Appendix A2 Relevant WIC Policy and Guidance Documents

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Appendix A2 Relevant WIC Policy and Guidance Documents

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Appendix A2
Relevant WIC Policy and Guidance Documents

Appendix A2. Relevant WIC Policy and Guidance Documents includes the
following:
1. Value Enhance Nutrition Assessment (VENA) in the Special Supplemental
Nutrition Program for Women, Infants, and Children. (2020).

2. “Special Supplemental Nutrition Program for Women, Infants and Children
(WIC): Revisions in the WIC Food Packages; Final Rule.” Federal Register
79:42 (March 4, 2014) p. 12274-12300.

Value Enhance Nutrition Assessment (VENA) in the Special Supplemental
Nutrition Program for Women, Infants, and Children. (2020).

Food and Nutrition Service

VENA

Value Enhanced Nutrition Assessment in the Special Supplemental
Nutrition Program for Women, Infants, and Children (WIC)

Updated Guidance

In accordance with Federal civil rights law and U.S. Department of
Agriculture (USDA) civil rights regulations and policies, the USDA, its
Agencies, offices, and employees, and institutions participating in
or administering USDA programs are prohibited from discriminating
based on race, color, national origin, sex, disability, age, or reprisal
or retaliation for prior civil rights activity in any program or activity
conducted or funded by USDA.
Persons with disabilities who require alternative means of
communication for program information (e.g., Braille, large print,
audiotape, American Sign Language, etc.) should contact the Agency
(State or local) where they applied for benefits. Individuals who are
deaf, hard of hearing, or have speech disabilities may contact USDA
through the Federal Relay Service at (800) 877-8339. Additionally,
program information may be made available in languages other
than English.
To file a program complaint of discrimination, complete the USDA
Program Discrimination Complaint Form, (AD-3027), found online at:
http://www.ascr.usda.gov/complaint_filing_cust.html, and at any
USDA office, or write a letter addressed to USDA and provide in the
letter all of the information requested in the form. To request a copy of
the complaint form call (866) 632-9992. Submit your completed form
or letter to USDA by:
Mail: U.S. Department of Agriculture
Office of the Assistant Secretary for Civil Rights
1400 Independence Avenue, SW
Washington, DC 20250-9410
Fax: (202) 690-7442
Email: [email protected]
This institution is an equal opportunity provider.
U.S. Department of Agriculture
Food and Nutrition Service
November 2020
FNS-880

Table of Contents

Section 1. Introduction ................................ 1
What Is VENA? .................................................... 2
VENA Guidance .................................................. 3

Section 5. Technology and
Assessment Tools ....................................... 31
Designing Assessment Questions ..................... 31

Using the VENA Guidance .................................. 6

Management Information Systems .................... 34

Section 2. VENA Approach—
Participant-Centered and Health
Outcome-Based ............................................ 7

Providing WIC Services Remotely ..................... 35

Participant-Centered Approach ........................... 7
Health Outcome–Based Approach ..................... 9

Other Technology to Collect
Assessment Data .............................................. 35

Section 6. Staff Competencies
and Training .................................................. 37

WIC Nutrition Risk and the Health
Outcome–Based Approach ...............................13

Competency Areas for WIC Nutrition
Assessment ...................................................... 37

Identifying Strengths, Positive Practices,
and Motivations ..................................................13

Identifying Training Needs ................................. 38

Section 3. The Process of the
WIC Nutrition Assessment ........................15
Set the Agenda ..................................................17
Collect Relevant Information ..............................17
Clarify and Synthesize Information .................... 20
Transition from Assessment Data to
Customized Nutrition Services .......................... 21
Document the Assessment ............................... 21

Building Competencies Through Training .......... 38
Planning Training to Build Competencies .......... 38

Section 7. Continuous Quality
Improvement ................................................ 40
Using Direct Observation to Evaluate
VENA Implementation ....................................... 40
Resources ..........................................................41
Quality Indicators for Direct Observation
of VENA Practices ............................................. 42

Conduct Follow-Up Assessment ....................... 23

Continuous Quality Improvement Strategies ..... 43

Section 4. Using Assessment
Data to Guide Nutrition Services ............ 25

Appendix 1. Glossary of Terms ............... 44

Behavior Change Theories ................................ 26
Promoting Positive Behaviors ............................ 28
Building Health Outcome–Based Goals ............ 29
Focus Goals on Small Achievable
Action Steps ..................................................... 30

Appendix 2. Health Outcome–Based
Assessment by Category .......................... 48
Table A2-1. Health Outcome–Based
WIC Nutrition Assessment for a
Pregnant Woman .............................................. 49

Value Enhanced Nutrition Assessment in WIC | Table of Contents i

Table A2-2. Health Outcome–Based
WIC Nutrition Assessment for a
Breastfeeding Woman .......................................51
Table A2-3. Health Outcome–Based
WIC Nutrition Assessment for a NonBreastfeeding Postpartum Woman ................... 53
Table A2-4. Health Outcome–Based
WIC Nutrition Assessment for an Infant ............. 55
Table A2-5. Health Outcome–Based
WIC Nutrition Assessment for a Child 12–60
Months of Age ................................................... 57

Appendix 3. Crosswalk of Health
Objectives and WIC Nutrition Risks....... 59
Table A3-1. Crosswalk for a Pregnant Woman.. 59
Table A3-2. Crosswalk for a Breastfeeding
Woman ............................................................. 60
Table A3-3. Crosswalk for a NonBreastfeeding Postpartum Woman ................... 63
Table A3-4. Crosswalk for an Infant ................. 65
Table A3-5. Crosswalk for a Child
12-60 Months of Age ......................................... 67

Appendix 4. Essential Staff
Competency for WIC Nutrition
Assessment .................................................. 69
Table A4-1. Competency Area 1—Principles
of Life Cycle Nutrition ........................................ 69
Table A4-2. Competency Area 2—The VENA
Approach to WIC Nutrition Assessment ............ 70
Table A4-3. Competency Area 3—
Anthropometric and Hematological
Data Collection Techniques ............................... 70

Appendix 5. Sample Springboard
Assessment Questions and Probing
Questions for Nutrition/Health
Objectives ..................................................... 73
Table A5-1. Health Outcome–Based
Springboard Questions for a Pregnant
Woman ............................................................. 73
Table A5-2. Health Outcome–Based
Springboard Questions for a
Breastfeeding Woman ...................................... 75
Table A5-3. Health Outcome–Based
Springboard Questions for a
Non-Breastfeeding Postpartum Woman ........... 76
Table A5-4. Health Outcome–
Based Springboard Questions for an Infant ....... 77
Table A5-5. Health Outcome–Based
Springboard Questions for a Child
12–60 Months of Age ........................................ 78

Appendix 6. Examples of Observation
Tools Used to Evaluate VENA
Practices ....................................................... 79
Table A6-1. Assessing Skills with Frequency
Used Rating and Examples to Provide
Feedback .......................................................... 79
Table A6-2. Assessing Skills to Determine
Competency and Mentoring Needed ................ 81
Table A6-3. Checklist of Skills Used During
Appointment ..................................................... 82
Table A6-4. Assessing Skills Using
Examples .......................................................... 83

Table A4-4. Competency Area 4—
Communication ..................................................71
Table A4-5. Competency Area 5—
Multicultural Intelligence/Awareness ...................71
Table A4-6. Competency Area 6—
Critical Thinking ................................................ 72

ii Value Enhanced Nutrition Assessment in WIC | Table of Contents

Section 1: Introduction
Nutrition assessment is a required1 and essential
part of the U.S. Department of Agriculture’s
(USDA) Special Supplemental Nutrition Program
for Women, Infants, and Children (WIC). The
WIC nutrition assessment is the process of
collecting and synthesizing nutrition and health
information in order to assess an applicant’s
nutrition and breastfeeding status, strengths,
and needs. It is used to determine eligibility,
through the identification of nutrition risks, and to
personalize WIC nutrition services. The delivery
of individualized nutrition counseling, breastfeeding
promotion and support, referrals, and food
package tailoring based on a nutrition assessment
is a unique feature of WIC among the Food
and Nutrition Service (FNS) nutrition assistance

programs. A WIC nutrition assessment uses the
Value Enhanced Nutrition Assessment (VENA)
approach which is participant–centered and
health outcome–based. It allows staff to engage
the participant in dialogue about her needs and
goals of healthy behavior. This process is critical
in meeting the nutrition education goals of WIC,
which are to (1) emphasize the relationship between
nutrition, physical activity, and health and (2) assist
the individual who is at nutritional risk in achieving
dietary and physical activity habits resulting in
improved nutritional status and the prevention
of nutrition-related problems.2 A WIC nutrition
assessment is the starting point for designing
all WIC nutrition services.

Electronic Code of Federal Regulations. Title 7. Agriculture. Part 246. Special Supplemental Nutrition Program
for Women, Infants, and Children. Section 246.7 Certification of Participants. August 2019. Available from:
https://www.ecfr.gov/cgi-bin/retrieveECFR?gp=&SID=7a2c252817410a1e102dbbaab0898e9e&mc
=true&n=pt7.4.246&r).#se7.4.246_17 .
2
Electronic Code of Federal Regulations. Title 7. Agriculture. Part 246. Special Supplemental Nutrition Program for
Women, Infants, and Children. Section 246.11 Nutrition Education. August 2019. Available from: https://www.ecfr.gov/
cgi-bin/retrieveECFR?gp=&SID=7a2c252817410a1e102dbbaab0898e9e&mc=true&n=pt7.4.246&r) .
1

Value Enhanced Nutrition Assessment in WIC | Introduction 1

What Is VENA?
Value Enhanced Nutrition Assessment (VENA) is
a participant-centered, health outcome–based
approach to WIC nutrition assessment. The VENA
approach incorporates a WIC nutrition assessment
process with policies, staff competencies, a
Management Information System (MIS),
and quality improvement strategies that together
enhance the delivery of WIC nutrition services.
It helps to ensure that WIC staff conduct quality
nutrition assessments that enrich the interaction
between WIC educator and participant, as well
as link collected health and diet information to the

/Definition/
Participant

Participant, for the purposes of this document,
refers to a WIC participant, an applicant, or a
parent/caregiver.

delivery of nutrition services relevant to the needs
of the participant. The VENA approach enhances
nutrition services offered to participants and
ensures the integrity of WIC as a premier public
health nutrition program.

Figure 1

WIC Nutrition Services

Assessment

Nutrition Education

Breastfeeding Promotion
and Support

Follow Up

Food Package

Referrals

2 Value Enhanced Nutrition Assessment in WIC | Introduction

VENA Guidance
VENA Guidance3 is intended to assist WIC State
agencies in developing policies and procedures
related to the WIC nutrition assessment. The
Guidance supports FNS Regional Offices, State
agencies, and local agencies in continuous quality
improvement and customer service efforts to
strengthen WIC nutrition assessment.

Background
FNS first issued VENA Guidance in 2006. It was
developed through a collaboration among FNS,
the National WIC Association, and individual WIC
State agencies. Both the original VENA Guidance
and VENA nutrition assessment policy 4 were
developed in response to recommendations made
in a report from the Institute of Medicine (IOM)5,
Dietary Risk Assessment in the WIC Program6 While
the IOM recommendations were specific to dietary
risk assessment, the report also highlighted the

/Definition/
Nutrition risk

Nutrition risk refers to conditions
that are used as a basis for certification.
The categories are:
(a) Detrimental or abnormal nutritional conditions
detectable by biochemical or anthropometric
measurements.
(b) Other documented nutritionally related medical
conditions.
(c) Dietary deficiencies that impair or endanger health.
(d) Conditions that directly affect the nutritional health
of a person, including alcoholism or drug abuse.
(e) Conditions that predispose persons to inadequate
nutritional patterns or nutritionally related medical
conditions, including, but not limited to, homelessness and migrancy.7

Pursuant to the Congressional Review Act (5 U.S.C. §801 et seq.), the Office of Information and Regulatory Affairs
designated this guidance as not major, as defined by 5 U.S.C. § 804(2).
4
WIC Policy Memorandum #2006 – 5: Value Enhanced Nutrition Assessment-WIC Nutrition Assessment Policy.
March 2006. Available from: https://www.fns.usda.gov/wic/wpm-2006-5 .
3

The Institute of Medicine is now the Health and Medicine Division of the National Academies of Sciences, Engineering,
and Medicine.
6
Institute of Medicine Committee on Dietary Risk Assessment in the WIC Program. Dietary Risk Assessment in the
WIC Program. Washington (DC): National Academies Press; 2002.
7
Electronic Code of Federal Regulations. Title 7. Agriculture. Part 246. Special Supplemental Nutrition Program for
Women, Infants, and Children. Section 246.2 Definitions. August 2019. Available from: https://www.ecfr.gov/cgi-bin/
retrieveECFR?gp=&SID=ede49f3ec92e9131f2fb220fedbe8ccd&mc=true&n=pt7.4.246&r=PART&ty=
HTML#se7.4.246_12 .
5

Value Enhanced Nutrition Assessment in WIC | Introduction 3

importance of assessing for other nutrition risks
such as growth issues, iron deficiency, nutritionally
related medical conditions as well as social and
environmental factors in order to provide targeted
nutrition services. The IOM report resulted in FNS
identifying the need for comprehensive nutrition
assessment guidance – the VENA Guidance.

For this update of the VENA Guidance, FNS
collected input from a range of stakeholders and
experts, including staff in WIC State agencies
and FNS Regional Offices as well as nutrition
assessment and counseling professionals. The
update was also shaped by a review of studies
and publications on nutrition assessment.

VENA Guidance Update

Summaries of key concepts in the updated VENA
Guidance appear below:

While the intent of the updated Guidance remains
the same (i.e., the personalization of WIC nutrition
services), it builds on the experiences of State and
local agencies in the implementation of VENA and
emphasizes nutrition and health determinants,
objectives, and outcomes; behavior change; the
use of technology in WIC; and the importance of
continuous improvement through observation and
evaluation of the VENA approach. Additionally,
science of behavior change also has influenced the
assessment process8,9,10 as have changes to WIC
federal regulations (e.g., food package changes,
extension of the certification period for children to
1 year) since the issuance of the original guidance.

/Definition/

Competent Professional
Authority (CPA)
Competent Professional Authority (CPA) refers
to WIC staff members authorized to conduct the
nutrition assessment, determine nutrition risk, and
prescribe supplemental foods. Federal WIC
regulations define the CPA as a physician, nutritionist,
registered nurse, dietitian, or medically trained State
or local health official, or a person designated
by physicians or medically trained State or local
health officials.11

•

VENA is a participant-centered, health outcome–
based approach to conducting nutrition
assessments in WIC. Using the VENA approach,
WIC staff can more easily identify and build on
participants’ strengths to help them achieve their
nutrition- and health-related goals.

•

In the health outcome–based approach, the WIC
Competent Professional Authority (CPA)
identifies nutrition risks and strengths (health
determinants) that affect health outcomes.
The staff then considers how best to support
participants’ needs and strengths depending
on each participant’s identified nutrition risks/
health determinants, interests, motivations,
preferences, and information needs.

•

The VENA approach emphasizes a collaborative
partnership between CPAs and participants.
Participant engagement and interaction are
integral parts of the nutrition assessment
process.

•

VENA allows the CPA to identify each
participant’s needs and provide individualized
nutrition services that may include customized
information sharing, guided goal setting,
tailored food packages, breastfeeding support,
and referrals for additional resources or services.

Spahn JM, Reeves RS, Keim KS, et al. State of the evidence regarding behavior change theories and strategies in
nutrition counseling to facilitate health and food behavior change. J Am Diet Assoc 2010;110(6):879-891. doi:10.1016/j.
jada.2010.03.021
9
Marley SC, Carbonneau K, Lockner D, et al. Motivational interviewing skills are positively associated with nutritionist
self-efficacy. J Nutr Educ Behav 2011;43(1):28-34. doi:10.1016/j.jneb.2009.10.009
10
Whaley SE, McGregor S, Jiang L, et al. A WIC-based intervention to prevent early childhood overweight. J Nutr Educ
Behav 2010;42(3):S47-S51. doi: 10.1016/j.jneb.2010.02.010
11
Electronic Code of Federal Regulations. Title 7. Agriculture. Part 246. Special Supplemental Nutrition Program for
Women, Infants, and Children. Section 246.2 Definitions. August 2019. Available from: https://www.ecfr.gov/cgi-bin/
retrieveECFR?gp=&SID=ede49f3ec92e9131f2fb220fedbe8ccd &mc=true&n=pt7.4.246&r=PART&ty=HTML
#se7.4.246_12 .
8

4 Value Enhanced Nutrition Assessment in WIC | Introduction

•

CPAs take consistent steps during the
assessment to collect and analyze information
and use critical thinking to prioritize topics
for discussion, recommend food packages,
and identify resources for referrals.

The updated VENA Guidance is divided into
seven sections:
•

Section 1 provides an introduction to the VENA
approach and the Guidance.

MIS and other electronic tools used for
assessment may be helpful in collecting
and synthesizing data but can become a
barrier to participant engagement if not used
appropriately.

•

Section 2 describes the VENA approach as
being participant centered and health
outcome based.

•

Section 3 describes how to apply the VENA
approach to the nutrition assessment process.

The VENA approach encourages WIC staff to
support participants as they set realistic goals
and act on small steps that can lead to better
health outcomes.

•

Section 4 discusses ways to use assessment
data to guide nutrition services.

•

Section 5 offers guidance for designing
assessment tools and the appropriate use of
MIS and other technology tools used to carry
out assessments.

•

Section 6 contains information on the skills staff
need to implement VENA successfully.

•

Section 7 describes suggestions for ongoing
quality improvement activities with an
emphasis on direct observation to evaluate
the implementation of VENA.

Ongoing staff training on nutrition assessment
skills will improve CPAs’ confidence and
proficiency as they continue to apply participantcentered approaches to the assessment
process.
Quality improvement efforts that include
direct observation of assessment practices
are essential to evaluating the implementation
of VENA.

Value Enhanced Nutrition Assessment in WIC | Introduction 5

Using the VENA Guidance

Operationalizing VENA Guidance

The VENA Guidance is designed to assist
State and local agencies in their efforts to
provide high-quality nutrition services. The WIC
Nutrition Services Standards12 outline nutrition
services components to guide State agencies
in establishing policy and practices. The VENA
Guidance complements the Nutrition Services
Standards and other WIC policy and guidance
documents.

Additional information is available throughout
the VENA Guidance to help State and local
agencies apply it in their work.
Tips From the Field: Suggestions from
State and local WIC staff on the topic area.
Additional Information to further explain
and reinforce content.

It is intended that State agencies use this
document to:

Definitions: Key terms to improve
comprehension.

• Develop policies and procedures related to
nutrition assessment.

The Importance of Language:
Recognizing the impact of terminology
and highlighting the importance of plain
language and participant-centered phrasing.

•

Evaluate and enhance their nutrition
assessment processes by conducting a selfevaluation of current nutrition assessment
policies and practices.
•

Evaluate current training and staff development
offerings and add new strategies and trainings
to build staff skills as needed.

•

Assess use of MIS and other technology tools
to ensure they fit with the VENA approach,
allow users to tailor services within a consistent
framework, and promote continuity of care.

•

Review opportunities to incorporate direct
observation of staff performance to ensure the
VENA approach is operationalized.

•

Identify areas of support needed at the State
or local level to promote adoption of the VENA
approach and communicate support needs to
the FNS Regional Offices.

Although some key terms are defined throughout
the document, a comprehensive list of terms is
available in the Appendix A: Glossary of Terms.

6 Value Enhanced Nutrition Assessment in WIC | Introduction

Section 2. VENA Approach—
Participant-Centered and Health Outcome–Based
VENA incorporates two approaches: participantcentered and health outcome–based. By utilizing
these two distinct but complementary approaches,
CPAs are able to create a welcoming and affirming
environment while elucidating necessary information
from the participant, and help guide the participant
to the appropriate nutrition and health goals.

Participant-Centered
Approach

risks, or negative behaviors. Participant-centered
services encourage staff to engage the participant/
caretaker in dialogue, information exchange,
listening, and feedback in order to translate the
assessment into action and customize the nutrition
services provided.”13

Characteristics of
Participant-Centered Approach
Characteristics of a participant-centered approach
include:

The VENA approach is participant-centered.
The WIC Nutrition Services Standards defines
participant-centered as “a systems approach
designed to focus on topics and issues that are
relevant to the participant. This approach puts
the participant’s needs and the goal of healthy
behaviors at the core of WIC services delivery and
focuses on a person’s capacities, strengths, and
developmental needs, not solely on the problems,

•

Collaboration. The VENA approach involves
a partnership between CPAs and participants.
Participant engagement and interaction are
essential parts of the nutrition assessment
process.

Tips From the Field—
Building Rapport and Trust
Feeling welcomed can build a sense of trust and
foster good rapport. When participants feel safe and
accepted, they are more likely to share honestly.
Honest communication will lead to the most effective
assessments. CPAs can build rapport and trust through
open communication and demonstrations of respect.
Sometimes the simplest actions demonstrate respect,
such as making eye contact, addressing a participant by
name, or starting by asking, “How are you today?” These
small demonstrations of respect can help ensure that
participants have a positive experience and do not feel
like they are just another number as they go through the
assessment process.

Value Enhanced Nutrition Assessment in WIC | VENA Approach 7

•

Optimism. The VENA approach recognizes
that participants have hopes and desires for
themselves and their families related to nutrition
and health. One goal of the process is to draw
forth these internal motivations from
the participant.

•

Nonjudgmental environment. Participants
are more likely to talk openly and honestly about
their behaviors, motivations, and challenges in
an accepting and nonjudgmental atmosphere.

•

Empowerment. The VENA approach
can build participants’ confidence in their
own abilities. CPAs find and affirm strengths
and positive practices in order to ensure
participants continue them and build additional
healthy habits.

CPA and Participant Roles in ParticipantCentered WIC Nutrition Assessments
In the VENA approach, both the participant and the
CPA contribute to an assessment’s overall success.
The CPA is a facilitator, guiding the participant
through a process that is driven by their unique
circumstances. CPAs work with participants to
identify their nutrition-related needs and concerns in
order to prioritize topics for the nutrition counseling
discussion. CPAs honor autonomy, recognizing
that the decision about whether to explore potential
behavior change rests with the participant.
Although CPAs have expertise in nutrition,
breastfeeding, and health, participants are experts
on their own situation and what will be best for
themselves and their family. In addition, WIC
participants are often exposed to many nutrition
messages in a variety of media. By assessing what
the participant already knows about a topic, CPAs
can affirm and build on the existing knowledge. The
ongoing partnership with participants, built on trust
and mutual respect, allows WIC to have a lasting
impact on behaviors.

Every aspect of WIC services has the potential
to affect the relationship between the participant
and WIC staff and influence the success of the
interaction. Factors such as clinic appearance,
customer service, wait time, and nutrition promotion
materials will influence a participants’ feelings
toward WIC and their engagement in services.14,15
For more information on training tools for staff on

The Importance
of Language
Terms, phrases, regulatory definitions, and
acronyms unique to WIC (i.e., jargon) serve to
make communication between co-workers easier;
however, it may not be effective language to use
with participants.
For example, a participant may understand the
words “food benefits” more readily than “food package” or “low blood iron” rather than “low hematocrit.”
CPAs are encouraged to use plain language that is
positive and participant-centered, including easily
understood words and inoffensive terms, when
talking with participants.

/Definition/
Plain language

Plain language is communication that your
audience can understand the first time they read
or hear it. There are many techniques that can
help you achieve this goal. Among the most
common are using:
• Logical organization with the participant in mind.
• “You” and other pronouns.
• Short sentences.
• Common, everyday words.

Deehy K, Hoger FS, Kallio J, et al. Participant-centered education: building a new WIC nutrition education model.
J Nutr Educ Behav 2010;42(3 Suppl):S39-S46. doi:10.1016/j.jneb.2010.02.003
15
Isbell MG, Seth JG, Atwood RD, et al. A client-centered nutrition education model: lessons learned from Texas WIC.
J Nutr Educ Behav 2014;46(1):54-61. doi:10.1016/j.jneb.2013.05.002
14

8 Value Enhanced Nutrition Assessment in WIC | VENA Approach

the topics of customer service and rapport building,
visit the WIC Works Resource Center.
For more information about plain language, please
visit the U.S. Government plain language
website.

•

U.S. Department of Health and Human
Services’ Healthy People16 — a plan to promote,
strengthen and evaluate the nation’s efforts to
improve the health and well-being of all people
that is updated every ten years.

•

Bright Futures,17 a set of health supervision
guidelines to “promote and improve the health,
education, and well-being of infants, children,
adolescents, families, and communities.”

Health Outcome–
Based Approach
While keeping the participant at the center of
nutrition assessment, the VENA approach uses a
health outcome–based approach as a framework
to organize the assessment. The health outcome–
based approach to a WIC nutrition assessment
focuses the conversation on a positive health
goal (health outcome) while discussing how other
areas of a participant’s life may influence the health
outcome. This framework is consistent with two
national public health initiatives:

The VENA health outcome–based approach
consists of a desired health outcome, nutrition and
health objectives, and health determinants. These
elements of the health outcome framework are
described as follows:
•

Desired health outcome—WIC’s overarching
health goal for each category of participant. The
specific goals for each participant category can
be found in Table 1.

