Effects of Reduced Juice Allowances in Food Packages for

DOI: 10.1542/peds.2012-3471; originally published online April 29, 2013;Pediatrics

Tatiana Andreyeva, Joerg Luedicke, Amanda S. Tripp and Kathryn E. Hendersonand Children Program

Effects of Reduced Juice Allowances in Food Packages for the Women, Infants,

http://pediatrics.aappublications.org/content/early/2013/04/24/peds.2012-3471

located on the World Wide Web at: The online version of this article, along with updated information and services, is

of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2013 by the American Academy published, and trademarked by the American Academy of Pediatrics, 141 Northwest Pointpublication, it has been published continuously since 1948. PEDIATRICS is owned, PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly

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Effects of Reduced Juice Allowances in Food Packagesfor the Women, Infants, and Children Program

WHAT’S KNOWN ON THIS SUBJECT: Juice consumption among2- to 5-year-old children exceeds dietary recommendations. In2007, the US Department of Agriculture revised the compositionand quantities of prescribed foods in WIC food packages to alignthem with dietary guidelines. Juice allowances were reduced byapproximately half.

WHAT THIS STUDY ADDS: WIC participants purchased abouta quarter less juice volume after implementation of the revisedWIC packages. Large reductions in WIC-provided juice were onlypartly compensated for by extra juice purchases with non-WICfunds. Little compensation occurred for other beverages.

abstractOBJECTIVES: In 2009, the Special Supplemental Nutrition Program forWomen, Infants, and Children (WIC) implemented revisions to the com-position and quantities of WIC food packages. Juice allowances werereduced by approximately half. This report describes changes in pur-chases of 100% juice and other beverages among WIC participants af-ter the WIC revisions.

METHODS: Scanner data from a New England supermarket chain wereused to assess juice and other beverage purchases among 2137 WIC-participating households during a 2-year period (N = 36 051household-months). Purchased beverage amounts were comparedbefore (January–September 2009) and after (January–September2010) implementation of the revised WIC packages. Generalizedestimating equation models were used.

RESULTS: Before the revisions, WIC juice accounted for two-thirds ofpurchased juice volume among WIC households. After implementationof the revisions, WIC juice purchases were reduced on par withallowance changes (43.5% of juice volume, 95% confidence interval[CI] 41.9%–45.1%). This reduction was only partly compensated for byan increase of 13.6% (8.4%–19.0%) in juice purchases using personaland other non-WIC funds. In total, juice purchases declined by 23.5%(21.4%–25.4%) from an adjusted monthly total of 238 oz to 182 oz perhousehold. WIC households increased purchases of fruit drinks by20.9% (14.9%–27.3%) and other noncarbonated beverages by 21.3%(12.1%–31.2%) but purchased 12.1% (8.1%–15.0%) less soft drinks.

CONCLUSIONS: After the WIC revisions, total purchases of 100% juiceamong WIC households declined by about a quarter, with little compen-sation occurring from non-WIC funds for juice and other beverages. Thepublic health impact of the shift in beverage purchase patterns couldbe significant. Pediatrics 2013;131:919–927

AUTHORS: Tatiana Andreyeva, PhD,a Joerg Luedicke, MS,a

Amanda S. Tripp, MPH,b and Kathryn E. Henderson, PhDa

aRudd Center for Food Policy and Obesity, and bYale School ofPublic Health, Yale University, New Haven, Connecticut

KEY WORDSfood assistance, WIC, juice, food policy

ABBREVIATIONSEBT—electronic benefit transferSNAP—Supplemental Nutrition Assistance ProgramUPC—Universal Product CodeWIC—Special Supplemental Nutrition Program for Woman,Infants, and Children

Dr Andreyeva conceptualized and designed the study, carriedout initial analyses, contributed to drafting and revising theinitial manuscript, and approved the final manuscript assubmitted; Mr Luedicke carried out the final analyses,contributed to drafting and revising the initial manuscript andinterpretation of results, and approved the final manuscript assubmitted; Ms Tripp contributed to data preparation andanalyses, revised the initial manuscript and interpreted results,and approved the final manuscript as submitted; andDr Henderson contributed to drafting and revising the initialmanuscript and interpretation of results and approved the finalmanuscript as submitted.

