United States

Department of

Agriculture

Economic 

Research 

Service

Food Assistance

and Nutrition

Research Report

Number 27

Victor Oliveira

Elizabeth Racine

Jennifer Olmsted

Linda M. Ghelfi

The WIC Program

Background, Trends,

and Issues
The WIC Program: Background, Trends, and Issues. By Victor Oliveira, Elizabeth

Racine, Jennifer Olmsted, and Linda M. Ghelfi, Food and Rural Economics Division,

Economic Research Service, U.S. Department of Agriculture. Food Assistance and

Nutrition Research Report No. 27. 

Abstract

The mission of the Special Supplemental Nutrition Program for Women, Infants, and

Children (WIC) is to safeguard the health of low-income women, infants, and children

up to age 5 who are at nutritional risk. WIC provides nutritious foods to supplement

diets, nutrition education, and referrals to health care and other social services.

Administered by USDA’s Food and Nutrition Service (FNS), the program has grown

rapidly since its establishment in 1972, and is now one of the central components of

the Nation’s food and nutrition assistance system. Almost half of all infants and about

one-quarter of all children 1-4 years of age in the United States now participate in the

program. Federal program costs were almost $4 billion in fiscal 2000, making WIC

the country’s third-largest food assistance program in terms of total expenditures. WIC

accounts for almost 12 percent of total Federal expenditures for food and nutrition

assistance. This report presents comprehensive background information on the WIC

program—how it works, its history, program trends, and the characteristics of the population it serves. It also examines issues related to program outcomes and administration. How the WIC community responds to these issues may have a large impact on

future program operations. 

Washington, DC 20036-5831 September 2002
Contents

Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .iii

Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

Chapter I. Overview of the WIC Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

Participant Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2

Participant Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3

Food Delivery Systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4

Administration of WIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

Priority System . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5

Cost-Containment Measures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .6

Chapter II. History of the WIC Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

Legislative and Regulatory History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7

Trends in Participation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .11

Trends in Program Costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12

Chapter III. Characteristics of WIC Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .13

Chapter IV. Outcome-Based Issues in WIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

WIC’s Effect on the Health of Participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .15

WIC and Breastfeeding Rates . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

WIC and Childhood Obesity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18

WIC’s Nutrition Education and Health Care Referral Programs . . . . . . . . . . . . . . . . . . . . . .20

Impact of the WIC Farmers’ Market Nutrition Program . . . . . . . . . . . . . . . . . . . . . . . . . . . .21

Chapter V. Administrative Issues in WIC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23

The WIC Food Package . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .23

WIC Eligibility Standards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .24

Access and Participation Issues . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .26

Estimating WIC Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27

Assessment of WIC’s Cost-Containment Practices . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .29

Fraud and Abuse in the WIC Program . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30

Chapter VI. Conclusions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33

References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .34

Appendix—Ongoing WIC-Related Research Funded by the Economic 

Research Service and the Food and Nutrition Service . . . . . . . . . . . . . . . . . . . . . . . . . . . .38

ii  The WIC Program: Background, Trends, and Issues/FANRR-27 Economic Research Service/USDA
Summary

The mission of the Special Supplemental Nutrition Program for Women, Infants, and

Children (WIC) is to safeguard the health of low-income women, infants, and children

up to age 5 who are at risk for poor nutrition. WIC provides nutritious foods to supplement diets, nutrition education, and referrals to health care and other social services.

Administered by USDA’s Food and Nutrition Service (FNS), the program is available

in each State, the District of Columbia, 33 Indian Tribal Organizations, Puerto Rico,

the Virgin Islands, American Samoa, and Guam. 

WIC is one of the central components of the Nation’s food assistance system. Almost

half of all infants and about one-quarter of all children 1-4 years of age in the United

States now participate in the program. Federal program costs were almost $4 billion in

fiscal 2000, making WIC the country’s third-largest food assistance program in terms

of total expenditures. WIC accounts for almost 12 percent of total Federal expenditures for food and nutrition assistance. 

WIC was created as a 2-year pilot program in 1972 by an amendment to the Child

Nutrition Act of 1966 and was made permanent in 1975. The program was established

during a time of growing public concern about malnutrition among low-income mothers and children. WIC is based on the premise that early intervention programs during

critical times of growth and development can help prevent future medical and developmental problems. Since its inception, the number of participants in the program has

expanded dramatically, from an average 88,000 participants per month in 1974 to an

average 7.2 million in 2000. Strong congressional support, generated by various evaluations that found WIC to have high rates of return for its investment, resulted in

increased funding for WIC, which, along with effective cost-containment practices,

allowed more people to participate in the program. Legislative and regulatory actions

and Federal/State/local partnerships that encouraged State innovations such as infant

formula rebates have helped shape and refine the program. In recent years, participation in WIC has leveled off, as appropriations for WIC have stabilized at what is

believed to be near full-funding levels. 

As a gateway through which many low-income families enter the public health system,

WIC reaches a large number of this Nation’s infants and children. Therefore, having

the most effective WIC program possible can have an important influence on the

health of America. Issues have been raised about the impact of the WIC program.

These include WIC’s effect on breastfeeding rates, prevalence of childhood obesity,

and the health of participating infants, children, and mothers. 

In addition to issues relating to WIC’s impact on the health of program participants,

numerous issues are associated with administering a program of WIC’s size and complexity. Issues related to the composition of the WIC food package, cost-containment

practices, program accessibility, eligibility standards, and reduction of fraud and abuse

in the program, directly affect the women, infants, and children who participate in the

program. Other groups, including food retailers, infant formula manufacturers, and

farmers, are indirectly affected.

While some of these issues have been addressed in the literature, others have not.

Additional research to determine the optimal method of operating the WIC program to

meet the needs of program participants given resource constraints will help shed light

on many of the issues currently facing the WIC program. 

Economic Research Service/USDA The WIC Program: Background, Trends, and Issues/FANRR-27  iii
Introduction

The mission of the Special Supplemental Nutrition

Program for Women, Infants, and Children (WIC) is to

safeguard the health of low-income women, infants, and

children up to age 5 who are at nutritional risk, by providing nutritious foods to supplement diets, nutrition

education, and referrals to health care and other social

services. WIC is based on the premise that early intervention programs during critical times of growth and

development can help prevent future medical and developmental problems. Administered by USDA’s Food and

Nutrition Service (FNS), the program provides grants for

supplemental foods, nutrition services, and administration to 88 WIC State agencies, including the 50 States,

the District of Columbia, Guam, the U.S. Virgin Islands,

American Samoa, the Commonwealth of Puerto Rico,

and 33 Indian Tribal Organizations. 

Since its establishment in 1972, WIC has grown rapidly while becoming one of the central components of

the Nation’s food assistance system. In fiscal 2000,

WIC served an average of 7.2 million participants per

month (USDA, 2001c). Almost half of all infants and

about one-quarter of all children 1-4 years of age in

the United States now participate in the program.

Federal program costs totaled almost $4 billion in fiscal 2000, making WIC the country’s third-largest food

and nutrition assistance program in terms of total

expenditures, trailing only the Food Stamp Program

($17.1 billion) and the National School Lunch

Program ($6.1 billion) (USDA, 2001c). WIC accounts

for almost 12 percent of the total Federal Government

expenditures for food and nutrition assistance. 

WIC experienced many significant changes as it

evolved into the current program. As a mature program, it continues to face a number of issues. How the

WIC community responds to these issues may have a

large impact on the program’s future operation. 

This report has two primary objectives. The first is to

present comprehensive background information on the

WIC program, specifically how it works, its history,

program trends, and the characteristics of the population it serves. The second is to examine a number of

issues currently facing the program, specifically those

related to program outcomes and program administration. In addition, descriptions of ongoing WIC-related

research being conducted by USDA’s Economic

Research Service (ERS) and Food and Nutrition

Service (FNS) are presented in the appendix.

Economic Research Service/USDA The WIC Program: Background, Trends, and Issues/FANRR-27  1

The WIC Program

Background, Trends, and Issues

Victor Oliveira

Elizabeth Racine

Jennifer Olmsted

Linda M. Ghelfi
WIC is a large and complex program that supplies a

package of benefits to a highly targeted group of participants who must meet a number of eligibility

requirements. Administratively, WIC operates at three

levels—Federal, State, and local. WIC is not an entitlement program and the number of people served by the

program may be limited by funding levels established

by Congress. Cost-containment practices play a major

role in increasing the number of participants the WIC

program can serve. 

Participant Eligibility

To qualify for WIC, applicants must meet categorical,

residential, income, and nutrition risk eligibility

requirements. 

(1) Categorical eligibility. To participate in the

WIC program, a person must be:

• A pregnant woman (includes women up to 6

weeks postpartum),

• A nonbreastfeeding woman up to 6 months

postpartum,

• A breastfeeding woman up to 1 year 

postpartum,

• An infant under 1 year of age, or 

• A child up to his/her fifth birthday. 

(2) Residential eligibility. WIC applicants must

reside within the State where they establish

eligibility and receive benefits. 

(3) Income eligibility. The family income of WIC

applicants must meet specified guidelines.1 All

WIC State agencies currently set the income

cutoff at the maximum 185 percent of the

Poverty Income Guidelines ($32,653 for a

family of four in July 2001). Applicants who

participate or who have certain family members who participate in the Food Stamp,

Medicaid, or Temporary Assistance for Needy

Families (TANF) programs, are adjunctively

income eligible, that is, they are deemed to

meet the income eligible criteria automatically.2 (TANF in 1997 replaced the Aid to

Families with Dependent Children program

(AFDC).) In addition, State agencies have the

option to deem individuals automatically

income eligible if they participate in other

State-administered programs that use income

guidelines at or below 185 percent of the

Poverty Income Guidelines and routinely

require income documentation. 

(4) Nutrition risk. Applicants must be at nutrition

risk, as determined by a health professional

such as a physician, nutritionist, or nurse.

Federal regulations recognize five major types

of nutrition risk for WIC eligibility: (1) detrimental or abnormal nutritional conditions

detectable by biochemical or anthropometric

measurements (such as anemia, low maternal

weight gain, or inadequate growth in children);

(2) other documented nutritionally related medical conditions (such as nutrient deficiency diseases, some specific obstetrical risks, or gestational diabetes); (3) dietary deficiencies that

impair or endanger health (such as highly

restrictive diets, inadequate diet, or inappropriate infant feeding); (4) conditions that directly

affect the nutritional health of a person, including alcoholism or drug abuse; and (5) conditions that predispose persons to inadequate

nutritional patterns or nutritionally related

medical conditions, including but not limited

to, homelessness and migrancy (7 CFR 246.2). 

2  The WIC Program: Background, Trends, and Issues/FANRR-27 Economic Research Service/USDA

Chapter 1

Overview of the WIC Program

1WIC regulations state that the maximum allowable family

gross income (i.e., before taxes are withheld) must not exceed the

guidelines for reduced-price school meals—185 percent of the

U.S. Poverty Income Guidelines (7 CFR 246.7). State agencies

may set the income guidelines equal to State or local guidelines

for free or reduced-price health care as long as they are equal to or

less than 185 percent of the poverty guidelines and not less than

100 percent of the poverty guidelines.

2In April 1998, over half of all WIC participants also participated in at least one of these three programs (Bartlett et al., 2000).
WIC participants are typically eligible to receive benefits for 6-month periods; they then must be recertified

in order to continue to receive benefits. However, pregnant women are certified for the duration of their pregnancy and up to 6 weeks postpartum, and most infants

are certified up to their first birthday. 

Participant Benefits

The WIC program offers three types of benefits to all

participants free of charge: a supplemental food package, nutrition education, and referrals to health care

and social services. 

Supplemental food package. WIC provides participants with supplemental foods that are high in nutrients frequently lacking in their diets. Such a lack may

result in adverse health consequences. The types of

foods included in the WIC food package are chosen

for their broad cultural and ethnic appeal, commercial

availability, versatility in preparation and use, and

administrative feasibility (USDA, 1997). The food

package is supplemental; it is not intended to meet the

total nutritional needs of the participants. There are

seven different food packages depending on the category of the recipient: (1) infants through 3 months, (2)

infants 4 through 12 months, (3) children or women

with special dietary needs, (4) children 1 to 5 years

old, (5) pregnant and breastfeeding women (basic),

(6) nonbreastfeeding postpartum women, and (7)

breastfeeding women (enhanced). WIC food packages

include combinations of the following foods: iron-fortified infant formula; iron-fortified infant and adult

cereal; vitamin C-rich fruit and/or vegetable juice;

eggs; milk; cheese; and peanut butter and/or dried

beans or peas, as shown in table 1. Special infant formulas and certain medical foods may also be provided

by the WIC food package when prescribed by a physician or health professional for a specific medical conEconomic Research Service/USDA The WIC Program: Background, Trends, and Issues/FANRR-27  3

Table 1—WIC food packages’ maximum monthly allowances

WIC food packages

I II III IV V VI VII

Infants Infants Children/ Children Pregnant & Nonbreastfeeding Breastfeeding

0-3 4-12 women with 1-5 years breastfeeding postpartum women

months months special dietary women women enhanced

Food needs package1

Infant formula 

(concentrated 

liquid)2 403 fl oz 403 fl oz 403 fl oz3

Juice (reconstituted

frozen)4 96 fl oz5 144 fl oz 288 fl oz 288 fl oz 192 fl oz 336 fl oz

Infant cereal 24 oz

Cereal

(hot or cold) 36 oz 36 oz 36 oz 36 oz 36 oz

Milk 24 qt 28 qt 24 qt 28 qt

Cheese6 1 lb

Eggs7 2-21⁄2 2-21⁄2 2-21⁄2 2-21⁄2 

dozen dozen dozen dozen

Dried beans/peas 1 lb 1 lb 1 lb 

and/or peanut or or and 

butter8 18 oz 18 oz 18 oz

Tuna (canned) 26 oz

Carrots (fresh)9 2 lb

1Available to breastfeeding women whose infants do not receive formula from the WIC program.

2Powdered or ready-to-feed formula may be substituted at the following rates: 8 lb powdered per 403 fl oz concentrated liquid; and 26 fl oz ready-to-feed per 13 fl

oz concentrated liquid.

3Additional formula may be available up to 52 fl oz concentrated liquid or 1 lb powered or 104 fl oz ready-to-feed.

4Single strength juice may be substituted at a rate of 92 fl oz per 96 fl oz reconstituted frozen.

5Infant juice may be substituted for adult juice at the rate of 63 fl oz per 92 fl oz single strength adult juice.

6A choice of various forms of milks and cheeses may be available. Cheese may be substituted for fluid whole milk at the rate of 1 lb per 3 qt, with a 4-lb maximum.

Additional cheese may be issued in cases of lactose intolerance.

7Dried egg mix may be substituted at the rate of 1.5 lb per 2 dozen fresh eggs; or 2 lb per 21⁄2 dozen fresh eggs.

81 lb of dry beans/peas or 18 oz of peanut butter.

9Frozen carrots may be substituted at the rate of 1 lb per 1 lb fresh; or canned carrots at the rate of 16-20 oz canned per 1 lb fresh.

Source: USDA, 1997.
dition. Packages are tailored to the specific needs of

each participant category. For example, breastfeeding

women whose infants do not receive infant formula

from WIC can receive an enhanced food package that

includes canned tuna and carrots in addition to other

WIC foods. 

WIC regulations specify the maximum quantities of

supplemental foods that may be prescribed to WIC

participants (7 CFR 246.10). The authorized maximum

monthly allowances of all WIC foods must be made

available to participants if medically and nutritionally

warranted. Local WIC agencies may tailor an individual’s food package based upon a participant’s nutritional or health status, their nutrition risk factors, and

food restrictions, intolerances, and preferences.3

Nutrition education. WIC makes nutrition education

available to all participants (or to the parents or caretakers of infant or child participants). WIC regulations

state that nutrition education should be designed to

achieve two broad goals: (1) stress the relationship

between proper nutrition and good health, and raise

awareness about the dangers of using drugs and other

harmful substances, and (2) assist the nutritionally atrisk individual in achieving a positive change in food

habits, resulting in improved nutritional status and in

the prevention of nutrition-related problems through

the optimal use of the supplemental foods and other

nutritious foods (7 CFR 246.11). Local WIC agencies

are required to offer participants at least two nutrition

education sessions during each 6-month period in

either an individual or group setting. Individuals who

do not attend the nutrition education activities are not

denied the WIC food package.

Referrals to health care and social services. WIC was

designed to serve as an adjunct to good health care during critical times of growth and development. Local WIC

agencies assist WIC participants in obtaining health care

and social services (such as the Food Stamp Program,

Medicaid, immunization programs, etc.) either through

onsite health services or referrals to other agencies. 

Food Delivery Systems

To provide program participants with supplemental

food packages, the State agencies may use three types

of food delivery systems (or any combination of the

three):

(1) Retail—Participants obtain supplemental food

by exchanging a food instrument at authorized

retail outlets. 

(2) Home delivery—Supplemental food is delivered to the participant’s home.

(3) Direct distribution—Participants pick up supplemental food from storage facilities operated

by the State or local agency.

In both home-delivery and direct-distribution food

delivery systems, WIC State agencies may purchase

the supplemental food in bulk lots and take advantage

of discounts available to them. However, most State

agencies have found these systems to be infeasible due

to the costs associated with administering the program

or because of its impact on participants (USDA, 1991).

As a result, most participants receive their supplemental foods via retail food delivery systems.4

WIC State agencies provide food instruments (e.g.,

checks or vouchers) to participants who exchange

them for supplemental foods at authorized retail outlets. The food instrument specifies the type and quantity of supplemental foods that can be purchased. Most

participants periodically pick up their food instruments

in person at the local agency or clinic every 1, 2, or 3

months.5 However, State agencies may issue the food

instrument through alternative means, such as mailing

or electronic benefit transfer (EBT).6

Only vendors authorized by the State agency may

accept food instruments. Currently, approximately

48,000 vendors are authorized by the WIC program

nationwide. Vendors must charge competitive prices for

supplemental foods and cannot collect sales tax on

WIC food purchases. 