Table 1. Participant Category and WIC Desired Health Outcome
Participant Category

WIC Desired Health Outcome

Pregnant Woman

Delivers a healthy, full-term infant while maintaining optimal
health status.

Breastfeeding Postpartum Woman

Achieves optimal health during the childbearing years and reduces the
risk of chronic disease.

Non-breastfeeding Postpartum
Woman

Achieves optimal health during the childbearing years and reduces the
risk of chronic disease.

Infant

Achieves optimal growth and development in a nurturing environment
and develops a foundation for healthy eating practices.

Child 12-60 Months of Age

Achieves optimal group and development in a nurturing environment
and begins to acquire dietary and lifestyle habits associated with a
lifetime of good health.

Office of Disease Prevention and Health Promotion. Healthy People 2030. September 2020. Available from:
https://health.gov/healthypeople.
17
American Academy of Pediatrics. Bright Futures: Guidelines for Health Supervision of Infants, Children, and
Adolescents. 4th ed. 2017. Available from: https://brightfutures.aap.org/materials-and-tools/guidelinesand-pocket-guide/Pages/default.aspx .
16

Value Enhanced Nutrition Assessment in WIC | VENA Approach 9

•

Nutrition and health objectives—actions,
practices, and settings that make it more likely
for the health goal to be achieved.

•

Health determinants—a range of behavioral,
biological, socioeconomic, and environmental
factors that affect the nutrition and health
objectives and overarching goal.18 Determinants
that promote a positive health outcome are
protective factors, while those that may hinder a
positive health outcome are WIC nutrition risks
and other related barriers or needs.

Using the VENA approach, CPAs start the
assessment with the desired health outcome in
mind. For example, the desired health outcome
for a pregnant woman is “Deliver a healthy full-term
infant while maintaining optimal health status.”
This desired health outcome is more likely to
occur when a woman meets/achieves the
following health objectives:
•

Consume a variety of foods to meet energy
and nutrient requirements and remain free
from foodborne illness.

•

Receive ongoing health care, including
prenatal care.

•

Achieve the recommended weight gain.

•

Remain free from nutrition-related illness or
complications.

•

Avoid alcohol, tobacco, and drugs.

•

Make an informed decision about breastfeeding.

•

Receive adequate community and family support.

In a WIC nutrition assessment, it is important to
view the participant holistically. The health outcome–
based approach helps the CPA to understand
the participant’s needs in the context of health
determinants. During the exploration of each
health determinant, nutrition risks are explored
and further probed to identify potential causes
such as knowledge, skills, attitudes and beliefs,
cultural practices, family and social environment
resources, and access to food and health care.
(See Appendix 5. Sample Springboard
Assessment Questions and Probing Questions
for Nutrition/Health Objectives for more
information.) In addition to nutrition risks, the CPA
identifies and reinforces strengths, motivations,

The determinants that affect the above health
objectives and the overall health goal are explored
with the participant by collecting and evaluating
relevant information during the WIC nutrition
assessment. For example, data on weight, height,
pre-pregnancy weight, and week of gestation are
collected and evaluated to assess whether the
pregnant woman is achieving the recommended
maternal weight gain.

Office of Disease Prevention and Health Promotion. Healthy People 2030. September 2020. Available from:
https://health.gov/healthypeople.

10 Value Enhanced Nutrition Assessment in WIC | VENA Approach

healthy practices, accomplishments, and
developmental progress. This approach
to assessment allows the participant to gain a
greater appreciation of how to attain good health
and recognize her own needs and/or an infant’s
or child’s needs for health improvement, and can
ultimately lead to more effective WIC interventions.
See Section 4. Using Assessment Data to
Guide Nutrition Services for more information
on how to use assessment data to personalize
nutrition services.

Table 2 shows how the nutrition assessment
is organized using health outcomes and health
determinants and the CPA’s role in assessment.
Please note that the examples of nutrition risks and
needs and protective factors are not a complete list.
The roles listed are examples and do not represent
an exhaustive list of all the actions a CPA will take
to complete a nutrition assessment. See Appendix
2. Health Outcome–Based WIC Nutrition
Assessment by Participant Category for similar
tables for all five participant categories.

Table 2. Health Determinants and CPA Role in WIC Nutrition
Assessment for a Pregnant Woman
Desired health outcome: Deliver a healthy full-term infant while
maintaining the mother’s optimal health status
Nutrition/
Health
Objective
Consume a
variety of foods
to meet energy
and nutrient
requirements,
and remain free
from foodborne
illnesses

Nutrition/
Health
Determinant
Category
Dietary Intake/
Nutrition
Practices

Receive ongoing Health/Dental
health care,
Care
including
Weight
prenatal care
Height Status
(Anthropometric)
a) Achieve
recommended
maternal weight
gain

Nutrition/Health Determinants
Examples of
Potential WIC
Nutrition Risks/
Needs*

Examples
of Protective
Factors*

Competent
Professional
Authority’s (CPA’s)
Role†

• Consumes a
diet very low in
calories and/
or essential
nutrients
• Compulsively
ingests nonfood
items
• Inadequate
vitamin/mineral
supplementation
• Food insecurity

• Eats a variety of fruits
• Assess current nutrition
and vegetables, lean
practices
proteins, and whole
• Assess current and
grains
potential impact on
• Takes prenatal vitamins
nutritional intake and
or multivitamins with
nutritional needs
adequate folic acid
• Assess factors that may
• Practices food safety
affect meal pattern
behaviors
• Identify misconceptions
about ideal nutrition
practices
• Assess potential for
foodborne illnesses

• Lack of adequate
prenatal care
• Lack of medical
or dental home
• Underweight
• Overweight
• Low maternal
weight gain

• Established a medical
home
• Enrolled in a health
insurance plan
• Receives regular oral
health care
• Eats a variety of
foods to meet
energy requirements

• High maternal
weight gain
• Lack of physical
activity

• Engages in physical
activity

• Assess barriers to
obtaining care
• Ask about dental status
and treatment already in
progress
• Assess level of access to
follow-up medical care
• Assess possible
contributors to weight
gain/loss (e.g., knowledge
and attitudes regarding
weight gain, physical
activity level, appetite,
stress)

Value Enhanced Nutrition Assessment in WIC | VENA Approach 11

Table 2. Health Determinants and CPA Role in WIC Nutrition Assessment
for a Pregnant Woman (continued)
Desired health outcome: Deliver a healthy full-term infant while
maintaining the mother’s optimal health status
Nutrition/
Health
Objective

Nutrition/
Health
Determinant
Category

Nutrition/Health Determinants
Examples of
Potential WIC
Nutrition Risks/
Needs*

Examples
of Protective
Factors*

Competent
Professional
Authority’s (CPA’s)
Role†

Remain free
from nutritionrelated
illness or
complications

Clinical/Health/
Medical

• Low hematocrit/
low hemoglobin
• Nutrition
deficiency
diseases
• Diabetes Mellitus

• Eats high iron foods
• Assess factors that may
affect hemoglobin/
• Takes prenatal
hematocrit levels
vitamins/minerals as
prescribed by health
• Assess whether it is likely
care provider
to be a nutritional or
physiological anemia
• Monitors and manages
blood glucose levels
• Assess/reinforce
compliance with treatment
plan from health care
provider

Avoid alcohol,
tobacco,
drugs, and
other harmful
substances

Substance Use

• Alcohol and
substance use
• Nicotine and
tobacco use

• Does not smoke
• Avoids alcohol, drugs,
and other harmful
substances

• Assess understanding of
the potential dangers to
herself and her pregnancy

Make an
informed
decision about
breastfeeding

Infant Feeding
Decisions

• Experienced
breastfeeding
complications
previously
• Lack of
breastfeeding
support

• Is knowledgeable
about different
feeding options
• Has an existing
support network for
breastfeeding

• Assess for more
information/participation
in breastfeeding peer
counseling and other
breastfeeding support
resources
• Assess for
contraindications to
breastfeeding

Has
environmental
and family
support to
thrive

Social Support/
Home
Environment

• Homelessness
• Recipient of
Abuse

• Has access to
adequate food
preparation and food
storage resources
• Has access to safe and
adequate water
• Lives in a supportive
and safe environment

• Assess food preparation
and food storage
equipment
• Assess home environment
• Identify referral
opportunities

• Assess attitude toward
treatment/cessation
programs
• Assess awareness of
available help and
readiness to access/
accept it

*The nutrition/health determinants listed are examples of some of the potential determinants that a CPA could identify
during a WIC nutrition assessment. They do not represent an exhaustive list of WIC nutrition risks nor protective factors.
†
The roles listed are examples of actions that a CPA will perform during a WIC nutrition assessment. They do not
represent an exhaustive list of all the actions a CPA will take to complete a WIC nutrition assessment.

12 Value Enhanced Nutrition Assessment in WIC | VENA Approach

WIC Nutrition Risk and
the Health Outcome–
Based Approach

objective in the health outcome based framework,
please see Appendix 3. Crosswalk of Health
Objective and WIC Nutrition Risks.

The WIC nutrition risks align with the health
outcome–based approach in that they are
important determinants to health. The Index of
Allowable Risk Criteria is a complete listing of
nutrition risk criteria that are used to determine
eligibility for WIC. The listing is on the FNS
PartnerWeb community for State agencies.19
These policy documents assist CPAs in identifying,
documenting, and addressing nutrition risks
that affect nutrition and health outcomes. Each
nutrition risk document includes a definition,
scientific justification, targeted nutrition messages,
and references. Categories of risk criteria include
anthropometric, biochemical, breastfeeding,
clinical/health/medical, dietary, and other risks.
Having a centralized list and supporting material
allows for a consistent understanding and
application of risks across State and local agencies
and is a resource when training staff. For a listing
of nutrition risk criteria aligned with each health

/Definition/

The Index of Allowable Risk Criteria
The Index of Allowable Risk Criteria is a tool that
lists nutrition risk criteria permitted for use in determining WIC eligibility and providing nutrition services
(nutrition education, food packages, referrals, and
breastfeeding support). The nutrition risk explanations
are a source of technical assistance to State and
local agency WIC staff, providing an evidence-based
definition and justification for risk assignment as well
as nutrition education messages for each criterion.20

FNS develops WIC nutrition risk criteria through
a work group called the Risk Identification and
Selection Collaborative (RISC). RISC membership
includes National WIC Association–appointed
State and local agency staff, along with the FNS
National Office and Regional Office staff. This work
group manages the ongoing review, revision, and
addition of WIC nutrition risk criteria. RISC ensures
that criteria are evidence based, practical for WIC
application, and nutritionally linked or related to
the nutrition services provided by WIC. For more
information about the use and management of
the FNS-issued nutrition risk criteria by WIC
State agencies, please consult WIC Policy
Memorandum 2011-5: WIC Nutrition
Risk Criteria.

Identifying Strengths,
Positive Practices,
and Motivations
The VENA approach to assessment
emphasizes healthy behavior change
and positive health outcomes.
Rather than focusing exclusively on
a participant’s deficiencies, the VENA
approach helps CPAs identify a
participant’s strengths, positive
practices, and motivations for
change. Research has shown
that using the assessment
process to only identify
deficiencies can
be less effective.21
Often this practice

For a complete listing of the most up-to-date WIC risk criteria, please access the
WIC Nutrition Risk PartnerWeb.
20
Electronic Code of Federal Regulations. Title 7. Agriculture. Part 246.
Special Supplemental Nutrition Program for Women, Infants, and Children. Section 246.2
Definitions. August 2019. Available from: https://www.ecfr.gov/cgi-bin/retrieveECFR?
gp=&SID=ede49f3ec92e9131f2fb220fedbe8ccd&mc=true&n=pt7.4.246&r=PART&ty=HTML#se7.4.246_12 .
21
Rollnick S, Miller W, Butler C. Motivational Interviewing in Healthcare. New York (NY): Guilford Publications; 2007.
19

Value Enhanced Nutrition Assessment in WIC | VENA Approach 13

Tips From the Field—
Assessing for Strengths
Just as important as finding out participants’
risks is learning what strengths they have that
can help them adopt healthy behaviors. In fact,
bringing out and acknowledging participants’
qualities will make those qualities even stronger.
Sometimes these strengths are apparent during
the conversation and can be affirmed or reflected
by the CPA (e.g., “You don’t give up,” “You’re
sensitive to her feeding cues,” “You know a lot
about nutrition”). CPAs can also ask questions

makes people feel judged and lowers their overall
confidence, thus reducing the likelihood that they
will adopt new habits.
By harnessing strengths and supportive healthy
behaviors, VENA builds participants’ self-efficacy
to make small, but meaningful, positive nutrition
and health choices for themselves and their family.
Participant strengths may include personality
characteristics (e.g., optimism, creativity), talents,
interests, education or knowledge around food

to call forth strengths. CPA questions can focus
on emotional strengths, positive resources, or
ways participants have successfully faced the
same barrier in the past. Some examples
might include:
• Tell me about the support you have at home
to help you after the baby is born.
• When you weaned your last child, what was
helpful?
• What part of feeding your child do you feel most
confident about?

and nutrition, or existing resources (e.g., a strong
support system at home, access to opportunities
for physical activity).

/Definition/
Self-efficacy

Self-efficacy refers to a participant’s belief about
their ability to succeed in reaching specific goals.

14 Value Enhanced Nutrition Assessment in WIC | VENA Approach

Section 3. The Process of the
WIC Nutrition Assessment
The WIC nutrition assessment is a core process of
WIC nutrition services that CPAs use to determine
program eligibility, and identify and draw out
participants’ interests, needs, desires, motivations,
concerns, and current health and nutritional
status. It is the foundation for subsequent nutrition
services, including customized nutrition education,
breastfeeding promotion and support, guided goal
setting, relevant referrals, and tailored food packages.
The VENA approach helps CPAs support each
participant reach their desired health outcome by
collecting and synthesizing relevant information
(e.g., dietary practices, desire for or aversion to
breastfeeding, interest in weight loss). With a holistic
view of the participant, CPAs use critical thinking
to identify topics for nutrition education, as well
as potential food package tailoring and referral
needs. CPAs assess several factors (i.e. health
determinants), including:
•

•

Health and nutrition status.22 Categories
of information for assessment include
anthropometric (body measurement- and
proportion-related), biochemical, breastfeeding,
clinical, dietary, and environmental. The CPA’s
objective is to identify health determinants
that will affect health outcomes, including WIC
nutrition risks, medical conditions, diet, and
health concerns.
Potential barriers to desired health
outcome. CPAs also identify barriers that are not
WIC nutrition risks but could affect participants’
ability to achieve their desired health outcome
(e.g., lack of physical activity). Participants may
face serious environmental or socioeconomic
barriers that may get in the way of successful
outcomes. When the CPA identifies a potential

barrier, further probing questions are necessary
to elicit whether there is an internal motivation for
change, there is a need for information sharing,
or a referral is necessary.
•

Strengths, knowledge, and capabilities.
CPAs identify and build on strengths by affirming
existing positive practices and supporting
participants in taking action steps that will
address barriers and advance toward goals.
Examples of protective factors could be
exercising regularly or eating the recommended
amount of fruits and vegetables each day.

•

Values, cultural practices, and
environmental factors. CPAs learn what is
important to each participant, which will help
determine where CPAs focus their efforts.
Factors to consider include cultural practices
and customs as well as environmental and
family influences that affect behavior.

•

Interests and current nutrition-related
knowledge. CPAs identify each participant’s
interests and knowledge. Personalizing the
conversation and information to the participant’s
interests and current knowledge encourages
them to engage in the process.

•

Motivation. CPAs listen for “motivation
language” in order to recognize a participant’s
internal motivation for change. Motivation
language may come in many forms, such
as stating a desire (“I want to breastfeed my
baby for as long as I am able”), emphasizing
something the participant values (“Having
family meals together is important to us”),
or expressing dissatisfaction (“I hate that she
is so picky”). State and local agencies can
help CPAs evoke, recognize, and respond to

It is required to document height/length and weight, and hematological test for anemia measurements. Electronic Code
of Federal Regulations. Title 7. Agriculture. Part 246. Special Supplemental Nutrition Program for Women, Infants, and
Children. Section 246.7(e)(1) Certification of Participants. August 2019. Available from: https://www.ecfr.gov/cgi-bin/
retrieveECFR?gp=&SID=7a2c252817410a1e102dbbaab0898e9e&mc=true&n=pt7.4.246&r).#se7.4.246_17 .

Value Enhanced Nutrition Assessment in WIC | The Process of the WIC Nutrition Assessment 15

different forms of motivation language through
training, mentoring, and other staff development
activities. CPAs can have a significant influence
on positive behaviors by encouraging, listening
for, and responding to motivation language.
Not only is the collection and assessment of
relevant information vital to the WIC nutrition
assessment process, but how CPAs conduct
the process is equally important. Some of the
skills that are of particular significance to a
participant-centered assessment are (see Section
6. Staff Competencies and Training for more
information):
•

Using critical thinking.

•

Listening.

•

Asking open-ended questions.

•

Affirming.

•

Reflecting.

•

Summarizing.

•

Empathizing.

•

Collaborating.

•

Identifying the stage of change.

•

Building rapport.

In order to provide high-quality assessments, it
is important to adequately define and develop a
systematic assessment process. This helps to
ensure quality and consistency across assessment
activities while creating a framework where WIC
staff can function with confidence. A systematic
assessment process has advantages, but it cannot
be so rigid as to reduce the assessment to a series
of questions or data collection points that limit the
CPAs’ critical thinking and make it more difficult to
build rapport with participants.
A WIC nutrition assessment can find balance
between standardization and flexibility through
the use of a systematic process, shown in
Figure 2, and the CPA’s rapport building skills.

The VENA approach contains elements of both
art and science. It requires the use of the CPA’s
skills in communication and rapport building and
the systematic approach to collect and evaluate
information elicited from the participant.

Additional Information—Standardized
Process Versus Standardized Care
“A standardized process refers to a consistent
structure and framework used to provide nutrition
care, whereas standardized care infers that
all patients/clients receive the same care. This
process supports and promotes individualized
care, not standardized care.” (American Dietetic
Association, August 2003)23

Figure 2

VENA Approach to WIC Nutrition Assessment

Set the
Agenda

Conduct
Follow-Up

Document
Assessment

Collect Relevant
Information

Assessment

Guide Nutrition
Services

Lacey K, Pritchett E. Nutrition Care Process and Model: ADA adopts road map to quality care and outcomes
management. J Am Diet Assoc. 2003;103(8):1061-1072. doi:10.1053/jada.2003.50564

16 Value Enhanced Nutrition Assessment in WIC | The Process of the WIC Nutrition Assessment

Clarify and
Synthesize

•

Increasing participant engagement
(buy-in). Being open about the intent of
the assessment will help build interest and
encourage participation in both assessment
activities and the resulting nutrition services.

There are multiple opportunities to set the agenda in
a WIC visit. It depends on the State agency or clinic’s
service model for when the agenda is set and by
which WIC staff. Ideally, the WIC team is clear about
the process—both what information is provided
and who provides it. Setting the agenda is a shared
responsibility that, when done effectively, makes
information clear and gets the participant involved.

Collect Relevant Information

Set the Agenda
CPAs actively involve the participant in the
assessment process through dialogue, information
exchange, listening, and feedback. Starting the
appointment by first setting the agenda, or explaining
the assessment process, serves several purposes:
•

•

Reducing participant anxiety. Uncertainty
about what will take place in any given situation
can make people anxious. Participants who
request WIC services are usually aware of the
food package benefits. Clarifying the other
services WIC provides, as well as the purpose of
the assessment, helps ease participants’ anxiety.
Creating a power-sharing dynamic. Telling
participants in advance what will be taking place
shows respect and sets up a framework for open
and honest communication. This collaborative
approach helps the WIC visit stay on track and
empowers both staff and participants to maintain
focus. Asking permission to proceed can be
part of setting the agenda and contributes to
the power-sharing dynamic.

The second assessment step is to collect relevant
information. The health determinants that affect
the desired health outcome are explored with the
participant. A consistent, organized approach
helps CPAs collect relevant information. Collecting
different types of information (e.g., anthropometric,
biochemical, breastfeeding, clinical, dietary, and
environmental) will help pinpoint protective factors
and WIC nutrition risks for each determinant.
Although the primary goal is to identify the

The Importance
of Language
When a CPA sets the agenda, he/she can help reduce
the participant’s anxiety. By opening up the conversation with language such as, “I’ll be asking some questions about your diet and health. This will help me focus
on the information and services WIC provides to meet
your needs,” the CPA is letting the participant know
what to expect. CPAs can also start the conversation
with WIC’s desired health outcome goal. For example, a CPA could say to a pregnant participant, “The
mission of WIC is to support you in delivering a healthy
baby and having good nutrition and health during your
pregnancy.”

Value Enhanced Nutrition Assessment in WIC | The Process of the WIC Nutrition Assessment 17

information, the information also needs to be
organized for meaning and relevance. How the
CPA works with the participant to elicit, identify,
and respond to information is key to making the

Sources of Relevant Information
A: Anthropometric (e.g., height, weight,
head circumference)
B: Biochemical (e.g., hematocrit,
hemoglobin, blood lead values24)
B: Breastfeeding (e.g., breastfeeding history,
healthcare provider recommendations,
mother’s breastfeeding goals)
C: Clinical (e.g., immunization record,25
pre-existing or current medical conditions
that may affect nutrition)
D: Dietary (e.g., food preferences,
intolerances, dietary patterns, infant and
child feeding practices)
E: Environmental (e.g., home environment,
socioeconomic status, substance use)

participant’s experience positive and helps the CPA
customize the WIC nutrition services.
Review of documented information from any prior
assessments or other pertinent sources, such as
referral information from a health care provider, is
also necessary. This review helps the CPA begin
the assessment with a better understanding of a
participant’s circumstances. This step can be critical
in building rapport, showing respect, and conveying
commitment to continuity of care. For example, it
can be tedious and frustrating for a parent who has
disclosed the child’s serious medical diagnosis on
several occasions to be asked again whether the
child has any health conditions.
Before beginning the assessment, reviewing
additional information sources may help the CPA
understand the participant more fully. However,
the availability of these sources depends on the
agency or clinic’s organizational structure and the
participant’s unique circumstances. Consider these
potential sources:
•

The WIC team. Other WIC staff who have
interacted with this participant, whether at the
same visit or previously, are a relevant source of
information. The WIC team has the opportunity
to function as a unit and share information
internally, appropriately, and expeditiously.

•

Pre-surveys. If the process involves collecting
information from the participant in advance
(e.g., via paper- or web-based questionnaires),
reviewing this information will help identify areas
where more clarification is needed and potential
areas for subsequent nutrition services. Failure
to review and use the information provided via
pre-surveys can harm the relationship between
staff and the participant: If the participant has
spent time and energy completing a pre-survey,

Upon enrollment of a child, the parent or caretaker must be asked if the child has had a blood lead screening test. If
the child has not had a test, the parent or caretaker must be referred to programs where he or she can obtain such a
test. See WIC Final Policy Memorandum 2001-1 at: https://partnerweb.usda.gov/sites/sfp/WIC-FMNP-SFMNP/
policymemodocs/2001-1-LeadScreening.pdf .

It is WIC policy to assure that children served by WIC are screened for immunization status and, if needed, referred
for immunizations. See WIC Policy Memorandum #2001-7 at: https://partnerweb.usda.gov/sites/sfp/WIC-FMNPSFMNP/policymemodocs/2001-7-ImmunizationScreeningandReferralinWIC.pdf .

18 Value Enhanced Nutrition Assessment in WIC | The Process of the WIC Nutrition Assessment

it is important that staff review this information in
advance and be prepared to build on it during
the assessment.
•

Anthropometric or biochemical
information. Reviewing past anthropometric
and biochemical information is important
because it can identify changes to health status
quickly. Growth charts and pregnancy weight
gain graphs are valuable as assessment tools
and may be used as counseling tools during the
nutrition services component of a WIC visit.

Ideally, State agencies will establish expectations,
support performance, and create a consistent
method of information sharing and documentation
from one WIC appointment to another. Similarly,
local agencies will identify and support best
practices for information sharing among staff to
eliminate duplication of effort and foster teamwork,
ensuring that WIC staff have easy and consistent
access to key information.
When collecting additional relevant information, it
is important to determine what information is best
gathered at the family level. WIC services are highly
individualized, but it is impractical and ineffective to
isolate the individual from the family. It is important
to consider what information is best identified at

Additional Information—
Dietary Risk Assessment
Dietary risk assessment is a critical element
of the nutrition assessment because it focuses
attention on food and diet as central to health.
The WIC dietary assessment is qualitative, not
quantitative. WIC staff are encouraged to ask
questions about food behaviors and preferences
rather than questions about specific nutrients,
ounces or servings. The dietary risk assessment
is required to:
• Screen applicants for inappropriate nutrition
practices.
• Determine specific concerns of the
participant or caregiver related to eating/
feeding practices.
• Ascertain participant acceptability and use
of WIC foods.
• Obtain information that might explain other
identified risk criteria.
• Allow a tailored intervention, including
anticipatory guidance for each participant.

