810.1 Policy 810 Nutrition-Focused Education and Counseling October 5, 2018 (Revised)

POLICY Local WIC programs shall offer nutrition-focused counseling to all WIC participants, parents or caregivers according to federal regulations, state guidelines and program goals. PURPOSE To ensure that WIC participants receive nutrition-focused counseling that considers their capacities, strengths and developmental needs. RELEVANT REGULATIONS 7 CFR §246.2—Definitions 7 CFR §246.11—Nutrition Education ¶(a) General, ¶(b) Goals, ¶(c)(4)—Procedures to ensure that nutrition education is offered, ¶(d) Local program responsibilities, ¶(e) Participant contacts, ¶(e)(4)—Documentation of nutrition education provided, and ¶(e)(5)— Provision of individual care plan based on need 7 CFR §246.12 ¶(d)—Compatibility of food delivery system, ¶(r)(1)—Parents/caretakers and proxies 7 CFR §246.14—Program Costs 7 CFR Part 246 Federal Register, Vol. 59, No. 48, Friday, March 11, 1994 WRO Policy Memo 807-K Letters dated September 23, 1994, and January 2, 1994, from the USDA Western Regional Office clarifying the federal interpretation of the regulations OREGON WIC PPM REFERENCES  215—Local Program Monitoring and Review  315—Fiscal Reporting Requirements  511—Food Benefit Issuance  610—Required Proofs: Identity, Residence, Income  660—Competent Professional Authority: Requirements  661—Competent Professional Authority: Appropriate Counseling for Risk Levels  820—Quarterly Nutrition Education Contacts  830—Counseling and Services for High Risk Participants  840—Documentation of Nutrition-Focused Education and Counseling

Nutrition-Focused Education and Counseling, Continued 810.2

APPENDICES N/A BACKGROUND The primary mission of the WIC program is to provide nutrition and breastfeeding education to participants along with supplemental foods and referrals to other health and social services. Although participation in the WIC program is short-term for most participants, nutrition education is the mechanism to improve the long-term health of participants. Federal Program Guidance Nutrition education is a program benefit and a required element of the WIC program, available at no cost to the participant. It is to be integrated into program operations and shall be provided to participants in a way that is understandable and practical for their family situations. The important relationship between nutrition and health is to be emphasized, particularly the nutritional needs of pregnant, postpartum, and breastfeeding women, infants and children under five years of age. A second emphasis is to assist individuals at nutritional risk to make food and behavior changes that result in improved nutritional status and the prevention of nutrition-related problems.

Oregon Philosophy The purpose of providing nutrition education and counseling in WIC is to help participants and families make gradual modifications in lifestyle and/or eating habits to ensure optimal nutrition and lifelong health. Enrollment in WIC includes nutritional risk assessment, nutrition-focused counseling, and the setting of next steps that lead to improved wellness. Oregon WIC provides leadership, guidance and resources to ensure quality WIC services that support collective public health efforts. DEFINITIONS First Cardholder: The required cardholder for a WIC family Electronic Benefit Account. The first cardholder is either the woman participant or the parent or caregiver from the same household as the infant or child participant, therefore, sharing the same address. This individual may attend nutrition education appointments, bring in a child for certification appointments and spend WIC food benefits. High-Risk Participant: A participant with a health risk that has been identified to meet one of the state’s high-risk criteria. See ⧫661—Competent Professional Authority: Appropriate Counseling for Risk Levels. Individual care plan: A written plan that outlines actions that will assist the participant in assuming responsibility for improving identified health-related problems on a prioritized basis. Non-WIC Nutrition Education: Nutrition education not sponsored by the WIC program. Nutrition Education (as defined in federal regulations): Individual or group education sessions and the provision of information and educational materials designed to improve health status, dietary habits and physical activity habits, and to emphasize the relationships between nutrition, physical activity and health, all in keeping with the individual’s personal, cultural, and socioeconomic preferences.

