WIC Nutrition Risk Criteria

I. PURPOSE

This policy memorandum describes nutrition risk eligibility in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC), and explains the requirements of the use and management of the Food and Nutrition Service (FNS)-issued nutrition risk criteria by WIC state agencies. It reinforces that state agencies must use the FNS criteria as a part of the certification process, and it outlines the process for updating and revising the criteria and related information.

This memorandum consolidates and replaces all previous versions to, and reorganizes and reiterates the narrative body of, WIC Policy Memorandum #98-9, Nutrition Risk Criteria, issued by FNS on June 29, 1998.

II. BACKGROUND

A. History of WIC Nutrition Risk

Requiring nutrition risk as an eligibility criterion is a unique feature of WIC. In addition to meeting categorical, income, and residency requirements, each WIC applicant must be determined to be at nutrition risk on the basis of a medical or nutrition assessment by a physician, nutritionist, dietitian, nurse, or some other competent professional authority (CPA), in order to be certified as a WIC participant.

For nearly 25 years after the WIC program was established, Federal policy permitted WIC state agencies to develop criteria, within broad Federal parameters, for use in their local programs to determine program eligibility. In 1989, the Child Nutrition and WIC Reauthorization Act (PL 101-147) mandated that the Department of Agriculture (USDA) conduct a review of risk criteria and the priority system. The purpose of this review was to ensure that WIC benefits were being provided to those most in need of them, in the event that funds were not available to serve all eligible program applicants. As a result of the variation in nutrition risk criteria among state agencies, the USDA awarded a grant in 1993 to the National Academy of Sciences' Institute of Medicine (IOM) to undertake a comprehensive, independent review of the criteria in use by WIC state agencies at that time. In 1996, IOM released its report titled WIC Nutrition Risk Criteria: A Scientific Assessment (referenced in this memo as the IOM Nutrition Risk Report). The report included a detailed review of the literature underlying each studied risk criterion, along with the Committee's recommendations concerning each criterion.

B. Risk Identification and Selection Collaborative

As a result of the 1996 IOM Nutrition Risk Report, FNS and the National WIC Association (NWA)-known at that time as the National Association of WIC Directors, established a collaborative partnership to address the issues and recommendations in the Report, and to develop an action plan to achieve greater consistency among WIC state agencies in the use and application of sound and appropriate nutrition risk criteria. The Risk Identification and Selection Collaborative (RISC) was created to manage the transition from this initial effort to an ongoing review process.

RISC is charged with revising currently-allowed and adding new WIC nutrition risk criteria. Such criteria must be based on sound science, practical for WIC application, and nutritionally linked or related to the nutrition services provided by WIC. RISC also periodically reviews allowed criteria to identify criteria that should be deleted because they are no longer supported by current science and research; or represent conditions that cannot be mitigated, controlled, or eliminated as a result of receiving WIC nutrition services (food packages, referrals, nutrition education/counseling, and breastfeeding promotion and support).

RISC membership includes NWA-appointed state and local agency staff along with FNS Headquarters and Regional Office staff. All RISC members are involved in the deliberation, development and composition of the criteria and guidelines. This allows for representative WIC state and local agency input at eve1y step in the development process for nutrition risk criteria.

C. Nutrition Risk Criteria and Nutrition Assessment Policy

Section 17(b)(8) of the Child Nutrition Act of 1966, as amended (the law that established and authorizes the WIC program) broadly defines nutrition risk as "(a) detrimental or abnormal nutritional conditions detectable by biochemical or anthropometric measures, (b) other documented nutritionally related medical conditions, (c) dietary deficiencies that impair or endanger health, or (d) conditions that predispose persons to inadequate nutritional patterns or nutritionally related medical conditions." This legislative definition is implemented at Section 246.7 (e)(2) of the Federal WIC regulations.

The Value Enhanced Nutrition Assessment (VENA) Guidance established standards for the nutrition assessment process used to determine WIC eligibility. In addition, WIC Policy Memorandum #2006-5: VENA - WIC Nutrition Assessment Policy (issued March 15, 2006) further explained that the nutrition assessment serves as the foundation on which other nutrition services (food packages, referrals, nutrition education/counseling, and breastfeeding promotion and support) are planned and provided. In order to facilitate this VENA principle, as individual criteria are revised, criteria write-ups will contain a section titled "Implications for WIC Nutrition Services". This section will describe how a given risk criterion is nutritionally linked to and has application for the nutrition services WIC provides to mitigate a given nutritional risk.

III. ISSUANCE AND DISSEMINATION OF NUTRITION RISK CRITERIA

Historically, specific risk criteria revisions, additions, or deletions have been issued via numbered policy; however, this will no longer be the process. In 2008, in an effort to improve communication and technical assistance to FNS Regional Offices and WIC state agencies, FNS began using SharePoint® software via its PartnerWeb to disseminate and communicate policy and guidance information.

