PENNSYLVANIA DEPARTMENT OF HEALTH Policy Number: 5.01 WIC State Agency USDA Approval Date: February 20, 2024 State Effective Date: April 20, 2024

POLICY MANUAL 5. WIC NUTRITION AND BREASTFEEDING SERVICES. 5.01 Nutrition Education and Counseling.

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A. POLICY OVERVIEW PA WIC shall make nutrition education available to all participants at no cost to promote healthy food and lifestyle choices.

B. POLICY 1. Planning Nutrition Contacts:

a. Nutrition education and counseling shall be made available to adult participants, parents or caregivers of infant and child participants, and whenever possible, child participants themselves.

b. Each participant shall be offered a minimum of four nutrition education contacts during each one-year certification period. For participants certified less than one year, nutrition education must be offered at the equivalent of one contact for every three months. The contacts shall be made available at four separate clinic visits, on four different dates.

c. The local agency (LA) shall have a procedure to reschedule participants who miss appointments that include nutrition education. The procedure shall assure that appropriate staff is available to provide nutrition education at the rescheduled appointment.

d. Routine nutrition education contacts may be provided by Certified Professional Authorities (CPAs), Competent Paraprofessional Authorities (CPPAs) and Program Assistants, designated by the LA. High-risk nutrition education contacts shall be provided in accordance with the guidelines listed in Section 4, Provision of Nutrition Education and Counseling for High-Risk Participants.

e. If the parent or caregiver is not present at the WIC appointment, nutrition education shall be made available to a proxy of a participant and the proxy shall be encouraged to share the information with the party represented.

f. The LA shall not require nutrition education as a condition to participate in the WIC program and may not withhold benefits when nutrition education is declined but shall document any failure or inability to participate in the Management Information System (MIS) for purposes of future nutrition education efforts and program monitoring.

PENNSYLVANIA DEPARTMENT OF HEALTH Policy Number: 5.01 WIC State Agency USDA Approval Date: February 20, 2024 State Effective Date: April 20, 2024

POLICY MANUAL 5. WIC NUTRITION AND BREASTFEEDING SERVICES. 5.01 Nutrition Education and Counseling.

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2. Provision of Nutrition Education and Counseling:

a. The purpose of nutrition education and counseling is to emphasize the relationship between nutrition, physical activity and health outcomes, and to assist participants in making positive changes in dietary and physical activity behaviors.

b. Nutrition education and counseling may occur in person or in accordance with the most current teleWIC guidance issued by the State agency (SA).

c. Nutrition education shall be made available through individual or group sessions covering topics that are appropriate to individual participant’s needs with consideration of the following:

(1) Nutritional needs and concerns as determined via Nutrition Assessment. (2) Food preferences. (3) Level of motivation and barriers to making positive changes. (4) Educational abilities and preferred learning styles. (5) Environmental influences/household situation. (6) Geographic location. (7) Cultural, ethnic, socioeconomic factors, and language needs. d. Nutrition education shall include a conversation with the participant. The following methods may be used to supplement, but may not replace, individual or group nutrition education:

(1) Pamphlets or newsletters (provided in-person, electronically, or by mail). (2) Posters, bulletin boards, or displays. (3) Information from reliable websites such as WIC-Works Resource Center, Centers for Disease Control and Prevention, Fruits and Veggies More Matters, Nemours KidsHealth.org, etc. (4) Audiovisual aids. (5) Educational props, such as food models, puzzles, games, etc. (6) Online nutrition education lessons. (7) Text messaging. (8) Education provided by partner organizations, unless approved by the SA.

e. Nutrition education for participants should include the following six elements:

(1) Consideration of participant risks, needs and concerns. (2) Setting individual, simple and attainable goals and providing ways to accomplish the goals. (3) Counseling methods that are easily understood.

PENNSYLVANIA DEPARTMENT OF HEALTH Policy Number: 5.01 WIC State Agency USDA Approval Date: February 20, 2024 State Effective Date: April 20, 2024

POLICY MANUAL 5. WIC NUTRITION AND BREASTFEEDING SERVICES. 5.01 Nutrition Education and Counseling.