Nutrition-Focused Education and Counseling, Continued 810.3 Nutrition-Focused Counseling: An interactive helping process focused on eating behaviors, physical activity, and lifestyle, designed to improve health status and help participants to achieve their personal goals. Quarterly nutrition education: Nutrition education opportunities that are offered at least every three months, or on a quarterly basis. It is provided individually or in a group setting and includes nutrition education that occurs during a mid-certification health assessment, online lesson, or counseling with the WIC nutritionist/RDN. See ⧫820—Quarterly Nutrition Education Contacts for clarification on content and frequency of follow-up nutrition education opportunities. Refusal of nutrition education: Participant states unwillingness or inability to attend any nutrition education offered. Second Cardholder: The optional second cardholder who has been issued an eWIC card with the permission of the first cardholder. This individual may attend nutrition education appointments, bring in a child for certification appointments and spend WIC food benefits. WIC Nutritionist: A professional who meets one of the following qualifications: A Registered Dietitian Nutritionist (RDN) with the Academy of Nutrition and Dietetics (AND), or eligible for AND registration; a master’s or doctoral degree in the field of nutrition from an accredited college or university; or an Oregon Licensed Dietitian (LD). SECTION LIST 1.0 Availability 2.0 Contact types 3.0 Nutrition education methods that do not use face-to-face communication 4.0 Unacceptable forms of nutrition-focused education and counseling 5.0 Frequency of nutrition-focused education and counseling 6.0 Scheduling nutrition-focused education and counseling contacts 7.0 Qualifications of staff providing nutrition-focused education and counseling 8.0 Food benefit issuance 9.0 Attendance of nutrition-focused education and counseling 10.0 Missed nutrition-focused education and counseling 11.0 Refusal of nutrition-focused education and counseling 12.0 Monitoring 13.0 Fiscal requirements for nutrition education 14.0 Nutrition education materials PROCEDURE Availability 1.0 Provide or make available nutrition-focused counseling to WIC participants using a state approved method. 1.1. All nutrition education contacts shall include two-way communication between staff and participants. 1.2. Nutrition education contacts shall be made available to ALL participants, including participants who do not receive food packages such as fully breastfeeding infants < 6 months old and some breastfeeding women whose infants are > 6 months old and mostly formula fed.

Nutrition-Focused Education and Counseling, Continued 810.4 1.3. Any nutrition-focused education and counseling provided to participants shall be accurate, up-to-date and evidence-based. WIC staff shall use a participant centered approach and are encouraged to share personalized nutrition information to meet the individual’s health care needs. See the Oregon WIC Training Module WIC Participant Centered Education (PCE) online course for guidelines on providing individual education, and Providing Participant Centered Groups for guidelines and training on providing group education. Contact types 2.0 There are three broad categories of contact types. 2.1. Individual nutrition education – in person one-to-one nutrition-focused counseling designed to meet a participant’s nutritional needs, risks, and interests. See the Oregon WIC Training Module WIC Participant Centered Education (PCE) online course for guidelines and training on providing individual education. 2.1.1. One-to-one counseling with the certifier may be offered to any participant. 2.1.2. High-risk participants shall receive at least two one-to-one contacts with a qualified RDN/WIC nutritionist during a one-year certification period. See ⧫661—Competent Professional Authority: Appropriate Counseling for Risk Levels for more information. 2.2. Group nutrition education – in person nutrition-focused group session provided by WIC staff to multiple WIC participants or their caregivers at one time. See the Oregon WIC Training Module “Providing Participant Centered Groups” for guidelines and training on providing group education. 2.2.1. Groups are designed to meet participants’ nutritional needs, risks, and interests. 2.2.2. Group sessions are most often used to meet the quarterly nutrition education contact requirement. 2.2.3. A lesson plan describing the group session must be created and on file for all groups offered. 2.2.4. In-person nutrition-focused group sessions may be provided by a partnering agency. Refer to ⧫820 - Quarterly Nutrition Education Contacts for details on entering into an agreement with an outside agency. See ⧫840— Documentation of Nutrition-Focused Education and Counseling for information on how to document these special group sessions in TWIST. 2.3. Self-guided nutrition education – an alternative form of nutrition education for participants who meet guidelines and are not high-risk. See ⧫820 - Quarterly Nutrition Education Contacts for more details. 2.3.1. Methods of self-guided nutrition education include: • Online lessons available through an approved provider such as WICHealth.org