The views expressed in this article are those of the authors anddo not necessarily represent the official views of EconomicResearch Service or US Department of Agriculture.

www.pediatrics.org/cgi/doi/10.1542/peds.2012-3471

doi:10.1542/peds.2012-3471

Accepted for publication Jan 29, 2013

Address correspondence to Tatiana Andreyeva, Rudd Center forFood Policy and Obesity, Yale University, 309 Edwards St, NewHaven, CT 06520-8369. E-mail: [email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2013 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have no financialrelationships relevant to this article to disclose.

FUNDING: Supported by a grant from the Economic ResearchService at the US Department of Agriculture.

PEDIATRICS Volume 131, Number 5, May 2013 919

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The Special Supplemental Nutrition Pro-gram for Women, Infants, and Children(WIC)hasprovidedasetofnutrient-densefoods, nutrition education and medicalreferrals to approximately half of allinfants born in the United States anda quarter of all children ages 1–4,pregnant and postpartum women.1 Dueto its broad reach and targeted impacton young children at high risk, WIChas significant capacity for early in-tervention to establish healthy eatinghabits and prevent obesity in low-incomeyouth. In 2009, on recommendation fromthe Institute of Medicine, WIC imple-mented revised WIC food packages thatalign with dietary guidelines to consumeless fat and sugar and more fiber.2

Noteworthy changes included a re-duction in dairy fat, the addition of wholegrains and cash-value vouchers forfruits and vegetables, and reduced milkand juice allowances. These were thelargest WIC package changes since theprogram’s inception in 1972, which pro-vided a unique natural experiment forassessing effects of the revisions onbehavior and nutrition outcomes in low-income communities.

Before the WIC food package revisions,the federal monthly allowance of 100%juice to WIC-participating 1- to 4-year-old children was 288 oz, althoughsome states provided less juice (eg,192 oz in Connecticut and 184 ozin Massachusetts).3 These provisionslargely exceeded dietary recommenda-tions for juice consumption in youngchildren (4 oz/d4,5). After the revisions,WIC-participating children in all statesreceive 128 oz/mo. Juice is no longerallowed for infants; women partic-ipants had their juice reduced by abouthalf.6 Even after a considerable re-duction, WIC still provides enough juiceto meet the maximum recommendedlevel of juice intake in young children.WIC-participating children almost cer-tainly receive juice from other sourcesas well (eg, childcare, restaurants).7

It is currently unknown how the re-duced WIC juice allowances affectedjuicepurchasesandconsumptionamongWIC participants. One hypothesis isthat all or most of the reduction in WIC-provided juice was substituted withincreased juice purchases using non-WIC funds (eg, cash). If such compen-sation occurred, no significant changesin juice consumption would be ob-served. It is also possible that WICparticipants chose to substitute the lostjuice allowances from WIC with in-creased purchases of less nutritiousbeverages such as fruit drinks or soda,whichwould be an unintended negativeconsequenceof theWICrevisions. Thesesubstitutes are never allowed by WICbut could appeal to participants due totheir lower cost. This study describesthe effect of the WIC food packagerevisions on supermarket purchases of100% juice and other beverages amongapanel ofWIC-participatinghouseholdsin New England.

METHODS

Scanner Data

The data come from a New Englandsupermarket chain with .60 stores intwo states. The chain has a loyalty cardsystem, which provides card users withaccess to store promotions. At least90% of the chain transactions includethe use of a loyalty card. The currentanalysis excludes purchases madewithout the use of loyalty cards, as theycannot be tracked over time. There is noidentifiable information about house-holds using loyalty cards, such associodemographics or availability ofmultiple cards per family. Each loyaltycard is assumed to represent 1 house-hold. The study was based on deidenti-fied secondary data and exempt frominstitutional review board approval.