Value Enhanced Nutrition Assessment in WIC | The Process of the WIC Nutrition Assessment 19

the family level and what additional clarification is
needed specific to each participant. This process
has a particularly strong impact on efficiency in
assessments for several family members. A familylevel assessment can also reduce caregivers’
frustration by minimizing the number of times the
same questions are asked about each sibling.
Nevertheless, while providing services at the family
level is desirable, it is also important to maintain
documentation at the individual level. The tools
used in assessment, such as the MIS, become key
to the success of WIC staff. Additional guidance
related to the MIS is provided in Section 5.
Technology and Assessment Tools.

Tips From the Field—
Integrating Assessment Information
Using critical thinking and taking a holistic approach to
assessment allows the CPA to see the “big picture” for
each participant. Several pieces of information,
assessment data, or nutrition risks may be interrelated
and affected by one health determinant or behavior. For
example, excessive milk intake, low iron, and overweight
could all be related to late weaning from the bottle. By
assessing the participant’s motivations and existing
knowledge, the CPA will be able to customize guided
goal setting and information sharing.

Throughout the process of gathering information,
it is essential that staff listen for the participant’s
needs, interests, strengths, motivation, and
potential knowledge gaps. These indicators will
determine subsequent nutrition services.

Clarify and Synthesize
Information
Synthesis is the critical thinking component of
assessment, where the CPA decides whether
additional information is needed or whether it
is time to move on to nutrition services. In this
step, WIC staff organize, evaluate, and prioritize
information by integrating facts and informed
opinions. By using counseling techniques (e.g.,
active listening, observation, questions) and critical
thinking, WIC staff engage in this circular approach,
moving from identifying information to synthesis and
back until they are satisfied that they have done a
thorough assessment.
In the process of synthesis, the CPA strives
to get satisfactory answers to the following
questions in order to identify nutrition risk(s)
and protective factors:
•

Do I hear needs, interest, or motivation?

•

Do I hear resistance or defensiveness?

•

Do I have a sense of health status within each
assessment category?

•

Do I know enough to confidently assign the
correct risk code(s) based on WIC definitions/
cutoff values?

•

Can I confidently tailor this participant’s food
package?

•

Do I have a sense of how receptive the
participant will be to nutrition services?

20 Value Enhanced Nutrition Assessment in WIC | The Process of the WIC Nutrition Assessment

Transition From Assessment
Data to Customized
Nutrition Services
A skillfully completed assessment with an adequate
synthesis of information will smoothly transition
to nutrition services. Additionally, a CPA will be
able to use the assessment data to customize
nutrition services to meet the participant’s needs.
Completing the assessment before moving on to
nutrition services ensures:
•

Prioritized counseling. Nutrition messages
are limited so that the participant is not
overwhelmed.

•

Accuracy of information sharing. Any tips or
suggestions are appropriate and actionable.

•

Individualized services. Messages, referrals,
and food packages are appropriate.

•

Efficient use of time. Appointment time is
spent focused on the most important issues.

Completing the assessment before moving on to
nutrition services does not mean WIC staff cannot
respond to a participant’s needs, questions, or
concerns during the assessment. Deciding when
and how to respond requires critical thinking from
the CPA.
For additional guidance on customizing nutrition
counseling discussions for participants, consult
the WIC Nutrition Education Guidance and
Section 4. Using Nutrition Assessment Data
to Guide Nutrition Services.

/Definition/
Critical thinking

Critical thinking is the disciplined process of

organizing and synthesizing information to evaluate
and prioritize it effectively. Critical thinking involves
combining facts, informed opinions, active listening,
and observations.

Document the Assessment
Documenting the assessment is a programmatic
requirement26 that supports continuity of care
over time. Documentation is also reviewed during
management evaluations and other program
monitoring activities to evaluate the quality of
WIC services provided. Since documentation
related to assessment is just one component
of WIC data collection/retention, agencies
should establish methods to allow for successful
assessment documentation within the broader
WIC services continuum. FNS provides guidance
on documentation in the WIC Nutrition Services
Standards, Standard 14.27 State agencies can
support local staff by establishing policies and
practices that balance adequate documentation
while preventing excessive data collection that
can reduce time available for nutrition services.

Electronic Code of Federal Regulations. Title 7. Agriculture. Part 246. Special Supplemental Nutrition Program for
Women, Infants, and Children. Section 246.7(e)(1) Certification of Participants. August 2019. Available from:
https://www.ecfr.gov/cgi-bin/retrieveECFR?gp=&SID=7a2c252817410a1e102dbbaab0898e9e&mc=true&n=
pt7.4.246&r).#se7.4.246_17 .
27
U.S. Department of Agriculture, Food and Nutrition Service, Supplemental Food Program Division. WIC Nutrition
Services Standards. 2013. Available from: https://wicworks.fns.usda.gov/sites/default/files/media/document/WIC_
Nutrition_Services_Standards.pdf .
26

Value Enhanced Nutrition Assessment in WIC | The Process of the WIC Nutrition Assessment 21

Tips From the Field—
Responding to Participant
Questions During the WIC
Nutrition Assessment
Completing a thorough assessment before
providing nutrition services is a best practice for
many reasons, but this does not mean that CPAs
cannot respond to a participant’s questions and
concerns during assessment. One question that
can help guide decisions about how to respond
appropriately to questions and concerns is,
“Do I have the information I need to answer this
person’s question?” If not, a CPA can respond by
assuring the participant that he or she will come
back to the question or concern after gathering
additional information. There may be other
instances when responding to a question or
concern during the assessment is appropriate.

When creating policies around the types of
information to be collected and documented, State
agencies should consider:
•

•

Utility. The collection of data that is not
required or acted upon should be minimized
or eliminated.
Ease of access. CPAs should know where to
find past assessment information quickly and
consistently.

• Referral data. CPAs should know if the State
agency and/or local agency has a Memorandum
of Understanding for data sharing with other
health care providers.
Consistent documentation processes make
communication with other WIC staff easier and
allow for continuity of care over time, helping to

CPAs should use their critical thinking skills to
determine what is best for each participant in
each situation.

streamline workflow and allowing the CPA to start
discussions after only a minimal review of the
previous nutrition assessment. See Section 5.
Technology and Assessment Tools for additional
guidance about MIS documentation.
High-quality documentation helps staff deliver
meaningful nutrition services and ensures
continuity of care for WIC participants. All risks
identified through the assessment process must
be documented along with other information
necessary to support ongoing care. For more on
documentation requirements, consult WIC Policy
Memorandum #2008-4, WIC Nutrition Services
Documentation, and the WIC Nutrition Services
Standards, Standards 6 and 14.28

22 Value Enhanced Nutrition Assessment in WIC | The Process of the WIC Nutrition Assessment

Conduct Follow-Up
Assessment
The process of assessment is ongoing, with
documentation from previous assessment(s)
creating the foundation for subsequent WIC visits.
At the follow-up visit, the CPA assesses any
change from previous visits and collects additional
information needed to help the participant achieve
small positive behavioral changes over time.
Depending on the situation, the CPA may prioritize
what information to include in the follow-up
assessment before moving forward. For example,
it may be necessary to update some of the original
assessment data, such as rechecking weight or
hemoglobin/hematocrit values. In many cases,
the follow-up will include checking on the status
of a prior referral or assessing progress toward
goals. This review will allow the CPA to work with
the participant to either set new goals or address
any challenges. Since there are many types of WIC
visits, the WIC State agency will determine policies
about when and how CPAs conduct follow-up
assessments.

Tips From the Field—
Don’t Start From Scratch
Many State agencies have a WIC MIS that make it
possible to see or import information from previous
certifications, allowing CPAs to start from an informed
standpoint and reducing the time needed for the
assessment process. Although some information will
change and need to be updated, other information,
such as chronic medical conditions, may not change.
Local agencies should use past assessment
information at follow-up appointments. This
information is helpful for monitoring growth or health
status, checking in on nutrition goals or creating new
goals, and closing the loop on referrals.

The Importance
of Language
The words used to document an assessment are
often different from those used to communicate with a
participant. It is important to make careful distinctions
between the language used for WIC administration and
that used with participants. For example, while a CPA
might document a participant as “high risk,” telling the
participants that they are high risk may be inappropriate and disruptive.

Value Enhanced Nutrition Assessment in WIC | The Process of the WIC Nutrition Assessment 23

Table 3 shows an example of the CPA’s role
at each step in the VENA approach to the WIC
nutrition assessment process for a child determined
to be overweight.

Table 3. Nutrition/Health Determinant Example: Overweight Child
WIC Nutrition Assessment Step

Competent Professional
Authority’s (CPA’s) Role

Setting the agenda

The CPA introduces him/herself and gives the parent/caretaker
a brief description of what they will be doing together. The CPA
discusses the desired health outcome for a child (see Table 1).

Collecting relevant information

Collects health and nutrition status information; potential barriers
to healthy outcomes; strengths, knowledge and capabilities; values,
cultural practices, and environmental factors; interests and current
nutrition knowledge; and motivations.

Clarifying and synthesizing information

Using springboard questions and probing questions, active
listening, and observation, the CPA assesses for motivations,
existing knowledge, and potential knowledge gaps. Is the parent/
caregiver concerned about the child’s weight? Are feeding practices
appropriate? Does the parent/caregiver have options for providing
physical activity for the child? Are the measurements accurate?
The CPA identifies nutrition risks and needs (e.g., high intake of
sugary beverages and snacks, overweight, lack of resources for
physical activity).
The CPA identifies protective factors (e.g., offering a variety of fruits
and vegetables, expressing interest in improving diet).

Using assessment data to guide
nutrition services

The CPA customizes information sharing and guided goal setting. For
example, if the parent/caregiver wants to increase the child’s activity,
the CPA can share information about local area activities for children.
If the parent/caregiver is concerned about how many sugary drinks
the child consumes, the CPA can help set a goal for reducing sugary
drinks and offer suggestions for alternatives.

Documenting the assessment

The CPA enters information in the participant’s record, including data
collected during the assessment that is required for eligibility (e.g.,
nutrition risk codes) and for follow-up care in future appointments
(e.g., referrals made, goals set).

Conducting the follow-up assessment

At the next assessment, the CPA rechecks the child’s weight and
height and follows up on any referrals provided or assesses progress
toward the goal set at the previous visit. The CPA affirms progress
and/or helps the parent/caretaker identify ways to overcome barriers.

24 Value Enhanced Nutrition Assessment in WIC | The Process of the WIC Nutrition Assessment

Section 4. Using Assessment Data
to Guide Nutrition Services
Outcomes of the VENA approach to the WIC
nutrition assessment process include customized
nutrition education and breastfeeding counseling,
a tailored food package, and targeted referrals if
needed. CPAs use critical thinking to integrate each
participant’s unique set of circumstances, medical
conditions, nutrition practices, and breastfeeding
goals into a cohesive plan for nutrition services.
Based on the participant’s needs identified during
the WIC nutrition assessment process, the CPA
provides referrals and tailors the food package as
necessary. For example, if a food allergy to egg is
identified, the CPA will tailor the participant’s food
package to remove the eggs. Likewise, if a lack of a

/Definition/

The Importance
of Language
When exploring nutrition risks identified through the assess-

ment, CPAs decide on the most effective communication
strategies to meet each participant’s needs. WIC State agencies may determine how the information is communicated
to participants, provided that it is reflective of the VENA approach. That is, the information is provided to participants as
part of a positive, participant-centered assessment process.31
Although the term “risk” is used for documentation, using the
term with participants may cause undue anxiety and negative
emotions and undermine the VENA approach. Instead, the
CPA can discuss the risk from an optimistic perspective, as
something that can be resolved or improved in the future
through behavior changes. The CPA can also normalize the
risk by saying something like, “A lot of parents worry about
their child drinking too much juice. Does that concern you?”

WIC nutrition assessment
WIC nutrition assessment is the process of
collecting and synthesizing relevant information
in order to:
• Assess an applicant’s nutrition and breastfeeding
status, risks, capacities, strengths, needs, and/or
concerns.
• Identify and assign WIC nutrition risk criteria.
• Customize counseling strategies (e.g., nutrition/
breastfeeding education, guided goal setting,
affirmations) that address a participant’s needs
and concerns.
• Tailor the food package to address nutrition
needs and breastfeeding status and preferences,
including those based on the participant’s culture.
• Make appropriate referrals.29,30

medical home is identified, the CPA will provide
the participant with a referral to local area health
care facilities.
During the WIC nutrition assessment process,
the CPA explores the protective factors unique to
a participant and reinforces positive behaviors,
motivations, and nutrition knowledge. CPAs
personalize each conversation to best help the
participant move closer to adopting nutrition
and health behaviors for positive outcomes. For
some participants, this might mean evoking and
responding to hopes (e.g., “I don’t want him on the
bottle too long; I worry about his teeth”) and using
guided goal setting to help participants take small

Electronic Code of Federal Regulations. Title 7. Agriculture. Part 246. Special Supplemental Nutrition Program for
Women, Infants, and Children. Section 246.2 Definitions. August 2019. Available from: https://www.ecfr.gov/cgi-bin/
retrieveECFR?gp=&SID=ede49f3ec92e9131f2fb220fedbe8ccd&mc=true&n=pt7.4.246&r=PART&ty=HTML#se7.4.246_12 .
30
U.S. Department of Agriculture, Food and Nutrition Service, Supplemental Food Program Division. WIC Nutrition
Services Standards. 2013. Available from: https://wicworks.fns.usda.gov/sites/default/files/media/document/WIC_
Nutrition_Services_Standards.pdf .
31
For more information on explaining the purpose of the assessment process for participants, consult WIC Policy
Memorandum #2008-1, WIC Program Explanation for Participants.
29

Value Enhanced Nutrition Assessment in WIC | Using Assessment Data to Guide Nutrition Services 25

behavioral action steps. For others, it may mean
affirming or building on existing plans or positive
behaviors. The CPA works with the participant to
mutually determine where to focus the nutrition
education conversation—using the nutrition risk and
needs identified in the assessment as the menu of
topics to choose from for discussion. Topics not
covered at the certification appointment may be
covered in later visits.
VENA both allows for and informs personalized
discussions. State agencies can strengthen this
approach by designing policies that help CPAs
use their best judgment. In addition to fostering
professional judgment or critical thinking, training
and mentoring help staff feel more comfortable
about the adequacy of their assessment practices
and documentation and nutrition services. For more
information on staff skills and training, see Section
6. Staff Competencies and Training.

Behavior Change Theories
The VENA approach emphasizes healthy
behavior change and positive health outcomes.
Behavior change theories and models provide the
rationale for effective assessment and counseling
approaches. Examples of behavior change theories
include the social-ecological model (SEM) and
the transtheoretical model (TTM), also called
Stages of Change.
The SEM provides a framework to show how an
individual’s food and physical activity choices
are influenced by many factors. Individual
demographics (e.g., age, ethnicity, income) and
personal factors such as knowledge, skills, and
preferences play a role, as does where individuals
work, play, shop, learn, and pray. Organizations,
businesses, and Government policies and systems
shape an individual’s access to healthy food and/
or opportunities to be physically active. Social and
cultural norms and values influence choices and,
ultimately, health.

Through VENA, the CPA can apply the SEM in
order to consider the multiple levels of individual
and social influences and protective factors that
can support participant behavior change to achieve
positive health outcomes. Evidence suggests
that changing behavior requires the support and
engagement of various sectors of society. For
example, a women’s decision to breastfeed is
highly influenced by her social network, and to be
successful she needs institutional support, such
as hospital practices that enable and encourage
breastfeeding and workplace policies that provide
accommodation for nursing mothers.
The TTM is based on the assumption that people
do not change behaviors quickly but gradually,
in incremental stages.32 There are five stages of
change that progressively move toward sustaining
a long-term behavior change (i.e., maintenance
stage). The model assesses a participant’s
willingness to make a behavior change in a
specified amount of time (e.g., “In 3 months, I want
to start walking every night after work”) and linking
it with a stage of change (e.g., the preparation
stage). By understanding which stage of change
the participant is in, the CPA can provide the
appropriate strategies that will help the participant
move into the next stage of change until ultimately
reaching behavior maintenance.

Prochaska JO, Redding CA, Evers K. The transtheoretical model and stages of change. In Glanz K, Rimer BK, Lewis
FM, eds. Health Behavior and Health Education: Theory, Research, and Practice. 3rd ed. San Francisco (CA): JosseyBass, Inc.; 2002:99-120.

26 Value Enhanced Nutrition Assessment in WIC | Using Assessment Data to Guide Nutrition Services

Table 4 shows the transtheoretical model’s stages
and their corresponding time frame.
There are also counseling methods that can help a
CPA apply the VENA approach to the WIC nutrition
assessment. Table 5 shows several counseling
methods based on behavior change theories that

have proven to be successful for identifying a
participant’s strengths and motivations for change,
even when time for intervention is limited.33,34
Note: Please see WIC Works Resources System
for staff training resources for some of the behavior
change theories described below.

Table 4. Transtheoretical Model and Stages of Change
Stage

Time Frame for Intended
Behavior Change

Precontemplation

Do not intend to start healthy behavior within the next 6 months

Contemplation

Intend to start healthy behavior within next 6 months

Preparation

Intend to start healthy behavior within next 30 days

Action

Currently performing healthy behavior for less than 6 months

Maintenance

Currently performing healthy behavior for more than 6 months

Table 5. Counseling Methods to Identify Strengths and Motivations for Behavior Change
Stage

Time Frame for Intended
Behavior Change

Motivational interviewing

Designed to explore and enhance an individual’s internal motivation to
change by resolving ambivalence, eliciting the importance for change, and
increasing confidence to make change.

Appreciative inquiry

Focuses on building confidence by drawing out positive feelings related to
what went well in the past, what is going well in the present, or what the
family wants for the future.

Emotion-based counseling

Taps into how an individual feels about a given topic. It recognizes that
while information and facts are important, emotions are more frequently
the driver behind change.

Three-step counseling

Designed to promote positive practices by asking open-ended questions
to reveal barriers or concerns, affirming and normalizing feelings, and
sharing targeted information.

Value Enhanced Nutrition Assessment in WIC | Using Assessment Data to Guide Nutrition Services 27

Promoting Positive Behaviors
In most behavior change strategies, the concept
of a person’s inner motivation for change plays
a central role.35 One underlying assumption is
that an individual’s success in making behavior
change is highly dependent on the person’s internal
beliefs and motivations regarding change. Unless
a participant has internal motivation, providing
information alone is unlikely to get the participant
to change the behavior. Through VENA, CPAs have
a powerful role in inspiring and building motivation
for adopting positive nutrition- and health-related
behaviors. Most participants have specific hopes
or goals for themselves and their families,
often centered on nutrition and
overall health. By drawing out
and building on these inner
motivators, CPAs can help
participants increase their
chances for success.
Often this involves the
CPA helping participants
connect goals
regarding nutrition
and health to small
achievable action
steps or identifying
and building on
existing positive
behaviors and
practices.

Sometimes the CPA might identify a nutrition risk
and other barrier and, through probing, determine
that the participant is not motivated to change or
that information does not need to be shared. For
example, a parent may share that she is aware of
the recommendation for bottle weaning but that
she prefers to wait until the child is older. Before
urging her to wean earlier, the CPA can ask probing
questions to identify the parent’s reasons for
delayed weaning. This framing is more likely to get
the parent to talk about her beliefs and concerns
around bottle use and weaning and may lead to an
opportunity for change.
Additionally, compelling someone to make positive
changes when the person is not ready can actually
increase the participant’s resistance to change and
call forth resistance talk.36 Knowing commonly
used resistance talk statements can help CPAs
identify resistance talk. CPAs can facilitate the
transition from resistance talk to behavior change
intention by expressing understanding, suggesting
alternative ways to think about the issue, and
performing guided goal setting.37 It is important
for the CPAs to facilitate these discussions with
respect for the participant’s autonomy.

/Definition/
Resistance

Resistance is a process of avoiding or diminishing
sharing about oneself because the individual feels
uncomfortable or anxious. Resistance talk is
verbal evidence that participants are not ready
to change and feel they need to defend against
change. The more participants put forth arguments
against change, the less likely it is that they will
change their behavior. Resistance talk could mean
participants are being pushed to make a change
they are not ready for.

Rollnick S, Miller WR, Butler CC. Motivational Interviewing in Healthcare. New York (NY): Guilford Publications; 2007.
Kellogg M. Counseling Tips for Nutrition Therapists Practice Workbook (Vol. 1 and 2). Philadelphia (PA): Kg Press;
2006, 2009.
37
Contento IR. Step 5: translating behavioral theory into educational strategies: a focus on enhancing motivation for
change. Nutrition Education: Linking Research, Theory, and Practice. 2nd ed. Burlington (MA): Jones & Bartlett Learning;
2011:254-255.
35
36

28 Value Enhanced Nutrition Assessment in WIC | Using Assessment Data to Guide Nutrition Services

Building Health
Outcome–Based Goals
The VENA approach, using health outcomes as a
focal point, allows discussions to be positive and
proactive. Rather than talking about a nutrition
deficiency as a problem to be solved in isolation,
the conversation is more broad, addressing
underlying determinants of health and emphasizing
the behaviors that will influence participants’ health
over the lifespan. For example, a normal growth
pattern and a healthy weight for a child are not
behaviors but rather outcomes influenced by several
behaviors, such as parents’ following good infant
feeding practices and the child’s eating a variety
of healthy foods and engaging in physical activity.
It is important to connect the overall WIC health
outcome (i.e., achieve a normal growth pattern) to
specific goals for the participant (i.e., child achieving
a healthy weight). Goals are achieved not by internal
motivation alone but rather through a combination
of observing the identified behavior change (e.g.,

Tips From the Field—
Less Is More
The nutrition assessment may identify several areas
where behavior change could improve a participant’s
nutrition and health outcome. However, addressing
too many areas at once can be overwhelming to the
participant and make taking action harder. CPAs can
use the VENA approach to prioritize topic areas.
Because there are multiple opportunities for nutrition
education over the course of a certification, CPAs can
focus on small targets and behaviors over time rather
than trying to address all determinants during one visit.

the parent observes the child’s eating pattern) and
applying nutrition and health knowledge (e.g., what
the parent learned from the CPA about appropriate
infant feeding practices). The CPA can guide the
participant through the goal-setting process and
break each goal into small achievable action steps.

Value Enhanced Nutrition Assessment in WIC | Using Assessment Data to Guide Nutrition Services 29

Focus Goals on Small
Achievable Action Steps
The CPA guides the participant toward improved
health outcomes through incremental behavior
change by breaking goals into small achievable
action steps. By demonstrating how a goal can
be achieved through small action steps, it will help
the participant gain confidence in their ability to
perform the action steps and achieve the goal. With
each successful step taken and goal achieved,
participants will gain more confidence and often
greater motivation, empowering them to maintain
healthy behavior.
Table 6 shows examples of participant goals
and action steps based on several nutrition/
health objectives.

The Importance of Language
In many programs, WIC staff strive to establish goals with
participants that are specific, measurable, achievable, relevant, and time-bound (SMART). However, different terms
such as “next steps” or “small changes” may be better
understood by participants. If a participant uses the term
“goal,” it is completely appropriate for the CPA to use that
word as well. As with all word choices, CPAs select the most
effective language based on real-time interactions and what
will be most effective with the individual participant.

Behavior change is complex, but the VENA
approach can help CPAs conduct the WIC nutrition
assessment in a way that will identify a participant’s
determinants of health and internal motivations.
Together, the CPA and participant can create small,
achievable goals that can be taken to achieve a
positive health outcome.

Table 6. Examples of Participant Action Steps
Nutrition/Health
Objective

Example of a
Participant Goal

Example of Action Step

Consume a variety of foods
to meet energy and nutrient
requirements and remain free
from foodborne illness.

• Bring a homemade lunch and
• Prepare lunch and snacks the night
healthy snacks, including fruits and/
before work.
or vegetables, to work instead of
eating fast food.

Receive ongoing health care, as
appropriate.

• Find a medical and dental home
for child.

• Make an appointment with a health
care provider.
• Contact one of the pediatric dentists
on the WIC referral list.

Achieve appropriate weight for
life stage.

• Increase physical activity.
• Decrease sugar intake.

• Take a walk four times per week.
• Limit juice offered to a child to 4
ounces or less per day.

Remain free from nutritionrelated illness or complications.

• Manage hyperemesis gravidarum
to reduce nausea.

• Put crackers or dry cereal by bed to eat
before getting up in the morning.

Avoid alcohol, tobacco, and
drugs.

• Reduce the number of cigarettes
smoked per day.

• Contact a smoking cessation helpline
for additional information and support.

Breastfeed successfully for as
long as desired.

• Exclusively breastfeed infant for
6 months.

• Create a plan for breastfeeding support
after delivery.
• Attend breastfeeding class next month.

