MISSOURI WIC PROGRAM IMPLEMENTATION OCTOBER 1, 2014 WIC FINAL FOOD RULE TRAINING: PHASE 1.

MISSOURI WIC PROGRAMIMPLEMENTATION OCTOBER 1, 2014

WIC FINAL FOOD RULE TRAINING: PHASE 1

OBJECTIVES

• Acknowledge the new food items on the WIC Approved Food List

• Identify the changes related to milk types• Identify factors which affect milk preference and

purchasing • Identify barriers to the use of lower fat milk • Identify the changes related to milk substitutes • An overview of WICHealth.org

MISSOURI ALREADY IMPLEMENTED

• Allows organic fruits and vegetables to be purchased with the CVV • October 1, 2009

• No longer allows cheese to be issued beyond the maximum monthly allowance • June 1, 2014

• CVV increased to $8.00 for children• June 1, 2014

POTATOES

• White potatoes • Not recommended by IOM• Not approved

• Sweet potatoes/Yams• Approved

CANNED FISH

• Canned Salmon• 5 oz.• Variety

• Pink salmon

• Any brand

• Sardines • 3.75 oz. • Varieties

• Water packed• Tomato sauce • Mustard sauce

• Any brand

Food Package VII-Fully Breastfeeding women-Partially Breastfeeding Multiples (mostly) -Pregnant women with multiples-Pregnant women who are still breastfeeding whose infants receive less than the max amount of formula allowed

LOW SODIUM PRODUCTS

• Low sodium foods• Cheese • Peanut butter

JUICE 46 OUNCES

• Women• 46 oz. can juice

• Not allowed as of October 1st • Allowed 11.5 or 12 oz. frozen

concentrate • The food list is being updated

PEANUT BUTTER

• Allowed• Smooth, creamy or regular• Store brand only• 16-18 oz. jar only

• Not allowed• Crunchy• Low-fat• Organic• Mixtures with jams, jellies, honey,

marshmallows or chocolate

GOAT MILK

• Size and Details • 12 oz.• Whole• Evaporated

• Variety • Meyenberg brand only

• Approved category• Children 12 – 23 months

GOAT MILK (CONT.)

• Size and Details • 12.6 oz.• Non-fat• Powder

• Variety • Meyenberg brand only

• Approved category• Children 24 - 59 months• Women

GOAT MILK 101

• Useful in some cases• Cow milk intolerance • Allergy to soy-based beverage

• Not appropriate in these situations• Cow’s milk protein allergy

• Increased allergic potential to goat milk

• Lactose intolerance • Lactose content is comparable to

cow’s milk

• As a replacement for infant formula

TOFU

• Size• 16 oz.

• Varieties• Azumaya

• Firm • Extra Firm

• NaSoya• Silken Organic

FOR ALL PROGRAM CATEGORIES

DAIRY ALLOWANCE

• Link to the video• www.fns.usda.gov/core-nutrition/milk

• Scroll to the bottom of the page

MILK VIDEO

DAIRY12 – 23 MONTHS OF AGE

• Standard issuance

(default) • Whole Milk

DAIRY12 – 23 MONTHS OF AGE (CONT.)

• Standard issuance (default)

• Whole Milk

• 2% Reduced fat milk• CPA determination • 2% milk cannot be

assigned simply because of a preference or parental request

WHEN CAN WE ASSIGN 2% TO CHILDREN 12 – 23 MONTHS OF AGE?

1. After the CPA makes the determination based upon: • Nutrition Assessment

• Health Assessment/Growth charts

• Risk factors

2. A request received from the health care provider

3. Document the justification in the record

4. Revise the default food prescription

WHEN CAN WE ASSIGN 2% TO CHILDREN 12 – 23 MONTHS OF AGE?

• CPA makes the determination based upon:

• Nutrition Assessment • These include

• Ensuring the child is drinking appropriate amounts of milk

• Weaning from the bottle around 12 months of age• Avoiding sweetened beverages• Avoiding sippy cups (and other covered containers

that a child can carry and drink from throughout the day)

• Ensuring snacks are structured and appropriate• Preparing and providing appropriate foods; limiting

fast food

WHEN CAN WE ASSIGN 2% TO CHILDREN 12 – 23 MONTHS OF AGE?

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CPA makes the determination based upon:

Health Assessment Growth related issues may include:

The growth pattern shows a trend of high weight gain

The participant’s health care provider requests 2% because of a health concern

Other issues or risks identified by the CPA

WHEN CAN WE ASSIGN 2% TO CHILDREN 12-23 MONTHS OF AGE?

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• CPA makes the determination based upon: • Risk Factors

• RF 114 Overweight • RF 115 High Weight-for-Length • When a CPA identifies a growth related issue or risk

during a complete health assessment.

USE YOUR CRITICAL THINKING SKILLS

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Mom and Dad bring in their 18 month old to be enrolled. MOWINS assigns Risk Factor 115. The parents express concerns about their weight but aren’t really concerned about their little one, yet. They drink 2% but give their 18 month old whole milk.