4  The WIC Program: Background, Trends, and Issues/FANRR-27 Economic Research Service/USDA

3With the approval of the Department, State agencies may substitute different foods providing the nutritional equivalent of foods

prescribed by the Secretary, to allow for different cultural eating

patterns (7 CFR 246.10).

4Vermont uses a home delivery system while Mississippi and

parts of Chicago, IL, use direct distribution. All other States currently use a retail food delivery system. 

5WIC regulations state that no more than a 3-month supply of

food instruments may be issued to any participant at one time (7

CFR 246.12).

6EBT is an electronic process that replaces the paper WIC food

instrument. It allows WIC food prescriptions to be authorized to a

participant account, which is accessed electronically during the

checkout process at an authorized retailer point of sale, where

redeemed WIC food benefits are electronically reconciled against

the available food balance.
Administration of WIC

WIC operates through a Federal/State/local partnership. FNS provides cash grants for program nutrition

services and administration and for food benefits to 88

WIC State agencies, including Washington DC, U.S.

territories, and Indian Tribal Organizations.7

State agencies are responsible for program operations

within their jurisdictions. They contract with about

2,000 local WIC sponsoring agencies, mostly State

and county health departments, but also some public

and private nonprofit health or human service agencies. The WIC State agencies allocate funds to them,

negotiate rebate contracts with manufacturers of infant

formula, and provide assistance to local agencies with

respect to program operations.8

The local WIC sponsoring agencies provide services to

WIC participants either directly, or through almost

10,000 local service sites or clinics, including county

health departments, hospitals, mobile vans, community

centers, and schools. Local WIC clinics certify applicants, provide nutrition education, make referrals to

health care and other social services, and distribute

food vouchers to be used at participating retail stores. 

WIC is funded primarily by Federal appropriations

with no requirement for State matching funds, although

some States use their own funds to supplement the

Federal grant.9

The Federal grants to the WIC State agencies are divided into food grants and nutrition services and administration (NSA) grants.10 Food grants cover the cost of

the supplemental food while NSA grants cover the cost

of certifying participants, determining nutrition risks,

providing outreach and nutrition education services,

breastfeeding promotion, printing food instruments, and

administering the food delivery system (U.S. General

Accounting Office, 1999).11 At least one-sixth of a

State’s NSA expenditures must be used for nutrition

education, and an additional portion of NSA funds

must be used for breastfeeding promotion and support. 

Priority System

WIC is a discretionary grant program funded by

appropriations law on an annual basis; therefore, the

number of participants that can be served each year

depends upon the annual appropriation and the cost of

operating the program.12 The program provides services to as many eligible people as funding allows.

Because WIC may not be able to serve all eligible persons, WIC uses a seven-point priority system in order

to ensure that those persons at the greatest nutrition

risk receive program benefits (table 2). In general, priority is given to persons demonstrating medically

based nutrition risks over dietary-based nutrition risks,

to pregnant and breastfeeding women and all infants

over children, and to children over postpartum women.

Expansion of the WIC program during the 1990s

allowed a greater number of lower priority applicants

to participate and the role of the seven-point priority

system in allocating available program slots among

applicants decreased in importance relative to previous

years when program funds were more limited.

Anecdotal evidence suggests that in recent years nearly everyone who was eligible and who applied for the

program has been able to participate. 

Economic Research Service/USDA The WIC Program: Background, Trends, and Issues/FANRR-27  5

7In addition, FNS issues regulations, monitors compliance with

these regulations, provides technical assistance to the State agencies, and conducts studies of program operation and compliance.

8Most of the WIC State-level agencies retain a portion of the

funds they receive from USDA for costs incurred for State-level

program operations. However, some State agencies, including most

of the Indian Tribal Organizations, operate WIC without delegating

authority to local agencies (U.S. General Accounting Office,

2000).

9According to the U.S. General Accounting Office (2000), 11 of

the 55 State-level WIC agencies (including the 50 States, the

District of Columbia, American Samoa, the Commonwealth of

Puerto Rico, Guam, and the U.S. Virgin Islands, but excluding

Indian Tribal Organizations) reported that their State government

contributed funds (totaling $38 million) for nutrition services and

administration in fiscal year 1998 (States may also provide funds

for food). In addition, some local agencies and Indian Tribal

Organizations received non-Federal funds for nutrition services

and administration. Some State-level WIC agencies, Indian tribal

organizations, and local WIC agencies also received in-kind contributions from non-Federal sources. 

10Costs to the Federal Government for WIC totaled $3.9 billion

in fiscal 1999, of which about 73 percent was for food and 27 percent was for nutrition services and administration (USDA, 1999d).

11The major expense covered by NSA grants is staff salary. 

12In contrast, USDA’s Food Stamp Program is an entitlement

program whereby everyone who meets the eligibility criteria may

receive benefits if they so choose.
Cost-Containment Measures 

Since 1989, Federal law has required that WIC State

agencies enter into cost-containment contracts for the

purchase of infant formula used in WIC.13 Generally, a

State agency awards a contract to a manufacturer of

infant formula for the exclusive right to sell its product

to WIC participants. These sole-source contracts are

awarded on the basis of competitive bids: the firm

offering the lowest net wholesale cost wins the WIC

contract.14 The contract-winning manufacturer is then

billed by the WIC State agencies for rebates on all

infant formula purchased by WIC participants with

vouchers at authorized retail outlets. Any savings from

cost containment accrue to the food portion of the

WIC grant, thereby enabling more persons to be

served. In fiscal year 2001, WIC is projected to receive

almost $1.5 billion from infant formula rebates, an

amount that supports 28 percent of all WIC participants (USDA, 2000b).

The WIC State agencies use a variety of cost-containment practices in addition to infant formula rebates.

Some State agencies have instituted rebate systems for

other foods, such as infant cereal and infant fruit

juice, but their savings are much smaller than for

infant formula.15 Other cost-containment practices

used by some WIC State agencies include limiting

WIC food selections to the lowest cost brand, limiting

the types and package sizes of WIC foods, restricting

the number of vendors, and ensuring that the prices

vendors charge for WIC foods are competitive (U.S.

General Accounting Office, 1997a). The average cost

of the monthly WIC food package in 1998 was $47.03

before rebates and $31.76 after all rebates (Bartlett et

al., 2000).

6  The WIC Program: Background, Trends, and Issues/FANRR-27 Economic Research Service/USDA

Table 2—WIC nutritional risk criteria system 

Priority Description

I Pregnant women, breastfeeding women, and infants at nutritional risk as demonstrated by hematological or anthropometric measurements, or other documented nutritionally related medical conditions which demonstrate the need

for supplemental foods.

II Except those infants who qualify for Priority I, infants up to 6 months of age of program participants who participated during pregnancy, and infants up to 6 months of age born of women who were not program participants during

pregnancy but whose medical records document that they were at nutritional risk during pregnancy due to nutritional conditions detectable by biochemical or anthropometric measurements or other documented nutritionally

related medical conditions which demonstrated the person’s need for supplemental foods.

III Children at nutritional risk as demonstrated by hematological or anthropometric measurements or other documented medical conditions which demonstrate the child’s need for supplemental foods.

IV Pregnant women, breastfeeding women, and infants at nutritional risk because of an inadequate dietary pattern.

V Children at nutritional risk because of an inadequate dietary pattern.

VI Postpartum women at nutritional risk.

VII Individuals certified for WIC solely due to homelessness or migrancy and, at State agency option, previously certified participants who might regress in nutritional status without continued provision of supplemental foods.

Source: 7 CFR Subpart C, Section 246.7.

13WIC accounts for over half of all infant formula sales in the

United States (U.S. General Accounting Office, 1998b).

14After rebates, WIC agencies paid, on average, 85 percent less

than the wholesale price for infant formula in 1996 (U.S. General

Accounting Office, 1998b).

15Savings from rebates for other food products are lower than

for infant formula in part because no other single product accounts

for as large a portion of WIC costs as infant formula and because

the market characteristics of other products make it unlikely that

manufacturers would offer large rebates per item (U.S. General

Accounting Office, 1998b).
While the previous section looked at how the current

WIC program operates, this section examines the legislative and regulatory history of WIC and how it

evolved into the program of today. Trends in both the

number of WIC participants and Federal expenditures

on the program are also examined. 

Legislative and Regulatory History

The origins of WIC date back to the 1960s when the

Nation began to recognize that many low-income

Americans were suffering from malnutrition. Various

studies identified hunger as a major problem in this

country and events such as the Poor Peoples’ March on

Washington DC, and the CBS documentary “Hunger

in America” helped to publicize the problem (USDA,

1999b). In 1969, the White House Conference on

Food, Nutrition, and Health was convened with the

intention of focusing national attention and resources

on the problem of malnutrition and hunger due to

poverty. Among the recommendations stated in the

conference report was that special attention be given to

the nutritional needs of low-income pregnant women

and preschool children (White House Conference on

Food, Nutrition, and Health, 1970). 

In response to the growing public concern about malnutrition among low-income mothers and children,

USDA established the Commodity Supplemental Food

Program (originally named the Supplemental Food

Program) in 1969 (Institute of Medicine, 1996). The

program provided commodities to feed low-income

pregnant women, infants, and children up to age 6.

However, it was eventually recognized that the available food assistance programs, including the Food

Stamp Program and the Commodity Supplemental

Food Program, were not meeting the special needs of

pregnant women and infants (USDA, 1999c). 

In 1968, a group of physicians met with officials from

the Department of Health, Education, and Welfare

(HEW) and USDA in Washington, DC (Leonard,

1994). The physicians described young women, often

pregnant, in their clinics with various ailments that

were caused by the lack of food. Out of this meeting

came a plan to build food commissaries, attached to

neighborhood clinics, that would be stocked with food.

Doctors or clinic staff would prescribe needed foods

with the prescription serving as a voucher that the

women would take to the commissary to obtain a food

package. Later that year, the first USDA commissary

program was established in Atlanta, GA.16 Independently, another voucher program to distribute foods in

a Baltimore, MD, neighborhood was developed by Dr.

David Paige of Johns Hopkins University. 

On September 26, 1972, WIC was formally authorized

by an amendment to the Child Nutrition Act of 1966.

The legislation (P.L. 92-433, sponsored by Senator

Hubert H. Humphrey), established the Special

Supplemental Food Program for Women, Infants, and

Children (WIC) as a 2-year pilot program.17 The legislation’s writers used the earlier Johns Hopkins voucher

program as a model, and designed the program to be a

2-year demonstration, with the expectation that the

program’s benefits would be so overwhelming that it

would be continued as a full program (Leonard, 1994).

USDA was given responsibility for administering the

program that was to provide supplemental foods to

participants. No mention was made of providing nutrition education or health care referrals. However, the

legislation, which grew out of concern that low-income

families were not receiving good health care or proper

nutrition, created a close association between the supplemental food aspect of the program and health care

services by requiring that nutrition risk was necessary

for eligibility and was to be determined by health professionals (U.S. General Accounting Office, 1979).

USDA took little action and in 1973 a Federal court

judge ordered the agency to implement the program. A

USDA task force was established to design the operatEconomic Research Service/USDA The WIC Program: Background, Trends, and Issues/FANRR-27  7

Chapter II

History of the WIC Program 

16The commissary in this program was stocked with USDA

commodity foods.

17In 1994, P.L. 103-448 changed WIC’s name to the Special

Supplemental Nutrition Program for Women, Infants, and

Children.
ing guidelines and develop regulations for the program

(USDA, 1999c). During this time, legislation (P.L 93-

150) was enacted that authorized federally recognized

Indian tribes to act as their own WIC State agencies.

Originally, WIC was set up to provide supplemental

foods to children up to age 4 and excluded nonbreastfeeding postpartum women. Over 2 years after the legislation that established the WIC Program was enacted,

the first WIC site officially opened in Pineville, KY, on

January 15, 1974. By the end of the year, WIC was

operating in 45 States. 

On October 7, 1975, P.L. 94-105 established WIC as a

permanent program. The legislation stated, “Congress

finds that substantial numbers of pregnant women,

infants and young children are at special risk in respect

to their physical and mental health by reason of poor

or inadequate nutrition or health care, or both. It is,

therefore, the purpose of the program authorized by

this section to provide supplemental nutritious food as

an adjunct to good health during such critical times of

growth and development in order to prevent the occurrence of health problems.” Categorical eligibility was

extended to nonbreastfeeding women (up to 6 months

postpartum) and children up to 5 years of age.18

Eligibility was limited to persons at nutrition risk and

with inadequate income (however, what constituted

inadequate income was not defined). Supplemental

foods were defined as foods containing nutrients

known to be lacking in the diets of populations at

nutrition risk, in particular foods containing high quality protein, iron, calcium, vitamin A, and vitamin C.

The program was designed to supplement food stamps,

and as a result, participation in the Food Stamp

Program did not preclude a person from participating

in WIC.19 The legislation required that the program

was to begin in areas most in need of special supplemental food, and allowed costs for nutrition education

as administrative expenses. 

In 1978, P.L. 95-627 defined nutrition risk and established income eligibility standards that were linked to

the income standards prescribed for free and reducedprice school meals.20 The legislation required that

nutrition education be provided to all program participants (or their parents or caretakers) and that not less

than one-sixth of administrative funds be used for

nutrition education activities. The Act also redefined

supplemental foods as foods containing nutrients

determined by nutrition research to be lacking in the

diets of the target population, as prescribed by the

Secretary of Agriculture. The Secretary (“to the degree

possible”) was also to assure that the fat, sugar, and

salt content of the foods prescribed by WIC were

appropriate. The Act also established the link between

WIC and the third component of its benefit package—

referrals to health and other services—by requiring

that WIC State agencies describe their plans to coordinate WIC operations with special counseling services

such as family planning, immunization, child abuse

counseling, and alcohol and drug abuse prevention

counseling.

Over time a number of other legislative acts have

affected the WIC program (table 3). Among the most

important was one requiring WIC State agencies to

implement cost-containment practices. In the mid1980s, infant formula accounted for nearly 40 percent

of total WIC food costs and infant formula retail prices

were rising more quickly than prices for other foods.

These factors led several WIC State agencies to look

into cost-containment practices to reduce infant formula costs. In 1987, Tennessee became the first State with

a retail food delivery system to implement a rebate

system to control costs associated with infant formula.

It used competitive bidding to award a contract to a

manufacturer of infant formula for the exclusive right

to provide its product to WIC participants in the State

in exchange for a rebate on the formula. P.L. 101-147,

enacted in 1989, required that all WIC State agencies

enter into cost-containment contracts for the purchase

of infant formula used in WIC. Funding for WIC is

fixed by congressional appropriations. Therefore, costcontainment practices allow the program to serve more

participants. Since the establishment of the infant formula rebate system, rebates have increased dramatically over time (fig. 1). 

This same 1989 act also established adjunct income

eligibility for Food Stamp, Medicaid, and AFDC participants. This was intended to simplify the WIC appli8  The WIC Program: Background, Trends, and Issues/FANRR-27 Economic Research Service/USDA

18It has been suggested that Congress established the age limit

at 5 years as a bridge between WIC and other child nutrition programs that begin when the child enters school (U.S. General

Accounting Office, 1985). 

19However, participation in the Commodity Supplemental 

Food Program disqualifies a person from participating in the WIC

program.

20The current guideline for reduced-price school meals is

household income at or below 185 percent of the U.S. Poverty

Income Guidelines.
Economic Research Service/USDA The WIC Program: Background, Trends, and Issues/FANRR-27  9

Table 3—WIC timeline

1972—Legislation created the Special Supplemental Food Program for Women, Infants, and Children (WIC) as a 2-year

pilot project (P.L. 92-433).

1974—The first WIC site officially opened in Pineville, KY.

1975—Legislation established WIC as a permanent national health and nutrition program (P.L. 94-105).

1978—The Child Nutrition Amendments of 1978 (P.L. 95-627) established a national income standard for program eligibility

based on income standards prescribed for reduced-price school lunches. The standards in 1978 were that a household’s income had to be 195 percent of the Federal poverty guidelines or lower. The Act also strengthened WIC’s

nutrition education component by requiring that nutrition education be provided to all program participants.

1979—The WIC Nutritional Risk Priority System was established.

1980—USDA set a maximum level of 6 grams of sugar per dry ounce for adult cereals in the WIC food package rule.

1981—The maximum income level for reduced-price lunches was lowered to 185 percent of the Federal poverty guidelines.

Since the WIC income eligibility standard was tied to the eligibility standard of the National School Lunch Program,

the maximum income level for WIC was also lowered to 185 percent of poverty.

1986—Tennessee became the first State to implement an infant formula rebate program.

1988—The Hunger Prevention Act of 1988 (P.L. 100-435) provided grants in up to 10 States to conduct Farmers’ Market

Demonstration Projects.

1989—The Child Nutrition and WIC Reauthorization Act of 1989 (P.L. 101-147) required WIC agencies with retail food distribution systems to use competitive bidding to procure infant formula unless another cost-containment approach yielded

equal or greater savings. The Act established adjunct income eligibility for Food Stamp, Medicaid, and Aid to Families

with Dependent Children (AFDC) recipients. The Act also required that USDA promote breastfeeding.

1992—The WIC Farmers’ Market Nutrition Act of 1992 (P.L. 102-314) established the WIC Farmers’ Market Nutrition

Program.

1992—An enhanced WIC food package (food package VII) was established for women who exclusively breastfeed their

infants, to encourage breastfeeding among WIC mothers (Federal Register, November 27, 1992).

1994—The Healthy Meals for Healthy Americans Act of 1994 (P.L. 103-448) changed the name of the program to the

Special Supplemental Nutrition Program for Women, Infants, and Children to emphasize its role as a nutrition

program.

1997—USDA kicked off the National Breastfeeding Promotion Campaign to encourage WIC participants to begin and

continue breastfeeding.