Data on every purchase include in-formation about products purchasedand types of payment used, includingSNAP benefits via electronic benefit

transfer (EBT), WIC benefits via paper-based vouchers, nonfood EBT (cashassistance), and personal funds (eg,cash).Themajorityofpurchases(∼80%)have a single method of payment.A household’s use of SNAP, WIC, and/ornonfood EBT benefits indicates its par-ticipation in the respective programat the time of the purchase. Programparticipants can have purchases forwhich they use only personal funds;participation is assessed based onmultiple purchases during each monthof the analysis.

Participants

The sample is conditioned on WIC par-ticipation to provide a policy-relevantsubset of low-income young families.Household WIC participation is de-termined based on the use of WICbenefits (ie, WIC purchase) at the chain.The panel is unbalanced as householdsjoined the sample at different points intime; many did not shop at the chainevery month. Approximately half of WIChouseholds also used SNAP benefits. Nodatawere collected for households thatnever participated inWIC due to incomeineligibility or self-selection into non-participation.

In a pre–post design, the current studyused data for households that partici-pated in WIC before and after the WICrevisions implementation in October2009. Households were selected if theyused WIC benefits during January–September 2009 and January–September2010, excluding a 3-month transitionperiod after the implementation toavoid misinterpretation of data.1* TheWIC sample with pre–post data werealso restricted to households usingWICbenefits regularly (ie, at least once ineach of the 3 quarters in 2009 and2010). Each household’s purchaseswere aggregated at themonthly level; if

*Old WIC checks were allowed for redemption upto 3 months after implementation.

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a household made multiple purchasesthatmonth, theywere summed. The finalsample included 2137 WIC householdsproviding 36 051 observation-months.

Beverage Identification

The grocery chain provided data on allproducts sold at the store, including 392119 Universal Product Codes (UPCs) andPrice-Look Up codes for products soldby weight. All beverages purchasedwere selected and coded for their con-tainer size, beverage type, and sweet-ener type. Two coders independentlyperformed cross-verification of bever-age UPCs using data from the store UPCdescription, ingredient lists in theGladson’s Nutrition Database,8 or Inter-net searches for UPCs or brand names.A total of 615 UPCs were identified as100% fresh (concentrate or not) or asfrozen fruit or vegetable juice, all with-out added sweeteners. More details onbeverage identification and categoriza-tion are available elsewhere.9

Outcome Variables

The primary outcome was total volume(or amount) of 100% juice purchased ina given month, measured in fluid oun-ces. In addition, juice purchases weredistinguished by payment type, such asthe amount of juice purchased with WICbenefits, juice purchasedwith personalfunds or cash assistance, and juicepurchased with SNAP benefits. Thestudy also assessed changes in thepurchased amounts of fruit drinks, softdrinks, bottled water, and new agebeverages (ie, sports drinks, energydrinks, flavored water, and ready-to-drink tea and coffee).

Predictor Variables

The main predictor was an indicatorvariable for preimplementation andpostimplementation periods of theWIC food package revisions: January–September 2009 and January–September 2010, respectively. A set of

household-level monthly variables in-cluded indicators for the state of thestore location, household’s SNAP par-ticipation, and receipt of nonfood cashassistance (assessed based on usingnonfood EBT). Total household monthlygrocery expenditure was included toaccount for differences in availablegrocery funds for shopping at thegrocery chain. Finally, a set of store-level variables was included to cap-ture differences in the socioeconomiccomposition of the areas surroundingsupermarkets, which may reflect neigh-borhood differences in prices andproduct selection and marketing, aswell as to serve as proxies for un-observed household-level sociodemo-graphics. Each store was linked toa census tract where it was located,with the census-level 5-year estimatesover 2006–2010 American CommunitySurvey data10 extracted for each tract.The average of census-tract measureswas calculated for household mem-bers shopping in multiple stores.

