1. Introduction to Nutrition Risk Factors

2. This module, Introduction to Nutrition Risk Factors, is part of the WIC SPIRIT Readiness training series. The series is designed to be an overview of major changes in the Arkansas WIC Program and to prepare WIC staff for further training in regards to SPIRIT, the new Management Information System.

3. The series includes VENA, the Value Enhanced Nutrition Assessment initiative, the WIC food packages, and nutrition risk factors.

4. Objective By the end of this module, the learner will be able to demonstrate knowledge of WIC nutrition risk factors by accurately assigning all applicable nutrition risks for each participant type.

5. Nutrition Risk Factors This module is intended as an overview of all nutrition risk factors for each participant type. Knowledge of all nutrition risk factors definitions is essential in completing a value enhanced nutrition assessment (VENA).

6. Nutrition Risk Factors Nutrition Risk Factors definitions can be viewed in SPIRIT through the Certification Guided Script. The next slides will show you how to access the Nutrition Risk Factors in SPIRIT.

7. 1. Click on Risk Factors/High Risk in the Certification Guided Script

8. 2. The Certification Risk Factors screen will appear next. 3. Click on Risk Factors Details Guide

9. 4. The Nutritional Risk Factors Guides screen will appear containing all the Nutrition Risk Factors and their definitions for the participant type with whom you are working.

10. Nutrition Risk Factors Click here to access and print the Nutrition Risk Factors document. Important Note: To return to the PowerPoint module, click on the back arrow in the upper left hand side of the screen.here Use the document as a reference in completing this module.

11. Nutrition Risk Factors The following is displayed in the Nutrition Risk Factors document: A.Applicable nutrition risk factors for participant type B. Priority Level of nutrition risk factor

12. Nutrition Risk Factors C. Number assigned to nutrition risk factor D. Title and definition of nutrition risk factor E. High risk assignment of nutrition risk factor as indicated by a check mark (  ).

13. Risk Factor for Participant Type PriorityAssigned Risk Factor Number Risk Factor Number Risk Factor Title & Definition High Risk Assigned Nutrition Risk Factors A B CD E

14. Nutrition Risk Factors by Participant Type Directions: Use your printed Nutrition Risk Factors document to review the: 1.applicable nutrition risk factors for each participant type 2.definition of each nutrition risk factor

15. Nutrition Risk Factors by Participant Type (continued) 3.number assigned to each nutrition risk factor 4. assignment of High Risk for each nutrition risk factor

16. Nutrition Risk Factors There will be four changes: 1.New nutrition risk factors will be added. 2.Some nutrition risk factors will be eliminated. 3.Definitions to some existing nutrition risk factors will change. S tarting Fall 2008:

17. Nutrition Risk Factors 4. Increased Risk/Moderate Risk terminology will no longer be used. Instead will use High Risk and Non-High Risk assignment to nutrition risk factors. S tarting Fall 2008 (continued):

18. Value Enhanced Nutrition Assessment Nutrition risk factors are and have always been categorized. All nutrition risk factor categories are included in a value enhanced nutrition assessment. The categories are: Anthropometric Biochemical Clinical Dietary Environment Family Other Health Issues

19. Nutrition Risk Factor Number Categories Risk Factor Categories are divided into the following: 100s = Anthropometrics 200s = Biochemical 300s = Clinical/Medical/Health 400s = Dietary 500s, 600s, 700s, 800s, 900s = Other (including - Environmental, Family and Other Health Issues )

20. Nutrition Risk Factor Numbers by Category 100s = A nthropometrics  101-Underweight Women  103-Underweight/At Risk of Underweight Infants/Children  111-Overweight Women  113-Overweight Children  114-At Risk of Becoming Overweight  121-Short Stature/At Risk of Short Stature  131- Low Maternal Weight Gain  132-Maternal Weight Loss During Pregnancy  133-High Maternal Weight Gain  134-Failure to Thrive  135-Inadequate Growth  141-Low Birth Weight/Very Low Birth Weight  142-Prematurity  151-Small for Gestational Age  153-Large for Gestational Age 100s Nutrition Risk Factors- A nthropometrics

21. Nutrition Risk Factor Numbers By Category 200s = B iochemical 201-Low Hemoglobin/Low Hematocrit 211-Elevated Blood Lead Levels 200s Nutrition Risk Factors - B iochemical

22. Nutrition Risk Factor Numbers By Category 300s = C linical/Medical/Health 301-Hyperemesis Gravidarum 302-Gestational Diabetes 303-History of Gestational Diabetes 311-History of Preterm Delivery 312-History of Low Birth Weight 321-History of Spontaneous Abortion, Fetal Loss, or Neonatal Loss 331-Pregnancy at a Young Age 332-Closely Spaced Pregnancies 333-High Parity and Young Age 334-Lack of or Inadequate Prenatal Care 335-Multifetal Gestation 337-History of Birth of a Large for Gestational Age Infant 338-Pregnant Women Currently Breastfeeding 300s Nutrition Risk Factors- C linical