1998—The William F. Goodling Child Nutrition Reauthorization Act of 1998 (P.L. 105-336) required at certification that,

except in limited circumstances, all applicants for WIC certification must be physically present, document their

income, and present proof of residency.

1999—WIC State agencies are required to use WIC nutritional risk from a national list established for use in the WIC program. States are not required to use all of the nutritional risk criteria on the list.

Figure 1

Infant formula rebates, fiscal years 1988-2000

$ billions

Source: USDA, Food and Nutrition Service, Office of Analysis, Nutrition, and Evaluation.

1988 89 90 91 92 93 94 95 96 97 98 99 2000

0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

1.6
cation process since, at that time, the income eligibility

criteria for these other programs were lower than those

for WIC.21 This provision also had the effect of

increasing the coordination between WIC and other

social service programs (Bartlett et al., 2000). Through

the provision of onsite health services or referrals to

other health-care and social-service providers, WIC

has become an important source for an array of health

and social services and has “evolved from being an

adjunct to maternal and child health services to

becoming the gateway program through which many

low-income households enter the public health system” (Macro International, 1995). 

The late 1980s also saw the beginning of an increased

emphasis on breastfeeding promotion and support in

WIC.22 Concern about the low rates of breastfeeding

among WIC mothers prompted Congress in 1989 to

mandate that $8 million be targeted for breastfeeding

promotion support activities in WIC and allow the use

of administrative funds for the purchase of breastfeeding aids by WIC agencies as part of P.L 101-147 (U.S.

General Accounting Office, 1993). A Breastfeeding

Promotion Consortium was established in 1990 to

exchange ideas on how the Federal Government and

private health organizations can collaboratively promote breastfeeding to WIC participants and the general public as the optimal form of infant feeding. A 1991

Act (P.L. 102-342) required that the Secretary of

Agriculture establish a breastfeeding promotion program to promote breastfeeding as the best method of

infant nutrition and to foster wider public acceptance

of breastfeeding in this country. In 1992, USDA established an enhanced WIC food package (food package

VII, see table 1) for breastfeeding mothers whose

infants do not receive WIC infant formula. In 1994,

P.L. 103-448 required WIC to spend at least $21 (to be

adjusted for inflation annually) for breastfeeding promotion on every pregnant or breastfeeding woman participating in the program. 

In 1989, P.L. 100-435 established a Farmers’ Market

Coupon Demonstration Project in which 3-year grants

were awarded in 10 States to create demonstration projects designed to provide WIC participants with

coupons that could be exchanged for fresh, unprepared

foods at farmers’ markets. Largely as a result of the

success of these demonstration projects, P.L. 102-314

in 1992 permanently established the WIC Farmers’

Market Nutrition Program. Because of limited funding,

the WIC Farmers’ Market Nutrition Program is only

available in some geographical areas. Participants in

the program receive $10-$20 (States may provide

more) worth of coupons per year to be spent at

approved farmers’ markets (a set of vouchers can be

provided to a household or to an individual). The

foods purchased must be fresh, nutritious, unprepared

foods (fruits and vegetables). 

In recent years, as the potential for loss through the

misuse of program funds and violations of program

regulations increased as WIC expanded, legislative

and regulatory actions have been enacted to strengthen integrity in the program. For example, the 1998

William F. Goodling Child Nutrition Reauthorization

Act (P.L. 105-336) required that WIC applicants at

certification, except in limited circumstances, must be

physically present, document their income if they

were not adjunctively income-eligible based on enrollment in certain other programs, and provide proof of

residency (to prevent dual participation).23 The Act

also requires WIC State agencies to permanently disqualify from the program those WIC vendors convicted of trafficking in food instruments (i.e., accepting

food instruments for cash). 

In 1999, the WIC program standardized nutrition risk

criteria for program eligibility and assigning individual

priority levels (the priority system was designed to

ensure that in the event that program funds were not

sufficient to serve all eligible persons, WIC benefits

would be provided to those most in need). Prior to

April 1, 1999, each WIC State agency developed its

own nutrition risk criteria, subject to broad Federal

parameters.

As of April 1, 1999, however, WIC State agencies are

required to use consistently defined nutrition risk criteria selected from a list of nearly 100 risk factors established specifically for use in the WIC program and

10  The WIC Program: Background, Trends, and Issues/FANRR-27 Economic Research Service/USDA

21Eligibility rules and practices in some States now enable persons with incomes above 185 percent of poverty to enroll in

Medicaid and therefore be income eligible for WIC (Lewis and

Ellwood, 1998). 

22Although breastfeeding was always of some concern in the

WIC program, the level of concern grew as the program grew

because of the increasing number of women being served and the

WIC’s growing share of the infant formula market (Schwartz et al.,

1992).

23Dual participation refers to simultaneous participation in the

WIC and Commodity Supplemental Food Program as well as to

participation in more than one local WIC program at the same

time.
issued by FNS (USDA, 1998).24 State agencies may

choose to use some or all of the nutrition risk criteria

on the national list; however, at least one of those

nutrition risks must be documented to be eligible for

WIC and the risk factor(s) must be used as defined by

FNS. 

Trends in Participation

In the quarter century since WIC’s formal inception, the

number of program participants has expanded dramatically. From an average of 88,000 participants per month

in 1974, the program grew to an average of 1.9 million

in 1980, 4.5 million in 1990, and peaked at 7.41 million

in 1997 (fig. 2). This increase in the number of participants was largely the result of increased congressional

funding as well as cost-containment measures, especially infant formula rebates. The increase in congressional

funding was stimulated in part by favorable evaluations

of the program that showed WIC to be a successful and

cost-effective program. 

Between 1988 and 1997, participation in WIC grew by

106 percent. Children made up the fastest growing

group of WIC participants during this period, increasing by 128 percent compared with 110 percent for

women, and 70 percent for infants. Since a large proportion of the higher priority pregnant women and

infants already participated in WIC, the program’s

expansion during this period allowed the program to

serve more lower priority children. 

WIC’s long period of uninterrupted growth in participation ended in fiscal 1998, as the number of WIC

participants dropped slightly (less than 1 percent), the

first decrease in participation since the program began

in 1974. This decline was followed by additional small

decreases in fiscal 1999 and fiscal 2000. Although program appropriations in real terms were relatively flat

or declining during this period, economic conditions

may also have influenced this result. The decrease in

the total number of participants in the last 3 years was

concentrated mostly among children and may be a

reflection of the Nation’s favorable economic conditions that decreased the demand for food assistance

(mothers of older children may be better able than

pregnant women and women with infants to take

advantage of the increased job opportunities and higher wages resulting from economic growth).25

Economic Research Service/USDA The WIC Program: Background, Trends, and Issues/FANRR-27  11

24Concerned about the variation in criteria used to determine

nutritional risk eligibility among WIC State agencies, Congress in

1989 (P.L. 101-147) directed USDA to conduct a review of risk

criteria (USDA, 1998). In 1993, USDA awarded a grant to the

Institute of Medicine (IOM) to conduct a comprehensive independent review of the nutritional risk criteria in use at that time.

Following the publication of the IOM report in 1996, a joint

National Association of WIC Directors (NAWD)/FNS workgroup

called the Risk Identification and Selection Collaborative (RISC)

was formed to review each of the criteria addressed by IOM. In

1998, FNS issued the list of the national nutrition risk criteria.

25Another possible reason for the decrease in participation is

the implementation of residency and income documentation

requirements in 1998. The new requirements might have discouraged persons who lacked such proof from applying (i.e., those who

are attempting to commit fraud). At the same time, illegal immigrants (who are eligible for WIC) may find it impossible to supply

such documentation. Furthermore, the 1996 welfare reform legislation outlawed food stamp benefits for legal immigrants (benefits

were restored to a limited number of legal immigrants in 1998)

and limited the number of legal immigrants eligible for

AFDC/TANF. These changes likely led to confusion over what

government benefits legal immigrants could apply for. Therefore,

legal immigrants might be less likely to apply for WIC and some

food stamp and AFDC/TANF caseworkers may have stopped referring them to WIC.

Figure 2

Average number of WIC participants per month,

fiscal years 1974-2000

Millions

Source: USDA, 1999a; USDA, 1999d; USDA, 2001c. 

1974 76 78 80 82 84 86 88 90 92 94 96 98 2000

0

1

2

3

4

5

6

7

8

Children

Infants

Women
Trends in Program Costs

Mirroring the increase in participation, costs of the

WIC program to the Federal Government also

increased dramatically over time. Total WIC costs

increased from $10.4 million in fiscal 1974 to almost

$3.9 billion in fiscal 2000 (fig. 3).26 Even after adjusting for inflation, WIC costs (in 2000 dollars) increased

each year from fiscal 1974 to fiscal 1997. The increase

in total program costs was due largely to the increase

in the number of participants served by the program as

the average cost of the monthly per person WIC food

package decreased during this period (fig. 4). In real

terms (in 2000 dollars, after adjusting for inflation),

the average monthly cost per person of the WIC food

package decreased from almost $60 in the mid-1970s

to $33 in 2000, attesting to the effectiveness of the

program’s cost-containment measures that WIC State

agencies began to initiate during the late 1980s. 

Since WIC is a discretionary program, its funding is

determined by annual appropriations law. As the program has approached full participation in recent years

(whereby every eligible person who applies for WIC is

accepted into the program), annual appropriations have

leveled off. As a result, real total program costs have

actually decreased slightly in each of the past 3 years. 

12  The WIC Program: Background, Trends, and Issues/FANRR-27 Economic Research Service/USDA

Figure 3

Real and nominal WIC program costs, 

fiscal years 1974-2000

Billion dollars

Note: Real costs were estimated using the Consumer Price Index for 

All Urban Consumers (CPI-U). 

Source: USDA, 1999a; USDA, 1999d; USDA, 2001c. 

1974 76 78 80 82 84 86 88 90 92 94 96 98 2000

0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

4.0

4.5

Nominal costs

Real costs

(in fiscal 2000 dollars)

Figure 4

Average real cost of the per person WIC food

package, fiscal years 1974-2000

Note: Real costs were estimated using the Consumer Price Index for 

All Urban Consumers (CPI-U).

Source: USDA, 1999a; USDA, 1999d; USDA, 2001c. 

1974 76 78 80 82 84 86 88 90 92 94 96 98 2000

0

10

20

30

40

50

60

70

Real cost 

(in fiscal 2000 dollars)

Dollars

26Total WIC costs include food costs, administrative costs, as

well as cost related to program evaluation, the Farmers’ Market

Nutrition Program, and special projects. Food costs totaled $2.8

billion in fiscal 1999, or about 73 percent of the total cost of the

WIC program (USDA, 1999d).
Every 2 years, USDA’s Food and Nutrition Service

(FNS) reports on the characteristics of WIC participants and the agencies administering the program. The

most recent report was published in 2000 and covers all

persons enrolled in WIC as of April 1998 (Bartlett et

al., 2000). In that month, 8 million women, infants, and

children were enrolled in the program. About 7.4 million used vouchers, thereby putting the month’s participation number at about 8 percent less than enrollment.

For simplicity and comparability with the 1998 report’s

terminology, enrollees are referred to as participants in

the following discussion of characteristics. 

Some of the demographic and economic characteristics

of WIC participants have changed over time. The more

important changes in the characteristics of the WIC

population between 1992 and 1998 are noted in the

discussion below based on data from FNS’ 1992 characteristics report (Randall and Boast, 1994). 

Participant category. Children made up slightly more

than half (51 percent) of all WIC participants in April

1998 (fig. 5). The proportion of children participating

decreased as their ages increased: 36 percent of all

WIC children were 1 year of age, 25 percent were 2

years of age, 22 percent were 3 years of age, and only

16 percent were 4 years of age. Infants accounted for

26 percent and women for 23 percent of all WIC participants. Almost half (48 percent) of the women who

participated in WIC were pregnant, and 32 percent

were postpartum, not breastfeeding. Twenty-one percent of all women in WIC were breastfeeding, up from

16 percent in 1992.

Race and ethnicity. In 1998, whites made up 39 percent of WIC participants, followed by Hispanics (32

percent), blacks (23 percent), Asians (3 percent), and

Native Americans (2 percent). Hispanics have grown

as a percentage of WIC participants during the 1990’s

(from 23 percent of WIC participants in 1992 to 32

percent in 1998) while percentages of non-Hispanic

blacks and whites fell. The Hispanic population in the

United States has grown faster than the other groups

and the WIC program has increased foreign language

outreach efforts, both trends contributed to the changing distribution by race and ethnicity during the 1990s

(Bartlett, et al., 2000).

Nutrition risks. On the records used in the 1998

report, up to three nutrition risks could be reported for

each WIC participant. Therefore, for participants with

more than three nutrition risks, some risks will go

unreported.27 For women, general obstetrical risks and

inadequate or inappropriate nutrient intake were the

risks most often reported. For almost three-quarters of

the infants, their mothers’ current nutrition risk or their

mothers’ risk during pregnancy was cited as the reason

for the infants’ eligibility. For children, 68 percent had

inappropriate or inadequate nutrient intake and 34 percent had anthropometric risks (such as low or high

weight for height) as the risks most often documented.

Income and poverty status. In the 1998 participant

records, 17 percent of the records had unreported

Economic Research Service/USDA The WIC Program: Background, Trends, and Issues/FANRR-27  13

Chapter III

Characteristics of WIC Participants

Figure 5

Distribution of WIC participants by participant

category

Source: Bartlett et al., 2000.

Pregnant

 (11%)

Postpartum

 (7%)

Breastfeeding

(5%)

Infants

(26%) 1 year 

of age (18%)

2 years 

of age (13%)

3 years 

of age (12%)

4 years

of age (8%)

27In addition, in some States, WIC agencies do not record all of

a participant’s nutrition risks. For example, some agencies only

record the single most important nutritional risk.
income or income reported as zero. Either of these

conditions may mean that the participant qualified

based on other program participation and income data

collection was not necessary. Zero may also mean that

the participant’s family had no cash income.

Participants with unreported income or income recorded as zero are left out of the income and poverty status

calculations because their true income cannot be determined from the administrative records. Among WIC

participants with reported income, the average annualized 1998 income of the participants’ families/economic units was $12,479. Among participant categories,

breastfeeding women had the highest average income

at $13,607 and postpartum women had the lowest

average income at $11,532. 

About 69 percent of the WIC participants reporting

income had incomes at or below the poverty level. In

contrast, fewer than 1 percent of participants had family income above the 185 percent of poverty threshold

that caps participation in WIC (some participants with

incomes above the cap can legally participate in WIC

because Medicaid makes them eligible and Medicaid

participation in several States is capped at income levels greater than 185 percent of the poverty guideline).

The percentage of very poor WIC participants with

incomes equal to or less than half of the poverty level

has decreased over time. In 1998, 34 percent of those

WIC participants reporting income had incomes at or

less than half the poverty level compared with 41 percent in 1992. WIC’s expansion during the 1990s has

allowed the program to serve more “near poor” participants with incomes between 100 and 185 percent of

poverty (Bartlett et al., 2000). 

Other program participation. Persons who participate

in either the Medicaid, Food Stamp, or TANF programs are automatically income eligible for WIC. In

1998, 57 percent of WIC participants received benefits

from at least one of these other public assistance programs at the time they were certified for WIC.

Medicaid was received by 48 percent of WIC participants, food stamps by 27 percent of WIC participants,

and TANF by 17 percent of WIC participants. Some

WIC participants received benefits from more than 1

of these other programs including 15 percent who

received benefits from all 3 of these other programs.

Participation in Food Stamps, TANF/AFDC, and to a

lesser extent Medicaid, has decreased since 1992

reflecting overall decreased participation in these programs since the passage of the Personal Responsibility

and Work Opportunity Reconciliation Act of 1996

(also known as the welfare reform legislation) (Bartlett

et al., 2000).

14  The WIC Program: Background, Trends, and Issues/FANRR-27 Economic Research Service/USDA
WIC serves more than 7 million persons each month at

a cost to the Federal Government of almost $4 billion

annually. Given that its mission is to safeguard the

health of low-income women, infants, and children, it

is therefore important to ask how effective is WIC in

improving the health of program participants, as measured by birth outcomes, nutritional status, and nutrient intake. WIC’s impact on related topics, including

breastfeeding rates and the incidence of childhood

obesity, is also discussed. 

WIC’s Effect on the Health 

of Participants

Over WIC’s history, many studies have looked at the

program’s effect on the health of its participants. In

fact, much of the strong congressional support for

WIC has been attributed to research that showed that

WIC had positive impacts on the health of program

participants. Two of the most influential studies of

WIC were completed in the early 1990s. Devaney et

al. (1990) found that each dollar spent on prenatal

WIC services yielded a $1.77 to $3.13 savings for

newborns and mothers in Medicaid costs over the first

60 days after birth. The study also found that prenatal

WIC participation was associated with increased birthweight, fewer preterm births, and longer gestational

age. The U.S. General Accounting Office (1992) statistically combined results from 17 studies that compared

rates of low birthweight among WIC participants and

similar nonparticipants. GAO concluded that each

Federal dollar spent providing WIC prenatal benefits

in 1990 saved an estimated $3.50 over an 18-year period in Federal, State, local and private health costs, primarily in the health care area.

Despite the body of research on WIC health outcomes,

questions remain about WIC’s impact on the health of

its participants because issues related to selection bias

have complicated the interpretation of much of the 

research. Selection bias may occur because WIC evaluation studies are not randomized for ethical reasons.28

Instead, WIC research is typically limited to a quasiexperimental design comparing those who participate

in the program with those who do not. A problem

exists if WIC participants differ in unobservable ways

from eligible nonparticipants, and if these unobservable differences influence outcomes. Selection bias can

either enhance or downplay the effects of WIC participation. For example, it can exaggerate the benefits of

WIC when individuals who value health and nutrition

are more likely to participate in the program than individuals who are at higher risk and do not see the value

of participating. WIC effects can be downplayed in

research if those not participating in WIC are at lower

health risk than the WIC sample. The potential for

selection bias is evident in almost all WIC studies.