Receive proper environmental
and family support to thrive.

• Feel like healthy behaviors are
supported by family members.

• Enroll in a free parenting class at a local
health center.
• Ask a partner to read the breastfeeding
handout.

30 Value Enhanced Nutrition Assessment in WIC | Using Assessment Data to Guide Nutrition Services

Section 5: Technology and Assessment Tools
Technology can enhance aspects of the VENA
approach. For example, technology enables
consistent data collection and rapid data analysis
(e.g., by plotting growth graphs or identifying
nutrition risks). It can support staff with an
assessment framework and access to reports
on participant characteristics (e.g., nutrition
risks, demographics), and it offers opportunities
for remote engagement with participants (e.g.,
videoconferencing).
In addition, State and local agencies may
emphasize the collection and use of referral data
from medical providers or other approved sources.
Advances in technology and use of electronic
medical records make it possible to use referral
data across programs (e.g., WIC staff in an agency
that provides health care may be able to access
participants’ medical records). For example, if a
child was tested for hematocrit/hemoglobin at a
recent medical appointment, using this information
streamlines the assessment process and means
there is more time to provide nutrition services. WIC
agencies may explore data sharing agreements to
permit access to referral data. Although establishing
those agreements can take some time and effort
up front, the return on investment typically makes it
worth the effort.
However, despite its many advantages, technology
can also present challenges in providing services
to participants. For example, it can hamper the
interpersonal communication between participants
and CPAs, make staff rely too much on the tool
and not enough on their own critical thinking skills,
encourage overzealous data collection, and shift
the focus from supporting health outcomes to just
completing the assessment process. It is important
to carefully balance priorities when incorporating
technology into the assessment process. This
section will address considerations to ensure that
the VENA approach is maintained when technology
is used during a WIC nutrition assessment.

Tips From the Field—
Don’t Start From Scratch
When designing assessment questions, State
agencies may collect tools and questions from other
State agencies and tailor questions to be appropriate
for their own populations. State-developed VENA
training tools and webinars can be found on the
WIC Works Resource System.

Designing Assessment
Questions
WIC State agencies establish policies and practices
to support a consistent VENA approach, including
determining what dietary information to collect
and what types of assessment tools and
questionnaires to use, that will lead to a quality
WIC service.
As information technology evolves and the needs
and demographics of participants change,
State agencies continue to improve assessment
methodologies and instruments. There is no one
tool or assessment process that will meet the
needs of all State agencies, so there is a great
deal of variation in tools and practices used.
Although the assessment instruments/methods
may vary, suggestions for designing processes
include the following:
•

Incorporate open-ended questions. Openended questions require more thought
and more detailed answers. They allow the
participant to share a range of responses and
can help the CPA collect information about
behaviors, values, and motivations.

Value Enhanced Nutrition Assessment in WIC | Technology and Assessment Tools 31

•

Consider question order. This affects
the assessment conversation. One
recommendation is to save highly personal
or sensitive questions until later in the
assessment, when more trust is established.
Starting with some open-ended springboard
questions (e.g., “What are some of your
child’s favorite foods?”) sends the participant
an early message that their engagement
and participation in the process are valued.
(For additional examples of springboard
questions, see Appendix 5. Sample
Springboard Assessment Questions and
Probing Questions for Nutrition/Health
Determinants.)

•

Encourage additional probing questions.
Although questions about behaviors will be
more qualitative, it is sometimes necessary
to ask follow-up questions to identify risk
factors. Probing questions are also useful in
determining whether a participant is motivated
to address barriers or whether information
sharing is appropriate.

•

Add questions to draw out internal
motivation and values. Questions
specifically designed to evoke a participant’s
inner motivation, hopes, or concerns around
health and nutrition will help the CPA
personalize the conversation. For example,
when working with a pregnant participant,
the CPA could ask, “For you, what are the
top three reasons you have decided to
breastfeed?” or “How do you feel on the days
when you manage to have a healthy breakfast
instead of stopping for fast food?”

•

Allow flexibility in phrasing. How CPAs
phrase questions should depend on several
considerations, such as the participant’s age,
literacy level, or knowledge of issues related
to nutrition and health. CPAs should also
practice multicultural awareness when
phrasing questions.

Tips From the Field—Testing
Participant-Facing Assessment
Tools
An important step in finalizing any assessment tool that
a participant will complete is to test it with a group of
participants who reflect the population’s diversity. Testing
can determine whether wording is appropriate, questions
are clear, time required to respond is not burdensome,
and the tool is effective in collecting the intended
information.

Tips From the Field—Evoking
Interests, Motivations, or
Challenges
In addition to collecting data about health status
and behaviors, CPAs can collect information on a
participant’s interests and motivations and any barriers
they face. All of this information can help customize the
conversation to the participant’s needs. Using openended questions that allow the participant to enter a
response or choose topics of interest is a good way to
engage the participant.

32 Value Enhanced Nutrition Assessment in WIC | Technology and Assessment Tools

The Index of Allowable Risk Criteria gives CPAs
a well-informed position to identify the nutrition
risks and needs of the participant. For example,
there are many WIC nutrition risks and needs
associated with nutritionally related medical
conditions; if a participant has such a condition,
it is important for the CPA to consider it when
customizing nutrition counseling. It is also
important that the CPA document the condition
to ensure continuity of care, providing information
for the next CPA who works with the participant.
However, it is not necessary or productive for
the CPA to ask about each medical condition
individually, expending valuable time that is
better spent providing tailored nutrition services.
Instead, CPAs can use global “springboard”
questions to ask about medical conditions
or identify other needs. The CPA can also
use “probing” questions to further pinpoint
deterrents.

Tips From the Field—
Springboard Questions
To make the assessment as efficient as possible,
CPAs often use open-ended springboard questions.
These questions will help the CPA determine whether
additional questions are necessary to probe for
protective factors or needs within each determinant.
For example, a CPA may say to a pregnant participant,
“Tell me about any concerns or problems you are
having with this pregnancy.” The participant’s
response might share information that will help the
CPA identify and document relevant risk factors. This
approach is more effective than asking about each
potential medical or health condition individually and
allows the CPA to target additional probing questions.
(For additional examples of health determinant–based
springboard questions, see Appendix 5. Sample
Springboard Assessment Questions and Probing
Questions for Nutrition/Health Determinants.)

Tips From the Field—
Maintain Focus on the
Participant
Although the MIS is critical to participant services,
CPAs should remember to maintain focus on the
participant, not on the computer. Focusing on the
participant helps build rapport and maintains the
CPA–participant relationship. The CPA can stay
focused on the participant by:
• Reviewing key historical information in the MIS
before welcoming the participant into the office.
• Making eye contact throughout the appointment.
• Setting up the office so it is not dominated by
the computer.
• Starting the assessment-related conversation
with the participant, then turning to the
computer to enter data, rather than doing both
simultaneously.
• Asking permission to turn away from the
participant to enter data as needed.

Value Enhanced Nutrition Assessment in WIC | Technology and Assessment Tools 33

Management
Information Systems
The FNS Functional Requirements Document
for a Model WIC Information System describes
data and functions associated with nutrition
assessment, including maintaining participant

nutrition and health characteristics, calculating
body mass index (BMI) and producing growth
charts, capturing and documenting blood test
results, and determining nutrition risk factors.38 A
well-designed WIC MIS can support a quality WIC
nutrition assessment. Table 7 below lists some MIS
functions to consider when a MIS is being designed
or updated.

Table 7. MIS Functions/Components and Considerations
MIS Functions/Components

Considerations

Policy alignment

• Do the structure and function of the management information
system (MIS) line up with the process and style Competent
Professional Authorities (CPAs) use to complete the assessment
and provide services?

Data collection

•
•
•
•

Risk assignment

• Does the MIS support auto-assignment of risk factors?
• Is it clear to staff which risks are auto-assigned and which are
manually assigned?
• Is it clear how an auto-assigned risk is generated?

Assessment questions

• How many assessment questions need to be included in the MIS?
• Are the questions provided as examples or scripted?
• What probing questions can be asked following a springboard
question?
• Is the wording of assessment questions aligned with best practice
expectations (e.g., open-ended questions when appropriate,
nonleading questions, questions to evoke needs and motivations)?

Notes

• Does the MIS make individualized documentation possible?
• Are notes available in a central location within the MIS?
• Is documentation for past visits easily accessible during
subsequent visits?

Length of assessment

• How many screens and clicks are needed to complete a
certification?
• How long does it take a staff member to navigate the system
to complete a certification or provide follow-up services?

What are the data used for?
Does the benefit outweigh the cost of collecting the data?
Is it clear which questions are mandatory and which are optional?
Are data maintained and easy to retrieve (e.g., prepopulated ) for
future certifications/appointments when appropriate?

U.S. Department of Agriculture, Food and Nutrition Service. Functional Requirements Document for a Model WIC
Information System. September 2008. Available from: https://fns-prod.azureedge.net/sites/default/files/apd/
FReD-v2.0-Final.pdf .

34 Value Enhanced Nutrition Assessment in WIC | Technology and Assessment Tools

Other Technology to
Collect Assessment Data
As technology advances, more WIC agencies
are introducing innovative strategies for collecting
assessment data before the one-on-one sessions.
Collecting some data ahead of time can allow
for a more personalized discussion. Instead of
spending time collecting the data, CPAs can
focus instead on building on the data and asking
additional questions to target support and
information sharing.
WIC agencies are using different types of
technologies and tools, including tablets,
cellphones, downloadable apps, and online
questionnaires, to collect assessment data.
Examples include having a participant complete
initial questions on a tablet in the waiting room
or asking the participant to complete questions
before the visit, using their own cellphone, tablet,
or computer. Important considerations when using
technology to collect assessment data before the
appointment include the following:
•

Workflow. To use the data effectively to inform
the assessment process, the CPA must have
time to review the data ahead of the session.
Doing this before the face-to-face discussion
demonstrates respect to the participant and
allows the CPA to follow up on any information
as necessary.

•

Choice of questions. Some assessment
questions may be appropriate to ask before the
visit, while others may be most effective if asked
during the one-on-one meeting. For example,
the CPA should ask commonly misunderstood
questions during the visit rather than providing
them to the participant beforehand. Regular
updates to any pre-assessment questionnaires
are also critical. Input from local agency staff is

valuable in identifying commonly misunderstood
questions and determining whether they should
be reworded or simply deleted.
•

Integrating or storing information. When
considering tools for collecting assessment
data, it is important to consider what data need
to be stored and whether the technology can
be integrated into the MIS. Regardless of how
the data are collected and stored, it is important
to prevent duplication of effort by WIC staff and
ensure confidentiality of any personal health
information.

Providing WIC
Services Remotely
Providing remote WIC services helps both the
Program and participants, with benefits such
as expanding scheduling options, requiring less
time for appointments, eliminating transportation
barriers, and reducing congestion in clinic
waiting areas. Before initiating remote services,
State agencies must develop detailed policies
and procedures for FNS review and approval.39
Technology also offers more types of encounters,
such as remote consultations with a registered
dietitian or breastfeeding consultant and flexibility
for the location where participants can receive
services (e.g., at home or in a workplace). Remote
access can also allow staff fluent in a particular
language to provide direct service in participants,
eliminating the need to work through an interpreter
service. These options offer convenience and
flexibility for participants. Reducing barriers to
accessing WIC services will make it easier for
participants to remain in and benefit from WIC.
WIC staff will require relevant training and support
to provide WIC services remotely. For example, new
workflow patterns or practices to accommodate
the addition of remote options may be needed.

Services can be provided remotely only when all regulatory requirements related to certification and physical presence
exceptions are met. Electronic Code of Federal Regulations. Title 7. Agriculture. Part 246. Special Supplemental Nutrition
Program for Women, Infants, and Children. Section 246.7(o) Certification of Participants. August 2019. Available from:
https://www.ecfr.gov/cgi-binretrieveECFR?gp=&SID=7a2c252817410a1e102dbbaab0898e9e&mc=true&n=
pt7.4.246&r).#se7.4.246_17 .

Value Enhanced Nutrition Assessment in WIC | Technology and Assessment Tools 35

Involving the local staff in planning will help ensure
their buy-in and that the resulting strategy meets
the needs of both the agency and participants.
Participants too may need training on how to
access and use the new technology. Pilot-testing
remote services with a small group of participants
or staff allows an opportunity to find and address
issues in the processes before launching them to
a wider audience.

more important. Techniques that CPAs can use
to compensate for lack of visual contact include
the following:

Technology can be effective for remote
appointments, but it is important to acknowledge
its limitations; it may not be appropriate for every
participant. For example, some participants
may not have Internet access, and others may
lack videoconferencing options on their phone
or computer or may find costs for data usage
prohibitive. Some participants may simply prefer
a face-to-face encounter. Other participants may
choose to attend some appointments in person and
others remotely. When conducting an appointment
remotely, consider the following strategies to make
the interaction effective.

Avoid Distractions
Reduce distractions both for the CPA and
the participant. Tell the participant in advance
that being in a private, quiet place during the
appointment is ideal. Provide the CPA with a
similar environment.

•

Smile at the beginning of the call; the participant
will sense the smile by the tone of your voice.

•

Set the agenda for your time together.

•

Use follow-up questions, reflective listening,
and summaries.

•

Listen even more carefully for motivation
language.

Tips From the Field—
Collecting Anthropometric
and Hematologic Data
Agencies must consider how to collect
anthropometric or hematologic data before
remote appointments. Referral data from medical
providers or access to electronic medical records
is helpful. Another option is to arrange brief
walk-in visits for measurements and blood tests
in the WIC clinic at a convenient time before the
remote appointment.

Prepare in Advance
Ensure that information such as measurements,
materials, or resources (e.g., handouts, websites,
apps) will be available during the discussion.

Compensate for Lack of Body Language
For audio-only assessments, account for the lack
of nonverbal communication. Body language is a
rich source of information that is not available via
telephone, so tone and word choice become even

36 Value Enhanced Nutrition Assessment in WIC | Technology and Assessment Tools

Section 6. Staff Competencies and Training
Hiring and training qualified staff are essential in
providing quality WIC services. State agencies
may put VENA into action with well-trained
professional or paraprofessional staff. Regardless
of staff members’ education or experience before
working with WIC, State and local agencies must
emphasize development of the essential knowledge
base and work skills. Training, followed by ongoing
staff development activities, ensures that WIC
personnel maintain and refine their skills and have
opportunities to develop new ones. For more
information, please see the WIC Nutrition Services
Standards, Standard 5.40

Competency Areas for
WIC Nutrition Assessment
Competencies are desired outcomes for
knowledge, skills, and behavior. When
learners demonstrate a competency, they are
demonstrating their ability to do something. In the
VENA approach, competencies address a variety
of knowledge and skill areas and are specific to
the environment where the CPA works. Developing
or selecting appropriate competencies should be
based on factors such as job responsibilities and
the CPA’s educational preparation and experience.
In developing staff competencies, it is important
to consider the individuals’ inherent talents and
abilities, as well as their learned skills.
Because the tasks involved in VENA are fairly
consistent among WIC agencies, the following
six competencies to perform those tasks have
been identified:
•

Principles of life cycle nutrition.
Understanding normal nutritional needs during
pregnancy, lactation, the postpartum period,
infancy, and early childhood.

• The VENA approach. Understanding the steps
in the VENA approach to nutrition assessment,
to include all the requirements related to
blood work, anthropometric measurements,
documentation, follow-up visits, and so on.
• Data collection techniques. Understanding
the importance of precise and valid data, as
well as how to collect anthropometric and
hematological data.
•

Communication. Knowing how to
communicate effectively with participants
and foster open exchanges.

•

Multicultural intelligence/awareness.
Understanding how sociocultural issues
(race, ethnicity, religion, group affiliation,
socioeconomic status, and worldview) affect
nutrition and health practices and nutritionrelated health problems.

•

Critical thinking. Knowing how to analyze
and synthesize information to draw appropriate
conclusions.

Value Enhanced Nutrition Assessment in WIC | Staff Competencies and Training 37

•

For more information about the knowledge
required and performance expected for each
competency, see Appendix 4. Essential
Staff Competency for WIC Nutrition
Assessment

Building Competencies
Through Training
Training approaches that focus on the outcome
rather than the process of learning are ideal.
Because many competency-based approaches
incorporate independent learning, CPAs
progress at their own rates. Training activities
are planned to accommodate differences in
learning styles and ensure that CPAs acquire
the skills, understanding, and attitudes needed
to function in their specific work roles. Because
the conditions and requirements for performing
most roles continuously evolve, it is important
to review and update competencies regularly.
State agencies may develop different training
programs based on staffing patterns and service
delivery models.

Tips From the Field—Ways to
Build and Maintain WIC Nutrition
Assessment Competencies
• Conduct regular in-service training to maintain focus
on quality services.
• Identify and address individual employees’ training
needs.
• Provide opportunities for staff to attend local, State,
and national nutrition training events and conferences
focusing on maternal and child nutrition.
• Use training opportunities to discuss participant case
studies and reinforce WIC nutrition assessment skills.
• Discuss successes and challenges during team
meetings or huddles.
• Include role-playing or simulations in training events.
• Observe staff conducting WIC nutrition assessments
and provide constructive feedback.

Tips From the Field—
Encourage Self-Assessment
Having staff assess their own skills can help identify
ongoing training needs. Self-assessment activities might
include the following:
• Conducting a short interview with each staff member to
ask about areas where the member is confident and
where the member feels she or he need more training.
• Asking staff to rate themselves on various skills, using
a scale where 1 equals “needs significant practice” and
5 equals “excellent.”
• Conducting a short survey with staff that includes
asking open-ended questions about their strengths,
areas needing improvement, and what support would
be most helpful in developing skills.
Trends or themes across staff members’ responses
can indicate areas where they require more training
or mentoring.

Identifying Training Needs
Staff training needs can be identified in several
ways. First, comparing essential competencies
and performance expectations with the content
of training programs for new staff can reveal gaps
or areas for enhancement. Second, observation
and mentoring provide excellent opportunities to
evaluate individual staff members’ performance with
WIC nutrition assessments and further build their
competence through constructive feedback. Third,
ensuring that staff understand what is expected
of them is essential to ensuring high-quality
performance.

Planning Training to
Build Competencies
CPAs must be able to do more than list or describe
facts, data, or other information. Competencies
combine higher-level cognitive skills and critical
thinking to determine a course of action. Training
begins with verifying that a foundation of knowledge
exists or providing opportunities to establish

38 Value Enhanced Nutrition Assessment in WIC | Staff Competencies and Training

Tips From the Field—
Use Mentors to Enhance
Competency
Mentoring in WIC is a form of ongoing staff
development that builds relationships between
colleagues, supports staff skill enhancement, and
identifies programmatic challenges to address. A
mentor is a trusted, highly skilled individual who
places the mentees’ best interests foremost in
each mentoring session. A mentor does not have
to play a specific WIC staff role but may be a CPA,
registered dietitian, site supervisor, State agency
consultant, or something else. The mentor’s
approach, competence, and character are more
important than their role. The most effective mentors:

such a foundation. Trainees can then move on
to synthesizing facts through problem-based
learning and evaluating their performance through
simulations. As training continues, opportunities for
independent learning and performance in the work
setting are incorporated until the trainee is proficient
at job-related tasks. A well-designed training
program includes various techniques to reach
training outcomes in all areas: knowledge, skills,
attitudes, and values. Table 8 shows appropriate
techniques for desired learning outcomes.

• Approach mentoring as an ongoing process,
modeling the style/technique expected of WIC
staff in interactions with participants and
recognizing that the time spent in mentoring
offers exponential gains to the program.
• Can discuss program initiatives and policies
broadly and specifically. Competent mentors
have real-world WIC experience and understand
the program’s vision.
• Embody the core values of WIC in their interactions
with colleagues, building trust, demonstrating
respect, seeking first to understand, listening more,
affirming specifically, managing expectations, being
sincere, and providing honest feedback.

Table 8. Matching Training Techniques to the Desired Learning Outcome
Desired Outcome

Appropriate Techniques

Knowledge

Lecture, symposium, seminar, or other classroom-based situation; video,
debate, dialogue, interview, recording, book-based discussion, reading,
and web-based learning.

Skills

Role-playing, games, participative exercises, simulations, nonverbal hands-on
exercises, skill practice exercises, drills, and coaching.

Attitudes

Experience-sharing discussion, group-centered discussion, role-playing,
case studies, games, and rewarding appropriate behavior.

Values

Lecture, debate, dialogue, video, symposium or seminar, dramatization,
guided discussion, experience-sharing discussion, role-playing, and games.

Value Enhanced Nutrition Assessment in WIC | Staff Competencies and Training 39

Section 7. Continuous Quality Improvement
The VENA approach to a WIC nutrition assessment
has evolved as State and local agencies learn
more about what drives behaviors and effective
strategies to support the adoption of healthy
nutrition practices among participants. The
commitment of staff at the federal, regional, State,
and local level to continuously improve the quality
of the participant experience and the impact of
WIC on health outcomes helps make this evolution
possible. Initiatives to improve program quality
also influence retention, helping to ensure that
eligible participants remain in WIC and benefit from
services. “Continuous quality improvement” is a
term for all ongoing efforts to advance WIC service
delivery, including WIC nutrition assessment.
There are several ways to promote continuous
quality improvement in WIC. State and local
agencies determine how to improve and enhance
their services through prospective and retrospective
reviews. Such reviews could be participant surveys
and direct observation.
Direct observation can take place during a
variety of activities, including formal evaluations,
informal technical assistance, or staff coaching.
Ongoing training, staff development, and other
targeted program enhancement initiatives are also
important quality improvement strategies. For more
information, please see the WIC Nutrition Services
Standards, Standard 16.41

Using Direct Observation
to Evaluate VENA
Implementation
Direct observation is an important part of evaluating
the overall quality of assessment practices
and the extent to which the VENA approach
is operationalized, as well as for identifying

opportunities for improvement. Although review of
documentation in participant records is a useful
indicator of what took place during a WIC visit,
observation provides a more complete picture of
not only what takes place during the WIC nutrition
assessment but also how the assessment is
conducted. While VENA is a framework for a
systematic assessment process, the ways in which
the assessment is carried out will vary. CPAs use
a variety of soft skills during the assessment, such
as body language, friendly greetings, and active
listening, which directly affect the effectiveness
of the assessment. Additionally, CPAs adapt the
assessment and their use of soft skills for each
participant based on what they believe will be most
effective. Because of this individualized approach,
CPAs’ use of soft skills can only be assessed
through watching the staff–participant interactions.
CPAs face many decision points during an
assessment, and they actively employ critical
thinking to guide conversations with participants
(e.g., evaluating the information they are receiving,
determining areas of interest, identifying when more
detail is needed). Because there is not one “right
way” to complete an assessment, observation is
also a useful tool in validating the CPAs decisions
and/or supporting additional skill development. A
brief conversation between the observer and CPA
immediately following the WIC assessment can
be instrumental in quality improvement. Similarly,
observers can look for trends among CPAs to
identify where a targeted training would be helpful.
Observers must be well trained in the VENA
approach as well as in the soft skills used in
assessment. This knowledge helps observers
effectively model the desired skills in their
communications with CPAs. By using these soft
skills, the observer will reinforce to CPAs that

40 Value Enhanced Nutrition Assessment in WIC | Continuous Quality Improvement

staff at all organizational levels believe these
are effective. The skill set of the observer can
be developed through periodic training, with
opportunities to practice the skills being evaluated.
When State and local agencies have more than
one person conducting observations, consistency
among observers is critical. Because VENA
and subsequent nutrition services are highly
individualized, they are also subjective and do not
fit neatly into a checklist of “meets expectations”
or “does not meet expectations.” State agencies
can help establish consistency among observers
through strategies such as:
•

Providing clear direction on core programmatic
objectives and vision (e.g., nutrition assessment
is a core process in the larger continuum of WIC
services that ideally culminates in supporting
positive health outcomes).

•

Meetings among observers to discuss the intent
of the VENA approach, related federal guidance,
and implications for service delivery.

•

Opportunities for multiple observers to watch
the same interaction (i.e., in-person or videorecorded session) and compare notes.

•

Periodically reviewing findings across agencies,
both positive and negative, to identify possible
inconsistencies.

to accommodate variations in staff proficiency,
experience, and/or training. These added levels
of competence allow for and encourage growth
among WIC staff and facilitate the identification
of training needs for individual staff and agencies
as a whole. For examples of observation tools
developed by State agencies, refer to Appendix
6. Examples of Observation Tools Used to
Evaluate VENA Practices.

Resources
The WIC Works Resource System (WIC Works)
is an online education, training, and resource
center for State and local WIC staff that offers a
variety of resources from FNS, WIC State and
local agencies, other federal agencies, and nonGovernmental entities.