FNS will use the PartnerWeb to disseminate all nutrition risk related information. When criteria are revised, removed, or added, the current index of allowable and not-allowable criteria (along with any other applicable appendices) will be posted to the Nutrition Risk section of the PartnerWeb community for WIC state agencies. The site will contain historical information, such as previous versions of policy memos and criteria write-ups, as well as directions for proposing a new risk criterion or criterion revision. In addition, technical information and expert reports will be available on the site.

Some criteria have been determined by FNS to be inappropriate or lack sufficient science-based evidence for use in certifying persons for the WIC program. Although some of these criteria may be considered to be nutritionally related, they do not reflect conditions that can be accurately assessed or effectively addressed through the nutrition services provided through the WIC program. Only risk criteria on the Index of Allowable Criteria may be used to certify WIC applicants.

The dissemination of new and/or revised criteria through PartnerWeb is more streamlined and flexible than previous processes for the issuance of revisions to nutrition risk criteria to WIC state agencies. This process will allow FNS to issue nutrition risk revisions on an as-needed basis, but generally once or twice a year. When criteria are added, revised, or deleted, an announcement will be posted to the FNS PartnerWeb indicating that updates to the nutrition risk section have been posted. The FNS PartnerWeb community for WIC state agencies can be accessed at https://www.partnerweb.usda.gov/default.aspx.

IV. IMPLEMENTATION

WIC state agencies are expected to implement any revised and new nutrition risk criteria they plan to adopt and to remove any that have been determined to be no longer allowable for use, by the implementation date specified on the transmittal memorandum that will be Published on the PartnerWeb. In general, state agencies will have a minimum of one fiscal year to implement the revisions based on the date they are published to the FNS PartnerWeb.

If a WIC state agency is unable to meet the implementation date for the addition or modification of a new/revised nutrition risk criterion, it must submit a request for an extension and a timeline for implementation to the appropriate FNS Regional Office. Regional Offices may extend the deadline, within reasonable limits, on an individual case basis, depending on the circumstances of the state agency. Long-term extension requests (more than 6 months) must receive concurrence from FNS Headquarters staff in the Supplemental Food Programs Division.

V. STATE AGENCY APPLICATION OF NUTRITION RISK CRITERIA

A. Reflective of Current/Recent Status

For all allowed nutrition risk criteria, the documented risk condition must apply to an applicant's current or most recent nutrition risk condition, as opposed to any history of the condition, unless otherwise stated in the specific definition of the nutrition risk criterion.

B. Self Report of a Physician' s Diagnosis

Section 246.7(i)(8) of the Federal WIC Program regulations requires the state agency to ensure that appropriate documentation is included in the applicant's WIC certification records to substantiate the nutrition risk condition(s) used to certify the applicant, and to validate conformance with the definition of nutrition risk condition(s). Some nutrition risk criteria, specified in the definition of each criterion, as appropriate, allow an applicant or caregiver to tell the CPA at the local WIC office (self-report) that the applicant has a condition that was diagnosed by a physician. Self-reporting of a diagnosis by a physician or other recognized medical authority should not be confused with self-diagnosis, where a person simply claims to have or have had a medical condition, without any reference to professional diagnosis of that condition.

A self-reported medical diagnosis should prompt the CPA to validate the presence of the condition by asking more probing questions related to the self-repo1ted professional diagnosis, such as:

• Whether the condition is being managed by a medical professional;
• The name and contact information for that medical professional (to allow communication and verification if necessary);
• Whether it is being controlled by diet, medication, or other therapy; and
• What types of medications, if any have been prescribed, rule being taken to address the condition.

For example, if a postpartum woman reports that she is experiencing mood swings, feelings of sadness and sleep disturbances - symptoms associated with postpartum depression - she should not automatically be assigned the risk criterion #361 Depression. If, upon further questioning, the CPA determines the woman has been medically diagnosed and is being treated for depression, it is appropriate to assign risk criterion #361 Depression. In those instances, when with additional questioning it is determined that the condition has not been diagnosed by a medical provider; the risk criterion may not be assigned. Although a risk may not be assigned based on a self-diagnosis (i.e., without a medical diagnosis), it is appropriate for WIC staff to provide referral services to participants who report having symptoms so that a medical provider can confirm or rule out the presence of a medical condition.

Self-reporting for "History of..." conditions should be treated in the same manner as self- reporting for current conditions requiring a physician's diagnosis, i.e., the applicant may report to the CPA that s/he was diagnosed by a physician with a given condition at some point in the past. As with current conditions, self-diagnosis of a past condition should never be confused with self-reporting.

C. Alternative to a Physician's Diagnosis

When a criterion requires the formal diagnosis of a physician, or alternatively, a person working under a physician's orders, this alternative is intended to be applied only to those persons working directly with the physician, i.e. physician's assistant, nurse practitioner, or other state recognized medical authority. This alternative is intended to facilitate access to referral data from private physicians, by permitting their nurses or physician's assistants to provide the necessary documentation without the WIC applicant having to spend the time or money for the actual physician to provide it.

