NC WIC Program Manual January 2026

Chapter 5 Nutrition Education

Table of Contents

This chapter describes WIC's nutrition education component, including required nutrition education topics, frequency of nutrition education contacts, making nutrition education available, guidance for documenting nutrition education, and information on nutrition education resources.

Section 1. Required Nutrition Education Topics .....................................................................1  Definition and Goal of Nutrition Education  Nutrition Education for all Women  Required Substance Abuse Education for all Parents and Caretakers  Nutrition Education for Parents and Caretakers before Issuance of Infant CVB

Section 2. Frequency of Nutrition Education ...........................................................................3  Required Minimum Nutrition Education Contacts  Additional Nutrition Education Contacts

Section 3. Access to Nutrition Education ................................................................................5  Nutrition Education at Certification/Subsequent Certification  Follow-up Nutrition Education  Participant Input

Section 4. Documentation of Nutrition Education ....................................................................9  Nutrition Education Made Available by Agency Staff  Nutrition Education Provided by Staff Outside the Local Agency  Non-Participation in Nutrition Education

Section 5. Nutrition Education Resources .............................................................................11  Education Resources Available from the Community Nutrition Services Section  Education Resources Obtained or Developed by the Local Agency

Attachments

Attachment 1. Breastfeeding Anticipatory Guidance Topic Checklist Required Local Agency Written Policies And Procedures  Local Agencies that use WIC management support staff to provide mini-lessons must have a written policy. (Section 3, page 6)  Local Agencies that provide group education must have written class outlines on file. (Section 3, page 7)

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January 2026 Required Nutrition Education Topics

Nutrition education, including breastfeeding promotion and support, must be made available to all WIC Program participants. At the time of certification, the local agency shall emphasize the positive, long-term benefits of nutrition education and encourage the participant to participate in nutrition education activities. However, individual participants shall not be denied supplemental foods for failure to attend or participate in nutrition education activities.

 Definition and Goal of Nutrition Education WIC program services offer nutrition education using methods, materials, and tools that are designed to enhance a participant’s understanding of the importance of nutrition and physical activity, to affect a desired change in behavior, or to reinforce desired behaviors related to dietary habits or health practices. The goal of nutrition education is to empower participants to make choices that will have a positive impact on their health and nutrition status.

 Nutrition Education for all Women All women participating in the Program must receive documented verbal and written information on the following five topics at least once by the time they complete their participation in the WIC Program.

 Importance of good nutrition. Local agencies must make information available on the importance of good nutrition to health.

 Breastfeeding. Local agencies must make information available on breastfeeding (unless contraindicated for health reasons) as the normal method of infant feeding. Staff must offer breastfeeding promotion and support to all pregnant and breastfeeding women throughout the prenatal and postpartum period. Please refer to Attachment 1 “Breastfeeding Anticipatory Guidance Topics Checklist” to tailor breastfeeding promotion and support based on the needs of the participant. For additional breastfeeding promotion and support information, see Chapter 9.

 Substance abuse education. Local agencies must make information available on the health risks associated with the use of alcohol, tobacco (including exposure to environmental tobacco smoke), and drugs. Local agencies must maintain a current list of local counseling and treatment resources for substance abuse and make this list available to all pregnant, breastfeeding, and postpartum women participating in WIC.

 Childhood immunizations. Local agencies must make information available to women regarding the importance of immunizations for their infants and children.

 Folic acid. Local agencies must make information available regarding the importance of folic acid for women who may become pregnant.

 Required Substance Abuse Education for all Parents and Caretakers WIC Program Federal Regulations require that all parents/caretakers of infants and children participating in the WIC Program receive information about the health risks associated with

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January 2026 the use of alcohol, tobacco (including exposure to environmental tobacco smoke), and drugs. This information should be provided to the parent/caretaker at least once during an infant’s/child’s participation, preferably at the initial certification of the infant/child. The information may be provided verbally or in writing.

 Nutrition Education for Parents and Caretakers before Issuance of Infant CVB The standard food package for infants 6 – 11 months old includes infant fruits and vegetables as ounces and as cash-value benefit, infant cereals, and infant meats for the fully breastfeeding infant. Prior to issuance of any infant CVB, the CPA must ensure participants are meeting their nutritional needs in a safe and effective manner by providing and documenting required nutrition education addressing developmental readiness, safe food preparation, storage techniques, and feeding practices.

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October 2025 Frequency of Nutrition Education

The frequency of nutrition education made available to a participant depends on the WIC participant category and nutritional needs of the participant.

 Required Minimum Nutrition Education Contacts Per federal regulation, local WIC agencies must make nutrition education available at a minimum frequency as outlined in the table below to ensure that health care and nutrition services are offered. A nutrition education contact may be made available in conjunction with a required nutrition assessment. Refer to Chapter 6C for information on nutrition assessment requirements.