Some State agencies have promoted
consistency among observers and assisted
local agencies by developing evaluation
criteria or quality indicators to explain how
to characterize “meets expectations”
or “does not meet expectations” in
practice. This helps observers and
local staff better understand
expectations for participant
interactions. In some
cases, State evaluation
tools allow for different
levels of competency

Value Enhanced Nutrition Assessment in WIC | Continuous Quality Improvement 41

Quality Indicators for
Direct Observation of
VENA Practices
When creating evaluation criteria or quality
indicators, State agencies incorporate as
much flexibility as possible to reflect how CPAs
individualize services. CPAs do not use all skills or
strategies during each appointment; rather, they
prioritize their approach depending on the needs
of the participant. One way to allow for flexibility
and encourage CPAs to individualize services is
to limit the number of indicators to be evaluated.
Key indicators include those that capture the
overall intents of the process, allowing the CPA the
freedom to personalize the appointment while still
meeting quality expectations. Having fewer criteria
will also make it easier to achieve consistency
across observers.
As State agencies determine how they will evaluate
strength-based assessment and counseling
practices, potential quality indicators to consider
include the following:
•

CPAs employ critical thinking skills to gather,
analyze, and prioritize assessment information.

•

CPAs individualize the assessment and
nutrition services conversation to the unique
circumstances of the participant.

•

CPAs identify and affirm participants’ strengths
and positive behaviors.

•

CPAs use open-ended questions to engage
the participant in the assessment and nutrition
services conversation.

•

CPAs document relevant information, nutrition
risks assigned, and nutrition interventions.

•

State agencies can support quality improvement
by making observation tools available to local
agencies in advance. Sharing these promotes
transparency and builds trust and clarity around
expectations for both State agency staff and
local staff. In addition, the tools can be used
by local agency managers or staff mentors to
observe services in their WIC sites and provide
coaching to help staff build skills. Inviting local
input when designing the tools will help ensure
the process reflects service delivery principles
important to local agencies and that the tools
will be used for ongoing monitoring within the
local agency.

42 Value Enhanced Nutrition Assessment in WIC | Continuous Quality Improvement

Continuous Quality
Improvement Strategies
Conversations between observers and WIC staff
members can be very effective in affirming skills
observed and offering ideas for strengthening the
interactions with participants or for conducting the
assessment process. A well-trained observer will be
able to identify both strengths and opportunities for
enhancement, and they will be skilled in providing
feedback in style that is consistent with VENA
approach. Observing the WIC nutrition assessment
process across multiple WIC staff, either within the
same agency or across multiple agencies, is useful
for identifying overall strengths, challenges, and
opportunities for improvement. The information

gleaned during direct observations may indicate a
need for additional training using existing curricula
or developing new training resources on new topics
or using different modes of learning. Alternatively,
the information may highlight the need for revisions
or clarification to a State or local policy or process.
This could involve a straightforward update and
communication about the change or it may require
a longer-term initiative, such as modifications to
the WIC MIS. In addition, comparing observation
findings across multiple observers may highlight
a need to refine current observation tools or
to provide additional training efforts. For more
information on staff training, refer to Section 6.
Staff Competencies and Training.

Value Enhanced Nutrition Assessment in WIC | Continuous Quality Improvement 43

Appendix 1. Glossary of Terms
Affirmation—A statement that acknowledges

an individual’s positive qualities (strengths, efforts,
or personal characteristics) and encourages
continued application of those qualities. Affirmations
strengthen relationships, encourage positive
behaviors, and build confidence in one’s ability
to change.

Autonomy—An individual’s ability and right

to make decisions concerning their lives. Although
the WIC staff supports behavior change, ultimately it is up to the individual to decide whether to
change. Recognizing and respecting a participant’s
autonomy supports behavior change by empowering participants and reducing the chance of
resistance.

Body mass index (BMI)—A measure of body
fat based on height and weight. The calculation
involves dividing weight in kilograms by height in
meters squared or dividing weight in pounds
times 703 by height in inches squared (kg/m2
or 703 × lbs./in2).
Competency—An individual’s demonstrated
knowledge, skills, or abilities performed to a
specific standard. Competencies are observable
behavioral acts demonstrated in a job context
and are influenced by an organization’s culture
and work environment.
Competent Professional Authority
(CPA)—An individual on the staff of a local agency

authorized to conduct the nutrition assessment,
determine nutrition risk, and prescribe supplemental
foods. Federal WIC program regulations define the
CPA as a physician, nutritionist, registered nurse,
dietitian, or medically trained State or local health
official, or person designated by physicians or
medically trained State or local health officials.42

Continuity of care—The process of ensuring

quality care over time. The participant and the
WIC staff collaborate to identify and support the
achievement of small steps toward health goals
over time. Continuity of care is supported by
appropriate documentation and processes to allow
for access to a participant’s history and seamless
sharing of information between staff members.

Critical thinking—The disciplined process of

organizing and blending information to evaluate
and prioritize it effectively. Critical thinking involves
integrating facts, informed opinions, active listening,
and observations.

Emotion-based counseling—A counseling

approach that recognizes that emotions drive
behaviors and that discussing a participant’s
motivations and emotions around change before
providing facts and information is most effective in
helping to bring about lasting behavior change.

Guided goal setting—The process of helping

participants set goals. The WIC staff and the
participant work together to identify potential goals
through the assessment process and develop
small progressive action steps toward positive
health outcomes. Guided goal setting is based
on the premise that participants who set realistic,
achievable goals for themselves are more likely to
make changes than those who do not set goals.

Health determinants—A range of behavioral,

biological, socioeconomic, and environmental
factors whose interactions affect people’s health
status. Health determinants that promote a positive
health outcome may be viewed as protective
factors, while determinants that may hinder positive
outcomes can be considered potential barriers,
e.g., WIC nutrition risks.

44 Value Enhanced Nutrition Assessment in WIC | Appendix 1

Health Outcome–Based Approach—An

approach to the WIC nutrition assessment where a
desirable health outcome (e.g., delivery of a healthy
full-term baby) serves as a focal point to collect
relevant information. The elements of this approach
include (1) a desired health outcome, (2) nutrition/
health objectives (e.g., consume a healthy diet)
and (3) health determinants (see definition). This
approach also allows participants to gain a greater
appreciation of how to attain good health and
recognize their own need(s) and/or needs of
an infant/child for health improvement.

Index of Allowable Risk Criteria—A list of

permitted nutrition risk criteria for use in determining
WIC eligibility and providing nutrition services
(nutrition education, food packages, referrals,
and breastfeeding support). The nutrition risk
explanations are a source of technical assistance
to State and local agency WIC staff, providing
an evidence-based definition and justification for
risk assignment, as well as nutrition education
messages, for each criterion.43

Management information system (MIS)—

A computerized information-processing system
designed to support data collection and synthesis
and service delivery.

Motivation—A person’s reason(s) for acting or

behaving in a particular way, or the general desire
to do something.

Motivational interviewing—An approach to
assessment and counseling designed to explore
and enhance an individual’s internal motivation
to change by resolving ambivalence, eliciting the
importance for change, and increasing confidence
to make a change.

Multicultural intelligence/awareness—The

capability to relate and work effectively with people
from different cultural backgrounds. Multicultural
intelligence includes an understanding of how
sociocultural aspects (race, ethnicity, religion, group
affiliation, socioeconomic status, and worldview)
affect nutrition and health practices.

Nutrition risk—Attributes that hinder positive

health outcomes, including (a) detrimental or
abnormal nutritional conditions detectable by
biochemical or anthropometric measurements;
(b) other documented nutritionally related medical
conditions; (c) dietary deficiencies that impair
or endanger health; (d) conditions that directly
affect the nutritional health of a person, including
alcoholism or drug abuse; or (e) conditions that
predispose persons to inadequate nutritional
patterns or nutritionally related medical conditions,
including, but not limited to, homelessness and
migrancy.44

Nutrition services—A comprehensive term for

activities that result from the assessment process.
WIC nutrition services encompass customized
nutrition counseling, referrals for additional programs
or services, assignment of a tailored food package,
and breastfeeding promotion and support.
Customized nutrition counseling could include
nutrition education, guided goal setting, sharing
relevant information, and/or reinforcing positive
behaviors.

Open-ended questions—Questions that

require more than a simple one-word answer, often
used to gain a broader situational understanding. In
contrast, closed-ended questions can be answered
simply (e.g., yes or no) and are often used to gather
specific information.

Electronic Code of Federal Regulations. Title 7. Agriculture. Part 246. Special Supplemental Nutrition Program for
Women, Infants, and Children. Section 246.2 Definitions. August 2019. Available from: https://www.ecfr.gov/cgi-bin/
retrieveECFR?gp=&SID=ede49f3ec92e9131f2fb220fedbe8ccd&mc=true&n=pt7.4.246&r=PART&ty=HTML#se7.4.246_12 .
44
Electronic Code of Federal Regulations. Title 7. Agriculture. Part 246. Special Supplemental Nutrition Program for
Women, Infants, and Children. Section 246.2 Definitions. August 2019. Available from: https://www.ecfr.gov/cgi-bin/
.
retrieveECFR?gp=&SID=ede49f3ec92e9131f2fb220fedbe8ccd&mc=true&n=pt7.4.246&r=PART&ty=HTML#se7.4.246_12
43

Value Enhanced Nutrition Assessment in WIC | Appendix 1 45

Participant—For the purposes of this document,

the word refers to a WIC participant, an applicant,
or a parent/caregiver.45

Participant-centered approach—A systems

approach designed to focus on topics and issues
that are relevant to the participant. This approach
puts the participant’s needs and the goal of healthy
behaviors at the core of WIC service delivery
and focuses on a person’s capacities, strengths,
and developmental needs, not solely on the
problems, risk, or negative behaviors. In contrast
to the traditional didactic WIC assessment and
education model, participant-centered services
encourage staff to engage the participant/caretaker
in dialogue, information exchange, listening, and
feedback, in order to translate the assessment
into action and customize the nutrition services
provided.46

Plain language—Communication used so your

audience can understand the first time they read or
hear it.47

Reflective listening—A statement that conveys
understanding. This can include paraphrasing
someone’s statement to confirm its meaning
or reflecting more than what was said directly,
such as emotions or intent. Reflective listening is
effective in a variety of scenarios and helps clarify
understanding, encourages greater exploration,
and builds relationships.

Resistance talk—Evidence of a person’s

defense against change, often in the form of
arguments against change. The more participants
argue against change, the less likely it is that they
will change their behavior.

Self-efficacy—Participants’ beliefs about their

ability to succeed in reaching specific goals. Efforts
to support participants’ beliefs about their own
strengths and abilities will affect how likely they are
to achieve goals.

Social-ecological model (SEM)—An

approach that addresses several social ecologies
or levels of influence on behavior at once.
These levels are labeled intrapersonal factors,
interpersonal processes and primary groups,
institutional factors, community factors, and public
policy and legislation.48

Three-step counseling—A strategy designed
to promote positive behaviors by asking openended questions to identify barriers or concerns,
affirming and normalizing feelings, and sharing
targeted information.

Transtheoretical model (TTM, stages of
change)—Proposes that self-change in behavior
is a process that occurs through five stages and
that individuals use a variety of psychological and
behavioral processes in making changes.49

Resistance—A process of avoiding or diminishing
sharing about oneself because the individual feels
uncomfortable or anxious.

See the following citation for regulatory definition: Electronic Code of Federal Regulations. Title 7. Agriculture. Part 246.
Special Supplemental Nutrition Program for Women, Infants, and Children. Section 246.2 Definitions. August 2019.
Available from: https://www.ecfr.gov/cgi-bin/retrieveECFR?gp=&SID=ede49f3ec92e9131f2fb220fedbe8ccd&mc
=true&n=pt7.4.246&r=PART&ty=HTML#se7.4.246_12 .

U.S. Department of Agriculture, Food and Nutrition Service, Supplemental Food Program Division. WIC Nutrition Services
Standards. 2013. Available from: https://wicworks.fns.usda.gov/sites/default/files/media/document/WIC_Nutrition_
Services_Standards.pdf .
47
U.S. Plain Language Action and Information Network. Available from: https://www.plainlanguage.gov/ .
48
Contento IR. Foundation in theory and research: promoting environmental support in action. Nutrition Education: Linking
Research, Theory, and Practice. 2nd ed. Burlington (MA): Jones & Bartlett Learning; 2011: 121–122.
49
Contento IR. Foundation in theory and research: facilitating the ability to take action. Nutrition Education: Linking Research,
Theory, and Practice. 2nd ed. Burlington (MA): Jones & Bartlett Learning; 2011: 108-112.
46

46 Value Enhanced Nutrition Assessment in WIC | Appendix 1

VENA Approach—a participant-centered,

health outcome–based approach to WIC nutrition
assessment. The VENA approach incorporates a
WIC nutrition assessment process with policies,
staff competencies, a Management Information
System (MIS), and quality improvement strategies
that together enhance the delivery of WIC nutrition
services. The words “VENA” and “the VENA
approach” are used interchangeably.

VENA Guidance—Comprehensive nutrition

assessment guidance to assist WIC State agencies
in operationalizing the VENA Approach to WIC
nutrition assessment.

WIC nutrition assessment—The process

of collecting and synthesizing relevant information
in order to assess an applicant’s nutrition and
breastfeeding status, risks, capacities, strengths,
needs, and/or concerns; identify and assign
WIC nutrition risk criteria; customize counseling
strategies (e.g., nutrition/breastfeeding education,
guided goal setting, affirmations) that address
a participant’s needs and concerns; tailor the
food package to address nutrition needs and
breastfeeding status and preferences, including
those based on the participant’s culture; and make
appropriate referrals.50,51

Electronic Code of Federal Regulations. Title 7. Agriculture. Part 246. Special Supplemental Nutrition Program for Women,
Infants, and Children. Section 246.11 Nutrition Education. August 2019. Available from: https://www.ecfr.gov/cgi-bin/
retrieveECFR?gp=&SID=7a2c252817410a1e102dbbaab0898e9e&mc=true&n=pt7.4.246&r)
50

Value Enhanced Nutrition Assessment in WIC | Appendix 1 47

Appendix 2. Health Outcome–Based
Assessment by Category
Health outcomes are dependent upon health
determinants, a set of factors influenced by
individual behaviors, past and current health
conditions, and the family and social environment.
Protective factors for each determinant are things
that will increase the likelihood of achieving the
desired health outcome, while identified WIC
nutrition risks may reduce the possibility of a
positive outcome. Each health determinant can
be explored with the participant by collecting and
synthesizing relevant information. For example,
data on weight, height, pre-pregnancy weight, and
weeks of gestation are collected and evaluated to
assess whether the pregnant woman is achieving a
recommended weight gain. During the exploration
of each objective, CPAs work to identify WIC
nutrition risks and protective factors and how they
relate to the nutrition/health objective. The CPAs
work with participants to identify relevant goals
and action steps (see Table 6). This systematic
process of exploring each health determinant
can be adapted for State and local processes and
contribute to positive outcomes for participants.52

Below is a framework for a health outcome–based
VENA for each participant category. The tables
describe the desired health outcomes, a list of
health objectives for each participant category,
and examples of potential WIC nutrition risks and
protective factors. The tables also include examples
of what actions the CPA can take to properly
identify a participant’s WIC nutrition risks and
protective factors.
It should be noted that the examples of potential
WIC nutrition risks, protective factors, and CPA’s
role are not exhaustive. For a complete listing
of WIC nutrition risks for each health objective
(crosswalk), please see Appendix 3. Crosswalk
of Health Objectives and WIC Nutrition Risks.
For a complete list of the most up-to-date WIC
risk criteria that include evidence-based definitions
and justifications for risk assignment, as well as
applicable nutrition education messages, please
visit the WIC Nutrition Risk PartnerWeb.

The order of health determinants below does not imply priority or importance. Each State agency establishes policies and
procedures about nutrition assessment tasks, including how tasks are organized and when each is completed.

48 Value Enhanced Nutrition Assessment in WIC | Appendix 2

Table A2-1. Health Outcome–Based WIC Nutrition
Assessment for a Pregnant Woman
Desired health outcome: Deliver a healthy full-term infant while
maintaining the mother’s optimal health status
Nutrition/
Health
Objective

Nutrition/
Health
Determinant
Category

Nutrition/Health Determinants
Examples of
Potential WIC
Nutrition Risks/
Needs*

Examples
of Protective
Factors*

Competent
Professional
Authority’s (CPA’s)
Role†

Consume a
Dietary Intake/
variety of foods Nutrition
to meet energy Practices
and nutrient
requirements,
and remain
free from
foodborne
illnesses

• Consumes a
diet very low in
calories and/
or essential
nutrients
• Compulsively
ingests nonfood
items
• Inadequate
vitamin/mineral
supplementation

• Eats a variety of fruits
and vegetables, lean
proteins, and whole
grains
• Takes prenatal
vitamins or
multivitamins with
adequate folic acid
• Practices food safety
behaviors

• Assess current nutrition
practices
• Assess current and
potential impact on
nutritional intake and
nutritional needs
• Assess factors that may
affect meal pattern
• Identify misconceptions
about ideal nutrition
practices
• Assess potential for
foodborne illnesses

Receive
ongoing health
care, including
early prenatal
care

Health/Dental
Care

• Lack of adequate
prenatal Care
• Lack of medical
or dental home

• Established a medical
home
• Enrolled in a health
insurance plan
• Receives regular oral
health care

• Assess barriers to
obtaining care
• Ask about dental status
and treatment already in
progress
• Assess level of access to
follow-up medical care

Achieve a
recommended
maternal
weight gain

Weight/
Height Status
(Anthropometric)

• Underweight
• Overweight
• Low maternal
weight gain
• High maternal
weight gain
• Lack of physical
activity

• Eats a variety of foods
to meet

• Assess possible
contributors to weight
gain/loss (e.g., knowledge
and attitudes regarding
weight gain, physical
activity level, appetite,
stress)

Remain free
from nutritionrelated
illness or
complications

Clinical/Health/
Medical

• Low hematocrit/ • Eats high iron foods
low hemoglobin • Takes prenatal
• Nutrition
vitamins/minerals as
deficiency
prescribed by health
diseases
care provider
• Diabetes Mellitus • Monitors and
manages blood
glucose levels

• Assess factors that may
affect hemoglobin/
hematocrit levels
• Assess whether it is likely
to be a nutritional or
physiological anemia
• Assess/reinforce
compliance with treatment
plan from health care
provider

Value Enhanced Nutrition Assessment in WIC | Appendix 2 49

Table A2-1. Health Outcome–Based WIC Nutrition
Assessment for a Pregnant Woman (continued)
Desired health outcome: Deliver a healthy full-term infant while
maintaining the mother’s optimal health status
Nutrition/
Health
Objective

Nutrition/
Health
Determinant
Category

Nutrition/Health Determinants
Examples of
Potential WIC
Nutrition Risks/
Needs*

Examples
of Protective
Factors*

Competent
Professional
Authority’s (CPA’s)
Role†

Avoid alcohol,
tobacco,
drugs, and
other harmful
substances

Substance Use

• Alcohol and
substance use
• Nicotine and
tobacco use

• Does not smoke
• Avoids alcohol, drugs,
and other harmful
substances

• Assess understanding
of the potential dangers
to herself and her
pregnancy
• Assess attitude toward
treatment/cessation
programs
• Assess awareness of
available help and
readiness to access/
accept it

Make an
informed
decision about
breastfeeding

Infant Feeding
Decisions

• Experienced
breastfeeding
complications
previously
• Lack of
breastfeeding
support

• Is knowledgeable
about different
feeding options
• Has an existing
support network for
breastfeeding

• Assess interest for more
information/participation
in breastfeeding peer
counseling and other
breastfeeding support
resources
• Assess contraindications
to breastfeeding

Receive proper
environmental
and family
support to thrive

Social Support/
Home
Environment

• Homelessness
• Recipient of
abuse

• Has access to
adequate food
preparation and food
storage resources
• Has access to safe and
adequate water
• Lives in a supportive
and safe environment

• Assess food preparation
and food storage
equipment
• Assess home
environment and
support systems
• Identify referral
opportunities

* The nutrition/health determinants listed are examples of some of the potential determinants that a CPA could identify
during a WIC nutrition assessment. They do not represent an exhaustive list of WIC nutrition risks or protective factors.
†
The roles listed are examples of actions that a CPA will perform during a WIC nutrition assessment. They do not
represent an exhaustive list of all the actions a CPA will take to complete a WIC nutrition assessment.

50 Value Enhanced Nutrition Assessment in WIC | Appendix 2

Table A2-2. Health Outcome–Based WIC Nutrition Assessment
for a Breastfeeding Woman
Desired health outcome: Achieve optimal health during the
childbearing years and reduce the risk of chronic diseases
Nutrition/
Health
Objective

Nutrition/
Health
Determinant
Category

Nutrition/Health Determinants
Examples of
Potential WIC
Nutrition Risks/
Needs*

Examples
of Protective
Factors*

Competent
Professional
Authority’s (CPA’s)
Role†

Consume a
variety of foods
to meet energy
and nutrient
requirements,
and remain free
from foodborne
illnesses

Dietary Intake/
Nutrition
Practices

• Consumes a
diet very low in
calories and/
or essential
nutrients
• Compulsively
ingests nonfood
items
• Ingests foods
that could be
contaminated
with pathogenic
microorganisms

• Eats a variety of fruits
and vegetables, lean
proteins, and whole
grains
• Limits calories from
added sugars and
saturated fats and
reduces sodium intake
• Practices food safety
behaviors
• Takes vitamins/
minerals as prescribed
by health care
provider

Receive ongoing
health care,
including early
postpartum care

Weight/
Height Status
(Anthropometric)

• Overweight
• Underweight
• Low maternal
weight gain
• High maternal
weight gain
• Lack of physical
activity

• Eats a variety of
foods to meet energy
requirements
• Engages in physical
activity

• Assess possible
contributors to
weight gain/loss (e.g.,
knowledge and attitudes
regarding weight gain,
physical activity level,
appetite, stress)

Achieve a
desirable
postpartum
weight or body
mass index (BMI)

Weight/
Height Status
(Anthropometric)

• Overweight
• Underweight
• Low maternal
weight gain
• High maternal
weight gain
• Lack of physical
activity

• Eats a variety of
foods to meet energy
requirements
• Engages in physical
activity

• Assess possible
contributors to
weight gain/loss (e.g.,
knowledge and attitudes
regarding weight gain,
physical activity level,
appetite, stress)

Remain free
from nutritionrelated illness or
complications

Clinical/Health/
Medical

• History of
gestational
diabetes
• Elevated blood
lead levels
• Lactose
Intolerance

• Takes vitamins/
minerals as prescribed
by health care
provider
• Is knowledgeable
about high iron foods

• Ask about potential
sources of lead exposure
• Assess special diet and
medications prescribed
to manage or treat
condition

Value Enhanced Nutrition Assessment in WIC | Appendix 2 51

Table A2-2. Health Outcome–Based WIC Nutrition Assessment
for a Breastfeeding Woman (continued)
Desired health outcome: Achieve optimal health during the
childbearing years and reduce the risk of chronic diseases
Nutrition/
Health
Objective
Avoid alcohol,
tobacco,
drugs, and
other harmful
substances

Nutrition/
Health
Determinant
Category

Nutrition/Health Determinants
Examples of
Potential WIC
Nutrition Risks/
Needs*

Examples
of Protective
Factors*

Competent
Professional
Authority’s (CPA’s)
Role†

Substance Use

• Alcohol and
substance use
• Nicotine and
tobacco use

• Does not smoke
• Avoids alcohol, drugs,
and other harmful
substances

• Assess understanding of
the potential dangers to
herself and her infant
• Assess attitude toward
treatment/cessation
programs
• Assess awareness of
available help and
readiness to access/
accept it

Breastfeed infant Infant Feeding
successfully
Decisions

• Breastfeeding
complications
or potential
complications
• Lack of
breastfeeding
support

• Breastfeeds enough to
ensure adequate milk
supply
• Eats a variety of
foods to meet energy
requirements
• Has an existing
support network for
breastfeeding

• Evaluate awareness
of breastfeeding
recommendations
• Assess effectiveness of
mother’s management
strategies
• Assess adherence to
medical providers’
recommendations
• Assess support system

Receive proper
environmental
and family
support to thrive

• Homelessness
• Recipient of
abuse
• Limited ability to
prepare food

• Has access to
adequate food
preparation and food
storage resources
• Has access to safe and
adequate water
• Lives in a supportive
and safe environment

• Assess possible
contributors to
weight gain/loss (e.g.,
knowledge and attitudes
regarding weight gain,
physical activity level,
appetite, stress)

Social Support/
Home
Environment

* The nutrition/health determinants listed are examples of some of the potential determinants that a CPA could identify
during a WIC nutrition assessment. They do not represent an exhaustive list of WIC nutrition risks or protective factors.
†
The roles listed are examples of actions that a CPA will perform during a WIC nutrition assessment. They do not
represent an exhaustive list of all the actions a CPA will take to complete a WIC nutrition assessment.