While, researchers know that it is an issue and attempt

to control for it in study design and analysis, it is

uncertain how successful they are.29

A recent ERS-funded review of USDA’s food assistance programs reviewed the body of research examining WIC’s effect on nutrition and health outcomes

(table 4) (Fox and Hamilton, forthcoming). Much of

this research focused on WIC’s impact on birth outcomes. Birth outcomes have been the major focus of

WIC research because they are the most critical: low

birthweight, preterm delivery, and infant mortality are

very serious health outcomes. These have also been

relatively easy to study, because the outcomes are

short-term and easily identified. The review concluded

that even with the pervasive problem of selection bias

Economic Research Service/USDA The WIC Program: Background, Trends, and Issues/FANRR-27  15

Chapter IV

Outcome-Based Issues in WIC

28In an ideal evaluation, the effects of WIC would be obtained

by randomly selecting from a group of persons eligible for WIC

some persons to receive and some not to receive benefits. On average, the characteristics of the two groups would not differ other

than whether or not they participated in WIC (assuming that all

persons selected to participate in WIC did so). Differences in the

health outcomes between the two groups could be attributed solely

to the effects of WIC, and not the result of selection bias.

29See Oliveira and Gundersen (2000) for results of a recent

study that examined the impact of WIC on the nutritional outcomes of children while controlling for possible self-selection bias. 
“the sheer weight of the research suggests that WIC

does have a positive impact on birthweight as well as a

number of other birth outcomes and significantly lowers birth-related Medicaid costs.” Other authors have

reviewed WIC evaluation studies with similar conclusions (see, for example, Abrams, 1993; Ku et al., 1994;

Owen and Owen, 1997; and Rossi, 1998). It is largely

on the basis of these studies on birth outcomes, including the Devaney et al., and GAO studies cited above,

that WIC is often cited as being one of the most costeffective food assistance programs in the Nation. 

Other health outcomes that may be associated with

WIC participation have not been the subject of as

many studies. The impact WIC has on the health of

participating mothers is one area that has not been

studied. WIC participation during pregnancy may

have an impact on mothers’ postpartum health (which

may affect future birth outcomes). The nutrition education received from WIC may result in long-term

positive health effects on the mother such as a

reduced risk of diabetes or heart disease. In addition,

the health of breastfeeding mothers and their infants

on WIC has not been studied. As breastfeeding rates

in the WIC program increase, more research in this

area will be important.

Another area that has not been thoroughly studied is

the health effect of WIC on children despite the fact

that children make up half of all WIC participants. For

example, little is known about the effect of WIC on the

long-term growth and development on both physical

and cognitive/psychological scales of children (Fox and

Hamilton, forthcoming). It is difficult to link future

health outcomes with WIC participation. Assessing

WIC’s impact on the growth and development of children requires a longitudinal study because a long period of time may be necessary to detect changes. In the

early 1990s, Congress canceled a planned FNS-funded

longitudinal study of the long-term developmental

effects of WIC on children due primarily to the high

costs of the project (Devaney, 1998). 

The strongest evidence of WIC’s positive impact on

children is in the area of iron-deficiency anemia, a serious health concern. “Virtually all studies that have

examined the issue have found that WIC participation

has a positive effect on mean levels of hemoglobin or

hematocrit and/or reducing the incidence of childhood

anemia” (Fox and Hamilton, forthcoming). WIC may

also have had an indirect effect on the iron status of

nonparticipants since some WIC foods on supermarket

shelves such as infant formula and cereal are required to

be iron-fortified and are consumed by nonparticipants as

well as WIC program participants (Devaney, 1998). 

Future research on the health of women, children, and

breastfeeding women and their infants would be useful

yet challenging. “The complexity of the health outcomes that have been studied has presented unique

challenges to WIC researchers, further compromising

their ability to obtain clear estimates of program

impact” (Fox and Hamilton, forthcoming).

WIC and Breastfeeding Rates

Breastfeeding is widely acknowledged to be the best

method of feeding most infants. The American

Academy of Pediatrics (AAP) recommends breastfeeding as the preferred form of feeding for all infants,

16  The WIC Program: Background, Trends, and Issues/FANRR-27 Economic Research Service/USDA

Table 4—Summary of WIC research findings in the areas of health outcomes, nutrient intake,

and nutritional status

Results of impact analyses of the WIC program

Outcome General findings Comments

Health outcomes Strong evidence of positive impact No large-scale study of impacts on

on birthweight, related outcomes, the health and development of

and associated Medicaid costs infants and children has been done

Nutrient intake Mostly positive significant impacts, Much of the available information

particularly for nutrients targeted is dated, and some population

by WIC groups have no studies or very few studies

Nutritional status Strong suggestion of impact on Many of the studies are old,

iron status of children; little useful essentially nothing is known about

information available for impacts some population groups 

on growth of infants and children

Source: Adapted from Fox and Hamilton (forthcoming).
including premature and sick newborns, with rare

exceptions (American Academy of Pediatrics, 1997).30

In general, human milk provides all the necessary nutrients for the first 6 months of life. It helps protect

infants against illness and allergy because of the antibodies from the mother that are transferred to the infant

through breast milk. Breastfeeding may also provide

benefits to the mother, including reduction in hip fractures, reduced risk of ovarian and premenopausal breast

cancer, and a earlier return to prepregnancy weight. In

their 1988 policy statement on the WIC program (reaffirmed in 1993), the Academy states that “breastfeeding

should be aggressively promoted among WIC participants because of its exceptional nutritional value and its

cost savings to the program” (American Academy of

Pediatrics, 1988). 

In spite of the benefits of breastfeeding, many women

choose to formula-feed. There are many reasons for

this: breastfeeding may be difficult to establish, it can

be painful for the mother if she does not have proper

instruction, some mothers feel breastfeeding is too

time-consuming, and mothers may become concerned

that their baby is not getting sufficient nourishment

because one cannot measure the amount of milk the

infant is consuming. It is also a challenge to return to

work or school when breastfeeding, especially for lowincome women who tend to work in environments that

do not allow for breaks to pump breast milk and do

not provide refrigerated storage facilities for the milk. 

Through its nutrition education and breastfeeding promotion programs, the WIC Program encourages mothers to breastfeed their infants if at all possible. In addition, breastfeeding women are a higher priority for certification into the program than are nonbreastfeeding

postpartum women and are eligible to receive program

benefits for up to 1 year postpartum compared with

only 6 months postpartum for nonbreastfeeding

women. The quantity and variety of food in the WIC

food package for breastfeeding women is also greater

than that for nonbreastfeeding women (see table 1). 

However, breastfeeding rates among WIC women,

both while they and their infants are in the hospital as

well as when their babies are 6 months of age, have

historically been significantly lower than those of nonWIC women (table 5). In 1999 (the latest data available), 56 percent of WIC women initiated breastfeeding (i.e., breastfed while in the hospital) compared

with 77 percent of non-WIC women.31 Rates of breastfeeding at 6 months of age were also lower for WIC

women than non-WIC women (20 percent versus 40

percent).32 Since the breastfeeding rate of women participating in WIC is so much lower than that of women

not in the program, some have questioned whether

WIC, by supplying infant formula, provides a disincentive to breastfeeding (Rossi, 1998).33 However,

women in lower socioeconomic groups, including

mothers who are black, poor, and have low education

levels, (i.e., women most likely to participate in WIC)

Economic Research Service/USDA The WIC Program: Background, Trends, and Issues/FANRR-27  17

30AAP recommends exclusive breastfeeding for approximately

the first 6 months after birth and the gradual introduction of ironenriched foods in the second half of the infant’s first year to complement the breast milk diet. Breastfeeding is recommended to

continue for at least 12 months and thereafter for as long as mutually desired (American Academy of Pediatrics, 1997).

31Mothers who since the birth of their child either participated

in WIC themselves or whose child participated in the program

were considered to be WIC participants. Non-WIC women included all women who did not participate in WIC regardless of

whether or not they were eligible for the program.

32Breastfeeding women included those who breastfed exclusively as well as those who supplemented breast milk with infant formula, or milk from other sources.

33The average cash value of the WIC food packages received by

a nonbreastfeeding postpartum woman and her formula-fed infant

is more than three times that received by a breastfeeding woman

whose infant does not receive formula through WIC (USDA,

2000a).

Table 5—Breastfeeding rates by WIC status, 1990-99

Status 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999

In hospital:

All infants 51.5 53.3 54.2 55.9 57.4 59.7 59.2 62.4 64.3 67.2

By WIC status:

WIC 33.7 36.9 38.8 41.6 44.3 46.6 46.6 50.4 52.6 56.0

Non-WIC 62.9 65.2 66.4 67.9 68.8 71.0 70.8 73.4 75.2 76.9

At 6 months:

All infants 17.6 18.2 18.9 19.0 19.7 21.6 21.7 26.0 28.6 30.7

By WIC status:

WIC 8.2 9.0 10.1 10.8 11.6 12.7 12.9 16.5 18.9 19.9

Non-WIC 23.6 24.6 25.6 25.8 26.5 29.2 29.5 35.5 38.5 40.3

Source: Abbott Laboratories, 1999.
have traditionally been less likely to breastfeed their

children (Abbott Laboratories, 1999). Furthermore,

WIC women experienced great increases in the prevalence of breastfeeding during the 1990s; the percentage of WIC women who initiated breastfeeding

increased by 66 percent from 1990 to 1999 while the

percentage who were breastfeeding at 6 months

increased by 143 percent. 

WIC breastfeeding rates, although improving, continue

to be significantly lower than the Healthy People 2010

target established by the U.S. Department of Health and

Human Services—that at least 75 percent of women initiate breastfeeding and at least 50 percent continue

breastfeeding for at least 6 months. Since 1989, a number of modifications have been made to the WIC

Program in an attempt to increase breastfeeding rates.

The Child Nutrition and WIC Reauthorization Act of

1989 earmarked $8 million/year to be spent by WIC to

promote breastfeeding. WIC State Agencies were

required to hire a breastfeeding promotion coordinator,

educate local agency staff on the benefits of breastfeeding, and coordinate promotion with programs in the

State. In 1992, an enhanced WIC food package was

established for women who exclusively breastfeed their

infants. In 1998, the William F. Goodling Child

Nutrition Reauthorization Act (P.L. 105-336) allowed

food funds to be used to purchase breast pumps for 

participants.

In 1993, the General Accounting Office (GAO) studied

the effect of WIC breastfeeding promotion activities

on breastfeeding rates (including the relationship

between prenatal WIC participation and breastfeeding

initiation) and WIC food costs associated with

increased breastfeeding (U.S. General Accounting

Office, 1993) After controlling for factors such as education, income, race, age, parity, infant birthweight,

marital status, and region, the authors found that there

was no significant difference in breastfeeding rates

between women who participated in WIC prenatally

and those that did not. Therefore, it is unclear whether

WIC promotion activities prenatally contributed to the

increase in breastfeeding rates. The study was conducted in 1991, only 2 years after the authorization of

funding specifically for breastfeeding promotion. GAO

did find that efforts to increase breastfeeding rates had

increased in WIC clinics by 1993. 

WIC and Childhood Obesity

Another emerging issue with direct implications on the

health of program participants is the relationship

between WIC and childhood overweight and obesity.

WIC was first established to combat the problem of

malnutrition and hunger among low-income

Americans. However, since that time, overweight and

obesity have become one of the most serious health

problems in the United States. Over one-third of all

adults in this country, 12 percent of adolescents, and 14

percent of children 6-11 years old are overweight and

the prevalence of overweight is increasing (Centers for

Disease Control and Prevention, 1997).34 Overweight

and obesity among children is a concern because overweight children tend to become overweight adults, and

there is a clear association between overweight and

obesity in adults and chronic diseases such as cardiovascular disease, diabetes, and hypertension. 

Different criteria for overweight have been used to

estimate prevalence, usually either weight-for-height

status above the 85th or 95th percentiles of the original

1977 National Center for Health Statistics/Centers for

Disease Control and Prevention (NCHS/CDC) weightfor-height reference growth charts.35/36 Because infants

and preschoolers are in a dynamic state of growth in

which body size is continually in a state of flux, it is

difficult to assign a single cutoff value to an age range.

Similarly, there is no defined criterion for obesity in

children. However, obesity generally refers to a more

extreme case of overweight. 

The proportion of children participating in the WIC

program who are overweight or obese is growing. A

recent study of low-income preschool children in 18

States who participated in several publicly funded

health and nutrition programs (mostly WIC) found that

1 out of 10 children in these programs was overweight

(based on the 95th percentile point for weight-for18  The WIC Program: Background, Trends, and Issues/FANRR-27 Economic Research Service/USDA

34Overweight for adults was defined as body mass index (BMI)

equal to or greater than 27.8 for men and 27.3 for women, while

overweight for children and adolescents was defined as body mass

index at or above the 95th percentile BMI cutoff points. 

35The growth charts were revised in 2000. 

36Weight-for-height does not directly measure the degree of

overweight. For example, a person with a high degree of lean body

mass could have high weight-for-height but would not be obese.

However, weight-for-height is strongly correlated with body 

fatness. 
height) in 1995 (Mei et al., 1998).37 That is an

increase of 20 percent from 1983. Since overweight

(defined by most WIC State agencies at that time as

being at or above the 90th percentile weight for length

or height based on established growth charts) is one of

the anthropometric nutrition risk criteria used for

determining eligibility into the program, it is not surprising that there would be a high incidence of overweight among WIC participants.38 In fact, for a given

participant category (i.e., infant, child, pregnant

women, etc.) the highest priority is given to persons

demonstrating medically based nutrition risks, including anthropometric risks such as overweight (see table

2). Obesity is also more prevalent among certain

minorities who disproportionately participate in the

WIC program. However, the increasing prevalence of

overweight among WIC children prompted concern

about a possible association with the foods provided

by WIC (Centers for Disease Control and Prevention,

1996). The WIC food basket can provide substantial

amounts of foods to some participants. For example,

the maximum quantity of milk (whole or low-fat),

authorized in food package IV—children 1 to 5 years

of age—is 24 quarts per month (see table 1).39

However, a study by the Centers for Disease Control

and Prevention (1996) concluded that WIC foods provide necessary nutrients without contributing to overweight.40 Another more recent study found that WIC

children were no more likely to be overweight than

other low-income children (Burstein et al., 2000). 

The increase in overweight among WIC children may

be a reflection of the increase in overweight among the

general population of children.41 In fact, WIC may

have a positive effect on reducing overweight if participants substitute nutritious WIC foods for high-caloriccontent foods in their usual diet. In addition, local

WIC agencies may tailor the WIC food package for an

individual based on nutritional need. For example, the

WIC food package may provide low-fat or nonfat milk

instead of whole milk to overweight children.42 The

nutrition education provided by WIC may also contribute to lowering the prevalence of obesity among

WIC children. One of the suggested goals of the nutrition education counseling provided by WIC “is to help

the infant/child achieve recommended rates of growth

and development by emphasizing food choices of high

nutritional quality while avoiding unnecessary calorierich foods and emphasizing age-appropriate physical

activity and exercise, thereby minimizing further risks

associated with increased childhood obesity” (USDA,

1998). The WIC program can also help individuals

with clinical complications obtain early diagnosis and

treatment by health professionals through its health

referral function (Institute of Medicine, 1996).

Recently WIC has increased its proactive approach to

preventing obesity among children. For example, FNS

has awarded grants for a multi-State project titled “Fit

WIC” to identify ways that WIC policies, practices, and

operations might be changed to help prevent childhood

obesity (USDA, 2001a). In the spring of 2001, FNS

added new nutrition risk criteria for infants and children—at risk of becoming overweight—to the allowable

criteria that may be used to establish WIC program eligibility (USDA, 2001d). The new criteria, based on

expert recommendations, makes children (24 months

old and older) at or above the 85th percentile weight for

height at risk of becoming overweight. The new criteria

also includes the existence of one or both obese parents

as an allowable contributing factor to the overall risk of

a child becoming overweight or obese in later years.

This factor is based on scientific evidence that suggests

that the presence of obesity in a parent greatly increases

the risk of overweight in preschoolers. 

The rise in obesity raises questions as to how WIC

may improve its efforts to confront this growing issue.

WIC, with its large number of children participants,

has the potential to positively impact the issue of

childhood obesity. More research on WIC’s impact on

childhood obesity is needed. USDA is currently funding several research studies that examine WIC-related

obesity topics (see appendix). 

Economic Research Service/USDA The WIC Program: Background, Trends, and Issues/FANRR-27  19

37The study was based on data collected on children younger

than 5 years of age in the Centers for Disease Control and

Prevention (CDC) Pediatric Nutrition Surveillance System. 

38Sixteen percent of all children in WIC in 1998 were reported

as having high weight for height as a nutrition risk at certification

(Bartlett et al., 2000). 

39It should be noted that foods provided by WIC are only a portion of the diet and when studying obesity, the whole diet must be

considered. 

40The report acknowledged that small sample sizes for some subgroups and the inability to control for nutrition risk limit the study’s

findings (Centers for Disease Control and Prevention, 1996).

41The prevalence of obesity among all boys 4 to 5 years of age

increased by almost 14 percent between 1971-74 and 1988-94.

Among all girls age 4 to 5, the prevalence of obesity increased by

86 percent over the same period (Ogden et al., 1997).

42The extent to which WIC clinics actually tailor the food package of overweight children has not been determined.
WIC’s Nutrition Education and

Health Care Referral Programs 

As discussed earlier, the body of research, with some

caveats, suggests that WIC is associated with positive

health outcomes, especially with regard to prenatal participation. Although WIC’s positive effects are usually

attributed solely to the provision of supplemental food,

they should be viewed as the joint effects of WIC’s

supplemental foods, nutrition education, and health

care referrals (Rossi, 1998). Yet, very little research has

been done to assess the impact of WIC’s nutrition education and referrals to health care services. 