Regression Analysis

Because the outcome variables arenonnegative and positively skewed,generalized linear models from thePoisson family with a logarithmic linkfunction11 were used. To account forrepeated observations within house-holds, the models were estimated us-ing generalized estimating equations12

with an exchangeable working corre-lation and robust SEs. Each outcomewas evaluated in 2 models. The firstmodel included a binary indicator forthe implementation period to esti-mate the adjusted mean differencebetween the 2 periods, controlling forcovariates. The model can be written as:

E½YitjXi; Xit� ¼ expðb0 þ b1 � PERIODitþ b2 � STATEi þ b3 � SNAPitþ b4 � EBTit þ b5 � TOTEXPitþ b6 � Tit þ b7 � CitÞ ð1Þ

where PERIODit is a period indicator(coded 1 for postimplementation);

STATEit is an indicator for the state inwhich household i shopped; SNAPitindicates SNAP participation for house-hold i at time t, EBTit is receipt of non-food cash assistance by household i attime t, TOTEXPit is total grocery expen-diture for household i at time t, and Titis a set of 8 indicator variables for themonth of purchase. Cit denotes a vectorof store-level sociodemographic cova-riates, reported in Table 1.

The second model analyzed temporalaspects within and between the 2periods to rule out potential markettrends, which could coincide withimplementation of the WIC revisions.Thiswas assessedby including amonthof the year as a continuous covariatewith second- and third-degree poly-nomials and interaction terms betweenthe month and the implementationperiod to check whether the fittedslopes differed across the 2 periods.The model selection included 2 steps:models with the second- and third-degree polynomials were fit to thedata, and the best fit was determinedbased on the quasi-likelihood under theindependence model information cri-terion and graphical and substantialassessments of the model fit.12 In thenext step, interaction terms with timeperiods were built to test whethereither quadratic or cubic slopeswere statistically significantly differentacross the 2 periods. If this was not thecase, the model without interactionterms was used. In addition, graphicinspections of the model fit were usedto check if a more parsimonious modelwas justified.

RESULTS

Before the implementation of the WICrevisions, WIC households purchasedon average 236 oz of 100% juice permonth, including 155 oz purchasedwith WIC benefits (Table 1). Personalfunds and SNAP benefits paid for aboutone third of all juice purchased. As the

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new WIC packages were implemented,WIC households purchased much lessjuice in total and with WIC benefits inparticular, an average monthly volumeof 174 and 84 oz, respectively. Juicepurchases with personal fundsremained flat, whereas monthly pur-chases with SNAP benefits by SNAPhouseholds increased by 9 oz. At thesame time, purchases of less nutri-tious fruit drinks increased betweenthe 2 periods, from 72 to 84 oz/mo, onaverage. A similar trend was seen fornew age beverages (76 to 89 oz). Therewas a considerable decline in pur-chases of the largest category of re-freshment beverages, soft drinks,which decreased from 277 to 236 oz,potentially reflecting ongoing mar-ket trends of shifting away fromsoda.13,14 WIC participants also re-duced amounts of bottled water from122 to 101 oz.

Figure 1 presents unadjusted data onpurchased monthly amounts of 100%juice and other beverages in January2009–September 2010. The expectedseasonal variation reflects the peaksin purchases in July–August for allbeverages and troughs in January–February for fruit drinks and otherrefreshment beverages, similar togeneral market trends.15 In contrast,100% juice had higher than averagepurchases in January, especially in2009.

Estimation results of the pre–postimplementation differences in pur-chases are reported in Table 2. Thevalues shown are exponentiated co-efficients from the Poisson modelsand can be interpreted as a per-centage change in the outcome[(exp(b) 2 1) 3 100] between thepreimplementation and postimple-mentation periods, after controlling

for household- and store-level cova-riates.1† After implementation, WICparticipants reduced total juice pur-chases by 23.5% (95% confidence in-terval [CI] 21.4%–25.4%), from 238 to182 oz (adjusted monthly). This re-duction was driven by a much largerdecline in juice purchased with WICbenefits, by 43.5% (41.9%–45.1%), from154 to 87 oz monthly, which reflectedlower juice allowances in the revisedWIC food packages. Juice purchaseswith personal funds, SNAP benefitsand nonfood cash assistance in-creased modestly by 13.6% (8.4%–19%), from 84 to 95 oz/mo. This in-crease in non–WIC-provided juicepurchases is considerably short ofmatching the reductions of WIC-provided juice.