Nutrition-Focused Education and Counseling, Continued 810.5 • Other pre-approved local agency developed online nutrition education lessons. See ⧫820 - Quarterly Nutrition Education Contacts for more details. • Self-paced lessons developed by the State agency, or locally developed lessons that have been pre-approved by the State agency. See ⧫820 - Quarterly Nutrition Education Contacts for more details. Nutrition education methods that do not use face-to-face communication 3.0 In special circumstances, nutrition-focused counseling may be provided in formats other than in person face-to-face encounters. For example, a high-risk participant is unable to come to the clinic for medical reasons, or a participant is unable to reschedule a missed face-to-face appointment with the RDN/WIC nutritionist. 3.1. Methods that do not use face-to-face communication include: • Telephone contacts • Text messaging using an approved HIPAA-compliant service on a secure platform • Contacts utilizing secure interactive video technology • Communication via secure email Refer to ⧫820 - Quarterly Nutrition Education Contacts and ⧫830 - Counseling and Services for High-Risk Participants for the specific details on when and how such methods may be used. Unacceptable forms of nutrition-focused education and counseling 4.0 Nutrition education materials enhance and support nutrition-focused counseling but are not nutrition education contacts in and of themselves. 4.1. Offering a participant, parent or caregiver a newsletter, nutrition education pamphlet, recipe card or other written information may not be counted as a nutrition education contact – unless the material is given as part of an individual counseling session. 4.2. Asking a participant, parent or caregiver to view a waiting room bulletin board or poster may not be counted as a nutrition education contact – unless this viewing is part of a larger group session or health fair. Frequency of nutrition-focused education and counseling 5.0 WIC participants, parents or caregivers shall receive a minimum of four nutrition education contacts during the 1-year certification period. These generally occur quarterly, to coincide with the issuance of benefits, but there may be exceptions depending on need. For example, a high-risk participant may be seen monthly for several months, rather than just once per quarter. 5.1. Education provided at the time of the initial certification is counted as one of the required contacts. See ⧫820 - Quarterly Nutrition Education Contacts for the required topics that must be covered at the initial certification appointment.

Nutrition-Focused Education and Counseling, Continued 810.6 5.2. Nutrition-focused counseling provided during the mid-certification appointment also meets one of the required contacts. 5.3. A minimum of two other nutrition contacts are also required during the year, generally falling between initial certification and mid-certification, as well as between mid-certification and recertification appointments. These contacts may or may not be evenly spaced, depending on the needs of the participant. Scheduling nutrition-focused education and counseling contacts 6.0 Local programs shall make a reasonable effort to schedule nutrition-focused counseling contacts at times and locations that enable participants to take part. The local program may want to consider implementing some of the following recommendations to overcome barriers to participating in nutrition education: 6.1. Offer educational opportunities during the lunch hour or extend clinic hours into the evening or Saturday morning. This can be effective for group sessions targeted to the larger participant populations, e.g., breastfeeding, infant feeding, toddler feeding, prenatal nutrition. 6.2. Offer more groups in satellite locations to help overcome transportation and time barriers for participants attending. 6.3. Work with partnering agencies such as OSU Extension, Head Start or adult education schools to provide nutrition education opportunities at different locations. 6.4. Identify marketing opportunities to help participants understand the benefits of participating in nutrition-focused education and counseling. Qualifications of staff providing nutrition-focused education and counseling 7.0 Nutrition-focused education and counseling is to be provided by a certifier, RDN/WIC nutritionist or a health professional who is appropriately trained to address the nutrition education or counseling topic. See ⧫660 - Competent Professional Authority: Requirements for more information. 7.1. The training supervisor shall provide oversight to paraprofessional CPAs providing nutrition education and counseling. For complex nutrition or breastfeeding issues, CPAs will consult with the RDN/WIC nutritionist or other health professional and will refer when appropriate. 7.2. A staff member who provides group nutrition education shall be a CPA and shall complete, at a minimum, the Oregon WIC Training Module “Providing Participant Centered Groups”. 7.3. Staff members who provide nutrition-focused counseling for high-risk participants must be a qualified RDN/WIC Nutritionist. 7.3.1. If a RDN/WIC Nutritionist is not available, another health professional may temporarily fill in. See ⧫661 - Competent Professional Authority: Appropriate Counseling for Risk Levels for more information. Food benefit issuance 8.0 Food benefit issuance is generally coordinated with WIC participants’ quarterly nutrition education opportunities. This provides a uniform procedure for issuing WIC