23. Nutrition Risk Factor Numbers By Category 300s = C linical/Medical/Health (continued) 339-History of Birth with Nutrition Related Congenital or Birth Defect 341-Nutrient Deficiency Diseases 342-Gastro-Intestinal Disorders 343-Diabetes Mellitus 344-Thyroid Disorders 345-Hypertension(Including Chronic and Pregnancy-Induced) 346-Renal Disease 347-Cancer 348-Central Nervous System Disorder 349-Genetic Congenital Disorders 350-Pyloric Stenosis 351-Inborn Errors of Metabolism 352-Infectious Diseases 300s Nutrition Risk Factors- C linical

24. Nutrition Risk Factor Numbers By Category 300s = C linical/Medical/Health (continued) 353-Food Allergies 354-Celiac Disease 355-Lactose Intolerance 356-Hypoglycemia 357-Drug Nutrient Interactions 358-Eating Disorders 359-Recent Major Surgery, Trauma, Burns 360-Other Medical Conditions 361-Depression 362-Developmental, Sensory, or Motor Disabilities Interfering with the Ability to Eat 371-Maternal Smoking 372-Alcohol and Illegal Drug Use 381-Dental Problems 300s Nutrition Risk Factors- C linical

25. Nutrition Risk Factor Numbers By Category 400s = Dietary * 401-Failure to meet Dietary Guidelines (Children 24 months and older; all Women) 411-Inappropriate Nutrition Practices for Infants 425-Inappropriate Feeding Practices for Children 427-Inappropriate Nutrition Practices for Women 428-Dietary Risk Associated with Complementary Feeding Practices (Infants 4 month through 12 months of age and Children 12 months through 23 months of age only) *New – further explanation to follow 400s Nutrition Risk Factors- D ietary

26. Nutrition Risk Factor Numbers By Category 500s 501-Possibility of Regression 600s 601-Breastfeeding Mother of Infant at Nutritional Risk 602-Breastfeeding Complications or Potential Complications (Women) 603-Breastfeeding Complications or Potential Complications (Infants) 700s 701-Infant Up to 6 Months Old of WIC Mother, or of a Woman Who Would have Been Eligible During Pregnancy 702-Breastfeeding Infant of Woman at Nutritional Risk 703-Infant Born of a Woman with Mental Retardation or Alcohol or Drug Abuse During Most Recent Pregnancy

27. Nutrition Risk Factor Numbers By Category 800s 801-Homelessness 802-Migrancy 900s 901-Recipient of Abuse 902-Woman or Primary Caregiver of Infant/Child with Limited Ability to make Feeding Decisions and/or Prepare Food 904-Exposure to Environmental Tobacco Smoke (also known as passive, secondhand or involuntary smoke)

28. Dietary Nutrition Risk Factors Highlight of Changes

29. The dietary nutrition risk factors have had the most significant changes impacting the WIC certification process. The following slides summarize these changes. Dietary Nutrition Risk Factors

30. The changes are a result of the Institute of Medicine findings (with one recommendation) and the RISC* literature review. Click here to read findings and recommendation. Important Note: To return to the PowerPoint module, click on the back arrow in the upper left hand side of the screen.here * RISC - Risk Identification and Selection Collaborative made up of National WIC Association members and Food and Nutrition Service members Dietary Nutrition Risk Factors

31. BEFORE SPIRIT Dietary Nutrition Risk Factors were: 400 410 1.Assessed with 24 Hour Diet Recall 2.Both numbers apply to all participant types WITH SPIRIT Dietary Nutrition Risk Factors will be: 401 427 411 428 425 1.Not assessed with 24 Hour Diet Recall 2.Different numbers apply to different participant types

32. New Dietary Nutrition Risk Factors 401 - Failure to meet Dietary Guidelines for Americans for participant types: Pregnant Women Breastfeeding Women Non-breastfeeding Postpartum Women Children > 2 years of age 411 – Inappropriate Nutrition Practices for Infant for participant types: Infants Birth to 12 months 425 –Inappropriate Nutrition Practices for Children for participant types: Children 12 to 59 months (1 through 4 years of age)

33. New Dietary Nutrition Risk Factors 427 – Inappropriate Nutrition Practices for Women for participant types: Pregnant Women Breastfeeding Women Non-breastfeeding Postpartum Women 428 - Dietary Risk Associated with Complementary Feeding Practices for participant types: Infant 4 to 12 months Children 12 through 23 months (< 2 years of age)

