3-2024 updated

Connecticut WIC Program Manual

WIC 300-03 SECTION: Nutrition Services

SUBJECT: Nutrition Education

Federal Regulations: §246.11(c)(6) Nutrition Services Standards: Standard 7: Nutrition Education and Counseling See also WIC Policies 100-14, 100-15, 200-28, 300-01, 300-09 and 300-15 POLICY Nutrition education shall be made available to each participant, parent, guardian, or caretaker at a rate of at least once per quarter, but not necessarily taking place within each quarter. Contacts shall be made available through individual or group sessions, which are appropriate to the individual participant’s nutritional needs, interests, household situation, cultural preferences, language spoken, literacy level and religious values. Nutrition education can be conducted in any of the following ways: in person, over the phone, using a virtual video platform and/or online nutrition education modules (WICSmart). Nutrition education must be provided with participant-centered counseling approaches and based upon the current U.S. Dietary Guidelines for Americans https://www.dietaryguidelines.gov/. Nutrition education is based on the participant’s individual nutrition assessment and connected to positive health outcomes established for the participant’s category. All pregnant participants shall be encouraged to breastfeed unless contraindicated for health reasons. Guidance

Staff should use participant-centered counseling approaches to support participants in identifying their own motivation for change, setting individualized and attainable goals while providing clear and relevant “how to” actions to accomplish those goals.

Nutrition education should be tailored to address the specific needs of migrant farm workers, homeless individuals, individuals with substance use disorder, high-risk participants, and /or breastfeeding women. WIC staff should also consider the following when providing nutrition education and breastfeeding promotion:

• General nutritional needs and concerns, household situation, cultural practices, geographic locations, environmental influences and educational abilities of the participant as identified through the nutrition assessment process. • Respect a participant’s literacy level and primary language spoken. • Identify participant’s access to technology i.e. virtual platforms, WICSmart • Account for a participant’s food preference, when applicable. • Provide messages on evidence-based and/or effective strategies, methodologies, techniques, and nationally recognized sources. Examples include Food and Nutrition Service (FNS) Core

3-2024 updated Messages, Have A Plant, Dietary Guidelines for Americans, Healthy People Goals and Objectives, The Surgeon General’s Call to Action to Support Breastfeeding, Physical Activity Guidelines for Americans, Bright Futures Nutrition, WIC Breastfeeding Support. • Encourage and support breastfeeding in a non-judgmental, evidenced based, manner with a focus on exclusively breastfeeding for 6 months and continuing for one year or longer as mutually desired by both mother and baby. To further promote success, work with participant to set realistic short-term goals, and consider a long-term plan. • Provide drug and other harmful substance use information to all pregnant, postpartum, and breastfeeding women and to parents or caretakers of infants and children. • Provide exit counseling for all women and child participants.

Documentation

Follow WIC Policy 300-09, which outlines appropriate documentation of nutrition education in CT- WIC.

Referrals

Offer newly enrolled participants an explanation of one or more of the following referrals:

• Supplemental Nutrition Assistance Program (SNAP) • Temporary Family Assistance (TFA) • Healthcare for Uninsured Kids & Youth (HUSKY) • Child Support Enforcement Program • Expanded Food & Nutrition Education Program (EFNEP) • Summer Food Service Program • Breastfeeding Peer Counseling Program (BFPC)

These key points should be conveyed to applicants/participants at the time of first enrollment. These items alone do not satisfy the nutrition education requirement for the certification period.

See WIC Policy 200-28 for additional information related to the Coordination of Services-Referrals to other programs by WIC Staff.

Subsequent certifications (Re-certification)

Re-certification should re-affirm key points covered in orientation/initial certification, however nutrition education should focus on the participant’s identified nutritional risk condition, specific area of concern (i.e. nutrition, diet, health, breastfeeding and/or referral) and ways to achieve the identified, category-appropriate positive health outcome(s).

Plan and offer subsequent nutrition education contacts that ensure continuity of care and follow-up on initial assessment to include a discussion of one of more of the following:

• Participant’s concerns or questions related to health, nutrition practices, breastfeeding, referrals, etc. • Participant’s nutritional needs according to the category of eligibility and desired health outcomes, i.e. needs of pregnant, breastfeeding, postpartum women, infants, and children. • Relationship between nutrition, food security, physical activity and health. • The benefits of consuming a variety of foods including those not provided by the WIC program.

3-2024 updated • CPA or client determined nutrient of special interest or need. • Additional nutrition related topics.

