a large effect on nutrients provided by the food package does not occur. However, inclusion of fish allows the food packages to provide the seafood food group, and omega-3 fatty acids, the amount of which could not be estimated. The cost of adding fish per food package and for the average per-participant food package are relatively high considering the small amounts added to food packages IV-B and V-A.

Rotating Peanut Butter, Legumes, and Fish

In some of the revised food packages, peanut butter, legumes, and fish are rotated over a 3-month period. Sensitivity tests were developed to evaluate the possible effect on nutrients, food groups, and redemption (in the case that the rotation resulted in confusion for participants about which food is issued in a particular month) because this is a new concept (apart from the current choice of peanut butter or legumes in some packages). The rotations were also evaluated without fish to determine the effect of its inclusion or exclusion from the rotation on nutrients and food groups (see Table 8-7).

Revised packages compared to the current packages Changing to a rotation of peanut butter and legumes, and adding fish to food package IV-B (for

Suggested Citation:"8 Sensitivity Analysis for Food Package Nutrient, Food Group, and Cost Models." National Academies of Sciences, Engineering, and Medicine. 2017. Review of WIC Food Packages: Improving Balance and Choice: Final Report. Washington, DC: The National Academies Press. doi: 10.17226/23655.
×

children) did not change nutrient levels more than ±8 percent. For food package V-A (for pregnant women), this rotation reduced fiber (a higher-priority nutrient for all WIC participants), magnesium, copper, and niacin (lower priorities for some women) in the package, but it also reduced added sugars and saturated fat (higher-priority “nutrients to limit” for most WIC participants). Inclusion of fish expanded the food package coverage of the DGA food groups to include seafood (a higher-priority food group for all WIC participants). The rotation also resulted in a reduction in provision of total vegetables, specifically the vegetables subgroup of beans, and nuts, seeds, and soy. The rotation in the revised food packages changes the per package cost between −$0.64 and +$0.11. The effect on the per-participant average food cost ranges from −$0.06 and +$0.04.

Alternatives to the revised packages compared to the current packages Removing fish from the food package rotation did not result in any changes above the 8 percent threshold for nutrients in food package IV-B. The HEI–2010 scores, however, decreased by more than 8 percent for greens and beans in the revised package and for the additional tests, but the overall HEI–2010 score changed by less than 8 percent. Increasing redemption of legumes from 53 percent (the assumption in the revised packages) to 69 percent did not affect level of fiber and achieved a cost savings. The cost change incurred from the additional tests ranged from −$1.09 to +$0.37. The average per-participant cost ranged from −$0.13 to +$0.13.

Evaluation The rotation of peanut butter, legumes, and fish in the revised food packages potentially reduces the level of fiber, magnesium, copper, and niacin, but it also reduces the amount of saturated fat and added sugars in the food packages. Inclusion of fish in the rotation achieved the addition of the DGA seafood food group to the packages where it was previously not included. For food package IV-B, although the HEI–2010 scores for greens and beans and seafood and plant proteins decreases, the overall change in HEI–2010 scores does not exceed the 8 percent threshold. The rotation results in a net savings because of the reduction of the amounts of peanut butter and legumes, despite the cost of adding fish.

Jarred Infant Food Vegetables and Fruits

Food package II is provided to all infants (fully formula-fed, partially breastfed, or fully breastfed) ages 6 to less than 12 months. Quantities of jarred infant food vegetables and fruits are reduced in the revised food package II for fully breastfeeding infants. In addition, a CVV substitution for the jarred infant food vegetables and fruits is allowed for all infants who receive this package. Given these changes, tests were developed for

Suggested Citation:"8 Sensitivity Analysis for Food Package Nutrient, Food Group, and Cost Models." National Academies of Sciences, Engineering, and Medicine. 2017. Review of WIC Food Packages: Improving Balance and Choice: Final Report. Washington, DC: The National Academies Press. doi: 10.17226/23655.
×

TABLE 8-7 Impact of Changes to Amounts and Redemption in the Peanut Butter/Legumes/Fish Rotation on Nutrient and Food Group Food Package Profiles and on the HEI–2010 Scores Relative to the Current Food Packages for Children Ages 2 to Less Than 5 Years (IV-B) and Pregnant Women (V-A)a