Since the nutrition education provided by clinics

varies, it is difficult to generalize findings of a few

clinics to the Nation. Nutrition education can be provided to clients either individually or in a group setting

using a variety of methods. The topics covered are

designed to be easily understood and bear a practical

relationship to participant nutritional needs, household

situation, and cultural preferences. Recently, USDA’s

Food and Nutrition Service funded an exploratory

study of the nutrition education component of the WIC

program for pregnant women (Fox et al., 1998).

Researchers followed pregnant women from six WIC

sites in three States from their enrollment in WIC to

4-6 months postpartum. The authors measured their

nutrition knowledge, attitudes, and behaviors at baseline and compared these at 32-36 weeks gestation (prenatal survey) and then at 4-6 months postpartum (postpartum survey).

The study found that nutrition knowledge increased

significantly from baseline to the prenatal survey.

Knowledge continued to increase in the postpartum

survey but to a lesser degree. Nutrition education in

the content areas of breastfeeding and infant feeding

practices increased the most dramatically. Baseline

nutrition knowledge was found to be significantly

higher in those women who had been WIC participants

with a previous child. 

Nutrition attitudes and perceptions were found to

change over time but to a modest degree. When looking at the nutrition-related behaviors over time, the

researchers found that the use of prenatal vitamins and

iron supplements increased significantly from the

baseline survey to the prenatal survey. Researchers

also found that the consumption of WIC foods

increased from the baseline survey to the prenatal survey. However, by the postpartum survey only the

increased consumption of WIC cereals was maintained. While most women followed recommended

infant feeding guidelines during the first few months

of life, the prevalence of undesirable feeding practices

increased for older infants. For example, the use of

solid foods before 4 months of age ranged from 39

percent to 67 percent of families across the six sites. 

A limitation to this study was that no control group

was identified to compare the change in knowledge,

attitudes, and behaviors from the prenatal to postpartum period for those not participating in the WIC program. The influence of other sources of information,

as well as hands-on experience, are likely to impact

nutrition knowledge, attitudes, and behavior. 

FNS also recently sponsored several demonstration

studies (one for prenatal WIC participants and one for

child WIC participants) on the effectiveness of innovative approaches to nutrition education. The prenatal

study incorporated two approaches: a computerized

touch-screen video for individual nutrition education

and a facilitated group intervention (Randall et al.,

2001b). Results of the study found no increase in

nutrition knowledge from the interventions. However,

the study reports that the assessment tool used in the

study (1) measured knowledge only and may or may

not have affected behavior; and (2) would not detect

knowledge in areas not covered by the test. 

The demonstration study for children’s nutrition education consisted of a preschool lesson that focused on

the areas of the Food Guide Pyramid, variety in the

diet, and making healthy food choices for 3- and 4-

year-old children (Randall et al., 2001a). Results of the

study found that children who received the preschool

lesson scored significantly higher on the nutrition

knowledge test than children not exposed to the

preschool lesson. The researchers concluded that providing nutrition education directly to 3- and 4-year-old

WIC participants is feasible and can increase nutrition

knowledge. 

The provision of health and social service referrals to

WIC participants is also one of the primary objectives

of the WIC program. One of the few studies in this

area documented the number and type of referrals provided over a 2-month period by nutritionists at a

Lawrence, MA, WIC clinic in 1990 (Sargent et al.,

1992). WIC nutritionists were asked to document each

20  The WIC Program: Background, Trends, and Issues/FANRR-27 Economic Research Service/USDA
referral provided. Over this 2-month period, 1,850 persons were seen and 597 (27 percent) were given referrals. Multiple referrals were reported for 21 percent of

the participants. The majority of referrals (59 percent)

were for nutrition-related services such as supplemental and emergency food. Twenty-three percent of referrals were for medical needs such as prenatal care, primary care, family planning, emergency care, dental

care, failure to thrive, and hematocrit and lead testing.

The remaining referrals were for education and development programs and to social services. 

One limitation to the study is that it was done in one

WIC clinic, and therefore is not representative of all

WIC sites. Second, the study asked WIC nutritionists

to document referrals provided. On one hand, this

requirement could have resulted in an increased awareness by the nutritionists to provide referrals, inflating

the frequency of referrals. On the other hand, nutritionists may not have documented every referral provided because of the extra paperwork involved, underestimating the number of referrals. The authors suggest

that WIC nutritionists would benefit from education on

the variety of social and medical services available in

their neighborhoods so that they can provide appropriate referrals.

Nutrition education and referrals to health and social

services are, along with supplemental food, key components of the WIC program. However, more research

is needed to estimate their effectiveness separately. If

nutrition education and referrals are found to be effective, it might suggest that more program funds be allocated to each. Conversely, if they are found to be ineffective, it might be better to try new ways to improve

them or else de-emphasize these components and reallocate their funds to providing supplemental foods to

additional participants. 

Impact of the WIC Farmers’ Market

Nutrition Program

The dual objectives of the WIC Farmers’ Market

Nutrition Program are (1) to provide resources in the

form of fresh, nutritious, unprepared foods (fruits and

vegetables) from farmers’ markets to persons who are

either participating in WIC or who are on the waiting

list for WIC; and (2) to expand the awareness, use of

and sales at farmers’ markets (7 CFR 248.1). Since its

beginnings as a demonstration project in 10 States during the late 1980s, the WIC Farmers’ Market Nutrition

Program has grown substantially and now operates in

35 States, the District of Columbia, Guam, and on 4

Indian reservations.43 In fiscal 2000, more than 12,800

farmers in over 1,600 farmers’ markets were authorized to participate in the program (USDA, 2001b).

That same year, about 1.9 million persons participated

in the program and they redeemed approximately

$17.5 million worth of coupons. However, despite its

growth, the impact of the WIC Farmers’ Market

Nutrition Program on farmers and WIC participants

has not been studied thoroughly. 

In 1991, USDA funded an evaluation of the then

Farmers’ Market Coupon Demonstration Project

(FMCDP) (Galford et al., 1991). At the time, the

FMCDP operated in only 10 States serving 250,000

WIC participants with 2,500 participating farmers. The

study looked at three issues: (1) the relationship

between the FMCDP and participants’ consumption of

fruits and vegetables, (2) the effect of nutrition education on fruit and vegetable consumption, and (3) the

effect of the FMCDP on farmers. The study found that

those who received the FMCDP coupons consumed

about 6 percent more fruit and 5 percent more vegetables than WIC participants who did not receive the

coupons. Researchers also found that those receiving

FMCDP coupons were almost twice as likely to

patronize farmers’ markets, even when they had

stopped receiving the coupons. Some WIC clinics also

provided education on fruit and vegetable preparation

in conjunction with the FMCDP. Women who said

they had received the produce preparation information

reported greater intake of fruits and vegetables than

those not receiving the information, independent of

FMCDP participation. The authors note that this finding may not be conclusive since health-conscious participants may be more likely to report having received

education. Finally, the report questioned women about

their satisfaction with the Farmers’ Market Nutrition

Program and found that two-thirds were “very satisfied” with the program. 

These results of the 1991 survey were similar to those

of a 1998 study conducted by the National Association

of Farmers’ Market Nutrition Programs (1999). Over

half (58 percent) of Farmers’ Market Nutrition

Program participants had never visited a farmers marEconomic Research Service/USDA The WIC Program: Background, Trends, and Issues/FANRR-27  21

43Compared with the total WIC program, the Farmers’ Market

Nutrition Program is relatively small—about $15 million in

Federal funds were earmarked for the farmers’ market program in

fiscal year 2000 (USDA, 2001b).
ket before taking part in the Farmers’ Market Nutrition

Program. Seventy-one percent of the participants

reported that they would continue to shop at farmers’

markets, even without coupons. Seventy-four percent

said they ate more fresh fruits and vegetables last summer than usual.

The 1991 FMCDP survey also looked at the impact of

the program on farmers. The survey reported that sales

increased slightly as a result of program participation;

over 80 percent of farmers reported receiving less than

$500 in FMCDP coupons. As such, farmers noted that

their farming operations were not altered as a result of

the program. (Even though farmers’ direct benefits 

from the program were small, there may be significant

indirect benefits to farmers. For example, a large proportion of the participants stated that they will use the

farmers’ markets more even without the coupons.)

Farmers indicated strong support for the program; 90

percent believed the program should continue. 

As the Farmers’ Market Nutrition Program continues

to expand, continued research looking at the outcomes

and effectiveness of the program would be useful. For

example, examining how the increased availability of

fresh fruits and vegetables contributes to the diet and

nutrition of WIC participants is an important area for

future study. 

22  The WIC Program: Background, Trends, and Issues/FANRR-27 Economic Research Service/USDA
In addition to issues relating to WIC’s impact on the

health of program participants, numerous issues are

associated with administering a program of WIC’s size

and complexity. Issues related to the composition of

the WIC food package, cost-containment practices,

program accessibility, eligibility standards, and reducing fraud and abuse in the program directly affect the

women, infants, and children who participate in the

program, as well as indirectly affecting other groups,

including food retailers, infant formula manufacturers,

and farmers.

The WIC Food Package

The last major revision to WIC food packages was in

1980. Since then, the ethnic/racial characteristics of

the WIC participant population and food consumption

patterns have changed considerably while nutritional

standards have evolved as the result of recent research

findings. It is therefore important to determine if the

current packages are adequate in assisting program

participants to meet nutritional standards for a healthful diet or if they can be improved to better meet the

needs of program participants. 

The WIC program provides participants with supplemental foods that are not intended to meet the total

nutritional needs of the participants.44 The WIC legislation defines “supplemental foods” as those foods

containing nutrients determined by nutritional research

to be lacking in the diets of the program’s target population, as prescribed by the Secretary of Agriculture

(Section 17(b)(14) of the Child Nutrition Act of 1966,

as amended). Historically, WIC food packages have

contained foods that are high in protein, calcium, iron,

and vitamins A and C. The legislation also states that

the Secretary, to the degree possible, shall assure that

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

appropriate (Section 17(f)(11)). As of 1980, Federal

regulations require that cereals eligible for use in the

WIC food packages for women and children must contain no more than 6 grams of sugar per dry ounce of

cereal (7 CFR 246.10).45 This regulation was in large

part in response to advice from nutrition and health

experts, the WIC community, and the general public,

as well as the recognition that dental caries is a major

public health problem and the role that sugars in foods

play in the development of dental caries (Federal

Register, March 18, 1996). 

Periodically, USDA has reviewed the nutritional adequacy of the WIC food package. The latest review,

completed by USDA’s Center for Nutrition Policy and

Promotion (CNPP) in 1999, was in response to

inquiries by members of Congress and representatives

of the food industry about the scientific basis for continuing the sugar limit for WIC-eligible adult cereals.46

Instead of focusing solely on one requirement of the

WIC foods (i.e. the sugar limit for WIC cereals),

USDA decided to conduct a review of the overall WIC

food packages. The study analyzed the nutrient intake

of WIC participants to determine how well they meet

current nutritional standards, including the 1989

Recommended Dietary Allowances (RDA), the 1995

Dietary Guidelines for Americans, and the Food Guide

Pyramid. The study examined the median intakes of

WIC participants, focusing on the five nutrients targeted in the WIC program—protein, iron, calcium, vitamins A and C, and four other nutrients of potential

concern (folic acid, zinc, vitamin B6 and magnesium)—as well as energy. 

Results of the study indicated that while WIC infants

and children generally achieved good nutrient intake,

the diets of WIC women needed improvement 

Economic Research Service/USDA The WIC Program: Background, Trends, and Issues/FANRR-27  23

Chapter V

Administrative Issues in WIC

44Participants are expected to obtain the balance of necessary

nutrients from other food sources.

45At the same time, a limit was placed on the amount of cheese

in the food packages to restrict salt intake. 

46Research continues to support the relationship between sugar

and dental caries, however, it has been shown that consumption of

any fermentable carbohydrate, starches as well as sugars, contributes to dental caries. In addition, recent research has failed to

demonstrate a positive relationship between sugar consumption

and chronic disease (Federal Register, March 18, 1996).
(Kramer-LeBlanc et al., 1999). 47 Infants and children

met all nutrient recommendations.48 Relative to the

RDA, pregnant women were deficient in the intake of

iron, calcium, folic acid, magnesium, zinc, and energy.

Nonbreastfeeding women did not consume the recommended amounts of calcium, vitamin C, and magnesium. The authors of the study concluded that pregnant

women and nonbreastfeeding women may either be

not purchasing the entire WIC food package or not

consuming all the WIC foods furnished in their package. The study also estimated the amount of sugar

added to foods in the manufacturing process in the

diets of WIC participants. Children 1-4 years of age

consumed over twice the amount of added sugar recommended by the Food Guide Pyramid, pregnant

women 1.5 times over the suggested amount, and WIC

nonbreastfeeding women 1.3 times over (breastfeeding

women did not exceed the suggested amount).

However, the authors concluded that the contribution

of the WIC package to added sugars in the overall diet

is very low.49

Concurrent with the CNPP review of the WIC food

packages, the National Association of WIC Directors

(NAWD) conducted its own independent review, based

in part upon a survey of its membership (National

Association of WIC Directors, 2000). They recommended significant changes to the WIC food prescriptions, defined as the specific combination and quantities of allowable foods issued to WIC participants,

including:

• Increased consumption of fruits, vegetables, whole

grains, and fiber-rich foods,50

• Reduction in the fat content of specific foods and

the overall food package

• Balanced contribution from the major food groups

in the Food Guide Pyramid

• Increased availability of nutrient-dense food prescriptions, and

• Substantially increased flexibility for WIC State

agencies to offer locally available foods that reflect

cultural groups served and regional dietary patterns. 

Minority groups, especially Hispanics, account for an

increasing percentage of WIC participants. Changing

demographics may support NAWD’s recommendation

to allow State agencies the flexibility to offer food prescriptions that respond to cultural or religious needs.

NAWD’s stated goal is to collaborate with USDA to

implement nutrition policy and practice changes related to the WIC food packages that will positively

impact the WIC population. USDA is currently in the

process of reexamining the composition of the WIC

food packages. 

WIC Eligibility Standards

Although support for WIC is generally widespread,

public concern has developed about the effectiveness

of WIC’s eligibility criteria and whether WIC has

expanded too much.51 In fiscal 2000, over 7 million

persons participated in the program each month. About

27 percent of all U.S. children and infants under 5

years of age now participate in WIC, including an estimated 47 percent of all infants born in this country. 

Eligibility for WIC is based on category, residency,

income, and nutrition risk. Because the number of participants in WIC is limited by funding levels, a priority

system is used to allocate program slots. The dramatic

growth in WIC’s funding during the 1990s has allowed

the program to serve more people with lower priority

and raised questions about whether the nutrition risk

criteria are too lenient. In developing estimates of the

number of persons eligible for WIC (used in part to

develop program budget estimates), USDA estimated

that 81 percent of all women, infants, and children,

including 95 percent of all infants, who were income

24  The WIC Program: Background, Trends, and Issues/FANRR-27 Economic Research Service/USDA

47Because of the difficulty of quantifying milk intake, breastfed

infants were not included in the analysis. 

48The study reported that shortfalls in the intake of zinc were

seen among children, pregnant women, and breastfeeding women.

However, in 2001 the National Academy of Sciences published

new recommendations for zinc intake. Breastfeeding women age

18 and older and children met the recommendations for zinc when

applying the new standards.

49Most of the added sugar in the WIC food packages comes

from peanut butter and ready-to-eat cereals. 

50Congress has also recommended that FNS look into ways to

increase produce consumption in WIC. In 2001, the Committee on

Appropriations urged FNS to study the feasibility of an incentive

pilot program to increase produce consumption under the WIC and

Food Stamp Programs. The increase in produce consumption

“could enhance the control of adverse health conditions such as

diabetes, high blood pressure, and osteoporosis” (U.S. House of

Representatives, 2001). 

51For example, Besharov and Germanis (1999) question “why a

remedial program like WIC is now provided so broadly.” Others,

on the other hand, are concerned that many fully eligible persons

are not seeking WIC benefits. The next section examines several

access and participation issues. 
eligible in 1997 also met the nutrition risk criteria

(table 6) (USDA, 1999e).

52

Prior to 1999, WIC State agencies were allowed to

develop their own nutrition risk criteria (within broad

Federal guidelines) for determining eligibility in WIC.

As a result, the criteria used to determine nutrition risk

eligibility varied among WIC State agencies. Concern

about this variation across State agencies led USDA to

award a grant to the National Academy of Sciences’

Institute of Medicine (IOM) in 1993 to conduct a comprehensive review of the scientific basis for the categories of nutrition risk criteria used in the WIC program—anthropometric, biochemical and other medical, dietary, and predisposing factors (USDA, 1998).

In 1996 IOM released its report of the study, which

concluded that while a majority of the nutrition risk

criteria used by the WIC program were supported by a

body of scientific evidence, some of the nutrition risk

criteria used by States consisted of loosely defined

conditions with generous cutoff points (Institute of

Medicine, 1996). The report also made recommendations for the use of specific nutrition risk criteria. A

Federal/State/local workgroup was then formed to

address the issues and recommendations of the report

and develop a list of allowable nutrition risk criteria

based on sound science. As of April 1999, WIC State

agencies began using criteria from this national list of

allowable nutrition risk criteria in determining an individual’s eligibility for WIC.

The development of nutrition risk criteria is ongoing.

The IOM report also identified areas in which further

research is needed. For example, IOM concluded that

the current methods used to determine which 

individuals are at nutrition risk due to diet are weak

and they recommended investing in the development

and validation of practical dietary assessment tools

that can be used for the identification of dietary

risks.53 USDA awarded a grant to IOM to review the

scientific basis for methods used in the assessment of

individuals for eligibility in WIC based upon dietary

risk. An interim report was released in 2000 and the

final report of this study is expected in 2002 (Institute

of Medicine, 2000). 