NOTE: A contact of an administrative nature (such as exchanging formula, phone call to a pharmacy to order a special formula, etc.) does not qualify as a nutrition education contact unless it also includes a substantive nutrition education component.

Participant category # of nutrition education contacts to be made available during a certification period Pregnant Women 2 contacts

1 contact for pregnant women certified >37 weeks gestation Breastfeeding Women 4 contacts

2 contacts for breastfeeding women whose infants are certified > 6 months of age Postpartum Women 2 contacts

Infants certified < 6 months of age 4 contacts. Best practice is to make nutrition education available at a quarterly rate. Infants certified > 6 months of age 2 contacts

Children 4 contacts. Best practice is to make nutrition education available at a quarterly rate.

 Additional Nutrition Education Contacts Making additional nutrition education available is optional and is based on a participant’s interests and nutritional needs as determined by a complete nutrition assessment. Follow-up may be more frequent for a participant assessed to have a high level of nutritional risk. Refer to Section 3 for more information on the level of nutritional risk.

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October 2025 Access to Nutrition Education

Nutrition education content and method for making nutrition education available must be appropriate to the participant’s age, nutritional requirements, interests, household circumstances, cultural preferences, language spoken and any special considerations the participant may have. Examples of specific considerations include migrant status; experiencing homelessness; having vision, hearing or learning impairments; and/or having limited English proficiency.

Nutrition education should be made available to adult participants, to parents/guardians/caretakers of infants and children, and to children directly whenever possible. Proxies may participate in nutrition education only as appropriate for the participant's care plan.

 Nutrition Education at Certification/Subsequent Certification Nutrition education must be provided by a competent professional authority (CPA) directly to a participant/parent/guardian/caretaker on an individual basis as a part of the certification/subsequent certification. Refer to Chapter 6C for information on who qualifies to be a CPA.

 Follow-Up Nutrition Education A participant’s nutrition status is evaluated and nutrition risk(s) identified during a nutrition assessment. Per the plan of care following an assessment, a participant may need low-risk or high-risk nutrition education follow-up contacts made available. A minimum number of nutrition education contacts must be made available to participants during a certification period as indicated in Section 2.

 Low-Risk Follow-Up Nutrition Education Low-risk nutrition education generally focuses on anticipatory guidance such as complementary infant feeding practices, avoiding tobacco smoke exposure or the recommended immunization schedule for young children. It can also focus on public health nutrition messages that promote lifelong positive dietary and physical activity habits such as eating more fruits and vegetables, choosing lower fat foods, increasing physical activity or limiting TV and screen time. Staff must ensure that nutrition education is made available and documented per Section 4 guidance, including any materials or additional resources provided at the agency or mailed or emailed as part of the nutrition education contact.

Low-risk follow-up nutrition education may be appropriate for: • a postpartum woman (non-breastfeeding); • a breastfeeding woman who has completed the mid-certification assessment; • a breastfeeding infant who has completed the mid-certification assessment; • a non-breastfeeding infant on a contract standard milk- or soy-based infant formula; or • a child.

Low-risk follow-up nutrition education may be provided by: • a CPA, • a trained non-CPA staff member (mini lessons only), or • an approved source outside the local agency.

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Individual Education Individual low-risk nutrition education is provided directly to an individual, parent/guardian/caretaker, or proxy when appropriate, by appropriate local agency staff. When possible, staff should provide education directly to participants, including children.

Types of individual low-risk nutrition education include: • Mini Lessons. These are brief, single objective communications which are developed by a nutritionist. Non-CPA staff in the agency who have been trained can provide simple nutrition or physical activity-related information referred to as mini lessons. ­ Each mini lesson used in an agency must have a written outline which includes the target audience, one educational objective, a summary of the information to be communicated to the participant, and a copy of any or all the educational handout(s) to be given to the participant. ­ Mini lessons may be offered in-person, over video conference, or by telephone as determined by the local agency mini-lesson policy. ­ Local agency mini lesson policy: Local agencies that train non-CPA staff to provide individual low-risk nutrition education must have a written policy to outline:  staff position responsible for coordination, provision, and documentation of mini lesson training for non-CPA staff. The documentation must include the training dates, content of the training, names of staff participating in the training, and name and title of trainer;  the specific staff or groups of staff who will be trained to provide mini lessons;  how the staff training will be provided on an ongoing basis to ensure staff maintain current knowledge of the nutrition subject(s);  a communication plan detailing which participants will receive a mini lesson, appropriate methods for providing mini lesson (in-person, videoconferencing, telephone) and when the mini lesson is to be provided; and,  Crossroads documentation expectations for mini lessons that have been made available to and/or completed by participants. Refer to Section 4 for documentation of nutrition education contacts. • Online. Online nutrition education provides independent learning opportunities for participants and allows them to complete low-risk follow-up nutrition education contacts at their convenience on a computer or mobile device. This should be made available as an option for all low-risk follow-up nutrition education. ­ wichealth.org. CNSS subscribes to wichealth.org, an online nutrition education system. This system allows participants to complete web-based educational modules on a variety of relevant topics. − Other online platforms. Refer to Section 5 on education resources developed or obtained outside of CNSS. Refer to Chapter 12 for more information on obtaining prior approval for the purchase of nutrition education items or equipment.

