Nutrition Services (NS) NS-1 Nutrition Counseling Revised October 1, 2022 1

Maine Center for Disease Control and Prevention WIC Nutrition Program Effective: October 1, 2012 Policy No. NS-1 Revised: October 1, 2023

Nutrition Counseling Authority 7 CFR §246.4(a)(9); §246.11(a)(1-3) and (c)(1, 3-7) 22 MRSA §255 and §1951 10-144 CMR Chapter 286, §II.O WIC Policy Memo, #94-9 WIC Exit Counseling Brochure

Policy 1. The State Agency shall be responsible for developing and coordinating the nutrition counseling component of the WIC program, taking into consideration Local Agency plans, needs, and available nutrition counseling resources. 2. Nutrition counseling shall be thoroughly integrated into participant interactions, the delivery of supplemental foods, and other program operations. It shall be designed to meet varying cultural and language needs of program participants. 3. The State Agency shall monitor Local Agency nutrition counseling activities. Nutrition counseling is considered a benefit of the program, and shall be made available at no cost to all participants. 4. Individual participants shall not be denied supplemental foods for failure to attend or participate in nutrition counseling activities.

Procedure 1. The State Agency requires that Local Agency nutrition counseling be coordinated with assessment of individual needs, and include participant-led goals, evaluation, and follow- up. 2. Nutrition counseling shall: 2.1 Be easily understood by participants. 2.2 Bear a practical relationship to participants’ nutrition needs. 2.3 Consider household situations and cultural preferences. 2.4 Include information for participants on how to make appropriate food selections for themselves and their families. 3. Local Agency staff may offer learning opportunities directly to child participants when feasible.

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4. When discussing nutrition needs of children, staff shall provide parents with the tools they need to feed children in a healthful manner, including information on: 4.1 Feeding relationships 4.2 Inappropriate feeding practices that have been identified during the interview process 4.3 Anticipatory guidance so parents will know what to expect as a child gets older

5. The State Agency develops minimum nutrition counseling standards for all participant categories, with additional standards for medically high-risk participants, including: 5.1 Number of contacts 5.2 Counseling requirements related to 5.2.1 Breastfeeding promotion 5.2.2 Information on drug and other harmful substance abuse 5.2.3 Nutrition topics relevant to participant assessment 5.2.4 Food safety education for infants 9-11 months with tailored CVB option 5.3 Documentation 5.4 Appropriate referral process 6. Nutrition counseling may be delivered by the following methods: 6.1.1 Face-to-face, individual or group 6.1.2 Remote/mobile technology based 6.1.3 Food demonstration 6.1.4 Online State Agency authorized WIC nutrition education modules 7. Local Agency staff shall document nutrition education in the participant’s electronic record in all of the following locations: 7.1 Nutrition education tab 7.1.1 Select individual or group contact; utilize education topic from drop- down list for initial and secondary; participant- established goals may be recorded utilizing the goal-setting section on this tab 7.2 Nutrition assessment tab 7.2.1 At certification and mid-certification and follow-up appointments (optional)

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8. Participants shall be offered nutrition counseling appointments at the following minimum frequency: 8.1 Infants certified for one year or until their one-year birthday shall be scheduled for nutrition assessment and counseling appointments at the following ages: 8.1.1 Birth-4 weeks 8.1.2 3-5 months 8.1.3 6-8 months 8.1.4 9-11 months 8.2 Infants and non-breastfeeding participants certified for six months shall be scheduled for counseling appointments at least two times during the certification period, including the initial assessment. Nutrition and growth assessment shall be included at all appointments for infants certified for six months. 8.3 Children and breastfeeding participants certified for twelve months shall be scheduled for the following: 8.3.1 Initial assessment and counseling appointment 8.3.2 Mid-certification and counseling appointment, ideally no more than six months after initial assessment is done 8.3.3 Counseling appointments, ideally no more than three months after initial and mid-certification assessments 8.4 Pregnant participants certified until their due date shall be scheduled for counseling appointments at a minimum frequency not to exceed every three months. 9. At the initial certification assessment visit, the participant/parent/guardian shall receive the following information: 9.1 Food benefits provided are intended for the participant 9.2 Nutritional value of food benefits provided by program 9.3 Notification that program is supplemental 9.4 Authorized WIC foods list