Questions have also been raised about whether the

income eligibility requirements for WIC are too

lenient. For example, the income eligibility limit for

WIC is 185 percent of poverty, more lenient than the

130 percent of poverty limit used in the Food Stamp

Program—the country’s principal food assistance program. In addition, some States’ Medicaid programs

now allow some persons with incomes greater than

185 percent of poverty to qualify for WIC since participation in Medicaid makes one adjunct (that is automatically) income eligible for WIC. Some have questioned whether WIC adjunct income eligibility policies

should necessarily apply in these States (Lewis and

Ellwood, 1998). 

Although income is used to determine eligibility for

WIC, it is not used in determining an individual’s priority level which is determined solely by participant

category and nutrition risk.54 Furthermore, the amount

of benefits participants receive are independent of their

economic need as measured by family income. That is,

a child in a family with income less than 50 percent of

Economic Research Service/USDA The WIC Program: Background, Trends, and Issues/FANRR-27  25

52A recent FNS-funded study determined that 9 out of 10 income

eligible persons in 1989 were also at nutrition risk based on medical and/or dietary criteria (Harell et al., 1999).

53Dietary risk is the most commonly reported nutrition risk for

determining WIC eligibility (Bartlett et al., 2000).

54A report by the U.S. General Accounting Office (1985) stated

that WIC program officials generally considered income to be an

unreliable indicator of vulnerability.

Table 6—1997 estimate of WIC eligibles

Postpartum and 

Pregnant breastfeeding Infants Children Total

Item women women

Thousands

Income eligible 1,202 860 1,617 6,813 10,492

Fully eligible 1,094 783 1,536 5,110 8,522

Participation 756 953 1,869 3,808 7,386

Coverage (percent) 69 122 122 75 87

Source: USDA, 1999e.
the poverty threshold will receive the same WIC benefits as a child at similar nutrition risk, in a family at

185 percent of poverty, holding all other factors constant. 55 This is different from the Food Stamp

Program, in which a household’s benefits decrease as

household income increases.56

A recent article by Besharov and Germanis (1999)

states that while the positive effects of WIC are probably concentrated among its most disadvantaged participants, all WIC participants in the same target group

receive basically the same set of WIC benefits regardless of differences in need. They argue that WIC,

instead of continuing to expand coverage to progressively less needy families, should target more WIC

resources to the most needy families. They suggest

that States should experiment with increasing the food

package and intensify counseling services for the most

needy families. Others have suggested that, given budgetary constraints, it might be advisable to reduce the

overall eligible WIC population by dropping certain

eligible categories of participants, such as all 4-yearolds (Library of Congress, 1997). 

Do certain groups, such as the lowest income, the most

nutritionally at risk, the youngest children, etc., benefit

more from WIC than others? At present, little is

known about the degree to which WIC benefits accrue

to the most disadvantaged. More research is needed on

the distributional effects of WIC participation to determine whether society would be better served by targeting more benefits to fewer, more needy families.

Conversely, additional research on those persons just

above the margin (e.g., nonbreastfeeding mothers 6- to

12-months postpartum and 5-year-old children) would

be useful in determining the degree to which they may

benefit by participating in WIC if eligibility were

expanded. 

Access and Participation Issues

While some are concerned that WIC eligibility

requirements may be too lenient, others argue that

access to the program should be improved, and ask

why more persons eligible to participate are not being

served (see Ku et al., 1999). Some WIC-eligible subgroups, for example children (especially older children), do not participate to the same degree as other

subgroups.57 Little research has been conducted on the

demographic characteristics of those WIC-eligible persons who do not participate in the program and their

reasons for not participating.

A related issue that concerns policymakers is whether

programs such as WIC are accessible to working

women and their children, particularly at a time when

welfare reform legislation, in the form of the Personal

Responsibility and Work Opportunity Reconciliation

Act (P.L. 104-193), is encouraging increased laborforce participation among low-income mothers. A

recent study by the U.S. General Accounting Office

(1997b) addressed the question of access by surveying

WIC directors.58 Potential barriers facing working

women, as well as changes the WIC offices have made

to assist working women, were both discussed in this

report. Directors identified a number of reasons that

working women might not participate in WIC, the primary ones being that the women lose interest in WIC

benefits as their income increases, there is a perceived

stigma associated with receiving WIC benefits, and

working women may think that they are not eligible to

participate in WIC. Difficulty in reaching the clinic,

long waits at the clinic, and the lack of service during

the lunch hour were other factors mentioned. 

The directors were also asked whether they used various strategies to accommodate working women. These

included scheduling appointments, designating an alternative person to pick up food instruments, and extending the hours that the WIC office was open. Almost all

clinics allowed the scheduling of appointments (instead

of taking participants on a first-come, first-served basis)

and allowed an alternative person to pick up the food

instrument. Similarly, most agencies issued food

26  The WIC Program: Background, Trends, and Issues/FANRR-27 Economic Research Service/USDA

55Participation in WIC does not preclude an individual from

participating in other food assistance programs such as food

stamps. Therefore, the child at 50 percent of poverty may be able

to receive food stamps in addition to WIC benefits while the child

at 185 percent of poverty would not be eligible for food stamps. A

1985 GAO report stated that many WIC policy officials believed

that individuals whose family incomes are too high to be eligible

for assistance from other programs may be at more economic need

and nutritional risk than individuals with lower incomes but who

qualify for other assistance programs (U.S. General Accounting

Office, 1985).

56As a result, the determination of the amount of benefits an

individual can receive in WIC is administratively simpler than in

the Food Stamp Program.

57Among children 1 to 4 years of age in WIC in 1998, 36 percent were 1 year of age while only 16 percent were 4 years of age

(Bartlett et al., 2000).

58The study was conducted from March to September 1997,

i.e., before the full impacts of the welfare reform legislation were

felt. 
vouchers for more than 1 month at a time (89 percent)

and were open during the lunch hour (75 percent).

About half offered evening hours although very few

were open Saturdays (11 percent) or early in the morning (21 percent). Although 76 percent of the directors

reported that accessibility to their clinics was at least

moderately easy for working women, 9 percent reported that accessibility was still a problem. Fifty-eight percent of those interviewed thought that their clinic was

more accessible in 1997 than it was in 1995, while

fewer than 1 percent thought it was less accessible. 

While the GAO study addressed some of the accessibility issues, a number of issues remain unaddressed.

For instance, no interviews of women actually participating in the program, or who were eligible for the

program but choose not to participate, were conducted.

Thus, the study only reiterates the concerns of a sampling of directors, but not those of the actual participants or eligible nonparticipants. 

The New York State Department of Health recently

conducted a study with a grant from USDA’s Food and

Nutrition Service to identify barriers to continuing on

WIC after the initial certification period. The study

provides information from the perspective of the participants themselves (Woelfel et al., 2001). The authors

developed a survey, which listed 68 potential barriers

to participation and asked WIC participants to identify

those items they perceived as barriers. The most commonly reported were:

• Long waiting time (reported by 42 percent of

respondents), overcrowded and noisy WIC clinics (reported by 36 percent of respondents) with

nothing for the children to do (42 percent),

• Nutrition education sessions that were boring

(27 percent) and repetitive (33 percent),

• Difficulty matching the amount of cereal specified on the WIC voucher to cereal box sizes in

the store (41 percent), and

• Respondents feeling that WIC did not issue

enough juice (27 percent) or infant formula (38

percent).

As a result of this study, the New York State WIC program has taken steps to minimize barriers to continued

participation in WIC. Other States may wish to identify barriers within their own clinics and develop policies to improve access to the program. 

Estimating WIC Eligibility 

A somewhat controversial policy issue surrounding

WIC concerns the estimation of the number of persons

eligible for WIC and the number of eligibles who

would participate if funds were available. These estimates, which are done separately for women, infants,

and children, are calculated by FNS and used for several purposes, including:

• Budget estimates. Projections of the number of

eligibles and the number who would likely participate if funds were available are considered in developing WIC program budget estimates used in the

President’s budget request and the congressional

budget process.

• Coverage estimates. Ratios of actual participants

to estimated eligibles for the program as a whole

and by participant category are used to assess how

close the program is to the administration’s goal of

“full funding” whereby the program would serve all

the eligible persons who apply. In 1997 (the most

recent available data), overall coverage was estimated at 87 percent, with rates of 122 percent for

infants, 75 percent for children, 69 percent for pregnant women, and 122 percent for postpartum

women (table 6) (USDA, 1999e).

Underestimating the number of people eligible and

likely to participate in WIC could result in a shortfall

of funds to serve them while overestimating the number of people eligible and likely to participate in WIC

could result in insufficient appropriations to other

important programs (National Research Council,

2001). In recent years, Congress has expressed some

concern about the accuracy of these estimates (U.S.

House of Representatives, 1998). For example, the

implausibly high participation rates (above 100 percent) for infants and postpartum women in recent

years suggest either that ineligible persons are participating in WIC, or that the number of eligibles has been

underestimated. FNS has sponsored a program of studies to improve the estimates.

One of these recent studies examined a number of

issues affecting the accuracy of estimating the number

of WIC eligibles (Gordon et al., 1999). For example,

annual income is currently used to estimate income

eligibility, while in reality the majority of participants

are eligible based on the family’s current income and

more individuals may be eligible based on monthly (or

Economic Research Service/USDA The WIC Program: Background, Trends, and Issues/FANRR-27  27
biweekly) income rather than annual income (for

example, during a recent period of unemployment).

The current estimation procedure also does not take

into account that certification is for 6 months to 1 year,

which could also lead to an underestimate of eligibles

since some WIC participants may not be currently

income-eligible but were when they were certified.59

Further, some of the datasets used in developing the

estimates are old and may not reflect current conditions. In addition, while applicants can meet any one

nutrition risk criteria to be eligible for WIC, comprehensive datasets containing information on all of the

nutrition risk criteria do not exist. 

A main reason cited for the possible underestimation

of WIC eligibles is that the current estimation technique does not take into account that some States

raised their Medicaid cutoff level for infants above the

cutoff for WIC, thus raising eligibility since by law

Medicaid participants are income-eligible for WIC

(Gordon et al., 1999).60 The impact of the Medicaid

program on estimating WIC eligibles is likely to

become even more important in the future if the

expansions of State Medicaid programs to infants with

incomes above 185 percent of poverty continues.

Another concern of Congress is that some States have

carried over unused balances in recent years, suggesting that WIC is fully funded and possibly serving ineligible persons (U.S. House of Representatives, 1998).

The General Accounting Office looked into this issue

and identified a number of reasons (some related to

how the program is administered) that States had

unspent funds, and concluded that “having unspent

funds does not necessarily indicate a lack of need for 

program benefits” (U.S. General Accounting Office,

1997c).61

A final concern is linked to the question of full funding and the estimation of the number of eligibles who

would participate if funds were available. For fiscal

years 1993 through 1996, estimates of full funding

needs were made based on the assumption that 80 percent of those eligible were likely to participate. This

figure was based on observed participation rates

among young children in the Aid to Families with

Dependent Children Program (AFDC) and the Food

Stamp Program during the late 1980s. The rate was

raised to 83 percent in fiscal 1997 to meet a goal of

funding 7.5 million participants. Although the rate was

purposely set for that goal, and was not based on direct

empirical evidence, there is some evidence that participation in other programs increased in the 1990s. For

example, participation by young children in the Food

Stamp Program has recently been estimated at 94.5

percent (Gordon et al., 1999). These results suggest

that the actual WIC full-funding participation rate may

be greater than 83 percent.62

In response to congressional interest, USDA asked the

National Research Council to convene an expert panel

to review the methodology used in developing the

estimates of the number of people who are eligible

and likely to participate in the WIC program. The

principal finding from the panel’s initial work “is that

the current methodology and assumptions employed

by FNS substantially understate the number of people

who are income eligible for WIC” (National Research

Council, 2001). The panel is currently examining

alternative methods and data sources for estimates and

is considering improvements in data that could affect

the estimates. 

28  The WIC Program: Background, Trends, and Issues/FANRR-27 Economic Research Service/USDA

59In other words, WIC accumulates new participants as they

become eligible, but drops those persons who become income ineligible in later months only after their certification period (usually a

6-month period but up to 12 months for most infants) ends (Lewis

and Ellwood, 1998). 

60As of 1996, seven States qualified infants with incomes above

185 percent of poverty for Medicaid—California, Hawaii,

Minnesota, Rhode Island, Tennessee, Vermont, and Washington

(Lewis and Ellwood, 1998).

61For example, because the Federal grant is the only source of

funds for WIC in most States, States exercise caution to ensure

that they do not spend more than their Federal grant. In addition,

because States use vouchers and checks to distribute food benefits,

it is difficult for them to determine the program’s food costs until

the vouchers and checks have been redeemed and processed. The

installation of a new computer system in one State temporarily

reduced the amount of time clinic staff had to certify and serve

new clients because they had to instead spend time learning new

software and operating procedures.

62Because of differences between the programs, the WIC fullfunding participation rate could be either higher or lower than participation rates in AFDC or the Food Stamp Program. See Gordon

et al. (1999) for a discussion of the reasons that WIC participation

rates may be either higher or lower than participation rates in these

other programs.
Assessment of WIC’s CostContainment Practices

Because WIC is a discretionary grant program that

serves as many people as the available funding permits, WIC officials seek to contain program costs, particularly food costs, to serve greater numbers of eligible people (food costs accounted for $2.8 billion or

about 73 percent of the total cost of the WIC program

in fiscal 1999). The WIC State agencies use a variety

of practices to control costs, which can be grouped

into three main categories:

(1) Negotiating rebate contracts with food

manufacturers.

(2) Restricting the size or brand of food items 

that participants can obtain with WIC food

instruments.

(3) Restricting the number and/or types of

approved WIC vendors.

The primary cost-containment practice is contracting

with manufacturers to obtain rebates on infant formula.

Since the late 1980s, Federal law has required that

WIC State agencies enter into cost-containment contracts for the purchase of infant formula used in WIC.

WIC is expected to receive nearly $1.5 billion in fiscal

2001 from infant formula rebates. Two concerns arose

around the question of formula pricing after the WIC

rebate requirement was put in place. The first concern

was that the policy change might lead to a rise in the

price of formula paid by non-WIC participants. The

second concern was whether rising prices would in

turn be an indication that non-WIC participants were

subsidizing WIC. 

According to a recent report by the U.S. General

Accounting Office (1998b), the wholesale price of formula rose 9 percent in 1989, the same year in which

the rebate policy was put into place. Although this rise

was considerably higher than increases in the years

before or after this change (which averaged 3 percent),

the report states that other explanatory factors for this

rise in price could not be ruled out. In particular,

changes in the structure of demand or production costs

may have led to increased prices. While the report did

not rule out that prices may have risen as a result of

the rebate program, it concluded that non-WIC consumers of infant formula were not subsidizing WIC

since the prices WIC pays for formula cover production costs, although they are far below wholesale

prices. In 1996, the average wholesale price of formula

was $2.48 per can while WIC paid only 15 percent of

that price, or 38 cents per can. 

In October 2000, Congress directed USDA’s Economic

Research Service (ERS) to report on the “number of

suppliers of infant formula in each State or major marketing area, and to compare the cost of formula that is

included in the WIC program versus the cost of formula that is not included in the WIC rebate program”

(H.R. 106-948). An interim report (presenting preliminary findings) from the ongoing study was released in

April 2001 (Oliveira et al., 2001). The final report was

sent to Congress in October 2001.

The study’s results indicate that infant formula from

the major manufacturers was available throughout the

country and that there was no clear and consistent relationship between a formula’s being the WIC contract

brand and having the highest average retail price.

In addition to the use of infant formula rebates, WIC

State agencies use a variety of other practices to control costs including contracting with manufacturers to

obtain rebates on other WIC foods.63 Some State agencies also limit authorized food selections by requiring

participants to select the lowest cost brands of food.

While decreasing food costs, limiting food items can

have a negative impact if WIC participants do not

select that food item or do not consume it (U.S.

General Accounting Office, 1997a).64 The least-cost

brand requirement may also make food selection more

burdensome for vendors and confusing for participants

(which, as a result, may use up scarce participant contact time explaining how to select the least-cost brands

that could be spent on nutrition education). 

While the use of rebates reduces food costs to WIC,

the procurement process requires additional administrative effort and resources by WIC State agencies. In

addition, State agencies could become increasingly

dependent on the funds provided through these rebate

contracts (U.S. General Accounting Office, 1997a). A

Economic Research Service/USDA The WIC Program: Background, Trends, and Issues/FANRR-27  29

63For example, in fiscal year 1996 nine WIC State agencies

obtained rebates on infant cereal and/or infant fruit juices (U.S.

General Accounting Office, 1997a).

64For example, the WIC State agency in Texas discontinued the

least-cost brand requirement for peanut butter after discovering

that participants were not selecting it (U.S. General Accounting

Office, 1997a).
problem could arise if the manufacturers begin to offer

lower rebates, in which case States may have insufficient funds to provide benefits to the current level of

participation. 

Some States also restrict the number of vendors and/or

select vendors with competitive prices in order to contain WIC costs. According to GAO, the retail community does not support placing limits on the number of

approved WIC vendors (U.S. General Accounting

Office, 1997a). Questions about whether the number of

vendors servicing WIC clients are adequate have also

been raised. Also of concern in inner cities and rural

areas is the issue of whether a vendor is located within

a convenient distance of some clients. 

Concerns have been raised that overly restrictive costcontainment policies may reduce WIC participants

access to and consumption of prescribed foods, ultimately leading to reduced participation and adverse

health impacts (Federal Register, June 28, 2000).

Some people have also questioned whether these costcontainment practices save enough in food costs to

compensate for their additional administrative costs. 

The William F. Goodling Child Nutrition

Reauthorization Act of 1998 (P.L.105-336) mandated

that USDA conduct a study on the effect of cost-containment practices (other than infant formula rebates)

in the WIC program on seven outcomes: (1) program

participation; (2) access and availability of prescribed

foods; (3) voucher redemption rates and actual food

selections by participants; (4) participants on special

diets or with specific food allergies; (5) participant use

and satisfaction of prescribed foods; (6) achievement

of positive health outcomes; and (7) program costs.