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(4) Opportunities for interaction and feedback. (5) Reinforcements: pamphlets, bulletin boards, toothbrushes, cups, etc. (6) Follow-up to assess for behavior change.

f. Nutrition education should be based on a Value Enhanced Nutrition Assessment (VENA). In accordance with the USDA’s VENA initiative, the nutrition assessment shall include data collection and the application of critical thinking across the assessment categories. g. Goal setting is an important component of VENA and, therefore, required at initial certifications, re-certifications, and health evaluations. The following are considered acceptable reasons goal setting may not occur at initial certifications, re-certifications, and health evaluations: i) The participant declines setting a goal after staff have made a good faith effort to engage them in the guided goal setting process. ii) A need that takes priority over other risks (e.g. unstable housing, unsafe or inadequate childcare, domestic abuse concerns) has been identified during the nutrition assessment.

h. Goal setting is considered a best practice at benefit pick-up appointments and is strongly encouraged for all participants who are high-risk.

i. Exit counseling, including State-provided exit counseling brochure, shall be offered to all women “graduating” from the WIC program during the final appointment within both the pregnancy and postpartum certification periods.

(1) Exit counseling shall emphasize a well-balanced diet, folic acid intake, breastfeeding promotion, importance of children’s immunizations and the health risks of alcohol, smoking and using drugs. (2) Exit counseling sessions may be waived to provide risk-specific nutrition counseling when deemed more appropriate, but the exit counseling brochure must still be provided. The reason for waiving the exit counseling session must be clearly documented in the MIS. (3) All exit counseling sessions and the provision of exit counseling brochures must be documented in the MIS. j. LA staff must educate on lead poisoning prevention, immunization screening schedule, and substance use/abuse as determined necessary during the nutrition assessment. Refer to Policy 5.00, Nutrition and Risk Assessment, for details on when screenings, provision of information related to these topics and referrals must be provided.

k. All nutrition education provided must be consistent with information from nationally recognized sources, such as the American College of Obstetrics and Gynecology, American Academy of Pediatrics, Bright Futures, USDA WIC Infant Feeding Guide,

PENNSYLVANIA DEPARTMENT OF HEALTH Policy Number: 5.01 WIC State Agency USDA Approval Date: February 20, 2024 State Effective Date: April 20, 2024

POLICY MANUAL 5. WIC NUTRITION AND BREASTFEEDING SERVICES. 5.01 Nutrition Education and Counseling.

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MyPlate, More Matters, FNS Core Nutrition Messages, and Dietary Guidelines for Americans. USDA guidance shall be deferred to when recommendations differ between other reputable sources.

3. Documentation of Nutrition Education and Counseling:

a. Nutrition education and counseling shall be documented in the MIS for each participant by both selecting nutrition education topic code(s) and recording specific education and counseling that took place during the appointment.

(1) Nutrition education topics should be selected only if there was substantial discussion on the topic, including provision of specific suggestions. Topics should not be selected if the topic was simply mentioned during the course of routine assessment. b. Documentation for nutrition education contacts at initial certifications, re-certifications, and health evaluations must include goal follow-up (if applicable), complete nutrition assessment, interpretation of weight gain/growth, justification/interpretation of assigned risk codes, nutrition education topics, nutrition education/counseling description, and a goal.

c. Documentation for nutrition education contacts at appointment types other than initial certifications, re-certifications, and health evaluations must include goal follow-up (if applicable), nutrition assessment update (changes since last assessment), nutrition education topics, referrals, nutrition education/counseling description, and a goal (if applicable).