34. Dietary Nutrition Risk Factors 411 – is the umbrella risk factor for Inappropriate Nutrition Practices for Infants Includes subcategories of 411.1 through 411.11 – All infants 425 –-is the umbrella risk factor for Inappropriate Nutrition Practices for Children Includes subcategories of 425.1 through 425.9 -All children

35. Dietary Nutrition Factors Dietary Nutrition Risk Factors 427– is the umbrella risk factor for Inappropriate Nutrition Practices for Women 427.1 through 427.5- Pregnant 427.1 through 427.4 - Breastfeeding 427.1 through 427.4 – Non-breastfeeding Postpartum

36. Presumed Dietary Risk Factors 401* – Failure to Meet Dietary Guidelines for Americans is used when no other risk factors are identified and the participant is a Child 24 months and older, or Pregnant Woman, or Breastfeeding Woman, or Non-breastfeeding Postpartum Woman * Must perform a complete nutrition assessment before assigning this risk factor.

37. Predisposing Dietary Risk Factors 428*– Dietary Risk Associated with Complementary Feeding Practices is used when no other risk factors are identified and the participant is a(n) Infant 4 months to 12 months, or Child 12 months through 23 months * Must perform a complete nutrition assessment before assigning this risk factor.

38. 428 Dietary Risk Associated with Complementary Feeding Practices NOTE: Infants between Birth and <6 months of age are unlikely to have no other nutrition risk factors identified because risk factor 701 would/should be assigned: Infant Up to 6 months old of WIC Mother, or of a Woman who would have been eligible during pregnancy.

39. Practice Using Nutrition Risk Factors Read the following scenarios and answer the questions using your printed Nutrition Risk Factors document for reference.

40. Scenario 1 Mary B., a pregnant woman, complains of stomach discomfort, cramps, and diarrhea whenever she drinks milk. She states she was told by her doctor that she has lactose intolerance. Which nutrition risk factor would be assigned for this participant? a.353- Food Allergies b.354-Celiac Disease c.355- Lactose Intolerance d.356-Hypoglycemia

41. Scenario 1 Answer Answer c – 355 -is correct! The definition of lactose intolerance includes: Presence of lactose intolerance diagnosed by a physician as self reported by applicant/participant/caregiver; or as reported or documented by a physician, or someone working under physician’s orders; or symptoms must be well documented by the competent professional authority. Documentation should indicate that the ingestion of dairy products causes the above symptoms and the avoidance of such dairy products eliminates them.

42. Scenario 1 (continued) Based on the assignment of the nutrition risk factor 355-Lactose Intolerance, will Mary be considered High Risk and need an appointment with the Nutritionist? a.Yes b.No

43. Scenario 1 Answer () Scenario 1 Answer (continued) Answer a – Yes -is correct! The nutrition risk factor of Lactose Intolerance is assigned as High Risk and must be referred to the Nutritionist for individual counseling.

44. Scenario 2 Henry W. is a 3-year-old child who has lost weight since his last certification. He now plots at the 8 th percentile BMI-for-age. Due to his assigned nutrition risk factor(s), he qualifies for peanut butter. Which nutrition risk factor(s) would be assigned for a BMI-for-age at the 8 th percentile? a. 103- Underweight/At Risk of Underweight b. 141- Low Birth Weight c. 142- Prematurity d. 151- Small for Gestational Age

45. Scenario 2 Answer Answer a – 103 At Risk of Underweight is correct! At Risk of Underweight is defined as: 2 to 5 years: 6 th through 10 th percentile Body Mass Index (BMI)- for- age

46. Scenario 3 James S. is a 2-year-old child for whom no nutrition risk factors are identified through the completion of a value enhanced nutrition assessment. Can James still be certified and participate in WIC? a. Yes b. No

47. Scenario 3 Answer Answer a – Yes - is correct! Nutrition Risk Factor 401- Failure to Meet Dietary Guidelines for Americans - can be assigned if no other nutrition risk factors are identified from the value enhanced nutrition assessment. Therefore James would be nutritionally eligible to participate in WIC.

48. Scenario 4 Mary S. is a 7-month-old infant who is being certified for WIC for the first time today. Mother was not on WIC during pregnancy. No nutrition risk factors have been identified through the value enhanced nutrition assessment. Can Mary still be certified and participate in WIC? a. Yes b. No

49. Scenario 4 Answer Answer a – Yes - is correct! Nutrition Risk Factor 428- Dietary Risk Associated with Complementary Feeding Practices- can be assigned if no other nutrition risk factors are identified from the value enhanced nutrition assessment. Therefore Mary would be nutritionally eligible to participate in WIC.

50. Summary The Arkansas WIC Program will be implementing many changes in the nutrition risk factors used for certification. It is important for the CPA to know definitions of nutrition risk factors in order to : -perform a comprehensive and accurate value enhanced nutrition assessment -to provide client-centered nutrition services.