TABLE 1 Descriptive Statistics

Preimplementation Period:January–September 2009

Post-implementation Period:January–September 2010

Mean SD Minimum Maximum Mean SD Minimum Maximum

Purchased amounts of 100% juice, oz/moWith WIC funds 155 151 0 1488 84 93 0 832With personal/nonfood cash assistance funds 48 126 0 4283 49 131 0 3744With SNAP funds 32 100 0 1983 41 111 0 1984Total, all payment types 236 228 0 5051 174 202 0 3872

Purchased amounts of other refreshment beverages, oz/moFruit drinks 72 174 0 4104 84 188 0 3480Soft drinks 277 469 0 9164 236 432 0 10 140Bottled water 122 334 0 5922 101 286 0 3840New age beverages 76 244 0 5974 89 330 16 761

Household-level covariatesSNAP participation 0.45 0.50 0 1 0.52 0.50 0 1Receipt of nonfood cash assistance 0.05 0.22 0 1 0.05 0.21 0 1Total monthly grocery expenditure, $ 235 190 0 1821 219 183 0 1620

Shopped area-level covariatesHousehold income, $10 000 5.6 1.6 2 12.2 5.6 1.6 2 12.2High-school graduates, % 33.6 7.1 10.2 46 33.6 7.1 10.2 46College graduates, % 15.9 5.8 4.9 32.7 15.9 5.8 4.9 32.7Non-English language at home, % 15.9 12 4 50.5 16 12 4 50.5Unemployed, % 8.1 2.8 1.5 16.5 8.1 2.8 1.5 16.5SNAP participants, % 11.1 8.4 0.4 33.3 11.2 8.4 0.4 33.3Households in poverty, % 8.5 6.4 0 26.5 8.6 6.4 0 26.5Non-Hispanic white, % 83.5 13.3 20.6 97.7 83.5 13.2 20.6 97.7Non-Hispanic African-American, % 3.8 5.3 0 36 3.7 5.1 0 36

N (observations) 17 740 18 311N (households) 2137 2137

New age beverages include energy drinks, sports drinks, flavored water, and ready-to-drink tea and coffee. Fruit drinks and other refreshment beverages cannot be purchased with WICbenefits. Store-level sociodemographics represent the census tract–level demographics of the store locations where household members shop.

†Full model results are available from the authorson request.



The effects were similar among WIChouseholds also using SNAP benefits(Table 2). Their postimplementationpurchases of 100% juice amounts de-clined in total by 22.2% (19.4%–24.9%).Juice amounts purchased with WICbenefits were, on average, reduced by43.6% (41.2%–45.9%). There was nochange in juice purchased with per-sonal funds, and juice amounts pur-

chased with SNAP benefits increasedby 14.3% (6.1%–23.2%). Changes in thetotal amounts of fruit drinks and otherbeverages were similar to the resultsfor all WIC households.

Figures 2 and 3 present estimationresults from the time–slope modelsthat control for temporal trends in thedata. They show the marginal pre-dictions and their confidence intervals

at discrete points in time, averagedacross other covariates in the model.The figures depicts a significant re-duction in WIC-provided (Fig 2A) andtotal juice purchases (Fig 2D) betweenthe 2 periods of analysis. Fruit drinksincreased significantly during this time(Fig 3A), but baseline purchase levelswere low and the monthly average in-crease was ∼10 oz. There was no shift

FIGURE 1Unadjustedmonthly averages of purchasedbeverage volumebeforeandafter implementation of theWIC foodpackage revisions. The shaded area indicates thetransition period after the WIC revisions implementation from October to December 2009. Soft drinks are carbonated diet and regular soft drinks; new agebeverages include energy drinks, sports drinks, flavored water, and ready-to-drink tea and coffee.