Other dairy products?

How much milk?

Other health issues?Sweetened

beverages

Growth pattern?

Other foods or sources of fat?

• Document the justification in the record • Revise the default food prescription

DAIRYCHILDREN > 24 – 59 MONTHS OF AGE

• Standard issuance• Non-fat (skim) and low-fat (1%)

• 2% Reduced fat milk• CPA determination • 2% milk cannot be assigned simply

because of a preference or parental request

WHEN CAN WE ASSIGN 2% TO CHILDREN 24 – 59 MONTHS OF AGE?

1. CPA makes the determination based upon: • Nutrition Assessment

• Health Assessment/Growth charts

• Risk factors • Underweight 103• Failure to Thrive 134 • Inadequate Growth 135

2. A request received from the health care provider

3. Document the justification in the participant's record

4. Revise the default food prescription

WHEN CAN WE ASSIGN 2% TO CHILDREN 24 – 59 MONTHS OF AGE?

• CPA makes the determination based upon: • Nutrition Assessment

• These include

• Ensuring the child is drinking appropriate amounts of milk

• Ensuring snacks are structured and appropriate

• Preparing and providing appropriate foods

WHEN CAN WE ASSIGN 2% TO CHILDREN 24 – 59 MONTHS OF AGE?

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CPA makes the determination based upon:

Health Assessment Growth related issues may include:

The growth pattern shows a trend of low weight gain

The participant’s health care provider requests 2% because of a health concern; or,

Other issues or risks identified by the CPA

WHEN CAN WE ASSIGN 2% TO CHILDREN 24 – 59 MONTHS OF AGE?

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• CPA makes the determination based upon: • Risk Factors

• Underweight 103• Failure to Thrive 134 • Inadequate growth 135 • When a CPA identifies a growth related issue or risk

during a complete health assessment.

USE YOUR CRITICAL THINKING SKILLS

29

Dad brings in his 3 year old daughter for a certification. The child’s general health and BMI are normal for her age. The fat content changes in milk have been explained. Dad is adamant that his family only drinks 2%.

What kinds of things should be considered?

Psychological environment?

Lack of food?

Excessive caloric

expenditure?

Growth pattern?

• Document the justification in the record • Revise the default food prescription

DAIRY WOMEN

• Standard issuance• Non-fat (skim) and low-fat (1%)

• Reduced fat milk (2%)• CPA determination • 2% milk cannot be assigned

simply because of a preference

WHEN CAN WE ASSIGN 2% TO WOMEN?

1. CPA makes the determination based upon: • Nutrition Assessment

• Health Assessment/Prenatal Weight Gain Chart

• Risk factors • Underweight 101 • Low Maternal Weight Gain 131• Maternal Weight Loss during pregnancy 132

• A request received from the health care provider• Document the justification in the participant's record• Revise the default food prescription

WHEN CAN WE ASSIGN 2% TO WOMEN?

• CPA makes the determination based upon: • Nutrition Assessment

• These include

• Ensuring snacks are structured and appropriate

• Preparing and providing appropriate foods

• Insufficient food sources

WHEN CAN WE ASSIGN 2% TO WOMEN?

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CPA makes the determination based upon: Health Assessment

These may include: The growth pattern shows a trend of low weight

gain (e.g. the PWGC shows a decrease in recommended weight gain channel);

Other issues or risks identified by the CPA Other issues or risk identified by the Healthcare

provider Issue must be documented Doesn’t require a WIC-27

WHEN CAN WE ASSIGN 2% TO WOMEN?

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• CPA makes the determination based upon: • Risk Factors

• RF 101 Underweight • Prenatal, breastfeeding and non-breastfeeding

women• RF 131 Low Maternal Weight Gain (prenatal)• RF 132 maternal Weight Loss during pregnancy

USE YOUR CRITICAL THINKING SKILLS

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What are some reasons women would need 2% milk?

What kinds of things should be considered?

Psychological environment?

Lack of food?

Excessive caloric

expenditure?PWGC?

• Document the justification in the record • Revise the default food prescription

WHAT IS IT CALLED?

WholeLow-fat

Reduced fat

Fat-freeNon-fatSkim

Barriers and strategies to transitioning to a lower fat milk?

BASED ON CATEGORIES

DAIRY SUBSTITUTIONS

LACTOSE-FREE MILK

• Lactose-free milk should be offered before non-dairy milk alternatives • tofu and soy milk

The value of vitamin D in milk assist with the development of bone mass.

TOFUWOMEN & CHILDREN

• Reason for issuance (e.g. milk allergy, lactose intolerance, vegan diet, etc.) • Four pound max can be issued

• Children (12 – 59 months of age)• CPA is authorized to determine the need

• Must document the reason for issuance • Women

• No CPA documentation needed

TOFU 101

• Overview• Rich in B vitamins • Low in sodium• Lacks vitamin D• Less calcium than milk• Lactose free• Casein free

• Useful in some cases• Lactose Intolerance• Cow’s milk allergies

Available in the warehouse

TOFU EXCHANGE

1pound tofu = 1quart of milk

SOY-BASED BEVERAGEWOMEN & CHILDREN

• Children (12 – 59 months of age)• CPA is authorized to determine the need

• Max allowed • Must document the reason for issuance (e.g. milk

allergy, lactose intolerance, vegan diet, etc.)