Food Package Adjustments (Amount and Redemption Rate)b Nutrients Food Group(s)c HEI Scored Package Per-Participant Cost WIC Average Per-Participant Cost Appendix S Table Reference
IV-B Revised: −2.7 oz legumes/mo, 53%; −3 oz peanut butter/mo; +3.3 oz fish/mo (+) seafood
(−) total vegetables; beans; nuts, seeds, and soy
(−) greens and beans score +$0.11 +$0.04 S-20
Test 1: −2.7 oz legumes/mo, 53%; −3 oz peanut butter/mo; no fish (−) total vegetables; beans; total protein; nuts, seeds, and soy (−) greens and beans score; seafood and plant proteins score −$0.34 −$0.13 S-20
Test 2: −2.7 oz legumes/mo, 38%; −3 oz peanut butter/mo; +3.3 oz fish/mo (−) copper (+) seafood
(−) total vegetables; beans; nuts, seeds, and soy
(−) greens and beans score −$0.13 −$0.05 S-20
Test 3: −2.7 oz legumes/mo, 69%; −3 oz peanut butter/mo; +3.3 oz fish/mo (+) seafood
(−) beans; total protein; nuts, seeds, and soy
(−) greens and beans score +$0.37 +$0.13 S-20
V-A Revised: −5.3 oz legumes/mo, 53%; −12 oz peanut butter/mo; +3.3 oz fish/mo (−) fiber, magnesium, copper, niacin, added sugars, saturated fat (+) seafood
(−) total vegetables; beans; total protein; nuts, seeds, and soy
NA −$0.64 −$0.06 S-21
Suggested Citation:"8 Sensitivity Analysis for Food Package Nutrient, Food Group, and Cost Models." National Academies of Sciences, Engineering, and Medicine. 2017. Review of WIC Food Packages: Improving Balance and Choice: Final Report. Washington, DC: The National Academies Press. doi: 10.17226/23655.
×
Test 1: −5.3 oz legumes/mo, 53%; −12 oz peanut butter/mo; no fish (−) fiber, magnesium, copper, niacin, saturated fat, added sugars (−) total vegetables, beans, total protein, nuts, seeds, and soy NA −$1.09 −$0.10 S-21
Test 2: −5.3 oz legumes/ mo, 38%; −12 oz peanut butter/mo; +3.3 oz fish/mo (−) fiber, magnesium, copper, niacin, saturated fat, added sugars (+) seafood
(−) total vegetables, beans, total protein, nuts, seeds, and soy
NA −$1.02 −$0.10 S-21
Test 3: −5.3 oz legumes/ mo, 69%; −12 oz peanut butter/mo; +3.3 oz fish/mo (−) copper, saturated fat (+) seafood
(−) beans, total protein, nuts, seeds, and soy
NA −$0.25 −$0.02 S-21

NOTES: — = indicates that no changes were in the range of more than approximately ± 8%; (+) = increased amount (an increased amount for saturated fat, added sugars, and sodium is undesirable); (−) = decreased amount (a decreased amount for saturated fat, added sugars, and sodium is desirable); HEI = Healthy Eating Index–2010; NA = unable to calculate change in HEI score for any but food package IV-B. Nutrient and food group composition of the food packages were based on the assumptions outlined in Appendix R.

a Notations for nutrients and food groups in the table represent changes of 8% or greater. Not all nutrients or food groups listed were identified in Chapter 5 as a priority for the target population subgroup.

b The adjustment is in reference to the current food package amounts. Redemption rates are only noted if changed in the series of tests.

c Food group noted corresponds to the appropriate food group or subgroup from the Dietary Guidelines for Americans. For current food packages in which no fish is provided, the seafood food group is noted as increasing.

d The committee created a tool to estimate the HEI for children ages 2 to less than 5 years considering the revised package change or test. To do this, the difference between the redeemed amounts of the HEI components for the current food package and the redeemed amounts of the HEI components for the test food package were added to the median intake estimated using NHANES 2011–2012.