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of purchases to other beverages suchas soft drinks (Fig 3B) or bottled water(Fig 3C). A slight increase was ob-served for new age beverages (Fig 3D),which likely reflects a general markettrend rather than a substitution effect.Purchases of energy drinks, sportsdrinks, and teas have been increasingrapidly over the past years while con-sumers have been shifting away fromsoft drinks.13

DISCUSSION

The current analysis shows that WIC-participating households purchasedabout a quarter less juice volume afterimplementation of the revised WIC foodpackages. Large reductions in WIC-provided juice were only partly com-pensated for by juice purchases withnon–WIC-provided funds. This indicatesthat WIC participants did not seek to

purchase the amounts of juice pro-vided by WIC before the food pack-age revisions. This conclusion echoesprevious data documenting that WIC-participating children were receivingexcessive amounts of 100% juice be-fore the WIC revisions (9.5oz/d), al-most twice the American Academy ofPediatrics–recommended daily limitfor preschool-age children.7,16 To ourknowledge, this is the first analysis todocument changes in juice purchasesamong WIC participants after the WICrevisions.

Another important finding of this studyis that the WIC revisions were not ac-companied by unintended negativeconsequences of the policy change,such as a dramatic increase in pur-chases of cheaper and less nutritiousbeverage substitutes. An increase inpurchases of fruit drinks and new age

beverages was overcompensated byreduced purchases of soft drinks, mostof which were sugar-sweetened.9,17

Reductions in soft drink purchasescould reflect ongoing market trends(soft drink sales have been decliningsince 2004, especially in the past severalyears17) or WIC success in nutritioneducation of participants. A reductionin juice and sugar consumption amongWIC participants was one of the goalsfor the revisions in the WIC food pack-ages.2 The current study documentsWIC success in this domain, at leastamongWIC-participating households inNew England. This is an importantpublic health achievement given thehigh prevalence of obesity in very youngchildren, particularly from low-incomefamilies.18

Although 100% fruit juices are widelymarketed as healthy beverages,19 theircaloric content is similar to one ofsodas, and they lack fiber present inwhole fruit. Excessive consumption of100% juice has been associated withincreased risk of weight gain20–22 anddental caries.22 Mounting evidencesupports the role of limiting con-sumption of 100% juice and otherenergy-dense beverages, in part be-cause liquid carbohydrates from bev-erages are poorly compensated for byreduced caloric intake elsewhere23,24

In addition, a recommended daily limitdoes not imply that children shouldconsume juice on a daily basis. Accord-ing to the American Academy of Pediat-rics, juice offers no nutritional advantageover whole fruit for children.6 monthsold.

Exposure to significant amounts ofenergy-dense sweet beverages is par-ticularly concerning in young children.The sweet taste of beverages makesthem more palatable than water, andchildren like sweet foods. Frequentconsumption of sweet beverages, in-cluding 100% juice, could affect child-ren’s taste sensitivity and make them

TABLE 2 Changes in Purchased Beverage Amounts After Implementation of the Revised WIC FoodPackages

Pre Post Differences inPurchased Volume

exp(b) 95% CI

All WIC households (N = 2137)100% JuiceTotal purchases 0.765*** 0.746–0.786Purchases with WIC benefits 0.565*** 0.549–0.581Purchases with non-WIC funds 1.136*** 1.084–1.190

Other beveragesFruit drinks 1.209*** 1.149–1.273Soft drinks 0.879*** 0.850–0.909Bottled water 0.864*** 0.813–0.918New age beverages 1.213*** 1.121–1.312

WIC households using SNAP benefits (n = 1584)100% JuiceTotal purchases 0.778*** 0.751–0.806Purchases with WIC benefits 0.564*** 0.541–0.588Purchases with SNAP benefits 1.143*** 1.061–1.232Purchases with personal funds 1.038 0.944–1.142

Other beveragesFruit drinks 1.208*** 1.129–1.293Soft drinks 0.891*** 0.850–0.933Bottled water 0.859*** 0.790–0.934New age beverages 1.121* 1.018–1.236