Group Education Agencies providing group low-risk nutrition education must have a written class outline

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October 2025 for each class including at a minimum: the target audience, objective(s), content of the presentation, and any activities/materials used. • Class outlines should be periodically reviewed and updated by a CPA to ensure they are relevant and accurate. • Staff may choose to coordinate with other group education services in the agency such as, but not limited to, childbirth education, breastfeeding, or parenting classes. These classes may fulfill low-risk nutrition education contacts if they include a clear nutrition component. The local agency must maintain a copy of the class outline on file. • Participant evaluation of classes is encouraged and recommended.

Nutrition Education Provided Outside the Local Agency Follow-up nutrition education may be provided by individuals who work outside the local WIC agency. For example, staff trained to provide general nutrition education who work in programs such as the Expanded Food and Nutrition Education Program (EFNEP) and the Head Start Program, may provide low-risk nutrition education to individuals who also participate in WIC. Refer to Section 4 for information on the communication and documentation of nutrition education provided by staff outside of the local agency.

 High-Risk Follow-Up Nutrition Education High-risk follow-up nutrition education is generally focused on education or counseling specific to a nutrition-related health/medical condition and is made available on an individual basis. Refer to Section 4 for information on documentation of nutrition education contacts.

High-risk follow-up nutrition education must be made available for: • all pregnant women; • all breastfeeding mother-infant dyads who have not completed the mid-certification assessment; • all infants receiving any formula other than the contract standard milk- or soy-based infant formula; • all participants receiving WIC-Eligible Nutritionals as part of Food Package III; and • any participant per CPA discretion following nutrition assessment.

Individual Education Individual high-risk nutrition education is made available directly to an individual, parent/guardian/caretaker, or proxy when appropriate, by a local agency CPA. Best practice methods for high-risk nutrition education include in-person and videoconferencing; however, a CPA can make high-risk nutrition education available over the phone due to participant hardship circumstances such as illness, confinement to bedrest, weather conditions or transportation limitations.

Nutrition Education Provided Outside the Local Agency A nutritionist, registered dietitian, dietetic technician registered, registered nurse, nurse practitioner, physician assistant, or physician who works in a setting outside of the local WIC agency may provide specialized nutrition education and counseling to WIC participants. Typical settings apart from WIC where specialized nutrition education and

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October 2025 counseling may occur include Children’s Developmental Services Agencies, metabolic centers, hospital outpatient clinics, high-risk maternity clinics, and private physicians’ offices. Refer to Section 4 for information on the communication and documentation of nutrition education provided by staff outside of the local agency.

 Participant Input To help ensure that the agency’s approach to nutrition education is relevant and meets the needs and interests of participants, staff are encouraged to obtain input from WIC participants. Examples of areas for input include nutrition education topics, barriers to attending or completing nutrition education sessions, preferred methods of nutrition education instruction, and/or effectiveness of breastfeeding promotion and support activities.

When gathering input, staff may establish a system just for WIC or coordinate their efforts with other programs in the agency. Participant input can be gathered in a variety of ways including surveys, focus groups, an advisory board comprised of participants, and/or an ongoing suggestion box located in the agency.

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October 2025 Documentation of Nutrition Education

All nutrition education made available to participants as part of the plan of care must be documented in the Crossroads system.

 Nutrition Education Made Available by Agency Staff

 Initial Nutrition Education. At an initial certification, all nutrition education provided by the CPA must be documented in the Crossroads system as part of the participant’s nutrition assessment and plan of care. Documentation should include at a minimum: • The person(s) who received the nutrition education, • Nutrition education topic(s)/content, and • Method of delivery. Note: Crossroads automatically captures the date of contact and staff identification during certification.

 Follow-Up Nutrition Education. Follow-up nutrition education made available by the local agency to the participant/parent/guardian/caretaker must be documented in the Crossroads system. If a participant does not attend or complete planned nutrition education, the local agency must make at least one additional contact attempt to provide nutrition education and document the details of the attempted contact(s) in Crossroads. Refer to Section 3 for low-risk and high-risk nutrition education information. • Low-Risk Nutrition Education Local agency staff must document the nutrition education topic(s)/content and method of delivery on the nutrition education screen. • High-Risk Nutrition Education A CPA must document in the participant Care Plan Summary screen the nutrition education topic(s)/content made available for each participant as part of the plan of care.