52 Value Enhanced Nutrition Assessment in WIC | Appendix 2

Table A2-3. Health Outcome–Based WIC Nutrition Assessment
for a Non-Breastfeeding Postpartum Woman
Desired health outcome: Achieve optimal health during the
childbearing years and reduce the risk of chronic diseases
Nutrition/
Health
Objective

Nutrition/
Health
Determinant
Category

Nutrition/Health Determinants
Examples of
Potential WIC
Nutrition Risks/
Needs*

Examples
of Protective
Factors*
• Eats a variety of fruits
and vegetables, lean
proteins, and whole
grains
• Limits calories from
added sugars and
saturated fats and
reduces sodium intake
• Practices food safety
behaviors

Competent
Professional
Authority’s (CPA’s)
Role†

Consume a
variety of foods
to meet energy
and nutrient
requirements,
and remain free
from foodborne
illnesses

Dietary Intake/
Nutrition
Practices

• Consumes a
diet very low in
calories and/
or essential
nutrients
• Consumes
sugary
beverages in
excess
• Ingests foods
that could be
contaminated
with pathogenic
microorganisms

Receive ongoing
health care,
including early
postpartum care

Health/Dental
Care

• Lack of adequate • Attends postpartum
postpartum care
visits to a health care
provider
• Lack of medical
• Enrolled in a health
or dental home
insurance plan
• Receives regular oral
health care

• Assess barriers to
obtaining care
• Ask about dental status
and treatment already in
progress
• Assess level of access to
follow-up medical care

Achieve a
desirable
postpartum
weight or body
mass index (BMI)

Weight/
Height Status
(Anthropometric)

• Overweight
• Underweight
• Low maternal
weight gain
• High maternal
weight gain
• Lack of physical
activity

• Eats a variety of
foods to meet energy
requirements
• Engage in physical
activity

• Assess possible
contributors to
weight gain/loss (e.g.,
knowledge and attitudes
regarding weight gain,
physical activity level,
appetite, stress)

Remain free
from nutritionrelated illness or
complications

Clinical/Health/
Medical

• History of
gestational
diabetes
• Elevated blood
lead levels
• Gastrointestinal
disorder
• Food allergy

• Adheres to diet
recommendations
provided by health
care provider
• Reads food labels
carefully to manage
food allergy

• Ask about potential
sources of lead exposure
• Assess special diet and
medications prescribed to
manage or treat condition
• Assess knowledge/
compliance with diet
recommendations for
medical condition

Value Enhanced Nutrition Assessment in WIC | Appendix 2 53

Table A2-3. Health Outcome–Based WIC Nutrition Assessment
for a Non-Breastfeeding Postpartum Woman (continued)
Desired health outcome: Achieve optimal health during the
childbearing years and reduce the risk of chronic diseases
Nutrition/
Health
Objective
Avoid alcohol,
tobacco,
drugs, and
other harmful
substances

Nutrition/
Health
Determinant
Category
Substance Use

Receiving proper Social Support/
environmental
Home
and family
Environment
support to thrive

Nutrition/Health Determinants
Examples of
Potential WIC
Nutrition Risks/
Needs*

Examples
of Protective
Factors*

• Alcohol and
substance use
• Nicotine and
tobacco use

• Does not smoke
• Avoids drugs other
harmful substances

• Homelessness
• Recipient of
abuse

• Has access to
adequate food
preparation and food
storage resources
• Has access to safe and
adequate water
• Lives in a supportive
and safe environment

• Limits alcohol to
recommended levels

Competent
Professional
Authority’s (CPA’s)
Role†
• Assess understanding of
the potential dangers to
herself and her infant
• Assess attitude toward
treatment/cessation
programs
• Assess awareness of
available help and
readiness to access/
accept it
• Assess food preparation
and food storage
equipment
• Assess home
environment
• Identify referral
opportunities

* The nutrition/health determinants listed are examples of some of the potential determinants that a CPA could identify
during a WIC nutrition assessment. They do not represent an exhaustive list of WIC nutrition risks or protective factors.
†
The roles listed are examples of actions that a CPA will perform during a WIC nutrition assessment. They do not
represent an exhaustive list of all the actions a CPA will take to complete a WIC nutrition assessment.

54 Value Enhanced Nutrition Assessment in WIC | Appendix 2

Table A2-4. Health Outcome–Based WIC Nutrition Assessment for an Infant
Desired health outcome: Achieve optimal growth and development
in a nurturing environment and develop a foundation for healthy eating patterns
Nutrition/
Health
Objective

Nutrition/
Health
Determinant
Category

Nutrition/Health Determinants
Examples of
Potential WIC
Nutrition Risks/
Needs*

Examples
of Protective
Factors*

Competent
Professional
Authority’s (CPA’s)
Role†
• Assess current and
potential impact on
nutritional intake,
nutritional needs, and
feeding
• Assess potential for
breastfeeding problems
• Assess cultural, medical,
and other influences on
feeding practices
• Assess developmental
skills related to feeding
• Assess potential for
foodborne illness
• Assess caregivers’
ability to mix formula
appropriately and follow
feeding recommendation
from baby’s health care
provider

Consume human Dietary Intake/
milk and/or iron- Nutrition
fortified infant
Practices
formula and
other foods as
developmentally
appropriate,
and remain free
from foodborne
illnesses

• Developmental
delays or feeding
barriers that
affect intake
• Routinely
feeding
inappropriately
diluted formula
• Routinely
offering
complementary
foods or other
substances that
are inappropriate
in type or timing
• Parent or
caregivers
routinely
using feeding
practices that
disregard the
developmental
needs or stage
of the infant
• Parent or
caregivers
routinely
using nursing
bottles or cups
inappropriately

Receive ongoing
health care,
including
screenings and
immunizations

• Inappropriate
• Attends recommended • Assess barriers to
preventive health
well-child visits and
obtaining care
care, including
receives appropriate
• Assess level of access to
screening and
immunizations
follow-up medical care
immunizations
• Lack of medical
or dental home

Health/Dental
Care

• Consumes adequate
breast milk and/or
iron-fortified infant
formula to meet
energy and nutrient
requirements
• Consumes
complimentary foods
as developmentally
appropriate
• Establishes feeding
patterns appropriate
for their age
• Uses nursing
bottles and/or cups
appropriately
• Achieves self-feeding
milestones
• Caregiver practices
infant feeding
recommendations and
is responsive to infant
feeding cues

Value Enhanced Nutrition Assessment in WIC | Appendix 2 55

Table A2-4. Health Outcome–Based WIC Nutrition Assessment for an Infant (continued)
Desired health outcome: Achieve optimal growth and development
in a nurturing environment and develop a foundation for healthy eating patterns
Nutrition/
Health
Objective
Achieve a
normal growth
pattern

Nutrition/
Health
Determinant
Category
Weight/
Height Status
(Anthropometric)

Nutrition/Health Determinants
Examples of
Potential WIC
Nutrition Risks/
Needs*
• Underweight
• High weight for
length
• Short stature/
length

Examples
of Protective
Factors*
• Consumes sufficient
calories to meet
energy and nutrient
requirements

• Low birth weight

Competent
Professional
Authority’s (CPA’s)
Role†
• Determine possible
contributors that may
affect growth
• Assess caregivers’
knowledge and attitudes
regarding development
of good eating habits,
satiety cues, and nutrition

Remain free
from nutritionrelated illness or
complications

Clinical/Health/
Medical

• Inborn error of
metabolism
• Failure to thrive
• Preterm or early
term delivery

• Attends medical
• Assess understanding
appointments for
of and compliance with
nutrition-related illness
treatment plan
• Caregiver understands • Assess current and
and complies with
potential impact on
treatment plan
nutritional intake,
nutritional needs, and
feeding
• Assess level of access to
follow-up medical care

Receive proper
environmental
and family
support to thrive

Social Support/
Home
Environment

• Homelessness
• Migrancy
• Exposure to
environmental
smoke
• A primary
caregiver with
limited ability to
make feeding
decisions and/or
prepare food

• Lives in an
environment that
is free of lead or
secondhand smoke
• Lives in a safe
environment and
establishes a trusting
relationship with the
caregivers

• Assess food preparation
and food storage
equipment
• Assess home environment

* The nutrition/health determinants listed are examples of some of the potential determinants that a CPA could identify
during a WIC nutrition assessment. They do not represent an exhaustive list of WIC nutrition risks or protective factors.
†
The roles listed are examples of actions that a CPA will perform during a WIC nutrition assessment. They do not
represent an exhaustive list of all the actions a CPA will take to complete a WIC nutrition assessment.

56 Value Enhanced Nutrition Assessment in WIC | Appendix 2

Table A2-5. Health Outcome–Based WIC Nutrition Assessment
for a Child 12–60 Months of Age
Desired health outcome: Achieve optimal growth and development in
a nurturing environment and begin to acquire dietary and lifestyle
habits associated with a lifetime of good health
Nutrition/
Health
Objective

Nutrition/
Health
Determinant
Category

Nutrition/Health Determinants
Examples of
Potential WIC
Nutrition Risks/
Needs*

Examples
of Protective
Factors*

Competent
Professional
Authority’s (CPA’s)
Role††

Consume a
variety of foods
to meet energy
and nutrient
requirements,
achieve
developmental
milestones for
self-feeding
and remain free
from foodborne
illnesses

Dietary Intake/
Nutrition
Practices

• Consumes an
inappropriate
beverage as the
primary milk
source
• High intake of
sugar-containing
beverages
• Intake of
potentially
contaminated
foods
• Routine
inappropriate
use of nursing
bottles, cups, or
pacifiers
• Inappropriate
feeding practices
for the child’s
developmental
stage/needs

Receive ongoing
health care,
including
screenings and
immunizations

Health/Dental
Care

• Inappropriate
• Attends regular
preventive health
appointments for oral
care, including
care after the age of 1
screening and
• Attends regular wellimmunizations
child visits that include
blood lead screening
• Lack of medical
and immunizations
or dental home

• Assess barriers to
obtaining care
• Ask about dental status
and treatment already in
progress
• Assess level of access to
follow-up medical care

Achieve a
normal growth
pattern

Weight/
Height Status
(Anthropometric)

• Underweight
• Overweight
• Low stature

• Determine possible
contributors that may
affect growth
• Assess caregivers’
knowledge and attitudes
regarding development
of good eating habits,
satiety cues, and nutrition

• Eats fruits and
vegetables, lean
proteins, and whole
grains
• Limits calories from
added sugars and
saturated fats and
limits sodium intake
• Consumes adequate
calories daily
• Weaned from
the bottle at an
appropriate age
• Achieves self-feeding
milestones
• Caregiver aware
of child feeding
recommendations

• Consumes sufficient
calories to meet
energy and nutrient
requirements
• Is given opportunities
for active play

• Assess current and
potential impact on
nutritional intake,
nutritional needs, and
feeding
• Assess cultural, medical,
and other influences on
feeding practices
• Assess developmental
skills related to feeding
• Assess potential for
foodborne illness
• Assess caregivers’
knowledge and attitudes
regarding development
of good eating habits,
satiety cues, and nutrition

Value Enhanced Nutrition Assessment in WIC | Appendix 2 57

Table A2-5. Health Outcome–Based WIC Nutrition Assessment
for a Child 12–60 Months of Age (continued)
Desired health outcome: Achieve optimal growth and development in
a nurturing environment and begin to acquire dietary and lifestyle
habits associated with a lifetime of good health
Nutrition/
Health
Objective

Nutrition/
Health
Determinant
Category

Nutrition/Health Determinants
Examples of
Potential WIC
Nutrition Risks/
Needs*

Examples
of Protective
Factors*

Competent
Professional
Authority’s (CPA’s)
Role†

Remain free
from nutritionrelated illness or
complications

Clinical/Health/
Medical

• Low hematocrit/
low hemoglobin
• Elevated lead
levels
• Recent surgery
or trauma

• Attends medical
• Assess understanding
or dental visits for
of and compliance with
nutrition-related illness
treatment plan
• Caregiver understands • Assess current and
and complies with
potential impact on
treatment plan
nutritional intake,
nutritional needs, and
feeding
• Assess level of access to
follow-up medical care

Receive proper
environmental
and family
support to thrive

Social Support/
Home
Environment

• Homelessness
• Recipient of
abuse
• Exposure to
environmental
smoke

• Lives in an
environment that
is free of lead or
secondhand smoke
• Lives in a safe
environment and
establishes a trusting
relationship with the
caregiver

• Assess food preparation
and food storage
equipment
• Assess home
environment

* The nutrition/health determinants listed are examples of some of the potential determinants that a CPA could identify
during a WIC nutrition assessment. They do not represent an exhaustive list of WIC nutrition risks or protective factors.
†
The roles listed are examples of actions that a CPA will perform during a WIC nutrition assessment. They do not
represent an exhaustive list of all the actions a CPA will take to complete a WIC nutrition assessment.

58 Value Enhanced Nutrition Assessment in WIC | Appendix 2

Appendix 3. Crosswalk of Health Objectives
and WIC Nutrition Risks
The purpose of this appendix is to list the WIC
nutrition risks that correspond to the health

objectives within the framework of a health
outcome–based assessment.

Table A3-1. Crosswalk for a Pregnant Woman
Consume a diet to meet energy and nutrient requirements
and remain free from foodborne illnesses
• Failure to Meet Dietary Guidelines for Americans
• Inappropriate Nutrition Practices for Women:
- Consuming dietary supplements with potentially harmful consequences
- Consuming a diet very low in calories and/or essential nutrients; or impaired caloric intake
or absorption of essential nutrients following bariatric surgery
- Compulsively ingesting non-food items (pica)
- Inadequate vitamin/mineral supplementation recognized as essential by national public health policy
- Pregnant woman ingesting foods that could be contaminated with pathogenic microorganisms

Receive ongoing preventative health care including prenatal care
• Lack of Adequate Prenatal Care

Achieve a recommended maternal weight gain
•
•
•
•

Underweight (Women)
Overweight (Women)
Low Maternal Weight Gain
High Maternal Weight Gain

Remain free from nutrition-related illness or complications
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•

Low Hemoglobin/Low Hematocrit
Elevated Blood Lead Levels
Hyperemesis Gravidarum
Gestational Diabetes
History of Gestational Diabetes
History of Preeclampsia
History of Preterm or Early Term Delivery
History of Low Birth Weight
History of Spontaneous Abortion, Fetal or Neonatal Loss
Pregnancy at a Young Age
Short Interpregnancy Interval
Multi-fetal Gestation
Fetal Growth Restriction
History of Birth of a Large for Gestational Age Infant
Pregnant Woman Currently Breastfeeding
History of Birth with Nutrition-Related Congenital
or Birth Defect
• Nutrition Deficiency Diseases
• Gastrointestinal Disorders
• Thyroid Disorders

•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•

Hypertension and Prehypertension
Renal Disease
Cancer
Central Nervous System Disorders
Genetic and Congenital Disorders
Inborn Errors of Metabolism
Infectious Diseases (Acute and Chronic)
Food Allergies
Celiac Disease
Lactose Intolerance
Hypoglycemia
Drug Nutrient Interactions
Eating Disorders
Recent Major Surgery, Physical Trauma, Burns
Other Medical Conditions
Depression
Developmental, Sensory or Motor Disabilities
Interfering with the Ability to Eat
• Oral Health Conditions
• Fetal Alcohol Spectrum Disorder

Value Enhanced Nutrition Assessment in WIC | Appendix 3 59

Table A3-1. Crosswalk for a Pregnant Woman (continued)
Avoid alcohol, tobacco, and drugs, and other harmful substances
• Nicotine and Tobacco Use
• Alcohol and Substance Use

Make an informed decision about breastfeeding
• Breastfeeding Mother of Infant at Nutritional Risk

Achieve a recommended maternal weight gain
•
•
•
•
•

Presumptive Eligibility for Pregnant Women
Homelessness
Migrancy
Recipient of Abuse
Woman or Infant/Child of Primary Caregiver with Limited Ability to Make Feeding Decisions
and/or Prepare Food
• Foster Care
• Environmental Tobacco Smoke Exposure

60 Value Enhanced Nutrition Assessment in WIC | Appendix 3

Table A3-2. Crosswalk for a Breastfeeding Woman
Consume a diet to meet energy and nutrient
requirements and remain free from foodborne illnesses
• Failure to Meet Dietary Guidelines for Americans
• Inappropriate Nutrition Practices for Women:
- Consuming dietary supplements with potentially harmful consequences
- Consuming a diet very low in calories and/or essential nutrients; or impaired caloric intake
or absorption of essential nutrients following bariatric surgery
- Compulsively ingesting non-food items (pica)
- Inadequate vitamin/mineral supplementation recognized as essential by national public health policy

Achieve a desirable postpartum weight or body mass index (BMI)
• Underweight (Women)
• Overweight (Women)
• High Maternal Weight Gain

Remain free from nutrition-related illness or complications
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•

Low Hemoglobin/Low Hematocrit
Elevated Blood Lead Levels
History of Gestational Diabetes
History of Preeclampsia
History of Preterm or Early Term Delivery
History of Low Birth Weight
History of Spontaneous Abortion, Fetal
or Neonatal Loss
Pregnancy at a Young Age
Short Interpregnancy Interval
Multi-fetal Gestation
History of Birth of a Large for Gestational Age Infant
History of Birth with Nutrition-Related Congenital
or Birth Defect
Nutrition Deficiency Diseases
Gastrointestinal Disorders
Diabetes Mellitus
Thyroid Disorders
Hypertension and Prehypertension
Renal Disease

•
•
•
•
•
•
•
•
•
•
•
•
•
•
•

Cancer
Central Nervous System Disorders
Genetic and Congenital Disorders
Inborn Errors of Metabolism
Infectious Diseases (Acute and Chronic)
Food Allergies
Celiac Disease
Lactose Intolerance
Hypoglycemia
Drug Nutrient Interactions
Eating Disorders
Recent Major Surgery, Physical Trauma, Burns
Other Medical Conditions
Depression
Developmental, Sensory or Motor Disabilities
Interfering with the Ability to Eat
• Pre-Diabetes
• Oral Health Conditions
• Fetal Alcohol Spectrum Disorder

Avoid alcohol, tobacco, and drugs, and other harmful substances
• Nicotine and Tobacco Use
• Alcohol and Substance Use

Value Enhanced Nutrition Assessment in WIC | Appendix 3 61

Table A3-2. Crosswalk for a Breastfeeding Woman (continued)
Breastfeeds her infant(s) successfully
• Breastfeeding Mother of Infant at Nutritional Risk
• Breastfeeding Complications or Potential Complications (Women)

Receive proper environmental and family support to thrive
•
•
•
•
•

Possibility of Regression
Homelessness
Migrancy
Recipient of Abuse
Woman or Infant/Child of Primary Caregiver with Limited Ability to Make Feeding Decisions
and/or Prepare Food
• Foster Care
• Environmental Tobacco Smoke Exposure

62 Value Enhanced Nutrition Assessment in WIC | Appendix 3

Table A3-3. Crosswalk for a Non-Breastfeeding Postpartum Woman
Consume a diet to meet energy and nutrient
requirements and remain free from foodborne illnesses
• Failure to Meet Dietary Guidelines for Americans
• Inappropriate Nutrition Practices for Women:
- Consuming dietary supplements with potentially harmful consequences
- Consuming a diet very low in calories and/or essential nutrients; or impaired caloric intake
or absorption of essential nutrients following bariatric surgery
- Compulsively ingesting non-food items (pica)
- Inadequate vitamin/mineral supplementation recognized as essential by national public health policy

Achieve a desirable postpartum weight or body mass index (BMI)
• Underweight (Women)
• Overweight (Women)
• High Maternal Weight Gain

Remain free from nutrition-related illness or complications
•
•
•
•
•
•
•

Short Interpregnancy Interval
Multi-fetal Gestation
History of Birth of a Large for Gestational Age Infant
History of Birth with Nutrition-Related Congenital or
Birth Defect
Nutrition Deficiency Diseases
Gastrointestinal Disorders
Diabetes Mellitus
Thyroid Disorders
Hypertension and Prehypertension

• Renal Disease

•
•
•
•
•
•
•
•
•
•
•
•
•
•
•

Avoid alcohol, tobacco, and drugs, and other harmful substances
• Nicotine and Tobacco Use
• Alcohol and Substance Use

Value Enhanced Nutrition Assessment in WIC | Appendix 3 63

Table A3-3. Crosswalk for a Non-Breastfeeding Postpartum Woman (continued)
Receive proper environmental and family support to thrive
•
•
•
•
•

64 Value Enhanced Nutrition Assessment in WIC | Appendix 3

Table A3-4. Crosswalk for an Infant
Consume human milk and/or iron-fortified infant formula and other
foods as developmentally appropriate, and remain free from foodborne illnesses
• Inappropriate Nutrition Practices for Infants:
- Routinely using a substitute(s) for breast milk or for Food and Drug Administration-approved iron-fortified
formula as the primary nutrient source during the first year of life
- Routinely using nursing bottles or cups improperly
- Routinely offering complementary foods or other substances that are inappropriate in type or timing
- Routinely using feeding practices that disregard the developmental needs or stage of the infant
- Feeding foods to an infant that could be contaminated with harmful microorganisms or toxins
- Routinely feeding inappropriately diluted formula
- Routinely limiting the frequency of nursing of the exclusively breastfed infant when breast milk is
the sole source of nutrients
- Routinely feeding a diet very low in calories and/or essential nutrients
- Routinely using inappropriate sanitation in preparation, handling, and storage of expressed breastmilk
or formula
- Feeding dietary supplements with potentially harmful consequences
- Routinely not providing dietary supplements recognized as essential by national public health
policy when an infant’s diet alone cannot meet nutrient requirements
• Dietary Risk Associated with Complementary Feeding Practices
• Breastfeeding Complications or Potential Complications (Infant)
• Breastfeeding Infant of a Woman at Nutritional Risk

Achieve a normal growth pattern
•
•
•
•
•

Underweight or At Risk of Underweight (Infants and Children)
Overweight or At Risk of Overweight (Infants and Children)
High Weight-for-Length (Infants and Children <24 Months of Age)
Short Stature or At Risk of Short Stature (Infants and Children)
Slowed/Faltering Growth Pattern

Remain free from nutrition-related illness or complications
•
•
•
•
•
•
•

Low Hemoglobin/Low Hematocrit
Elevated Blood Lead Levels
Failure to Thrive
Low Birth Weight and Very Low Birth Weight
Preterm or Early Term Delivery
Small for Gestational Age
Low Head Circumference (Infants and Children
<24 Months of Age)
• Large for Gestational Age
• Nutrition Deficiency Diseases
• Gastrointestinal Disorders

•
•
•
•
•
•
•
•
•
•

Inborn Errors of Metabolism
Infectious Diseases (Acute and Chronic)
Food Allergies
Celiac Disease
Lactose Intolerance
Hypoglycemia
Drug Nutrient Interactions
Recent Major Surgery, Physical Trauma, Burns
Other Medical Conditions
Developmental, Sensory or Motor Disabilities
Interfering with the Ability to Eat

•
•
•
•
•
•
•

•
•
•
•

Oral Health Conditions
Fetal Alcohol Spectrum Disorders
Neonatal Abstinence Syndrome
Infant up to 6 Months Old of WIC Mother of or a
Woman Who Would Have Been Eligible During
Pregnancy

Diabetes Mellitus
Thyroid Disorders
Hypertension and Prehypertension
Renal Disease
Cancer
Central Nervous System Disorders
Genetic and Congenital Disorders

Value Enhanced Nutrition Assessment in WIC | Appendix 3 65

Table A3-4. Crosswalk for an Infant (continued)
Receive proper environmental and family support to thrive
•
•
•
•
•

66 Value Enhanced Nutrition Assessment in WIC | Appendix 3

Table A3-5. Crosswalk for a Child 12-60 Months of Age
Consume a variety of foods to meet energy and nutrient requirements
as developmentally appropriate, and remain free from foodborne illnesses
• Failure to Meet Dietary Guidelines for Americans (only for children after 24 months)
• Inappropriate Nutrition Practices for Children:
-

Routinely feeding inappropriate beverages as the primary milk source
Routinely feeding a child any sugar-containing fluids
Routinely using nursing bottles, cups, or pacifiers improperly
Routinely using feeding practices that disregard the development needs or stage of the child
Feeding foods to a child that could be contaminated with harmful microorganisms
Routinely feeding a diet very low in calories and/or essential nutrients
Feeding dietary supplements with potentially harmful consequences
Routinely not providing dietary supplements recognized as essential by national public health policy
when a child’s diet alone cannot meet nutrient requirements
- Routine ingestion of non-food items (pica)
• Dietary Risk Associated with Complementary Feeding Practices

Achieve a normal growth pattern
•
•
•
•
•
•
•

Underweight or At Risk of Underweight (Infants and Children)
Obese (Children 2-5 years of Age)
Overweight or At Risk of Overweight (Infants and Children)
High Weight-for-Length (Infants and Children <24 Months of Age)
Short Stature or At Risk of Short Stature (Infants and Children)
Low Birth Weight and Very Low Birth Weight (Children <24 Months of Age)
Preterm or Early Term Delivery (Children <24 Months of Age)

Remain free from nutrition-related illness or complications
•
•
•
•
•
•
•
•
•
•
•
•
•
•

Low Hemoglobin/Low Hematocrit
Elevated Blood Lead Levels
Failure to Thrive
Small for Gestational Age
Low Head Circumference (Infants and Children
<24 Months of Age)
Nutrition Deficiency Diseases
Gastrointestinal Disorders
Diabetes Mellitus
Thyroid Disorders
Hypertension and Prehypertension
Renal Disease
Cancer
Central Nervous System Disorders
Genetic and Congenital Disorders

•
•
•
•
•
•
•
•
•
•

Value Enhanced Nutrition Assessment in WIC | Appendix 3 67

Table A3-5. Crosswalk for a Child 12-60 Months of Age (continued)
Receive proper environmental and family support to thrive
•
•
•
•
•

68 Value Enhanced Nutrition Assessment in WIC | Appendix 3

Appendix 4. Essential Staff Competency
for WIC Nutrition Assessment
The following tables represent samples of
knowledge required and performance expected
for each competency. These tables can help guide
State agencies in developing VENA staff training.