Presented are exponentiated coefficients [exp(b)] and 95% CIs for the binary variable indicating the time periods before(January–September 2009) and after (January–September 2010) the WIC food package revisions from separate generalizedestimating equation regression models for longitudinal data with a logarithmic link function (Poisson family); all modelsincluded control variables as shown in Equation 1. New age beverages include energy drinks, sports drinks, flavored water,and ready-to-drink tea and coffee. Fruit drinks and other refreshment beverages cannot be purchased with WIC benefits;SNAP households refer to households using SNAP benefits on the month of analysis; *P , .05; **P , .01; ***P , .001.



more averse to less sweet foods.25 Waterand low-fat milk could be convenientalternatives to energy-sense sweet bev-erages. More work is necessary to ed-ucate parents about healthy beverageoptions for their children. Pediatricians,dentists, and WIC nutritionists can playa crucial role in informing parents abouthealthy beverages for their children.The WIC program has already improvedbeverage consumption among WICparticipants through nutrition educa-tion and the revisions in WIC packages.

Continuing efforts are important tomaintain focus on reducing sugar andcaloric beverage intake in youth.

This study has a number of strengths. Ituseduniquedata ongrocery purchasesof .2000 WIC-participating house-holds during the pre–post imple-mentation period. The source ofpayment for groceries was available toexamine the use of WIC and SNAP ben-efits along with personal funds. Gen-eralized estimating equation modelswere used to assess changes in bev-

erage purchases of WIC households.The analysis was also subject to limi-tations. Data were from two New Eng-land states, which may differ inbeverage purchase patterns from otherregions. For example, per capita pur-chases of 100% juice were consider-ably higher in the northeast than inthe southwest or south, while softdrink consumption in the south andwest central region was more thandouble that observed in the Pacificarea in 2008.14,17 Given the lower

FIGURE 2Predicted purchases of 100% juice (marginal volumes and their 95% CIs) before and after implementation of the WIC food package revisions.

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baseline juice allowances in Connec-ticut and Massachusetts, the imple-mentation effects could be moresignificant in states with higher base-line allowances and larger relativereductions in juice after the revisions.In addition, no household sociodemo-graphic characteristics were availablein this study, including no data about

how juice and other beverage con-sumption was partitioned betweenmembers of WIC households. Finally,these data reflect purchase behaviorsat a single grocery chain and donot represent all household bever-age purchases and actual beverageconsumption by the household or in-dividual WIC participants.

CONCLUSIONS

These data support the positive impact ofthe revised WIC food packages on over-all purchases of 100% juice by WIC-participating households. Importantly,decreased juicepurchasesdonot appeartobeoffsetbyanincrease in thepurchaseof other caloric, less healthy beverages,such as soda. On a population level, such

FIGURE 3Predictedpurchasesof otherbeverage (marginal volumesand their 95%CIs) beforeandafter implementationof theWIC foodpackagerevisions. Soft drinks arecarbonated diet and regular soft drinks; new age beverages include energy drinks, sports drinks, flavored water, and ready-to-drink tea and coffee.



a shift in beverage purchase patternscould significantly affect health out-comes related to excessive consump-tion of caloric beverages in vulnerablepopulations. Future research shouldexplore the impact of the revised WIC

food packages on dietary intake in WICparticipants nationwide.

ACKNOWLEDGMENTSThe authors thank Victoria Zigmontfor excellent research assistance and

Rachel Colchamiro and Caroline Cookefor helpful advice on the state-specificimplementationof theWIC foodpackagerevisions. Special thanks go to the con-fidentialgrocerystorechain forsharingits data.

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DOI: 10.1542/peds.2012-3471; originally published online April 29, 2013;Pediatrics

Tatiana Andreyeva, Joerg Luedicke, Amanda S. Tripp and Kathryn E. Hendersonand Children Program

Effects of Reduced Juice Allowances in Food Packages for the Women, Infants,

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