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9.5 Benefit redemption procedures 9.6 Proxy policies 9.7 Policy on lost/stolen benefits 9.8 Instructions regarding WIC Shopper and BNFT app 9.9 Participant rights and responsibilities, including dual participation policies and actions considered fraudulent 9.10 The benefits of nutrition counseling and the expectation for participation in nutrition education activities 9.11 Local resources for drug and other harmful substance abuse counseling and treatment (all participants) 9.12 Benefits of breastfeeding and local breastfeeding support resources (all pregnant participants) 9.13 Importance of prenatal care (pregnant participants) 9.14 Contraindications to breastfeeding, including HIV and specific drugs (pregnant and breastfeeding participants) 9.15 Contract brand of cow’s milk-based and soy-based formulas (pregnant participants planning to formula feed and non-breastfeeding participants) 9.16 Importance of adequate intake of folic acid (breastfeeding/non-breastfeeding participants) 9.17 Importance of immunizations (infant and child participants) 10. Follow-up contacts provide opportunities for counseling staff to assess participants’ progress on specific goals established at previous visits. 10.1 Participant follow-up contacts may be done: 10.1.1 one-on-one 10.1.2 group sessions 10.1.3 online nutrition education modules (participants assessed to be at a low nutrition risk priority) 10.2 Follow-up contacts shall be documented in the participant’s electronic record. 11. The documentation for nutrition counseling is as follows: 11.1 All documentation of nutrition counseling activities shall be done in the participant’s electronic record.

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11.2 Entries for individual counseling shall only be made by local agency WIC staff authorized to provide participant counseling (Refer to Policy No. OM-4, Local Agency Staffing for further information). 11.3 Entries shall contain sufficient information to: 11.3.1 Support the nutrition assessment and risk code assignment 11.3.2 Justify the health and nutrition advice 11.3.3 Support a referral 11.4 Entries may document pertinent socioeconomic information, client issues or staff concerns. 11.5 Entries are permanent. 11.6 Non-nutrition related contacts (such as lost/stolen eWIC card, appointment changes, Farmer’s Market check issuance, requests for proxy changes, etc.) shall be documented in a general notes section of the participant electronic record. 11.7 The type of nutrition counseling provided as well as any refusal or inability of the participant/parent/guardian to attend or participate in nutrition counseling must be documented in the participant electronic record. 11.8 Online nutrition education module completed by participant, including name of module, verified from certificate of completion. 11.9 Documentation shall include topics covered, goal(s) chosen by participant (if any), and progress toward goal(s) as appropriate. 12. Nutrition counseling shall be participant-lead. Specific behavioral goals as they relate to the participant’s nutrition risk and/or nutrition care plan shall be addressed. Guidance is available to provide staff members with appropriate counseling strategies (Appendices NS-1-A, NS-1-B, and NS-1-C). Every effort shall be made to maximize the subject matter expertise of the local agency nutritionists and counseling staff members. 13. Nutrition counseling may be reinforced by other agencies such as Head Start, Public Health Nursing, Healthy Families/Home Visiting Programs, University of Maine Cooperative Extension, SNAP-Ed, or local Healthy Maine Partnerships. These can be valuable partners in providing more information and support to assist participants in reaching and maintaining goals. 14. The State Agency ensures that nutrition risk data is used in providing appropriate nutrition counseling during individual contacts, and that group nutrition contacts are tailored to the participants’ needs. Examples of group contacts that may be offered by WIC local agencies include:

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14.1 “Methods of Infant Feeding” offered to pregnant participants who enroll early in pregnancy. 14.2 “Appropriate Toddler Snacks” offered to parents who express need for more ideas for healthy snack options for a picky toddler, which may include discussion and food demonstration. 14.3 “Making Your Own Baby Foods” offered to parents of infants younger than 6 months who express a desire to learn how to make foods at home for their babies. 15. Participants with qualifying medically high risk conditions shall be referred to local agency or consultant RD/LD (see NS-6 Medically High Risk Participants). 15.1 Documentation will occur in participant record as a referral (if necessary) and be entered into the Medical High Risk Log (NS-Appendix-6-A). 16. Postpartum participants whose categorical participation in the program is ending shall be provided with exit counseling to reinforce critical health messages. This last counseling appointment is not intended to replace nutrition education that is personalized for individual nutrition risks. In general, the key messages to be reinforced include but are not limited to: 16.1 Continued importance of adequate folic acid intake during childbearing years 16.2 Continued breastfeeding (if appropriate) 16.3 Up to date immunizations for the woman and her child(ren) 16.4 Health risks associated with intake of alcohol, tobacco, and other drugs 16.5 Importance of a well-balanced diet 17. The State Agency monitors Local Agency progress toward meeting annual agency nutrition counseling goals, nutrition counseling action plans and objectives via: 17.1 Year-end summary report 17.2 Annual Local Agency reviews 18. Each Local Agency shall develop an annual Local Agency nutrition plan consistent with the State Agency’s nutrition counseling component of program operations and in accordance with USDA/FNS guidelines. The Local Agency shall submit its nutrition counseling plan to the State Agency prior to the start of each federal fiscal year. 19. Participant views on nutrition counseling and breastfeeding promotion and support are used in the development of the Maine CDC WIC Nutrition Program State Plan as well as Local Agency nutrition counseling plans. Participant views may be obtained by one or more but not limited to the following methods: 19.1 State-developed questionnaire issued by Local Agencies 19.2 Locally developed additional questions (approval by State Agency is required)

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19.3 State and/or Local Agency survey questions in the participant electronic record