Suggested Citation:"8 Sensitivity Analysis for Food Package Nutrient, Food Group, and Cost Models." National Academies of Sciences, Engineering, and Medicine. 2017. Review of WIC Food Packages: Improving Balance and Choice: Final Report. Washington, DC: The National Academies Press. doi: 10.17226/23655.
×

the revised food package II (weighting the feeding modes by participation) and the substitution option. No nutrient changes greater or less than 8 percent were observed for the revised food package. Similarly, a test of a 50 percent substitution of the jarred foods with a CVV did not result in changes beyond the 8 percent threshold. The 50 percent CVV substitution decreased the package cost by $0.31 and decreased the average per-participant package cost by $0.04 (see Appendix S, Table S-22).

Shifts in Participation from Formula-Feeding to Partially Breastfeeding

In the revised food packages, a 5 percent shift in participants from a formula-feeding to partially breastfeeding dyad was incorporated. The overall change in the weighted average per-participant cost from the current set of packages increases less than 1 percent, including or excluding formula rebates (see Table 8-8). Shifting 8 percent of participants from formula to partially breastfeeding resulted in a change of the same magnitude, but at a cost-savings. Costs initially increased with the 5 percent shift in participants because postpartum women stay on the program after 6 months if they are partially breastfeeding. As a greater number of participants shift to partial breastfeeding, there is a cost savings, primarily because infant formula is expensive and less of it is provided.3

SUMMARY

In this chapter, results of the sensitivity analyses are presented and discussed. The sensitivity tests were applied to food packages IV-B, V-A, and VII, and assessed the degree to which changes to the quantities of foods and other assumptions applied in the committee’s food package model affect nutrients, food groups, and costs. The analyses conducted evaluated both major changes to the current food packages to create the revised food packages, as well as additional tests that altered quantities of food amounts in the packages and the assumptions applied to create the revised food packages. To summarize the effects for the various assumptions tested, the committee applied an 8 percent threshold as a potentially meaningful change. However, the degree to which the change observed can be considered meaningful is a function of the specific nutrient or food group, the target population group or subgroup, and the outcome of interest, as prioritized by USDA-FNS. The tables provided in Appendix S can serve as a detailed reference to support future regulatory decisions. The committee’s overall findings from this analysis are summarized below in Table 8-9.

__________________

3 See Appendix U for a description of the methodology applied for assessing shifts in participation.

Suggested Citation:"8 Sensitivity Analysis for Food Package Nutrient, Food Group, and Cost Models." National Academies of Sciences, Engineering, and Medicine. 2017. Review of WIC Food Packages: Improving Balance and Choice: Final Report. Washington, DC: The National Academies Press. doi: 10.17226/23655.
×

TABLE 8-8 Impact of Shifting Participation from Formula-Feeding to Partially Breastfeeding on Cost

Food Package Current Participation Revised: Shift 5% of FF to FF/BF Test 1: Shift 8% of FF to FF/BF
Cost Without Rebates ($) Cost with Rebates ($) Cost Without Rebates ($) Cost with Rebates ($) Cost Without Rebates ($) Cost with Rebates ($)
I (0 to <6 mo, FF, BF, FF/BF) 123.00 43.57 120.04 42.52 118.26 41.89
II (6 to <12 mo, FF, BF, FF/BF) 115.37 51.37 113.28 50.63 112.02 50.19
Average food package (I–VII) 53.45 37.28 52.98 37.34 52.68 37.24
Average change from current −0.46 +0.06 −0.77 −0.03
Average change from current (%) −0.87 +0.16 −1.44 −0.09

NOTES: BF = breastfed; FF = fully formula-fed; FF/BF = partially breastfed; FP = food package.

Suggested Citation:"8 Sensitivity Analysis for Food Package Nutrient, Food Group, and Cost Models." National Academies of Sciences, Engineering, and Medicine. 2017. Review of WIC Food Packages: Improving Balance and Choice: Final Report. Washington, DC: The National Academies Press. doi: 10.17226/23655.
×

TABLE 8-9 Sensitivity Testing of Changes and Assumptions in the Revised Food Packages: Overall Findings and Conclusions