The goal of this study is to provide the first systematic

data on the balance struck by WIC State agencies

between the goals of nutritional improvement and customer satisfaction and the need to make the most of

limited program funds (Federal Register, June 28,

2000). Information from this study will provide WIC

officials with a better understanding of the potential

impacts of cost containment as they make future decisions regarding the implementation of these cost-containment practices. The study, funded by ERS, is

scheduled to be completed in fall 2002 (an interim

report by Kirlin and Cole was released in February

2001). 

Fraud and Abuse in the 

WIC Program

Fraud and abuse in WIC wastes taxpayers’ money and,

since WIC serves only as many eligible people as

funding allows, may result in fewer eligible persons

being able to participate in the program. Three separate groups could engage in fraud or abuse—food

retailers (or vendors), participants, and employees:

• Vendor fraud and abuse is any intentional or unintentional action of a vendor that violates the vendor

agreement, program regulations, policies, or procedures. Vendor fraud includes providing unauthorized

foods, or nonfood items to participants in exchange

for food instruments; charging the program for supplemental foods not received by participants; and

charging the program more for supplemental foods

than other non-WIC customers are charged for the

same foods. 

• Participant fraud and abuse occurs when participants obtain benefits to which they are not entitled

and/or to misuse the benefits they receive and

includes intentionally making a false statement to

obtain WIC benefits (e.g, by misrepresenting their

income, claiming fictitious dependents), receiving

benefits from multiple local agencies or clinics (dual

participation), and exchanging food instruments for

cash or unauthorized items. 

• Employee fraud and abuse occurs when employees violate program regulations, policies, or procedures and includes obtaining benefits for themselves

or for persons not eligible for the program. 

Two early studies funded by USDA’s Food and

Nutrition Service estimated the extent of fraud and

abuse in WIC (U.S. General Accounting Office, 1999).

The WIC Income Verification Study found that 5.7

percent of all WIC enrollees in 1988 were income ineligible (either deliberately or unintentionally) and they

accounted for 5.8 percent of the total cost of WIC food

benefits.65 The WIC Vendors Issues Study found that

in 1991 an estimated 22 percent of vendors overcharged and these overcharges amounted to less than 2

percent of the total dollar value of WIC food vouchers

redeemed. A followup to the WIC Vendors Issues

Study was conducted in 1998 and examined the extent

30  The WIC Program: Background, Trends, and Issues/FANRR-27 Economic Research Service/USDA

65A recently released study estimated that 4.5 percent of WIC

enrollees in 1998 were not eligible for WIC benefits (Cole et al.,

2001).
to which WIC vendors were violating program rules

and regulations (Bell et al., 2001). The results indicated that about 8 percent of all vendors overcharged buyers for the items purchased, however, fewer than 2 percent of all WIC redemptions nationally were attributed

to overcharge.66 Over one-third of all vendors (35 percent) allowed minor substitutions of unauthorized

foods within a WIC food category (e.g., unauthorized

cereals), while only 4 percent of all vendors allowed

major substitutions involving a purchase of an item

outside of the WIC food category (e.g., soda). 

The U.S. General Accounting Office recently conducted a study in response to congressional concerns about

the potential for fraud and abuse in the WIC program

and the lack of reliable information on the subject.

Information for the study was based on a survey of all

State WIC agencies and a random sample of local

WIC agencies. Their report, released in 1999,

described what is known about the level of fraud and

abuse in WIC, and examined the efforts taken to prevent and detect fraud and abuse (U.S. General

Accounting Office, 1999). According to GAO, WIC

State agencies reported that about 9 percent of all vendors committed fraud or abuse during fiscal 1997 and

1998.67 The level of detected participant and employee

fraud and abuse was much lower. Over the same 2-

year period, local WIC agencies reported that only

0.14 percent of the average monthly number of participants committed fraud or abuse of a serious nature

(such as exchanging food vouchers for cash or dual

participation), while 1.6 percent of the average monthly number of participants committed less serious

offenses (such as redeeming food vouchers outside

authorized dates). Little fraud or abuse by employees

was reported. GAO acknowledged that their estimates

of fraud and abuse underestimate actual levels, in part

because detected levels of fraud and abuse reflect the

level of detection efforts which differed among the

State and local WIC agencies. In addition, some fraud

and abuse (by vendors, participants, and employees)

goes undetected regardless of detection efforts. 

Monitoring the WIC program for fraud and abuse is

resource-intensive and the lack of resources, in terms

of both personnel and funding, was cited by many

WIC State officials as one of the barriers inhibiting

efforts to detect and prevent fraud in the WIC program. Activities associated with detecting and preventing fraud and abuse are funded through the Nutrition

Services and Administration (NSA) grants to the WIC

State agencies. Therefore, fraud and abuse detection

and prevention activities compete with the other activities funded by the NSA grants, such as nutrition education, and program outreach, for limited resources. 

State officials also cited limited resources as inhibiting

their ability to implement the electronic benefits transfer (EBT) system. Using the EBT system to issue WIC

food benefits offers a means of reducing some of the

vulnerabilities for fraud and abuse by both vendors and

participants (Federal Register, June 16, 1999). Instead

of paper checks or vouchers, EBT uses a computer

chip on the EBT card to issue and transact food instruments. Only when the EBT system approves the food

item for purchase is the item accepted as part of the

WIC transaction. Participants must enter a secret personal identification number (PIN) to access their EBT

card, thereby reducing the likelihood that unauthorized

individuals will use the card to obtain WIC food benefits. Since the person’s EBT account lists the authorized WIC foods available to the recipient, the universal product code (UPC) listed on food items can be

checked against the list of authorized foods to determine if that food item is allowable, as the cashier electronically scans each food item. The use of the UPC

reduces the opportunity for overcharging, substitution,

and charging for food items not received. Only if the

computer indicates that the food item is allowable will

that item be accepted as part of the WIC transaction.

Currently, EBT is only in operation in parts of

Wyoming, Ohio, and Nevada, which are conducting

pilot tests examining the feasibility of using EBT in

the WIC program statewide in fiscal year 2002.

However, other States (including Connecticut, Maine,

Massachusetts, Michigan, New Hampshire, New

Jersey, New Mexico, North Dakota, Rhode Island,

Texas, and Vermont) are in various stages of planning

for EBT pilot studies (USDA, 1999b).

The GAO recommendations to improve program

integrity include: amend program regulations to

require State agencies to limit the number of vendors

they authorize to a number they can effectively manEconomic Research Service/USDA The WIC Program: Background, Trends, and Issues/FANRR-27  31

66Overcharges are not necessarily deliberate attempts to commit

fraud. For example, simple cashier error could result in an overcharge. Almost 7 percent of all vendors undercharged WIC buyers. 

67The number of vendors committing fraud or abuse varied

greatly by State. Fifteen States reported no detection and 6 States

reported detecting 25 percent or more of their vendors as having

committed fraud or abuse.
age while meeting the regulatory requirements for participant access; develop and implement cost-effective

strategies for the States to use in collecting and monitoring information on incidences of participant fraud

and abuse; and require WIC State agencies to have

policies and procedures for addressing employee conflicts of interest.68/69

Since its inception, WIC regulations have contained

provisions directed specifically at the prevention and

detection of fraud and abuse. For example, participants

are required to meet eligibility criteria in order to

receive WIC benefits and State agencies are required

to conduct onsite monitoring visits to at least 10 percent of authorized food vendors each year. However, in

recent years Congress has expressed concern that as

the WIC program has grown in size and complexity, so

too has the potential for loss of program funds through

fraud and abuse (Federal Register, June 16, 1999).

Recent legislation in the form of the William F.

Goodling Child Nutrition Reauthorization Act of 1998

(P.L. 105-336) contained provisions specifically

designed to strengthen integrity in WIC. For example,

the Goodling Act requires State agencies to (1) implement a system to prevent and identify dual participation within each local agency and between local agencies under the State agency’s jurisdiction; and (2) identify high risk vendors and conduct compliance buys on

them.

Vendors who have been convicted of either trafficking

in WIC vouchers or other serious violations may be

permanently disqualified from participating in WIC

unless disqualification of the vendor would cause hardship to participants. The Goodling Act also requires

that all applicants, except in limited circumstances, be

physically present, document their income (or participation in the Food Stamp, Medicaid, or TANF programs) and provide proof of residency and identification, at certification.70 Prior to this legislation, States

were allowed to establish their own documentation

requirements for applicants. A study by the U.S.

General Accounting Office (1997a) conducted prior to

the passage of the Goodling Act, found that at least 14

States did not require applicants to provide documentation of income eligibility, 20 States did not require

applicants to provide proof of residency, and 12 States

did not require applicants to provide proof of identity. 

In December 2000, USDA published a final rule

amending regulations governing the WIC food delivery

systems (Federal Register, December 29, 2000). The

rule increases program accountability and efficiency in

food delivery and should decrease vendor violations of

program requirements and loss of program funds. It

strengthens vendor management in retail food delivery

systems by establishing mandatory selection criteria,

training requirements, criteria to be used to identify

high-risk vendors, and monitoring requirements,

including compliance investigations. 

Given the size of the program and the costs associated

with its operation, integrity issues in the WIC program

will continue to come under scrutiny. 

32  The WIC Program: Background, Trends, and Issues/FANRR-27 Economic Research Service/USDA

68By limiting the number of vendors, States can more frequently monitor vendors and conduct compliance investigations to

detect and remove vendors from the program who commit fraud or

other serious program violations, according to Federal and WIC

State officials (U.S. General Accounting Office, 1998a).

69Potential conflicts of interest may arise when employees also

participate in WIC or when an employee both certifies and issues

benefits to the same individual.

70Although the family income of participants must be 

documented, WIC State agencies are not required to verify the

documentation.
WIC has grown dramatically since its establishment

almost three decades ago. Strong congressional support, generated by various evaluations that found WIC

to have high rates of return for its investment, resulted

in increased funding for WIC, which, along with effective cost-containment practices, allowed more people

to participate in the program. Legislative and regulatory

actions and Federal/State/local partnerships that

encouraged State innovations such as infant formula

rebates have helped shape and refine the program as it

evolved into one of the central components of the

Nation’s food assistance system. In recent years, participation in WIC has leveled off, as appropriations for

WIC have stabilized at what is believed to be near fullfunding levels. 

As a gateway through which many low-income families enter the public health system, WIC reaches a

large number of this Nation’s infants and children.

Therefore, having the most effective WIC program

possible can have an important influence on the health

of America. The WIC community faces a number of

issues that have been raised by policymakers,

researchers, and WIC program managers at the

Federal, State, and local levels about both the impact

and the administration of the WIC program. While

some of these questions have been addressed in the literature, others remain unanswered. Additional research

to determine the optimal method of operating the WIC

program to meet the needs of program participants

given the resource constraints is needed. USDA’s

Economic Research Service and the Food and

Nutrition Service are both currently conducting

research related to WIC (see appendix for a brief

description of some of these ongoing studies). Results

from these studies will help shed light on many of the

issues currently facing the WIC program. 

Economic Research Service/USDA The WIC Program: Background, Trends, and Issues/FANRR-27  33

Chapter VI

Conclusions
Abbott Laboratories, Ross Products Division. Ross

Mother Survey: Breastfeeding Trends Through 1999.

Unpublished report, 1999. 

Abrams B. “Preventing Low Birth Weight: Does WIC

Work? A Review of the Special Supplemental Food

Program for Women, Infants, and Children,” Annals

New York Academy of Sciences (678), March 1993.

American Academy of Pediatrics. “Policy Statement:

Breastfeeding and the Use of Human Milk

(RE9729),” Pediatrics 100(6), December 1997.

American Academy of Pediatrics. “Policy Statement:

WIC Program (RE8122),” June 1988.

Bartlett, S., M. Brown-Lyons, D. Moore, and A.

Estacion. WIC Participant and Program

Characteristics 1998. No. WIC-00-PC. Prepared by

Abt Associates Inc., for U.S. Department of

Agriculture, Food and Nutrition Service, Office of

Analysis, Nutrition and Evaluation. May 2000. 

Bell, L., M. Harkins, V. Shayne, S. Schreiber, C.

Miller, D. Smith, and P. Moore. WIC Vendor

Management Study, 1998. Prepared by Health

Systems Research, Inc., for U.S. Department of

Agriculture, Food and Nutrition Service, Office of

Analysis, Nutrition and Evaluation, July 2001. 

Besharov, D. J., and P. Germanis. “Is WIC as Good as

They Say?” The Public Interest (134), Winter 1999. 

Burstein, N. R., M. K. Fox, J. B. Hiller, R. Kornfeld,

K. Lam, C. Price, D. T. Rodda. Profile of WIC

Children. Prepared by Abt Associates Inc., for U.S.

Department of Agriculture, Food and Nutrition

Service, Office of Analysis, Nutrition, and

Evaluation, March 2000.

Centers for Disease Control and Prevention.

“Nutritional Status of Children Participating in the

Special Supplemental Nutrition Program for

Women, Infants, and Children—United States,

1988-1991,” The Morbidity and Mortality Weekly

Report, 45(3), January 26, 1996. 

Centers for Disease Control and Prevention. “Update:

Prevalence of Overweight Among Children,

Adolescents, and Adults—United States, 1988-

1994,” The Morbidity and Mortality Weekly Report,

46(9), March 7, 1997. 

Cole, N., D. Hoaglin, and J. Kirlin. National Survey of

WIC Participants. Prepared by Abt Associates Inc.,

for U.S. Department of Agriculture, Food and

Nutrition Service, Office of Analysis, Nutrition, and

Evaluation, October 2001. 

Devaney, B. “Commentary,” Ed. P. Rossi, Feeding the

Poor: Assessing Federal Food Aid, Washington, DC:

American Enterprise Institute, 1998.

Devaney, B., L. Bilheimer, and J. Schore. The Savings

in Medicaid Costs for Newborns and Their Mothers

from Prenatal Participation in the WIC Program:

Volume 1. Prepared by Mathematica Policy

Research, Inc., for U.S. Department of Agriculture,

Food and Nutrition Service, October 1990. 

Federal Register. November 27, 1992, pp. 56231-

56241.

Federal Register. March 18, 1996, pp. 10903-10907.

Federal Register. June 16, 1999, pp. 32308-32343. 

Federal Register. June 28, 2000, pp. 39854-39856. 

Federal Register. December 29, 2000, pp. 83248-

83289.

Fox, M.K., N. Burstein, J. Golay, and C. Price. WIC

Nutrition Education Assessment Study. Prepared by

Abt Associates Inc., for U.S. Department of

Agriculture, Food and Nutrition Service, September

1998.

34  The WIC Program: Background, Trends, and Issues/FANRR-27 Economic Research Service/USDA

References
Fox, M.K. and W. Hamilton. Nutrition and Health

Outcomes Study: Review of the Literature. Prepared

by Abt Associates Inc., for U.S. Department of

Agriculture, Economic Research Service, forthcoming.

Galford, G., J. Thompson, and K. Wise. Evaluation of

the Farmers’ Market Demonstration Project.

Prepared by Price Waterhouse for U.S. Department

of Agriculture, Food and Nutrition Service, March

1991.

Gordon, A., R. Kliman, J. Ohls, J. Anderson, and K.

LaBounty. Estimating the Numbers of People

Eligible for WIC and the Full-Funding Participation

Rate: A Review of the Issues, Final Report. Prepared

by Mathematica Policy Research, Inc., for U.S.

Department of Agriculture, Food and Nutrition

Service, February 1999.

Harell, M.L., R. Franklin, K. Zack, and L. Scher.

Nutrition Risk and Eligibility for WIC. Prepared by

Sigma One Corporation for U.S. Department of

Agriculture, Food and Nutrition Service, 1999. 

Institute of Medicine. Framework for Dietary Risk

Assessment in the WIC Program: Interim Report.

Washington, DC: National Academy Press, 2000.

Institute of Medicine, WIC Nutrition Risk Criteria: A

Scientific Assessment. Washington, DC: National

Academy Press, 1996.

Kirlin, J.A., and N. Cole. Assessment of WIC CostContainment Practices: An Interim Report to

Congress. E-FAN-01-005. Prepared by Abt

Associates Inc., for U.S. Department of Agriculture,

Economic Research Service, February 2001.

Kramer-LeBlanc, C.S., A. Mardis, S. Gerrior, and N.

Gaston. Review of the Nutritional Status of WIC

Participants. CNPP-8. U.S. Department of

Agriculture, Center for Nutrition Policy and

Promotion, December 1999. 

Ku, L., B. Cohen, and N. Pindus. Full Funding for

WIC: A Policy Review. Washington, DC: The Urban

Institute, 1994.

Ku, L., D.J. Besharov, and P. Germanis. “Debating

WIC,” The Public Interest, Spring 1999. 

Leonard, R.E. “Recalling WIC’s Program’s 1960s

Humble Beginnings,” Nutrition Week 24(15), April

22, 1994. 

Lewis, K., and M. Ellwood. Medicaid Policies and

Eligibility for WIC. Prepared by Mathematica Policy

Research, Inc., for U.S. Department of Agriculture,

Food and Nutrition Service, July 1998.

Library of Congress, Congressional Research Service.

The WIC Program. CRS Report to Congress. 96-

172 EPW. May 27, 1997.

Macro International. The WIC Dynamics Study, Volume

1, Final report. Prepared for U.S. Department of

Agriculture, Food and Consumer Service, February

1995. 

Mei, Z., K.S. Scanlon, L.M. Grummer-Strawn, D.S.

Freedman, R. Yip, and F.L. Trowbridge. “Increasing

Prevalence of Overweight Among U.S. Low-income

Preschool Children: The Centers for Disease

Control and Prevention Pediatric Nutrition

Surveillance, 1983 to 1995,” Pediatrics 101(1),

January 1998. 

National Association of Farmers’ Market Nutrition

Program. Program Impact Report for the 1998 WIC

Farmers’ Market Nutrition Program. NAFMP,

Washington, DC, May 1999.