4. Provision of Nutrition Education and Counseling for High-Risk Participants:

a. High-risk nutrition services are intended for participants who are at higher risk for nutrition or health problems that can be prevented or improved through appropriate nutrition intervention.

b. WIC staff shall identify participants who are at high-risk and require special nutrition intervention. Participants may be identified as high-risk at any time during a certification period. High-risk status must be indicated in the MIS. Where applicable, physical charts for high-risk participants should be readily identifiable using a marker, color coded folder or other system.

c. High-risk nutrition care should be individualized, timely, and directed at stabilizing or improving the risk condition(s). Services required are the same as non-high-risk participants but must be provided, monitored and documented by a CPA. CPAs have

PENNSYLVANIA DEPARTMENT OF HEALTH Policy Number: 5.01 WIC State Agency USDA Approval Date: February 20, 2024 State Effective Date: April 20, 2024

POLICY MANUAL 5. WIC NUTRITION AND BREASTFEEDING SERVICES. 5.01 Nutrition Education and Counseling.

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the discretion to determine whether more frequent nutrition care is needed for a high- risk participant.

d. When a CPA is not available, a CPPA may provide and document the high-risk care. When a CPPA provides services to a high-risk participant, a CPA must review and approve the documented contact. When additional follow up is deemed necessary by a CPA, a high-risk follow up with a CPA must take place within 10 business days of the appointment with the CPPA. CPA approval of high-risk care provided by the CPPA and/or any additional follow up needed must be documented in the MIS.

e. For participants who are high-risk for the reason of receiving Food Package III, refer to Policy 5.10, Exempt Infant Formulas and WIC-Eligible Nutritionals, regarding food package prescription requirements.

f. High-risk contacts shall be documented in the MIS according to State agency guidance.

g. High-risk status can be discontinued by a CPA, except for participants receiving exempt infant formulas or WIC-eligible nutritionals, when the problem(s) no longer exist(s), the condition is stable, or the participant leaves the WIC Program. (1) If a participant is determined to no longer be high-risk, CPAs must document in the MIS that high-risk status has been resolved and include the justification. (2) CPAs may determine that it is beneficial to continue high-risk status after the condition is stable to prevent regression.

h. The LA Nutrition Education Coordinator shall train staff on high-risk nutrition services in accordance with Policy 3.03, Training of WIC Staff.

5. Nutrition Education Plans:

a. The LA shall develop and submit to the SA an annual nutrition education plan in accordance with the guidance distributed by the SA.

b. Annual nutrition education plans shall be prepared by the Nutrition Education Coordinator using the written guidance provided by the SA. When feasible, all staff that provides nutrition education should be given the opportunity to participate in developing the LA’s nutrition education plan.

c. All staff that provides nutrition education at the LA shall be familiar with Federal and SA requirements for nutrition education and shall be familiar with the LA’s nutrition education plan contents.

PENNSYLVANIA DEPARTMENT OF HEALTH Policy Number: 5.01 WIC State Agency USDA Approval Date: February 20, 2024 State Effective Date: April 20, 2024

POLICY MANUAL 5. WIC NUTRITION AND BREASTFEEDING SERVICES. 5.01 Nutrition Education and Counseling.

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6. Nutrition Education Coordination Between WIC and External Programs:

a. Local agencies (LAs) are encouraged to coordinate program operations, especially nutrition education activities, with special counseling services and other programs, including but not limited to: Supplemental Nutrition Assistance Program (SNAP), Healthy Beginnings Plus (HBP), Early Intervention, Head Start, teenage pregnancy and parenting projects, family planning, immunization, prenatal and postpartum care, well- child care, dental care, lead testing, smoking, alcohol, and drug abuse counseling, and child abuse counseling. b. The LA shall maintain a working relationship with county Expanded Food and Nutrition Education Program (EFNEP) staff in its WIC Program service area. The local EFNEP contact information shall be included in the LA’s list of referral agencies. c. Coordination with these programs supplements, but does not replace, nutrition education provided by WIC staff, unless approved by the SA.

__________________ References:

1. WIC Regulations: 7 CFR Part 246.11, including 7CFR Part 246.11(a)(3); 7 CFR 246.2. 2. Public Law 108-265, the Child Nutrition and WIC Reauthorization Act of 2004 (June 30, 2004). 3. WIC Nutrition Services Standards, FNS, USDA (August 2013). 4. WIC Program Nutrition Education Guidance (January 2006).

__________________ Policy Status: This Policy supersedes Policy 5.01 dated August 10, 2018.