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

4. 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

5. 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

6. POTATOES White potatoes Not recommended by IOM Not approved Sweet potatoes/Yams Approved

7. 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

8. LOW SODIUM PRODUCTS Low sodium foods Cheese Peanut butter

9. JUICE 46 OUNCES Women 46 oz. can juice Not allowed as of October 1 st Allowed 11.5 or 12 oz. frozen concentrate The food list is being updated

10. 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

11. GOAT MILK Size and Details 12 oz. Whole Evaporated Variety Meyenberg brand only Approved category Children 12 – 23 months

12. GOAT MILK (CONT.) Size and Details 12.6 oz. Non-fat Powder Variety Meyenberg brand only Approved category Children 24 - 59 months Women

13. 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

14. TOFU Size 16 oz. Varieties Azumaya Firm Extra Firm NaSoya Silken Organic

15. FOR ALL PROGRAM CATEGORIES DAIRY ALLOWANCE

16. Link to the video www.fns.usda.gov/core-nutrition/milk Scroll to the bottom of the page MILK VIDEO

17. DAIRY 12 – 23 MONTHS OF AGE Standard issuance (default) Whole Milk

18. DAIRY 12 – 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

19. 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

20. 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

21. WHEN CAN WE ASSIGN 2% TO CHILDREN 12 – 23 MONTHS OF AGE? 20  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

22. WHEN CAN WE ASSIGN 2% TO CHILDREN 12-23 MONTHS OF AGE? 21 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.

23. USE YOUR CRITICAL THINKING SKILLS 22 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?

24. Document the justification in the record Revise the default food prescription

25. DAIRY CHILDREN > 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

26. 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

27. 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

28. WHEN CAN WE ASSIGN 2% TO CHILDREN 24 – 59 MONTHS OF AGE? 27  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

29. WHEN CAN WE ASSIGN 2% TO CHILDREN 24 – 59 MONTHS OF AGE? 28 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.

30. 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?

31. Document the justification in the record Revise the default food prescription

32. 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

33. 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 2.A request received from the health care provider 3.Document the justification in the participant's record 4.Revise the default food prescription

34. 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

35. WHEN CAN WE ASSIGN 2% TO WOMEN? 34  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

36. WHEN CAN WE ASSIGN 2% TO WOMEN? 35 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

37. USE YOUR CRITICAL THINKING SKILLS 36  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?

38. Document the justification in the record Revise the default food prescription

41. WHAT IS IT CALLED? Whole Low-fat Reduced fat Fat-free Non-fat Skim

42. Barriers and strategies to transitioning to a lower fat milk?

45. BASED ON CATEGORIES DAIRY SUBSTITUTIONS

46. 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.

47. TOFU WOMEN & 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

48. 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

49. TOFU EXCHANGE 1pound tofu = 1quart of milk

50. SOY-BASED BEVERAGE WOMEN & 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

51. 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 cases Milk allergies People who don’t consume dairy products Children’s diets may be nutritionally inadequate when milk is replaced with other foods.

52. SOY-BASED BEVERAGE EXCHANGE 1 half-gallon of soy milk = 2 quarts of milk

53. 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

54. 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)

55. 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

56. 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

57. GENERAL CHANGES Terminology change From Medical foods to WIC eligible nutritionals Metabolic formulas Changed from 3 months to providing up to 2 months

58. BREASTFEEDING AMOUNT

59. RESOURCE AAP policy statement http://pediatrics.aappublications.org/content/122/1/198.fu ll http://pediatrics.aappublications.org/content/122/1/198.fu ll

60. wichealth.org Statewide Promotion 2014

61. 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

62. 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.

63. 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

64.  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%

65.  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

66.  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

67.  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.

68.  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

69.  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.

70.  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.”

71.  “ 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.

72.  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

73. Bulletin Board Promoting wichealth.org

74. 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

75. Rose Sipakati rose.sipakati@health.mo.org 573-522-2831