Competency Statement: Understanding of
normal nutritional needs for pregnancy, lactation,
the postpartum period, infancy, and early
childhood.

Table A4-1. Competency Area 1—Principles of Life Cycle Nutrition
Competency Statement: Understanding of normal nutritional needs for pregnancy, lactation, the
postpartum period, infancy, and early childhood.

Knowledge Required

Performance Expected

Nutrition requirements and dietary recommendations
for the women, infants, and children WIC serves.

• Analyzing health and nutrition information based on life
cycle stage.
• Evaluating the impact of the parent/feeding dynamics
on nutritional status, growth, and development.

Federal nutrition policy guidance and what it means for
women, infants, and children.

• Interpreting and comparing dietary practices of
participants with federal policy guidance.
• Differentiating between protective and harmful
nutrition practices.

Relevant, evidence-based recommendations published
by reputable sources.

• Comparing participant dietary practices with evidencebased recommendations.

Basic physical and practical elements of breast milk
production (lactation) and breastfeeding and evidencebased techniques for managing lactation, including
potential difficulties.

• Applying knowledge of the human body in assessing
breastfeeding problems.
• Completing breastfeeding assessments at critical
points in the early postpartum period according to
State agency policies.

Value Enhanced Nutrition Assessment in WIC | Appendix 4 69

Table A4-2. Competency Area 2—The VENA Approach to WIC Nutrition Assessment
Competency Statement: Understanding of the WIC nutrition assessment process.

Knowledge Required

Performance Expected

Purpose and process of a WIC nutrition assessment.

• Providing individualized nutrition assessment.
• Obtaining and synthesizing relevant assessment
information.
• Using nutrition assessment information to identify WIC
nutrition risk and provide subsequent nutrition services.
• Using systematic processes according to State agency
policies.

WIC nutrition risk criteria.

• Applying risk definitions correctly and using
appropriate cutoff values when assigning
nutrition risks.

Process for documenting WIC nutrition assessment
results.

• Documenting relevant information appropriately
according to State agency policy.
• Using information documented during previous
appointments to provide follow-up and continuity
of care.

Table A4-3. Competency Area 3—Anthropometric and Hematological
Data Collection Techniques
Competency Statement: Understanding of the importance of precise and valid data as well as the
methodology for collecting anthropometric and hematological data.

Knowledge Required

Performance Expected

Relevance of anthropometric data to health and
nutrition status.

• Demonstrating appropriate anthropometric
measurement techniques.
• Reading and recording measurements accurately.
• Interpreting growth data and prenatal weight
gain correctly.

Relationship of hematological parameters to health
and nutrition status.

• Demonstrating appropriate techniques for performing
a hemoglobin or hematocrit assessment according to
State agency policies.
• Evaluating blood work results according to State
agency policy.

70 Value Enhanced Nutrition Assessment in WIC | Appendix 4

Table A4-4. Competency Area 4—Communication
Competency Statement: Knowledge of how to communicate effectively with participants and foster
open communication.

Knowledge Required

Performance Expected

The principles of effective communication for collecting
WIC nutrition assessment information.

• Using appropriate techniques to establish a relationship
and begin a conversation.
• Practicing active listening.
• Collecting information without bias or prejudicing a
participant’s response.
• Avoiding jargon unfamiliar to the participant.
• Adapting word choice, rate of speech, and
communication mannerisms to be more like those of
the participant.
• Confirming accuracy of understanding by paraphrasing
or reflecting what was heard.
• Comparing participant’s verbal responses to nonverbal
indicators to assess participant’s attitude and feelings.
• Using open-ended and closed-ended questions
appropriately.
• Ensuring adequacy of understanding before providing
nutrition services.
• Selecting self-administered information-gathering tools
that are appropriate according to State agency policy.

Table A4-5. Competency Area 5—Multicultural Intelligence/Awareness
Competency Statement: Understanding of how sociocultural issues (race, ethnicity, religion, group
affiliation, socioeconomic status, and worldview) affect nutrition and health practices and nutrition-related
health problems.

Knowledge Required

Performance Expected

Cultural groups in the target population.

• Respecting different belief systems.
• Assessing cultural practices for protective or potential
harm to the participant’s health or nutrition status.

Cultural eating patterns.

• Asking about cultural foods and recognizing their
nutrient contributions in assessment of eating patterns.
• Evaluating food

Culturally based communication differences.

• Using culturally appropriate communication styles
to collect WIC nutrition assessment information.
• Using interpretation and/or translation services
appropriately.

Value Enhanced Nutrition Assessment in WIC | Appendix 4 71

Table A4-6. Competency Area 6—Critical Thinking
Competency Statement: Knowledge of how to synthesize and analyze information to draw
appropriate conclusions.

Knowledge Required
Principles of critical thinking.

Performance Expected
• Collecting adequate relevant information before
drawing a conclusion and guiding further nutrition
services.
• Clarifying information and verifying accuracy of
understanding as needed.
• Recognizing protective and harmful behavioral factors.
• Recognizing irrelevant information and disregarding it.
• Considering the participant’s perspectives and opinions
about nutrition and health behaviors.
• Identifying causal relationships between behaviors
and health.
• Verifying the accuracy of inconsistent or unusual
measurements and referral data.
• Prioritizing nutrition services based on synthesis of
assessment information and participant’s interests,
needs, and desires.

72 Value Enhanced Nutrition Assessment in WIC | Appendix 4

Appendix 5. Sample Springboard Assessment
Questions and Probing Questions for Nutrition/
Health Objectives
The following tables are examples of springboard
assessment questions a CPA might ask a
participant in order to elucidate all the nutrition/
health objectives related to the participant’s

health outcome. This is not an exhaustive list of
springboard assessment questions or probing
questions.

Table A5-1. Health Outcome–Based Springboard Questions
for a Pregnant Woman
Desired health outcome: Delivery of a healthy full-term
infant while maintaining the mother’s optimal health status
Nutrition/Health Objectives

Examples of Springboard
Assessment Question

Examples of Probing
Questions

Consuming a variety of foods
to meet energy and nutrient
requirements and remain free from
foodborne illnesses

Tell me what you eat in a typical day.

• Are there any foods you avoid
or dislike?
• How many meals and snacks do
you eat in a day?
• What are some foods you eat that
are related to your culture?
• Do you have safe water and
refrigeration at home?

Receiving ongoing health care,
including prenatal care.

Are you going to all of your prenatal
appointments?

• Are you having trouble getting a
doctor’s appointment?

Achieving the recommended
weight gain.

How do you feel about your weight
gain during this pregnancy?

• How much weight did your doctor
tell you to gain?
• How much did you gain with your
last pregnancy?
• How often do you go on walks or
work out?

Remain free from nutrition-related
illness or complications.

Tell me about any concerns or
• Do you take any medications?
problems you are having with this
• Are you on a special diet?
pregnancy. Do you have any medical
• Do you receive treatments for any
conditions?
medical condition?

Avoid alcohol, tobacco, and drugs.

Is there anything you feel you should • Do you use nicotine products?
do less of in order to have a healthy • Do you drink alcohol?
pregnancy?
• Does anyone living with you use
nicotine products?

Value Enhanced Nutrition Assessment in WIC | Appendix 5 73

Table A5-1. Health Outcome–Based Springboard Questions
for a Pregnant Woman (continued)
Desired health outcome: Delivery of a healthy full-term
infant while maintaining the mother’s optimal health status
Nutrition/Health Objectives

Examples of Springboard
Assessment Question

Examples of Probing
Questions

Make an informed decision about
breastfeeding.

What have you heard about
breastfeeding?

• Would you like to know more about
breastfeeding?
• Tell me about previous experience
with breastfeeding?
• What are your mom/partner/
friends telling you about how to
feed your baby?

Receive proper environmental and
family support to thrive.

Tell me about who is available to
help you during your pregnancy and
with the new baby.

• Do you feel supported by your
partner/parent/relative?
• Do they have experience with a
newborn?

74 Value Enhanced Nutrition Assessment in WIC | Appendix 5

Table A5-2. Health Outcome–Based Springboard Questions
for a Breastfeeding Woman
Desired health outcome: Achieving optimal health
during the childbearing years and reducing the risk of chronic diseases
Nutrition/Health Objectives

Examples of Springboard
Assessment Question

Examples of Probing
Questions

Consume a variety of foods to meet
energy and nutrient requirements
and remain free from foodborne
illnesses.

Tell me about the foods you typically • Do you feel like you’re eating
enough?
eat over the course of a week.
• Do you drink/eat raw or
unpasteurized milk/dairy products?
• Has your diet affected your milk
supply?
• Do you drink plenty of fluids?

Receive ongoing health care,
including early postpartum care.

Have you been attending or have
you scheduled your postpartum
check-up?

• Have you had any trouble getting
an appointment?

Achieve a desirable postpartum
weight or body mass index (BMI).

How do you feel about your weight?

• How often do you go on walks or
work out?
• Are you losing weight according to
your doctor’s recommendation?
• What do you think is your ideal
weight?

Remain free from nutrition-related
illness or complications.

Do you see a doctor for a medical
condition?

• Do you use nicotine products?
• Do you drink alcohol?
• Does anyone living with you use
nicotine products?

Avoid alcohol, tobacco, and drugs.

Breastfeed her infant(s) successfully.

How’s breastfeeding going?

• What questions or concerns do you
have about breastfeeding?
• What do your partner and family
members say about

Receive proper environmental and
family support to thrive.

Tell me about who is helping you
with breastfeeding or caring for
your baby.

• How do you feel your partner
has been able to support your
breastfeeding efforts?
• If you have returned to work*, is
there a clean and safe place for you
to pump and store your milk?

* These sample questions use “if you have returned to work.” In practice, it is more participant-centered to ask the
postpartum woman participant whether she has returned to work and then use probing questions to further investigate
her feelings and circumstances.
Value Enhanced Nutrition Assessment in WIC | Appendix 5 75

Table A5-3. Health Outcome–Based Springboard Questions
for a Non-Breastfeeding Postpartum Woman
Desired health outcome: Achieving optimal health during
the childbearing years and reducing the risk of chronic diseases
Nutrition/Health Objectives

Examples of Springboard
Assessment Question

Examples of Probing
Questions

Consume a variety of foods to meet
energy and nutrient requirements
and remain free from foodborne
illnesses.

What are some of your favorite
foods?

• Do you eat foods from all of the
food groups?
• Do you like to cook/prepare
family meals?

Receive ongoing health care,
including early postpartum care.

What did your doctor tell you during
your postpartum visit?

• Do you understand what your
doctor told you?
• Did your doctor prescribe you any
medications?

Achieve a desirable postpartum
weight or body mass index (BMI).

How do you feel about your weight
currently?

• Do you feel like you are losing
weight at an appropriate rate?
• Has your doctor said anything
about losing weight after a baby?

Remaining free from nutritionrelated illness or complications.

Have you been diagnosed with any
medical condition/disease?

• Do you feel like you are
properly managing your medical
complications*?

Avoid alcohol, tobacco, drugs, and
other harmful substances.

What, if any, concerns do you have
about alcohol, tobacco, or drugs for
yourself or others around you and
the baby?

• Is there anyone at home who is
using nicotine products?
• Are you aware of what is in
secondhand smoke?

Receive proper environmental and
family support to thrive.

Who is available if you need help?

• If you have returned to work†, do
you feel like your work environment
is supportive?
• Do you feel supported by those
at home?

* These sample questions use “medical complications.” In practice, it is more participant-centered to use the participant’s
medical history and say the medical complication by name (e.g., diabetes, hypertension).
†
These sample questions use “if you have returned to work.” In practice, it is more participant-centered to ask the
postpartum woman participant whether she has returned to work and then use probing questions to further investigate
her feelings and circumstances.

76 Value Enhanced Nutrition Assessment in WIC | Appendix 5

Table A5-4. Health Outcome–Based Springboard Questions for an Infant
Desired health outcome: Achieving optimal health during
the childbearing years and reducing the risk of chronic diseases
Nutrition/Health Objectives

Examples of Springboard
Assessment Question

Examples of Probing
Questions

Consume human milk and/or
iron-fortified infant formula and
other foods as developmentally
appropriate and remain free from
foodborne illnesses.

How does your baby* act when he
or she is hungry?

• What is your baby eating?
• How often is your baby nursing/
drinking a bottle?
• If formula fed, how do you mix
formula?
• What are your thoughts about when
to give your baby solids?
• Has your doctor prescribed
vitamins/minerals for your baby?

Receive ongoing health care,
including screenings and
immunizations.

• Is your baby up to date on his/her
What has your baby’s doctor told
immunizations?
you during the well-baby check-ups?
• Are you able to make all of your
baby’s doctor’s appointments?

Achieve a normal growth pattern.

How do you feel about your baby’s
weight and growth?

• Do you feel that your baby is
getting enough to eat?
• What does the doctor say about
your baby’s growth

Remaining free from nutritionrelated illness or complications.

Does your baby have any medical
conditions?

• Does your baby have any medical
conditions that make it hard for
him/her to eat?
• Is your baby on any medications?
• Is your baby able to perform the
appropriate milestone†?

Receiving proper environmental and
family support to thrive.

Who helps you care for your baby?

• Tell me about where your baby
sleeps.
• Does anyone at home smoke?

* These sample questions use “your baby.” In practice, it is more participant-centered to use the infant’s name when
speaking with the parent/caregiver.
†
This sample question uses “appropriate milestone.” In practice, the CPA would know the age of the baby and the
corresponding milestone to inquire about. For example, if the participant is 9 months old, it would be appropriate to
ask whether the baby is picking up cereal O’s with its thumb and index finger.
Value Enhanced Nutrition Assessment in WIC | Appendix 5 77

Table A5-5. Health Outcome–Based Springboard Questions
for a Child 12–60 Months of Age
Desired health outcome: Achieving optimal growth and development
in a nurturing environment and beginning to form dietary and
lifestyle habits associated with a lifetime of good health
Nutrition/Health Objectives

Examples of Springboard
Assessment Question

Consume a variety of foods to meet Tell me about feeding times with
energy and nutrient requirements,
your child.*
achieve developmental milestones
for self-feeding and remain free from
foodborne illnesses

Examples of Probing
Questions
• Do you feel that your child eats a
variety of food?
• Is there anything that your child
refuses to eat?
• Describe mealtime at your house.
• How often does your family eat
out?

Receive ongoing preventive health
care, including screenings and
immunizations.

What has your child’s doctor
told you?

• Are you able to make all of your
child’s doctor’s appointments?
• Has your child been screened for
blood lead?
• Is your child on any medications?

Achieve a normal growth pattern.

How do you feel about your child’s
growth?

• What does your child’s doctor say
about his/her growth?
• What kind of play activities does
your child enjoy?

Remain free from nutrition-related
illness or complications.

Does your child have any medical
conditions?

• Does your child see a doctor
for anything other than a wellchild visit?
• Is your child on any special diet?
• Does your child have any cavities
or fillings?

Achieve developmental milestones.

Tell me something your child has
recently learned to do on his/her
own.

• Is your child able to perform the
appropriate milestone†?

Who helps you care for your child?

• Does your child have a safe place
to play?
• When you’re not home, who is
feeding your child?

Receive proper environmental and
family support to thrive.

• How does your child tell you
he/she is full?

* These sample questions use “your child.” In practice, it is more participant-centered to use the child’s name when
speaking with the parent/caregiver.
†
This sample question uses “appropriate milestone.” In practice, the CPA would know the age of the baby and the
corresponding milestone to inquire about. For example, if the baby were 9 months old, it would be appropriate to ask if
he/she is picking up cereal O’s with the thumb and index finger.

78 Value Enhanced Nutrition Assessment in WIC | Appendix 5

Appendix 6. Examples of Observation Tools
Used to Evaluate VENA Practices
The following tables represent examples of
observation tools used by State agencies to
evaluate VENA practices. There are strengths and
weaknesses to each of the samples, and State

agencies are encouraged to adapt or create tools
that best match their Program operations, quality
improvement, and integrity needs.

Table A6-1. Assessing Skills with Frequency Used Rating and Examples
to Provide Feedback
On a scale of 1 to 5, indicate the extent to which the WIC staff member applied each skill.
(1 = not at all, 2 = slightly, 3 = moderately, 4 = to a good extent, 5 = to a great extent)

Skill

Score

Opened the session in an engaging way and informed the participant what to expect from
the visit.
Write examples below for giving feedback:

blank

Listened with presence and gave undivided attention to the participant.
Write examples below for giving feedback:

blank

Used reflective listening to repeat what the participant has said as a way to confirm
understanding and build a positive rapport.
blank

Write examples below for giving feedback:

Asked mostly open-ended questions rather than closed-ended questions.
Write examples below for giving feedback:

blank

Probed with questions to clarify information and gain a better understanding of the
participant’s needs.
Write examples below for giving feedback:

blank

Value Enhanced Nutrition Assessment in WIC | Appendix 6 79

Table A6-1. Assessing Skills with Frequency Used Rating and Examples
to Provide Feedback (continued)
Skill

Score

Allowed silence in session to give participant time to think and respond.
Write examples below for giving feedback:

blank

Affirmed the participant by saying things that are positive or complimentary, focusing on
strengths, abilities, or efforts.
Write examples below for giving feedback:
blank

Tailored the session to the participant’s questions and experiences.
Write examples below for giving feedback:
blank

Focused on the participant and not the computer or other forms.
Write examples below for giving feedback:
blank

Recognized and supported the participant’s culture and living situation and how that may
affect dietary and health decisions.
Write examples below for giving feedback:
blank

Source: FNS Western Region

80 Value Enhanced Nutrition Assessment in WIC | Appendix 6

Table A6-2. Assessing Skills to Determine Competency and Mentoring Needed
Needs to Be Mentored in
Specific Identified Skills

Area/Action
Invest in the Interaction
Welcome the participant and
build rapport by opening the
conversation in a warm, inviting,
genuine tone.

Assessment
Uses critical thinking skills to
gather, analyze, evaluate, and
prioritize the assessment to
appropriately assign WIC codes.

Nutrition Counseling and
Education
Offers appropriate, relevant, and
accurate counseling and advice

Support Health Outcomes
Encourage success by closing the
conversation.

Demonstrates
Competence

•
•
•
•

Greets participant by name
Introduces self
Sets the agenda
Reviews previous notes at an
inappropriate time
• Uses participant-centered
practices

• Reviews previous notes before calling
client
• Greets client by name
• Staff introduces self
• Sets the agenda in the spirit of
participant-centered services
• Affirms client

• Assessment is incomplete
• Uses ABCDE (anthropometric,
biochemical, breastfeeding,
clinical, dietary, and
environmental), misses key
areas in a section
• Introduces “Getting to the Heart
of the Matter” tool, but does not
connect it to the assessment
• Asks the client relevant closedended questions
• Actively listens to client
• Asks probing questions
• Interrupts complete assessment
process to identify WIC codes

• Uses ABCDE completely; introduces
“Getting to the Heart of the Matter”
tool appropriately
• Introduces “Getting to the Heart of
the Matter” tool at start and connects
it to the assessment
• Asks the client relevant open-ended
questions
• Asks probing questions to get
complete information
• Reflects what client is saying
• Identifies WIC codes after assessment
is complete

• Offers different topics to discuss
based on assessment and client’s
interest at appropriate times
• Offers anticipatory guidance
• Offers education in a didactic
manner

• Offers different topics to discuss based
on assessment and client’s interest at
appropriate times
• Offers anticipatory guidance
• Tailors discussion around client’s
assessed needs and interests
• Uses OARS (open-ended questions,
affirmations, reflections, summaries)
• Asks permission
• Uses consensus
• Explores and offers ideas
• Explores client’s feelings

• Asks client about next steps
• Briefly summarizes discussion

• Asks and discusses with client next
steps
• Summarizes discussion in more detail
• Affirms client
• Sets up topics for next appointment
for follow-up

Source: Arizona WIC Program

Value Enhanced Nutrition Assessment in WIC | Appendix 6 81

Table A6-3. Checklist of Skills Used During Appointment
Yes

Not applicable
(NA)

Are client concerns, knowledge, readiness for
change explored?

Was the client actively involved in the encounter?

Are nutrition education topics discussed based
on client concerns?

Is the previous nutrition education topic reviewed?

Was the encounter friendly, supportive, accommodating,
respectful, welcoming?

Was the encounter positive and based on health
outcomes not deficiencies?

Question

Is this documented?

Source: Michigan WIC Program

82 Value Enhanced Nutrition Assessment in WIC | Appendix 6

Table A6-4. Assessing Skills Using Examples
Observations:
Specific examples you
heard or observed

Skill to Listen and Watch for:
Engages the participant
• Introductions
• Sets agenda

blank

Focuses the appointment
• Completes assessment
• Listens first—before sharing
• Open-ended questions
• Affirmations
• Reflections
• Summaries
• Tracks potential topics for counseling
• Prioritizes topics to explore

blank

Evokes change talk
• Allows time for participant to talk
• Reflects change talk
• Explore—offer—explore
• Asks permission to share information with participant
• Provides nutrition-focused counseling
• Rolls with resistance
• Uses brain science strategies

Plans with the participant
• Works with the participant to develop an actionable
next step/plan
• Summarizes the next step for the participant
• Documents the plan
• Shares hope for a positive health outcome

blank

Source: Oregon WIC Program

Value Enhanced Nutrition Assessment in WIC | Appendix 6 83

November 2020

“Special Supplemental Nutrition Program for Women, Infants and Children (WIC):
Revisions in the WIC Food Packages; Final Rule.” Federal Register 79:42 (March 4,
2014) p. 12274-12300.

Vol. 79

Tuesday,

No. 42

March 4, 2014

Part II

Department of Agriculture

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Food and Nutrition Service
7 CFR Part 246
Special Supplemental Nutrition Program for Women, Infants and Children
(WIC): Revisions in the WIC Food Packages; Final Rule

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Federal Register / Vol. 79, No. 42 / Tuesday, March 4, 2014 / Rules and Regulations
FOR FURTHER INFORMATION CONTACT:

DEPARTMENT OF AGRICULTURE

Anne Bartholomew, Chief, Nutrition
Services Branch, Supplemental Food
Programs Division, Food and Nutrition
Service, USDA, 3101 Park Center Drive,
Room 522, Alexandria, Virginia 22302,
(703) 305–2746 OR
ANNE.BARTHOLOMEW@
FNS.USDA.GOV.

Food and Nutrition Service
7 CFR Part 246
[FNS–2006–0037]
RIN 0584–AD77

Special Supplemental Nutrition
Program for Women, Infants and
Children (WIC): Revisions in the WIC
Food Packages

SUPPLEMENTARY INFORMATION:

Food and Nutrition Service
(FNS), USDA.
ACTION: Final rule.
AGENCY:

This final rule considers
public comments submitted in response
to the interim rule revising the WIC food
packages published on December 6,
2007. The interim rule implemented the
first comprehensive revisions to the
WIC food packages since 1980. The
interim rule revised regulations
governing the WIC food packages to
align them more closely with updated
nutrition science and the infant feeding
practice guidelines of the American
Academy of Pediatrics, promote and
support more effectively the
establishment of successful long-term
breastfeeding, provide WIC participants
with a wider variety of food, and
provide WIC State agencies with greater
flexibility in prescribing food packages
to accommodate participants with
cultural food preferences. This rule
makes adjustments that improve clarity
of the provisions set forth in the interim
rule.
DATES: Effective Date: This rule is
effective May 5, 2014.
Implementation Dates:
• State agencies must implement the
provision in Table 2 at 7 CFR
246.10(e)(10) increasing the cash-value
voucher for children to $8 per month no
later than June 2, 2014.
• The provision found at 7 CFR
246.12(f)(4) requiring split tender for
cash-value vouchers shall be
implemented no earlier than October 1,
2014 and no later than April 1, 2015.
• Footnote 11 of Table 2 at 7 CFR
246.10(e)(10) shall be implemented on
the later of October 1, 2014, or the date
on which the State agency exercises
their option to issue authorized soybased beverage or tofu to children who
receive Food Package IV.
• The provisions in Footnote 10 of
Table 2 at 7 CFR 246.10(e)(10) and
Footnote 12 of Table 3 at 7 CFR
246.10(e)(11) authorizing yogurt for
children and women in Food Packages
III–VII may be implemented no earlier
than April 1, 2015.