• Women• No CPA documentation needed

• Max allowed

SOY-BASED BEVERAGE 101

• Overview• Source of omega-3 fatty acids• Has the same amount of protein as cow's milk• Eating 25 grams a day of soy protein might help

lower blood cholesterol levels

• Useful in some casesMilk allergies

People who don’t consume dairy products

Children’s diets may be nutritionally inadequate when milk is replaced with other foods.

SOY-BASED BEVERAGE EXCHANGE

1 half-gallon of soy milk = 2 quarts of milk

CHEESE EXCHANGE

• One pound of cheese = 3 quarts of milk• Total amounts which can be issued

• One pound - Food Packages IV, V & VI• Two pounds - Food Package VII

THE “DANGLING QUART”

• Dangling quart substitutes could be:• 1-12 oz. can of evaporated milk• 1 quart of buttermilk• 1 quart of milk (whole, 2%, 1%, skim)

FOOD PACKAGE III

• ER# 2.07000• Children 24 – 59 months of age and women

• Types of milk may be issued:• Whole milk• Evaporated whole milk• Lactose free whole milk• Requires a WIC 27 • Formula or medical food must be issued along with

the whole milk request

FOOD PACKAGE III (CONT.)

• ER# 2.07000• Not authorized for:

• Infants whose only condition is formula intolerance or food allergy to lactose, sucrose, milk or soy protein

• A non-specific formula or food intolerance

• Women and children who have a food intolerance to lactose or milk protein

• Solely for the purpose of enhancing nutrient intake or managing body weight

GENERAL CHANGES

• Terminology change• From Medical foods to WIC eligible nutritionals

• Metabolic formulas • Changed from 3 months to providing up to 2 months

BREASTFEEDING AMOUNT

RESOURCE

• AAP policy statement http://pediatrics.aappublications.org/content/122/1/198.full

wichealth.org

Statewide Promotion 2014

• Stage-based, participant-centered, behavior change nutrition education for WIC participants

• 26 lessons available online• Available for English and Spanish speaking

participants• Currently used by WIC programs in 23 other states

• WIC staff promote wichealth.org to eligible participants.• Participant creates an account and completes a lesson.• Participant provides the Certificate of Completion to the

WIC agency.• Upon verification of completed lesson staff follow up with

participant.

• Number of Lessons Completed: 607 lessons

• Average Time Spent on Site: 12.13 minutes

• Average Number of Links Visited: 1.56 links

• Number of Participant Accounts Created:390 accounts

Most Popular Lessons: Make Meals and Snacks Simple 85% Secrets for Feeding Picky Eaters 57% Fun and Healthy Drinks for Kids 49% Trust your child to eat enough 49% Happy Healthy Active Children 40% Fruits and Veggies Grow Healthy Kids 39% Understanding your baby’s cues 37%

User Ages: 77% of parent/guardians were between the ages of 25 – 29 years.

Computer Locations: 45% home, 34% WIC Clinic,7% work, 3% parent’s home

Convenient for the participant, especially working parents

Freed up some staff time

Participants say they like it and the topics too.

Wide range of information that can be tailored to individual interests/needs/learning styles

Well received by participants who like choosing what time to have their lesson (working mom, class schedule, etc)

Created room in my schedule to accommodate those who needed to reschedule

Participants liked the lesson choices.

Nice to have a different way of learning for those that like to read or watch videos online and not always like to listen to something we say. 

Explaining the program without making it sound too difficult

Figuring out how it was going to work for our agency

at first

Participants with no internet access Hoping participants won't forget to do their lesson

Figuring out how to present wichealth.org and make it sound as exciting as it actually is

Getting all the staff on board and excited to promote wichealth.org

Participants not emailing their Certificates of Completion after they finished a lesson

Internet access seems to be an issue with our participants, and some think it would be too difficult.

WIC Program Participants“I really enjoyed the way material was presented and I

look forward to utilizing these tips in day to day settings with my kids. Also love that there were several recipe suggestions.”

“Inspired me to create different ways to play with my daughter indoors, even in a small apartment.”

“I really like getting the recipes for smoothies. We’ve started making them at our house and the kids really enjoy them.

Yes!

Why? Convenient for participants especially working families

Provides another perspective on nutrition education

Schedule flexibility: covering staff vacations, more time for continuing education, more appointment times open for certifications/mid-certifications

Provides another option for completing that nutrition education visit

Full statewide implementation Timeline for Implementation

Training –September 2014. Dates to be finalized.

Nutrition policy being revised to accommodate WICHealth.org

Agency Logistics-Promotion to LWP staff and Participants. Implementation and Support of Nutrition Education

Rose Sipakatirose.sipakati@health.mo.org

573-522-2831