Nutrition-Focused Education and Counseling, Continued 810.7 food benefits to participants and encourages participation in quarterly nutrition education. The maximum amount of food benefit issuance is three months at one time. Attendance of nutrition-focused education and counseling 9.0 Local programs shall stress the positive long-term benefits of nutrition education and encourage the participant to attend and participate in nutrition education activities. 9.1. First and/or second cardholders can attend nutrition education activities and be issued food benefits. 9.2. All nutrition education contacts shall be documented in TWIST. If nutrition education is relevant for multiple family members, document the education received in each family member’s TWIST record. See ⧫840—Documentation of Nutrition-Focused Education and Counseling for specific details. Missed nutrition-focused education and counseling 10.0 Participants or cardholders shall not be denied food benefits for failure to attend or participate in nutrition education activities. 10.1. If a participant or cardholder is unable to attend the scheduled nutrition education appointment, contact them to reschedule another nutrition education appointment within the same month, if possible. 10.2. If it is not possible to reschedule them within the same month, reschedule the participant for a nutrition education activity the following month, and issue the participant or cardholder one month of benefits. 10.3. One month’s food benefits may be issued when nutrition education is missed and two-way communication is made with the participant or cardholder to reschedule the nutrition education activity. Two-way contact means the participant has responded to clinic staff in person or by calling, texting or emailing back. See ⧫610—Required Proofs: Identity, Residence, Income for acceptable proof of identity before issuing benefits. Refusal of nutrition-focused education and counseling 11.0 Participants who refuse quarterly nutrition education offered during the initial certification or subsequent recertifications must contact their WIC clinic either in person or over the phone the month their food benefits end to continue receiving benefits on the program. 11.1. Document “NE Refusal” in the participant’s TWIST record at the time of certification, using the “NE Refusal” button. See ⧫840—Documentation of Nutrition-Focused Education and Counseling for specific details. 11.2. WIC staff shall indicate the month the participant needs to contact the clinic on the WIC Benefits List, WIC ID card, or other document. 11.2.1. When contacted, encourage staff to ask if the participant has any questions or concerns about using the food benefits. 11.3. Follow local procedure for frequency of food benefit issuance. The maximum allowed is three months at one time.

Nutrition-Focused Education and Counseling, Continued 810.8 11.4. Local programs are encouraged to offer anticipatory guidance to participants who refuse nutrition education. Although this does not meet the definition of quarterly education, it does support the mission of WIC. Monitoring 12.0 Local programs shall be reviewed for compliance with federal and state regulations during monitoring visits by state program nutrition consultants. Monitoring visits include observations of staff using participant centered counseling skills to provide evidenced-based nutrition education and counseling. For more information see ⧫215—Local Program Monitoring and Review and ⧫840—Documentation of Nutrition-Focused Education and Counseling. Fiscal requirements for nutrition education 13.0 In Oregon, local programs are required to spend at least 20% of their yearly grant on nutrition education. 13.1. Nutrition education expenses include staff time and nutrition-related activities as explained on the quarterly time studies. 13.2. Submit expense reports to the State agency. See ⧫315—Fiscal Reporting Requirements, for details in reporting nutrition education expenses. Nutrition education materials 14.0 Nutrition education materials provided by the State agency are designed to support and enhance nutrition-focused counseling efforts in local programs. Materials selected are evaluated for content accuracy and appropriateness for WIC participants. 14.1. Materials are routinely reviewed for scientific accuracy and health literacy principles such as plain language, reading level, format and graphic design. 14.2. Local agencies obtain nutrition and breastfeeding education materials through Shopify, Oregon WIC’s online ordering system. 14.2.1. Educational materials listed in Shopify are for local agency use only and are not available to partners or out-of-state entities. 14.2.2. Partnering agencies may obtain WIC outreach materials via the Oregon WIC website: https://www.oregon.gov/oha/PH/HEALTHYPEOPLEFAMILIES/WIC/P ages/partners.aspx 14.2.3. Certain materials pertaining to Oregon’s breastfeeding laws are available to any interested parties in Oregon. 14.3. Local agencies may purchase additional nutrition education materials on their own. These materials are to be reviewed and approved by their local RDN/WIC nutritionist prior to purchase and use. It is recommended that a copy of such materials be submitted to the local agency’s state nutrition consultant for reference. 14.4. Local agencies may also develop nutrition education materials for participants. Prior to use, these materials are to be reviewed and approved by their local RDN/WIC nutritionist.

Nutrition-Focused Education and Counseling, Continued 810.9 14.5. The state nutrition consultant will ask for and review any locally developed or purchased materials as part of the biennial WIC compliance review process. REFERENCES 1. WIC Nutrition Services Standards, US Department of Agriculture, Food and Nutrition Service, August 2013.

POLICY HISTORY Date * Revised, Reviewed, Released 10/5/2018 Released

The date located at the top of the policy is the date of the most recent release. Policies are to be implemented on release date and will become compliance findings 6 months from the release date. *Released: Significant changes made to policy. Release notes can be found in the corresponding document on the Policy and Procedure Manual page. Reviewed: The writer looked at this policy to make sure it was still accurate. Formatting changes may have occurred. Revised: Minor edits or formatting has occurred without need for release. USDA has accepted a policy and watermark is reviewed. Date of Origin: Date policy was initially released

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