 Nutrition Education Provided by Staff Outside the Local Agency When nutrition education or counseling provided by an outside agency is documented as part of the WIC plan of care, documentation from the external provider must be provided to the local WIC agency. This documentation should be scanned into the participant’s Crossroads record and a note entered in the participant Care Plan Summary screen. The note should state that the participant received nutrition education or counseling from an external source and reference the scanned document.

 Low-Risk Nutrition Education. There should be a written agreement between the local WIC agency and any outside agency routinely providing nutrition education to WIC participants. The agreement must include arrangements for documenting and communicating information to the local WIC agency about date, nutrition topic(s)/content covered, and method of delivering nutrition education to the participant.

 High-Risk Nutrition Education. Health professionals outside of the local WIC agency who provide specialized nutrition education and counseling to WIC participants should

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October 2025 send written documentation of the service (including the date, content, and provider) to the local WIC agency for inclusion in the participant’s health record as outlined above.

 Non-Participation in Nutrition Education The local agency must document the types and formats of Nutrition Education made available to participants. The refusal of a participant to participate in nutrition education made available to them must be documented in the Crossroads system in the Nutrition Education Refusal section on the Nutrition Education screen.

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October 2025 Nutrition Education Resources

Local WIC agency staff are encouraged to use nutrition education resources to enhance their nutrition education efforts. Staff may use printed materials, visual displays, audiovisual materials or electronic resources for nutrition education. A variety of nutrition and health education resources are available on the NC WIC program website under sections ‘For Participants’ and ‘For Staff’.

 Education Resources Available from the Community Nutrition Services Section The Community Nutrition Services Section (CNSS) has printed education materials on a variety of topics. These materials may be ordered from CNSS using the Community Nutrition Services Section Materials Requisition Form (DHHS Form 2507) available on the NC WIC Program website. Refer to Chapter 1 for more information about ordering materials.

 Education Resources Obtained or Developed by the Local Agency All nutrition education resources including but not limited to electronic, online, or printed resources, regardless of cost or funding source, must be approved by the local agency’s RNC prior to purchase (if applicable) or use with WIC participants. Refer to Chapter 12 for more information on obtaining prior approval for purchasing equipment.

The criteria below should be used to evaluate the quality, usefulness, and appropriateness of materials for use within the WIC Program.

 Language. Materials should be provided in languages commonly spoken by the agency’s participants.

 Literacy level. Materials should be written at or below a sixth grade reading level.

 Content. Information must be current, accurate and promote scientific and evidence- based nutrition and physical activity practices that are relevant to WIC Program participants.

 Graphic Design. Graphics and photographs should reflect the participants served by the WIC Program.

 Advertising. Materials should be free from any manufacturer advertising or marketing and free from any advertising or marketing of any products and/or concepts that are not scientific and evidence-based nutrition principles or do not support goals of the WIC Program including the promotion and support of breastfeeding.

 Non-Discrimination Statement. Refer to Chapter 4 for requirements on use of the nondiscrimination statement on locally developed materials.

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Attachment 1

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October 2024, Page 1 Breastfeeding Anticipatory Guidance Topic Checklist

Breastfeeding Topic* Prenatal 0 Months 3 months 6 months 9 and 12 months WIC encourages and supports moms to breastfeed X X X X X Changes to a mother’s body X X

Breastfeeding benefits the mom and the baby X X X X X Support is critical to breastfeeding success X X X X X Hospital practices and their impact on the breastfeeding relationship X X

Supplemental feedings interfere with a mother’s milk supply and her breastfeeding success X X X

Maternal nutrition during breastfeeding X X X X X Breastfeeding when returning to work or school X X X

Breastfeed as soon as possible after birth X X

Importance of colostrum and transition to mature milk X X

Comfort and proper positioning X X

Recognize hunger and fullness cues X X X X X Feeding frequencies and maintaining milk supply X X X X X

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October 2024, Page 2 Breastfeeding Topic* Prenatal 0 Months 3 months 6 months 9 and 12 months Signs the infant is getting enough human milk X X X X

Appropriate weight gain/loss for infants X X X X X Basic breast care/Avoidance of common breastfeeding related breast and nipple issues

X X

Appetite/Growth spurts

X X X X Vitamin D and iron supplementation

X X X

Teething

X X Introducing complementary foods

X X

Breastfeed for as long as mutually desirable X X X X X

*The timeframes are guidelines and may need to be adjusted depending on the participant’s individual needs determined at assessment.