Aspect of the Revised Food Packages Tested in the Sensitivity Analysis Finding(s) and Conclusion(s)
Overall magnitude of changes observed In most cases, the change to nutrient amounts in the revised package is less than 8% of the amount in the current package. Exceptions are cases in which larger reductions in milk or larger increases in the CVV are made. For food groups, larger proportional changes are observed, primarily due to reductions in legumes and peanut butter, and the increase of the CVV. In parallel, the estimated HEI–2010 sub-scores for children receiving food package IV-B generally change 8% or more from the current HEI–2010 score in the direction of the food group change. However, the overall HEI–2010 score changes less than 1%.
Changes in substitutions within food categories The nutrients provided and the costs of the food packages depend on participants’ selection among the options offered such as their selection of dairy substitution options.
Shift in funds from juice to the CVV Shifting funds from juice to the CVV increases fiber in the food packages by at least 8%, but also decreases potassium and vitamin C by at least 8% unless additional funds are added to the CVV. The nutrients provided through redemption of the CVV ultimately depend on the participants’ selection of specific vegetables and fruits.
Change to all whole grain-rich breakfast cereals If cereals in the revised food package are redeemed at the current rate (instead of at a reduced rate), the change to whole grain-rich cereals increases provision of several micronutrients and whole grains in comparison to the current food package; however, the cost of the whole grains cereals is higher.
Addition or reduction of fish Fish is a relatively expensive component of the food packages and changes in amounts affect the package costs. The inclusion of fish increases the contribution of the food packages to the seafood food group. Fish also provides omega-3 fatty acids, but the lack of a DRI and readily accessible composition data limited the committee’s ability to conduct a quantitative assessment.
Effects on overall program costs for food The effects on overall program costs for food (measured through the average food cost per person) depend on the proportion of participants represented by the changed food package. Of the packages evaluated, changes to food package IV-B (for children ages 2 to less than 5 years) have the largest proportional effect on overall program costs.

NOTES: CVV = cash value voucher; DRI = Dietary Reference Intake; HEI–2010 = Healthy Eating Index–2010.

Suggested Citation:"8 Sensitivity Analysis for Food Package Nutrient, Food Group, and Cost Models." National Academies of Sciences, Engineering, and Medicine. 2017. Review of WIC Food Packages: Improving Balance and Choice: Final Report. Washington, DC: The National Academies Press. doi: 10.17226/23655.
×

REFERENCES

Fung, E. B., L. D. Ritchie, B. H. Walker, G. Gildengorin, and P. B. Crawford. 2010. Randomized, controlled trial to examine the impact of providing yogurt to women enrolled in WIC. Journal of Nutrition Education and Behavior 42(3 Suppl):S22–S29.

USDA/ARS (U.S. Department of Agriculture/Agricultural Research Service). 2014. Food Patterns Equivalents Database 2011-12: Methodology and user guide. http://www.ars.usda.gov/SP2UserFiles/Place/80400530/pdf/fped/FPED_1112.pdf (accessed December 20, 2016).

USDA/ARS. 2016. USDA National Nutrient Database for Standard Reference, Release 28. Beltsville, MD: USDA/ARS. https://ndb.nal.usda.gov/ndb (accessed September 14, 2016).

USDA/HHS (U.S. Department of Agriculture/U.S. Department of Health and Human Services). 2016. Dietary Guidelines for Americans 2015–2020. Washington, DC: U.S. Government Printing Office. https://health.gov/dietaryguidelines/2015 (accessed August 29, 2016).

Suggested Citation:"8 Sensitivity Analysis for Food Package Nutrient, Food Group, and Cost Models." National Academies of Sciences, Engineering, and Medicine. 2017. Review of WIC Food Packages: Improving Balance and Choice: Final Report. Washington, DC: The National Academies Press. doi: 10.17226/23655.
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The Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) began 40 years ago as a pilot program and has since grown to serve over 8 million pregnant women, and mothers of and their infants and young children. Today the program serves more than a quarter of the pregnant women and half of the infants in the United States, at an annual cost of about $6.2 billion. Through its contribution to the nutritional needs of pregnant, breastfeeding, and post-partum women; infants; and children under 5 years of age; this federally supported nutrition assistance program is integral to meeting national nutrition policy goals for a significant portion of the U.S. population.

To assure the continued success of the WIC, Congress mandated that the Food and Nutrition Service of the U.S. Department of Agriculture (USDA) reevaluate the program's food packages every 10 years. In 2014, the USDA asked the Institute of Medicine to undertake this reevaluation to ensure continued alignment with the goals of the Dietary Guidelines for Americans. In this third report, the committee provides its final analyses, recommendations, and the supporting rationale.

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