Types of Nutrition Education Contacts Face to Face (In person): A face-to-face (FTF) visit with the participant is either provided individually or in a group, where nutrition issues of consequence to the participant are discussed. Nutrition education should address participant needs (nutrition risk factors), participant concerns and/or relevant anticipatory guidance topics. Based on principles of adult learning theory selecting 1-2 topics to address during a single visit results in better compliance. However, the Nutritionist should consider the participant’s interest when selecting education topics. Topics not discussed during the appointment can be entered in the participant’s Plan to be addressed at a future visit. Education Choice for Second Contacts: Several nutrition education options are available at second contacts/follow-ups not requiring an in-person visit. These nutrition education options should not be provided to participants who require a certification, recertification, or when current data is needed to make an accurate assessment (such as anthropometric measurements, hemoglobin values). A clinic visit for high risk participants is preferable; however, when not feasible a telephone/video call with a nutritionist can be considered a high-risk nutrition education contact per the high-risk referral protocol. Education Choice options include: • In-person visit (FTF): Participants may choose to return to the clinic for an in-person follow-up visit. • WICSmart: An internet-based, online nutrition education website available in English, Spanish and some in Portuguese. Verification that a WICSmart nutrition education module has been completed by the authorized person should be documented in CT-WIC. See WIC Policy 300-15 Online Nutrition Education for more details on offering, verifying and documenting WICSmart modules. The goal that was created at the certification, recertification or mid-certification may be followed-up on at the next nutrition education contact. Upon completion of the WICSmart module and during the month in which the participant’s food benefits will expire, staff will verify the lesson completion, contact the participant to issue food benefits remotely and document nutrition education including module and date completed in Nutrition Education and remote benefit issuance in Alerts. Technical and nutrition-related assistance and follow up must be available to address questions and to provide feedback to participants. WICSmart option is available for low-risk child participants, some infant participants (6-12 months) and prenatal participants (preferably not first-time parents). • Telephone: All required components of a WIC visit must be performed per policy, including documentation. During the end of the telephone contact, staff will issue food benefits remotely and schedule the participant for a subsequent visit. • Interactive Video Call (Virtual Platform): Technology that allows video conference calls, such as Zoom for Healthcare, Microsoft Teams, Doxy.me, Cisco Webex Meetings/Webex Teams, Skype for Business or FaceTime. The local agency is responsible for selecting the virtual platform and verifying HIPAA compliance. The local agency will provide for installation and maintenance of the equipment necessary for the virtual platform contact. All required components of a WIC visit must be performed per policy, including documentation. During the end of the video call contact, staff will remotely issue food benefits and schedule the participant’s next visit. Interactive video calls should occur in an environment that promotes effective communication between the WIC staff and the participant and ensures that both are actively involved in the interaction. Confidentiality of participant information must be protected.

3-2024 updated Reminder: Nutrition education expenditures must account for at least 25% of each local agency’s total expenditures. State Developed Participant Nutrition Education Materials The Connecticut WIC Program updated its WIC Nutrition Education materials in 2021 to include both digital and print formats. Staff can access the digital materials at Connecticut WIC | NUTRITION IS JUST the BEGINNING (wicresources.org) For print materials, Coordinators and Program Nutritionists have access to order through the Brush Art warehouse. The suite of materials includes the general WIC outreach brochure, two fatherhood brochures and category specific series for women (pregnancy and postpartum), infant and children. The infant and child series detail a different age range, highlighting developmental and nutritional milestones. All materials were updated to reflect the 2020-2025 Dietary Guidelines for Americans. Staff may offer participants either digital or print materials during nutrition counseling. When appointments are conducted remotely staff can email or text the digital platform directly to the participant Connecticut WIC | NUTRITION IS JUST the BEGINNING (wicresources.org) for staff to review/discuss the nutrition material(s) during the participants appointment. When nutrition education materials are provided staff should document the resource in Nutrition Education notes. Quality Assurance

• In addition to the quarterly chart audit requirements (25 charts per quarter – 5 of which must be for peer services if the agency has a BFPC program) outlined in the local agency contract, local agency management staff must also conduct observations, at minimum quarterly, of nutrition and breastfeeding education sessions as part of on-going quality assurance activities. Observations must be conducted as part of the off-year Local agency Self-Assessment (WIC Policy 100-15). However, in most cases to effectively report on the measurable strategies in Local Agency Plan, results of staff observations must be included. Additionally, observations of program assistants are required to ensure appropriate customer service is provided, and program overview and program integrity topics are discussed. Peer Counselor observations are required if the local agency hosts a Breastfeeding Peer Counseling Program. • If services are provided remotely, observations must be done for phone and/or virtual platform visits. See Phone Counseling Observation Checklist for phone counseling guidance and checklist tools. • Per WIC Policy 100-14, program management is required to review and document the review of State agency memorandums, new and updated policies with all local agency staff. Local agencies should review their own policies, procedures, training materials and locally developed participant education materials to ensure they reflect current science and comply with Federal regulations. • Weekly review and assessment of the clinic no-show rate and adjustment of clinic schedule for effectiveness of minimizing participant no-shows and accepting/accommodating walk-ins is expected.

References • U.S. Department of Agriculture, Food and Nutrition Service. WIC Nutrition Education Guidance 2006.

3-2024 updated • U.S. Department of Agriculture, Food and Nutrition Service. WIC Nutrition Education Guidance, Appendix A 2006. • U.S. Department of Agriculture, Food and Nutrition Service.