National Association of WIC Directors. NAWD WIC

Food Prescription Recommendations. WIC Position

Paper 00-001, 2000. 

National Research Council, Committee on National

Statistics, Division on Behavioral and Social

Sciences and Education. Estimating Eligibility and

Participation for the WIC Program: Phase 1 Report,

2001. 

Ogden, C.L., R.P. Troiano, R.R. Briefel, R.J.

Kuczmarski, K.M. Flegal, and C.L. Johnson.

“Prevalence of Overweight Among Preschool

Children in the United States, 1971 through 1994,”

Pediatrics 99(4), April 1997. 

Oliveira, V., and C. Gundersen. WIC and the Nutrient

Intake of Children. FANRR-5. U.S. Department of

Agriculture, Economic Research Service. March

2000. 

Economic Research Service/USDA The WIC Program: Background, Trends, and Issues/FANRR-27  35
Oliveira, V., M. Prell, E. Frazao, and D. Smallwood.

Infant Formula Prices and Availability: ERS Interim

Report to Congress. U.S. Department of

Agriculture, Economic Research Service, April

2001.

Owen, A.L., and G.M. Owen. “Twenty Years of WIC:

A Review of Some Effects of the Program,” Journal

of the American Dietetic Association 97(7), July

1997.

Randall, B., and L. Boast. Study of WIC Participant

and Program Characteristics 1992. Prepared by Abt

Associates Inc., for U.S. Department of Agriculture,

Food and Nutrition Service, Office of Analysis and

Evaluation, April 1994.

Randall, B., K. Sprague, D.B. Connell, and J. Golay.

WIC Nutrition Education Demonstration Study:

Child Intervention. Report no. CN-01-WICNECI.

Prepared by Abt Associates Inc., for U.S.

Department of Agriculture, Food and Nutrition

Service, Office of Analysis and Evaluation, March

2001a. 

Randall, B., K. Sprague, D.B. Connell, and J. Golay.

WIC Nutrition Education Demonstration Study:

Prenatal Intervention. Report no. CN-01-WICNEPI.

Prepared by Abt Associates Inc., for U.S.

Department of Agriculture, Food and Nutrition

Service, Office of Analysis and Evaluation, March

2001b. 

Rossi, P.H. Feeding the Poor: Assessing Federal Food

Aid. Washington, DC: The American Enterprise

Institute, 1998.

Sargent, J.B, L. Attar-Abate, A. Meyers, L. Moore, and

E. Kocher-Ahern. “Referrals of Participants in an

Urban WIC Program to Health and Welfare

Services,” Public Health Reports 107(2), 1992.

Schwartz, J.B., D.K. Guilkey, J.S. Akin, and B.M.

Popkin. The WIC Breastfeeding Report: The

Relationship of WIC Program Participation to the

Initiation and Duration of Breastfeeding. Prepared

by the Research Triangle Institute for U.S.

Department of Agriculture, Food and Nutrition

Service, September 1992.

U.S. Department of Agriculture, Food and Consumer

Service, Supplemental Food Programs Division. The

WIC Foods and Food Packages, Memo, September

1997. 

U.S. Department of Agriculture, Food and Nutrition

Service, Office of Analysis, Nutrition, and

Evaluation. Cost-Effectiveness of Infant Formula

Rebate Systems in the Special Supplemental Food

Program for Women, Infants, and Children (WIC),

May 1991.

U.S. Department of Agriculture, Food and Nutrition

Service. Final WIC Policy Memorandum 98-

9,Revision 1, Nutrition Risk Criteria, December

1998.

U.S. Department of Agriculture, Food and Nutrition

Service. Annual Historical Review, Fiscal Year

1997, September 1999a.

U.S. Department of Agriculture, Food and Nutrition

Service. Directions: The WIC Program Technology

Newsletter, Spring/Summer 1999b. 

U.S. Department of Agriculture, Food and Nutrition

Service. History of WIC 1974-1999, 25th

Anniversary, Activities Which Led to WIC’s

Establishment.

http://www.fns.usda.gov/wic/menu/new/wic25.htm.

1999c. 

U.S. Department of Agriculture, Food and Nutrition

Service. Budget Division. Program Information

Report (Keydata), U.S. Summary, September 1999,

November 1999d.

U.S. Department of Agriculture, Food and Nutrition

Service. Special Supplemental Nutrition Program

for Women, Infants, and Children (WIC): Eligibility

and Coverage Estimates, 1997 Update, 1999e. 

U.S. Department of Agriculture, Food and Nutrition

Service, Office of Analysis, Nutrition, and

Evaluation. Summary: FY1999 WIC Food Package

Cost Analysis, November 2000a.

U.S. Department of Agriculture, Food and Nutrition

Service, Office of Analysis, Nutrition, and

Evaluation. WIC Infant Formula Rebates–Fiscal

Year 2001, November 2000b. 

36  The WIC Program: Background, Trends, and Issues/FANRR-27 Economic Research Service/USDA
U.S. Department of Agriculture, Food and Nutrition

Service. Fit WIC: National Project Summary.

(Developed for Food and Nutrition Conference and

Exhibition), October 2001a. 

U.S. Department of Agriculture, Food and Nutrition

Service. “WIC Farmers’ Market Nutrition Program:

Program Description.” http://www.fns.usda.gov/

wic/content/fmnp/fmnpfaqs.htm. Updated August

2001b.

U.S. Department of Agriculture, Food and Nutrition

Service, Budget Division. Program Information

Report (Keydata), U.S. Summary, June 2001, August

2001c. 

U.S. Department of Agriculture, Food and Nutrition

Service, Supplemental Food Programs Division,

WIC Policy Memorandum 98-9, Revision 5,

Nutrition Risk Criteria, March 23, 2001d. 

U.S. General Accounting Office. The Special

Supplemental Food Program for Women, Infants,

and Children (WIC)—How Can It Work Better?

Report by the Comptroller General. CED-79-55.

February 1979. 

U.S. General Accounting Office. Need to Foster

Optimal Use of Resources in the Special

Supplemental Food Program for Women, Infants,

and Children (WIC). GAO/RCED-85-105.

September 1985.

U.S. General Accounting Office. Early Intervention:

Federal Investments Like WIC Can Produce Savings

GAO/HRD-92-18. April 1992.

U.S. General Accounting Office. Breastfeeding: WIC’s

Efforts to Promote Breastfeeding Have Increased.

GAO/HRD-94-13. December 1993.

U.S. General Accounting Office. Resources,

Community, and Economic Development Division.

Food Assistance: A Variety of Practices May Lower

the Costs of WIC. GAO/RCED-97-225. September

1997a.

U.S. General Accounting Office. Resources,

Community, and Economic Development Division.

Food Assistance: Working Women’s Access to WIC

Benefits. GAO/RCED-98-19. October 1997b. 

U. S. General Accounting Office. WIC: States Had a

Variety of Reasons for Not Spending Program

Funds. GAO/RCED-97-166. June 1997c.

U.S. General Accounting Office. Information on

Selected Aspects of WIC. GAO/T-RCED-98-128.

1998a.

U.S. General Accounting Office. Information on WIC

Sole-Source Rebates and Infant Formula Prices.

GAO/RCED-98-146. May 1998b.

U.S. General Accounting Office. Resources,

Community and Economic Development Division.

Efforts to Control Fraud and Abuse in the WIC

Program Can Be Strengthened. GAO/RCED-99-

224. August 1999.

U.S. General Accounting Office. Resources,

Community, and Economic Development Division.

Food Assistance: Financial Information on WIC

Nutrition Services and Administrative Costs.

GAO/RCED-00-66. March 2000.

U.S. House of Representatives. A Report to the

Committee on Appropriations, U.S. House of

Representatives, on the Special Supplemental

Nutrition Program for Women, Infants, and

Children. Surveys and Investigations Staff, March

1998. 

U.S. House of Representatives. House Report 107-116.

Agriculture, Rural Development, Food and Drug

Administration, and Related Agencies

Appropriations Bill, 2002. June 27, 2001. 

White House Conference on Food, Nutrition and

Health, 1970. 

Woelfel M.L., R. Pruzek, H. Stratton, D. Hernandez,

Shackman G., and R. AbuSabha. Barriers to

Retention Among NYS WIC Infants and Children.

New York State Department of Health, Division of

Nutrition, Evaluation and Analysis Unit. December

2001.

Economic Research Service/USDA The WIC Program: Background, Trends, and Issues/FANRR-27  37
Since 1998, USDA’s Economic Research Service

(ERS) has had responsibility for conducting studies

and evaluations of the Nation’s domestic food and

nutrition assistance programs, including WIC. ERS

established the Food Assistance and Nutrition

Research Program (FANRP) to carry out this responsibility. FANRP projects utilize the capabilities of both

external researchers and ERS staff and are designed to

meet the critical information needs of program managers, policy officials, the research community, and the

public at large. USDA’s Food and Nutrition Service

(FNS), the agency responsible for administrating

USDA’s food and nutrition assistance programs, also

sponsors studies and analyses that inform policymaking and management of FNS programs, and coordinates program-related nutrition policy and services.

Some of the ongoing WIC-related research projects at

ERS and FNS are summarized below. More information on ERS’s WIC-related research can be found at

the ERS website at http://www.ers.usda.gov.

Information about the status of ongoing WIC-related

studies funded by FNS can be found at the FNS website at http://www.fns.usda.gov/fns.

ERS Studies:

Report to Congress on WIC Program CostContainment Practices and their Impacts

Objective: to access the effects of cost-containment

practices by WIC State agencies—such as limiting

brand-named products in the WIC food package—on

program participation, access to and availability of

prescribed foods, voucher redemption rates, actual

food selections by participants, participants on special

diets or with specific food allergies, participant use of

and satisfaction with prescribed foods, achievement of

positive health outcomes, and program costs. Awarded

to Abt Associates. An interim report to Congress was

released in February 2001 (Kirlin and Cole, 2001); the

final report is due summer 2002. 

Report to Congress on Infant Formula Prices

and Availability

Objective: to determine the number of suppliers of

infant formula in each State or major marketing area,

and to compare the cost of formula that is included in

the WIC rebate program versus the cost of formula

that is not included in the WIC rebate program.

Conducted by ERS. An interim report to Congress was

released in April 2001 (Oliveira et al., 2001). The final

report may be found on the ERS website at

http:\\www.ers.usda.gov\publications\efan02001.

Obesity in Low-Income Mothers and Children

Objective: using a data set that links WIC administrative data with birth certificate data on approximately

35,000 mother-child pairs, the study will examine factors that may influence the probability that by age 4 a

WIC child with an obese mother will also be obese.

Awarded to the Children’s Hospital Medical Center,

University of Cincinnati College of Medicine. The

final report is due winter 2002/2003. 

Economic Benefits of a Breastfeeding

Promotion: A Controlled Clinical Trial

Objective: to evaluate the benefits of a breastfeeding

promotion intervention campaign among low-income

women. A randomized controlled clinical trial will

examine the effects on breastfeeding prevalence and

duration, infant health, and infant medical costs of providing the mother with personalized breastfeeding

counseling. Awarded to the Montefiore Medical

Center, Albert Einstein College of Medicine. The final

report is due winter 2002/2003.

38  The WIC Program: Background, Trends, and Issues/FANRR-27 Economic Research Service/USDA

Appendix

Ongoing WIC-Related Research Funded 

by the Economic Research Service 

and the Food and Nutrition Service
Expert Review of Methodology for Estimating

Number of Individuals Eligible for WIC

Objective: to review the methodology that USDA uses

in preparing estimates for how many individuals are

eligible for, and likely to participate in, the WIC program. The project is being conducted in two phases.

During Phase I, the National Research Council

reviewed the current eligibility and participation estimation methodology and pertinent literature, conducted a workshop, and issued a report that provides an

assessment of the methodology (National Research

Council, 2001). The objective of Phase II will be to

achieve consensus on recommendations concerning a

methodology for estimating eligibility for, and participation in, the WIC program. This phase of the work

may also include preparing and critiquing test estimates produced using different methodologies under

consideration by the panel. The final report is due

summer 2003. 

Identify and Evaluate Methods to Prevent

Fraud and Abuse Among Staff and

Participants in WIC

Objective: to identify and evaluate the best tools for

detecting fraud and abuse by WIC staff or participants.

This study will review existing tools and data systems

presently in use by some WIC State agencies for

detecting fraud and abuse among WIC vendors.

Awarded to Applied Techno-Management Systems,

Inc. The final report, in two volumes, was posted on

the ERS website in early 2002 at

http://www.ers.usda.gov/publications/efan01011 and

http://www.ers.usda.gov/publications/efan01012.

Factors Associated with Iron Status Among

WIC Infants in Rural West Virginia

Objective: to collect primary data on WIC infants and

toddlers, ages 6 to 24 months, in West Virginia counties that are known to have high rates of iron-deficiency anemia, to identify dietary factors that are associated with poor iron status, and to provide data that can

be used to design and implement effective nutrition

education and intervention programs. Awarded to West

Virginia University Research Corporation. The final

report is due spring 2003.

Diet Intake and Health Outcomes

Objective: to develop and evaluate dietary assessment

tools for young children that can be used in WIC program centers, recognizing that adaptations may be

needed for culturally diverse populations. The tools

will serve several functions, including screening for

dietary patterns that do not meet Federal dietary recommendations, facilitating the triage of patients for

services, and serving as the basis for general nutrition

education. Awarded to Harvard School of Public

Health and Research Triangle, Inc. The final report is

due winter 2001/2002.

Feasibility and Accuracy of Record Linkage to

Estimate Multiple Program Participation

Objective: to identify the feasibility of linking the

administrative data files from food stamps, WIC, and

child nutrition programs to facilitate analysis of multiple program participation and to improve program

operations in such areas as one-stop shopping, adjunctive eligibility determination, program integrity, and

administrative and client burden. Conducted by Abt

Associates. The final report is due winter 2002/2003.

Early Childhood Longitudinal Study—Birth

Cohort 2001

Objective: to support enhanced data collection necessary to examine the link between WIC participation in

infancy and childhood to cognitive development, obesity, and food security by adding a bank of questions

to the Early Childhood Longitudinal Study—Birth

Cohort (ECLS-B) conducted by the National Center

for Educational Statistics, U.S. Department of

Education. Added questions include information on

WIC participation, infant feeding practices, health

care, height and weight, and related information.

Interagency agreement with the U.S. Department of

Education. 

FNS Studies:

Dietary Risk in the WIC Program: A Scientific

Assessment

Objective: to review the scientific basis for methods

currently employed in the dietary risk assessment of

individuals for eligibility to participate in WIC. In

phase one, funded by FNS, the National Academy of

Sciences convened an expert committee to develop a

framework for assessing dietary risk among WIC

Program applicants, focusing in particular on Failure

to Meet Dietary Guidelines as a risk criterion for

women and children. An interim report was released in

October 2000 (Institute of Medicine, 2000). In the second phase of the study, funded by ERS, the Committee

will review a variety of approaches, and recommend

one or more for use in WIC. They will also recomEconomic Research Service/USDA The WIC Program: Background, Trends, and Issues/FANRR-27  39
mend specific cutoffs for establishing WIC eligibility

of women and children using the recommended

approach(es) using the decision framework developed

for this project, and identify specific areas in which

additional research or instrument development may be

needed to fully implement the recommended

approach(es). The release of the final report is scheduled for 2002.

Adolescent WIC Participants Study

Objective: To describe WIC’s benefits and services

through the perception of adolescent WIC participants.

This project is in light of the fact that pregnant teens

and/or adolescent mothers may have different needs

than other WIC participants. Program areas in which

the needs of WIC adolescents may differ from those of

WIC clients as a group include: Knowledge of nutrition, Adoption of healthy dietary practices, Knowledge

of available health care services, and Access to available services. FNS surveyed a representative sample of

pregnant adolescents and adolescent mothers who

were enrolled in WIC. This survey provides precise

estimates of the magnitude of teen clients’ needs. A

concurrent survey of local WIC agencies describes

activities undertaken at the local level to address needs

of adolescent participants. Focus groups of eligible

nonparticipating adolescents provide insight into needs

of adolescents not covered by the survey. 

WIC/CHIP Enrollment Demonstration Project

Objective: to evaluate the feasibility and costs of using

WIC clinics to identify and enroll eligible children in

Medicaid and the Children’s Health Insurance Program

(CHIP). Conducted by the Indiana Department of

Health in conjunction with FNS. The Indiana

Department of Health will conduct Medicaid/CHIP

enrollment for approximately 2 years in about 20 WIC

clinics. Each site will receive up to $10,000 each fiscal

year for the project. The demonstration project studies

the number of children enrolled in Medicaid/CHIP,

income levels of families enrolled, cost of enrollment

activities, effect of enrollment of activities on WIC

clinic operations and caseloads, and other factors that

are not yet determined by FNS.

Participant Characteristics Monograph Series

Conducted by Abt Associates Inc. Monographs will be

produced on two topics: Native Americans and overweight children. Each monograph will include a profile of the sociodemographic characteristics, risk profiles and health care usage patterns of the relevant

group of participants. These reports will be based primarily on data available in the biennial participant

characteristics data sets. The report on overweight

children is available on the FNS website (Report No.

WIC-01-PCOM).

Survey of State Public Health Nutrition

Workforce

Objective: to monitor trends in the education and training, work experience, areas of practice, and training

needs of the public health nutrition workforce at the

State and local government levels. The Association of

State and Territorial Public Health Nutrition Directors

(ASTPHND) in cooperation with FNS, is conducting a

survey of public health nutritionists to monitor trends

in education and training, work experience, areas of

practice and training needs. ASTPHND has conducted

similar surveys periodically beginning in 1985. A profile describing the workforce will assist the FNS in

determining the extent to which the current and future

workforces have the necessary requirements to carry

out the WIC program. A final report is due to FNS in

2002. 

40  The WIC Program: Background, Trends, and Issues/FANRR-27 Economic Research Service/USDA