Non-traditional health care providers such as shamans, medicine men or women, acupuncturists, chiropractors, or holistic health advisors are not considered to be physicians whose diagnoses can be accepted for purposes of this policy or for establishing the eligibility of an applicant for WIC Program benefits.

D. Case File Documentation

Section 246.7(e)(l) of the WIC Program regulations require that every certified applicant's case file contain the specific condition(s) for which the applicant was found to be eligible to receive Program benefits. It must be possible, when reviewing a case file, to identify the specific condition(s) for which the applicant was determined to be at nutrition risk for WIC eligibility, certification and nutrition education purposes. FNS has established minimum and follow-up documentation requirements in WIC Policy Memorandum #2008-4, WIC Nutrition Services Documentation. In addition, this policy memorandum identifies the purpose, necessary elements and outcomes for nutrition services documentation in the WIC Program.

In some circumstances, it may be appropriate to request that the applicant or parent/caregiver complete and sign a consent form, so that WIC staff can communicate with the applicant's health care provider. This consent would allow the collection of pertinent medical or dietary information to support the nutrition risk determination, and to assist the WIC CPA in developing the nutrition care plan for the participant.

Related to case file documentation, if a participant transfers in from another state or local agency and presents a valid Verification of Certification card containing information on the nutrition risk(s) used to certify the participant in the previous location, it is not necessary to reassess at the new agency. For more information on how to handle transfer of certification, please see nutrition risk criterion #502 Transfer of Certification, FNS Instruction 803-11 Rev. I-Verification of Ce1tification (VOC) and Section 246.7 (k) of the Federal WIC Regulations.

E. Use of Referral Data for Professionally Diagnosed Nutrition Risk Conditions

Every effort has been made to establish the cut-offs/thresholds in the list of allowed criteria based on prevailing scientific data; therefore, a reasonable assumption is made that the medical/health community routinely uses compatible and comparable thresholds and criteria for medical diagnosis. A referral diagnosis from a physician or other health care professional documenting an allowed WIC nutrition risk criterion may thus be assumed to meet the stipulated definition, cut-off or threshold of the applicable criterion. For example, a physician's referral diagnosis of infant prematurity could be used at face value by WIC staff to certify for nutritional risk, without further review or validation against the definition for risk criterion #311 History of preterm delivery.

The acceptability of referral data from physicians and other health care professionals does not eliminate the regulatory requirement for documentation of anthropometric and biochemical assessment data (height, weight, and hematocrit/hemoglobin levels) in each participant's file.

F. State Agency Modifications to Risk Criteria Designations

State agencies may use the groupings, names, and numbers provided on the allowable index, or they may regroup, rename or renumber allowed risk criteria. A state agency may also use more restrictive criteria, revise the units of measure, or choose not to use certain criteria at all.

State agencies choosing to group, name, or number individual criteria differently from the way they are issued must include in their state plans a clear cross-reference between the FNS allowable criteria and the State agency's classification system. A state agency may also revise the units of measure as long as the revisions are equivalent (or more restrictive than) the thresholds established in the definition.

A state agency may not change the definition(s) or cut-off values of the allowable risk criteria, unless such changes result in a more stringent definition or criterion than that issued by FNS.

Local agency CPA's may encounter isolated incidents of diseases or illnesses that meet the definition for a given criterion - that is, the condition in question sufficiently interferes with food consumption or nutrient absorption, or compromises nutritional status to justify its addition as a condition to establish WIC program eligibility - but are not specifically included in the list of examples provided in the risk criterion's definition. For example, a CPA might assign Huntington's disease to Risk #348 Central Nervous System Disorders. The condition meets the definition of a central nervous disorder and can therefore be assigned. In specific localities or regions, a state agency may observe a more frequent incidence of such a condition not included on the list in the criterion's definition. In such cases, the state agency may amend its risk criterion accordingly to include the condition, after obtaining concurrences and approval from the FNS Regional Office.

All state agency modifications to nutrition risk criteria (outside of the regular state plan submission schedule) must be submitted to the regional office for approval prior to implementation, along with a justification supporting the proposed modification. Such a modification is typically submitted as a state plan amendment, which includes amendments to a state agency's Policy and Procedures Manual or Handbook, which is part of the official state Plan of Operations.

G. WIC Participant and Program Characteristics (PC) Reporting

Nutrition risk reporting is part of the minimum data set for the biennial PC studies. state agencies are asked to report all risk criteria identified (up to a maximum of 10). State agencies that provide data using their own coding schemes will need to provide a crosswalk or index between their codes and the Federal nutrition risk codes.

VI. EFFECTIVE DATE

This policy is effective on the date it is issued. State agencies should direct any questions to their FNS regional office.

DEBRA R. WHITFORD
Director
Supplemental Food Programs Division