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SUMMARY:

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I. Overview
This final rule addresses public
comments submitted in response to the
interim rule revising the WIC food
packages published on December 6,
2007 (72 FR 68966), and makes
adjustments that improve clarity of the
provisions set forth in the interim rule.
II. Background
An interim rule revising the WIC food
packages was published in the Federal
Register on December 6, 2007 (72 FR
68966). The interim rule implemented
the first comprehensive revisions to the
WIC food packages since 1980 and
largely reflected recommendations made
by the National Academies’ Institute of
Medicine (IOM) in its Report ‘‘WIC
Food Packages: Time for a Change’’
(‘‘Report’’).1 The interim rule aligned
the food packages more closely with
updated nutrition science, promoted
and supported more effectively the
establishment of successful long-term
breastfeeding, provided WIC
participants with a wider variety of
food, and provided WIC State agencies
with greater flexibility in prescribing
food packages to accommodate
participants with cultural food
preferences. WIC State agencies were
required to implement the changes by
October 1, 2009.
III. General Summary of Comments
Received on the Interim Rule To Revise
the WIC Food Packages
The interim rule revising the WIC
food packages provided an extensive
public comment period to obtain
comments on the impact of the changes
experienced during implementation of
the new food packages. The interim rule
comment period ended February 1,
2010.
A total of 7,764 comment letters were
received on the interim rule; of those,
111 were form letters. A total of 6,664
of the letters were from program
participants, and included comments
submitted in Spanish, Chinese, and
other languages, in addition to English.
1 Institute of Medicine, National Academy of
Sciences. ‘‘WIC Food Packages: Time for a Change,’’
2005. Available at Internet site: http://
www.fns.usda.gov/wic-food-packages-time-change.

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The remaining comment letters were
submitted from a variety of sources,
including WIC State and local agencies
and Indian Tribal Organizations, the
National WIC Association (NWA),
professional organizations and
associations, advocacy groups,
healthcare professionals (including
universities), members of Congress, the
food industry, vendors, farmers, and
private citizens.
In general, commenters expressed
broad support for the changes and
reported relatively smooth
implementation of the new WIC food
packages. Commenters also voiced
concerns about various aspects of the
interim rule and made
recommendations for clarifying or
improving specific provisions of the
interim rule. Overall, participants
expressed overwhelming support for the
revised WIC food packages, especially
the addition of whole grains and fruits
and vegetables. However, many
participants who were enrolled in WIC
during the transition from the previous
food packages to the revised food
packages expressed displeasure with
changes to fat-reduced milks and less
cheese.
FNS considered all timely comments
without regard to whether they were
provided by a single commenter or
repeated by many. Importance was
given to the substance or content of the
comment, rather than the number of
times a comment was submitted.
WIC State agencies are to be
commended for the staff and vendor
training that led to successful
implementation of the new WIC food
packages, as well as nutrition education
provided to participants on the benefits
of the new foods in the WIC food
packages. Successful implementation of
the new WIC food packages was further
enhanced by the efforts of WIC’s
partners in the advocacy, retail, and
medical communities.
IV. Discussion of the Final Rule
Provisions
The following is a discussion of the
major provisions set forth in this final
rule, a brief summary of the comments
received on the interim rule that
addressed these issues, and FNS’
rationale for either modifying or
retaining provisions in this final rule.
Provisions not addressed in the
preamble to this final rule did not
receive significant or substantial public
comments and remain unchanged.
The preamble to this final rule
articulates the basis and purpose behind
significant changes from the December
6, 2007 interim rule. The reasons
supporting provisions of the interim

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regulations were carefully examined in
light of the comments received to
determine the continued applicability of
the justifications. Unless otherwise
stated, or unless inconsistent with this
final rule or this preamble, the
rationales contained in the preamble to
the proposed and interim regulations
should be regarded as the basis for this
final rule. Therefore, a thorough
understanding of the rationales for the
interim regulations may require
reference to the preamble of the August
7, 2006 proposed rule (71 FR 44784) and
the December 6, 2007 interim rule (72
FR 68966).

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A. Definitions
The following definitions have been
added or modified in the final rule.
Farmers’ market. As described in a
subsequent section of this preamble,
this final rule adds the definition of
‘‘farmers’ markets’’ at 7 CFR 246.2.
Full nutrition benefit. As described in
a subsequent section of this preamble,
this final rule adds the definition of
‘‘full nutrition benefit’’ at 7 CFR 246.2.
WIC-eligible medical foods. Based on
review and discussion with the Food
and Drug Administration (FDA), this
final rule changes the name of the food
category ‘‘WIC-eligible medical food’’ to
‘‘WIC-eligible nutritionals,’’ but does
not substantively change this food
category. This nomenclature
modification better describes the group
of special WIC-eligible nutritional
products the WIC Program provides to
participants with qualifying conditions,
and alleviates confusion associated with
the use of the term ‘‘medical food,’’
which is defined by regulations
governing FDA and differs from the WIC
use of this term. The FNS definition for
‘‘WIC-eligible medical food’’ and the
FDA definition for ‘‘medical food’’ are
both comprehensive and detailed.
Although the definition of ‘‘WIC-eligible
medical food’’ closely aligns with the
FDA definition for ‘‘medical food,’’
there are slight differences, such that
some, but not all ‘‘WIC-eligible medical
foods’’ meet FDA’s definition of
‘‘medical food.’’ In an effort to alleviate
confusion, and distinguish between the
two product categories and definitions,
FNS is modifying the name of the food
category from ‘‘WIC-eligible medical
food’’ to ‘‘WIC-eligible nutritionals.’’
Other than the name change, the
definition for this food category put
forth in the interim rule remains
unchanged in this final rule.

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B. General Provisions That Affect All
WIC Food Packages
1. Nutrition Tailoring
Prior to the interim rule, FNS policy
allowed both categorical and individual
nutrition tailoring of WIC food
packages. Categorical nutrition tailoring
is the process of modifying the WIC
food packages for participant groups or
subgroups with similar supplemental
nutrition needs, based on scientific
nutrition rationale, public health
concerns, cultural eating patterns, and
State established policies. The interim
rule prohibits categorical nutrition
tailoring, but continues to allow
individual nutrition tailoring based on
the Competent Professional Authority’s
(CPA) assessment of a participant’s
supplemental nutrition needs.
A total of 33 commenters (of these, 8
were form letters) opposed the provision
that prohibits categorical tailoring,
stating that State agencies need the
flexibility to propose modifications to
food packages that respond to rapid
changes in food industry, science,
dietary recommendations,
demographics, and other factors.
Commenters asked that State agencies
be able to request approval for
categorical tailoring to meet nutritional
needs and preferences.
As stated in the preamble to the
interim rule, the IOM conducted a full,
independent and rigorous scientific
review of the nutritional needs of WIC
participants prior to recommending the
quantities and types of WIC foods to
address those needs in its Report. In
addition, Section 232 of Public Law
111–296 amended Section 17(f)(11)(C)
of the Child Nutrition Act of 1966, as
amended (42 U.S.C. 1786), by requiring
the Secretary to conduct, as often as
necessary, but not less than every 10
years, a scientific review of
supplemental foods available under the
program and to amend the foods, as
needed, to reflect nutrition science,
public health concerns, and cultural
eating patterns. As such, future reviews
of the WIC food packages by FNS will
be conducted as needed and used to
determine the need for modification of
current WIC food packages. FNS
believes that this is the appropriate
process for changes to the WIC food
packages and that State agencies will
best be able to meet the nutritional
needs of each WIC participant through
nutrition assessment and individual
tailoring of the food package. Therefore,
the provision to disallow State agency
proposals to categorically tailor WIC
food packages is retained in this final
rule at 7 CFR 246.10(c).

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2. Cultural Food Package Proposals
The interim rule allows State agencies
to submit to FNS a plan for substitution
of food(s) to allow for different cultural
eating patterns. The interim rule
includes criteria for submitting plans for
substitutions and the criteria FNS will
use to evaluate such plans. A total of 26
commenters (8 form letters) asked FNS
to change the criterion that ‘‘any
proposed substitute food must be
nutritionally equivalent or superior to
the food it is intended to replace’’ to be
less restrictive and easier to satisfy.
The increased variety and choice in
the supplemental foods in the interim
rule, as recommended by the IOM,
provide State agencies expanded
flexibility in prescribing culturally
appropriate packages for diverse groups.
Further, the interim rule allows State
agencies flexibility to meet
unanticipated cultural needs of
participants by submitting plans for
substitutions. The criteria are not meant
to preclude justifiable cultural
substitution proposals submitted by
WIC State agencies, but are intended to
ensure that WIC food substitutions
maintain the nutritional integrity of the
WIC foods they replace. FNS will
continue to make determinations on
proposed plans for cultural
substitutions based on existing
evaluation criteria as appropriate.
Therefore, the criteria for submitting
State agency plans for substitutions for
different cultural eating patterns and the
criteria FNS will use to evaluate such
plans are retained at 7 CFR 246.10(i).
The interim rule increased the variety
and number of substitutions available
for several WIC foods. This final rule
further increases the number of
substitutions and options available, i.e.,
yogurt, canned jack mackerel, and
whole wheat macaroni (pasta) products.
These additions are within the context
of the IOM recommendations. FNS
believes that these changes already
provide substantial flexibility for
prescribing food packages and that
further modifications of the current WIC
food packages are best determined
through future scientific reviews of the
WIC food packages. FNS will, therefore,
not accept WIC State agency plans for
substitutions of WIC foods for reasons
other than to accommodate cultural
eating patterns as provided for in 7 CFR
246.10(i).
3. Medical Documentation and
Supervision Requirements
a. Milk and Milk Alternatives
Under the interim rule, medical
documentation by a health care
professional licensed to write medical

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prescriptions is required for the
issuance of certain milk alternatives for
children and women. A total of 180
comment letters (53 of these form
letters) opposed this requirement,
primarily the documentation for
children to receive soy-based beverage.
Commenters stated that the provision is
unnecessary, costly and burdensome for
participants and physicians, creates
barriers to services, and undermines
FNS’ efforts to provide foods that meet
the cultural needs of participants. The
NWA and the American Dietetic
Association (now known as the
Academy of Nutrition and Dietetics)
stressed that WIC dietitians and
nutritionists are trained health
professionals capable of doing a
complete nutrition assessment, selecting
WIC foods, and providing appropriate
education to participants and caregivers,
in consultation with the health care
provider when warranted.
Based on the experiences cited by
WIC State and local agencies related to
medical documentation throughout
implementation of the new food
packages, FNS will no longer require a
health care professional licensed to
write medical prescriptions to provide
documentation for children to receive
soy-based beverage and tofu as milk
substitutes. Also, FNS will no longer
require documentation from a health
care professional licensed to write
medical prescriptions for women to
receive tofu in excess of the maximum
substitution allowance. Instead,
consistent with IOM recommendations
for documentation from a ‘‘WIC
recognized medical authority,’’ FNS will
allow the CPA to determine and
document the need for tofu and soybased beverage as substitutes for milk
for children, as established by State
agency policy. Such determination must
be based on individual nutritional
assessment, as required under the
interim rule and retained in this final
rule at 7 CFR 246.10(b)(2)(ii)(C), and
consultation with the participant’s
health care provider, as appropriate.
Such determination can be made for
situations that include, but are not
limited to, milk allergy, lactose
intolerance, and vegan diets. As
previously discussed, the interim rule
revised regulations governing the WIC
food packages to, among other things,
accommodate participants with cultural
food preferences. Since cultural
practices may affect nutrient intake,
FNS will allow soy for cultural practices
that prevent participants from including
in their diets cow’s milk and lactose-free
or lactose-reduced fortified dairy

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products in amounts that meet their
nutritional needs.
FNS will allow the CPA, as
established by State agency policy, to
determine the need for tofu in quantities
that exceed the maximum substitution
rates. Such determination can be made
for situations that include, but are not
limited to, milk allergy, lactose
intolerance, and vegan diets.
FNS believes that allowing the CPA to
make determinations for milk
substitutes is consistent with IOM
recommendations for documentation
from a ‘‘WIC recognized medical
authority.’’ Although FNS is no longer
requiring documentation from a health
care professional licensed to write
medical prescriptions, it is incumbent
upon WIC State agencies to ensure that
participants and caregivers receive
education that stresses the importance
of milk over milk substitutes, and that
appropriate policies and procedures are
in place for appropriate issuance of milk
substitutes. Parents and caregivers
should be made aware that children’s
diets may be nutritionally inadequate
when milk is replaced by other foods,
and provided appropriate nutrition
education. The value of milk for WIC
participants, particularly in the
development of bone mass for children,
should be emphasized. Lactose-free or
lactose-reduced fortified dairy products
should be offered before non-dairy milk
alternatives to those participants with
lactose intolerance that cannot drink
milk. Also, if milk is replaced by milk
alternatives that are not vitamin D
fortified, vitamin D intakes may be
inadequate. Thus, replacements for milk
are to be approached with caution even
if they are rich in calcium.
Therefore, Table 2 of 7 CFR
246.10(e)(10) of this final rule requires
that issuance of tofu and soy-based
beverage as substitutes for milk for
children be based on an individual
nutritional assessment by the CPA, in
consultation with the participant’s
health care provider as appropriate.
Table 2 of 7 CFR 246.10(e)(10) allows
the CPA, as established by State agency
policy, to determine the need for
women to receive tofu in excess of the
maximum substitution allowance.
b. Technical Requirements for Medical
Documentation
Under the interim rule, technical
requirements for medical
documentation were established. A total
of 51 comments opposed the provision
requiring health care providers to
prescribe the supplemental foods and
quantities appropriate for a participant’s
qualifying condition in Food Package III
(for participants with qualifying

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conditions). Commenters believe that
medical documentation, especially for
authorization of supplemental foods in
Food Package III, is burdensome to State
agencies, participants and the medical
community. Commenters stated that this
provision has little value since the foods
could otherwise be purchased by the
participants at grocery stores.
Commenters also stated that the WIC
nutritionist or registered dietitian is
capable of determining appropriate
amounts and types of supplemental
foods to issue to participants based on
a nutrition assessment of the
participant.
Due to the nature of the health
conditions of participants who are
issued supplemental foods in Food
Package III, close medical supervision is
essential for each participant’s dietary
management. FNS considers it
appropriate that the responsibility for
this close medical supervision remain
with the participant’s health care
provider. Medical documentation
requirements for specific supplemental
foods that do not usually require a
prescription were established to ensure
that the participant’s healthcare
professional has determined that the
supplemental foods are not medically
contraindicated by the participant’s
condition. Therefore, FNS retains the
technical requirements for medical
documentation for supplemental foods
in Food Package III as written in the
interim rule. However, FNS recognizes
that WIC registered dietitians and/or
qualified nutritionists play an important
role in the continuum of care of
medically fragile WIC participants.
Therefore, FNS would support State
agency policy that allows health care
providers to refer to the WIC registered
dietitian and/or qualified nutritionist for
identifying appropriate supplemental
foods (excluding WIC formula) and their
prescribed amounts, as well as the
length of time the supplemental foods
are required by the participant. This
arrangement would be supported only
in situations where the health care
provider has indicated on the medical
documentation form that the provider
acknowledges referral to the WIC
registered dietitian and/or qualified
nutritionist for such determinations.
This gives the health care provider
medical oversight while allowing the
WIC registered dietitian and/or qualified
nutritionist to determine the appropriate
issuance of WIC foods to participants
with qualifying conditions in Food
Package III.
4. Sodium Content of WIC Foods
In its Report, the IOM found that
intakes of sodium were excessive in the

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diets of WIC participants. The IOM
reported that more than 90 percent of
WIC children 2 through 4 years and of
pregnant, lactating, and nonbreastfeeding postpartum women had
usual sodium intakes above the
Tolerable Upper Intake Level (UL). More
than 60 percent of WIC children age 1
year had usual sodium intakes above the
UL. As such, the IOM recommended,
and the interim rule reflected,
reductions in the overall sodium level of
WIC food packages. The majority of WIC
foods under the interim rule may not
contain added salt (sodium).
However, options for some WIC foods,
i.e., cheese, vegetable juice, canned
vegetables, canned beans, peanut butter,
and canned fish include both regular
and lower sodium varieties. In an effort
to support participants in reducing
sodium intake, FNS provided technical
assistance to State agencies encouraging
them to offer only lower sodium
varieties of these foods when these
options exist.
FNS encourages WIC State agencies
that offer canned vegetables to allow
only lower sodium canned vegetables
and lower-sodium versions of other
WIC-eligible foods, i.e., breads, as they
become more widely available in the
marketplace. FNS encourages food
manufacturers to reduce excess sodium
in processed foods and to make a wider
variety of these foods available to help
WIC achieve its goal to safeguard the
health of children and women.
5. Organic Foods
The interim rule authorizes organic
forms of foods that meet minimum
nutrition requirements described in
Table 4 of 7 CFR 246.10(e)(12).
However, WIC State agencies are
responsible for determining the specific
brands and types of foods to authorize
on their State WIC food lists. Some State
agencies allow organic foods on their
foods lists, but this will vary by State.
The decision may be influenced by a
number of factors such as cost, product
distribution within a State, and WIC
participant acceptance.
FNS received 52 comments asking
that State agencies be required to offer
organic foods in the WIC food packages.
Many of these comments were from one
State where the WIC State agency had
recently removed organic milk from its
list of authorized WIC foods. This final
rule continues to provide State agencies
the option to offer organic forms of WICeligible foods through the regular WIC
food instrument, e.g., milk, eggs, peanut
butter, and encourages State agencies to
make available authorized foods that are
acceptable and will be consumed by
participants, including organic varieties.

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This final rule clarifies in Table 4 of 7
CFR 246.10(e)(12) that State agencies are
required to allow organic forms of fruits
and vegetables purchased with the cashvalue voucher.
C. Supplemental Foods and Food
Packages
Note: The order of some of the topics in
this section is modified from the interim rule
for the purposes of discussion.

1. Fruits and Vegetables in Food
Packages III Through VII
a. Dollar Amount of Cash-Value
Voucher
In order to maintain cost neutrality,
the interim rule published December
2007 (72 FR 68966) only provided fully
breastfeeding women with the IOM
recommended amount of $10.00 per
month fruit and vegetable cash-value
vouchers; all other women participants
were provided $8.00 per month, and
children were provided $6.00. An
amendment to the interim rule was
published in the Federal Register on
December 31, 2009 (74 FR 69243) to
provide all WIC women participants
with $10.00 per month fruit and
vegetable cash-value vouchers,
consistent with IOM’s
recommendations.
A total of 448 commenters (76 form
letters) asked FNS to increase the fruit
and vegetable cash-value voucher to the
IOM recommended level from $6 to $8
for children. The Department has
responded to commenters’ requests
under this final rule by increasing the
cash-value voucher for children to $8
per month. This increase will allow
State agencies to further efforts to
increase fruit and vegetable
consumption by children.
A total of 162 commenters (36 form
letters) asked FNS to further increase
the fruit and vegetable voucher for fully
breastfeeding women from $10 to $12 to
provide incentive for women to choose
to fully breastfeed, and to meet the
intent of the IOM to provide an
enhancement to the food packages for
fully breastfeeding women. While FNS
understands the benefit of increasing
the value of the food package for fully
breastfeeding women, it is not possible
under this rulemaking to go beyond the
dollar value for the cash-value voucher
for the fully breastfeeding package due
to cost. Therefore, the cash-value
voucher remains at $10 for all women,
including fully breastfeeding women, in
this final rule. The base year for
calculation of the value of the fruit and
vegetable voucher and the base value to
be used are updated in 7 CFR
246.16(j)(2).

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b. Clarification of Authorized Fruits and
Vegetables
To improve the consumption of fresh
fruits and vegetables and to appeal to
participants of different cultural
backgrounds, the interim rule
authorized a wide variety of choices
within the authorized fruit and
vegetable options. The interim rule
reflects the IOM recommendation to
provide a cash-value fruit and vegetable
benefit to participants with few
restrictions. The following is a
discussion of clarifications and
revisions to the interim rule pertaining
to authorized fruits and vegetables.
Technical corrections in this final rule
clarify that both fresh fruits and fresh
vegetables must be authorized by State
agencies. This final rule further clarifies
that 21 CFR 101.95 defines the term
‘‘fresh’’ when referring to eligible fresh
fruits and vegetables.
Technical corrections in this final rule
clarify that the cash-value voucher may
be redeemed for any eligible fruit and
vegetable (refer to Table 4 of 7 CFR
246.10(e)(12) and its footnotes). Except
as authorized by this final rule, State
agencies may not selectively choose
which fruits and vegetables are available
to participants. For example, if a State
agency chooses to offer dried fruits, it
must authorize all WIC-eligible dried
fruits, i.e., those without added sugars,
fats, oils, or sodium, and may not allow
only a single variety of dried fruits. This
final rule clarifies that State agencies
may, however, invoke their
administrative option at 7 CFR
246.10(b)(1)(i) to establish criteria in
addition to the minimum Federal
requirements in Table 4 of 7 CFR
246.10(e)(12), which could include
restricting packaging (such as plastic
containers) and package sizes (such as
single serving) of processed fruits and
vegetables available for purchase with
the cash-value voucher. In addition,
State agencies may identify specific
types of certain processed WIC-eligible
fruits and vegetables (e.g., salsas, tomato
sauces, stewed and diced tomatoes) on
their food lists if they believe there is
cause for significant vendor and
participant confusion in identifying
specific items within those categories
that are WIC-eligible.
A technical correction has been made
in Table 4 of 7 CFR 246.10(e)(12) to
clarify that the following products are
not allowed: Dried white potatoes,
mixed vegetables containing white
potatoes, noodles, nuts or sauce packets,
and decorative flowers and blossoms.
Canned tomato sauce and tomato paste
without added sugar, fats, oils are
authorized. Salsa and spaghetti sauce

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without added sugar, fats, and oils are
also authorized.
This final rule clarifies that the fruit
or vegetable must be listed as the first
ingredient in WIC-eligible processed
fruits and vegetables. In addition, it
clarifies that frozen fruits may not
contain added fats, oils, salt (i.e.,
sodium) or added sugars.
For the reasons described in section
IV.B.4 of this preamble, Table 4 of 7
CFR 246.10(e)(12) will be revised to
allow State agencies the option to offer
only lower sodium canned vegetables
for purchase with the cash-value
voucher.

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c. White Potatoes
The interim rule excludes the
purchase of white potatoes with the
cash-value voucher. A total of 266 (of
these, 213 were form letters) opposed
the restriction of white potatoes.
Commenters stated that white potatoes
should be included in the WIC food
packages because they are versatile,
economical, contain key nutrients, and
are preferred by participants. Thirty-two
commenters (20 form letters) stated that
the exclusion of white potatoes is
difficult to administer.
The restriction of white potatoes, as
recommended by the IOM, is based on
data indicating that consumption of
starchy vegetables meets or exceeds
recommended amounts, and food intake
data showing that white potatoes are the
most widely used vegetable. Including
white potatoes in the WIC food packages
would not contribute towards meeting
the nutritional needs of the WIC
population and would not support the
goal of expanding the types and
varieties of fruits and vegetables
available to program participants, as
recommended by the IOM. Therefore,
the provision to exclude white potatoes
from the WIC food packages is retained
in this final rule. The Department
recognizes that white potatoes can be a
healthful part of one’s diet. However,
WIC food packages are carefully
designed to address the supplemental
nutritional needs of a specific
population. Although white potatoes are
not offered in the WIC food package,
nutrition education provided to WIC
participants will continue to include
white potatoes as a healthy source of
nutrients and an important part of a
healthful diet.
d. Dried Fruit and Dried Vegetables for
Children
As recommended by the IOM, the
interim rule disallows dried fruits and
vegetables to be purchased with the
cash-value voucher for children because
of the risk of choking. FNS received a

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small number of comments asking that
dried fruits be allowed for children,
citing a lack of evidence that they pose
choking hazards for all children.
Recommendations made by IOM for the
Child and Adult Care Food Program
allow dried fruits for children as long as
they do not pose a choking hazard.2
Therefore, at the State agency’s option,
this final rule authorizes dried fruits
and dried vegetables to be purchased
with the cash-value voucher for
children. Nutrition education regarding
choking hazards, developmental
readiness, proper food preparation, and
oral health care should be provided to
caregivers of young children.
e. Standards of Identity for Canned
Fruits and Canned Vegetables
Two technical corrections have been
in made in Table 4 of 7 CFR
246.10(e)(12) related to the standards of
identity for canned fruits and canned
vegetables. This final rule corrects the
specifications for WIC-eligible canned
fruits to reflect that only those WICeligible canned fruits that have a
standard of identity, as listed at 21 CFR
Part 145, must conform to the FDA
standard of identity. Similarly, this final
rule corrects the specifications for WICeligible canned vegetables to reflect that
only those WIC-eligible canned
vegetables that have a standard of
identity, as listed at 21 CFR Part 155,
must conform to the FDA standard of
identity. The provision that WIC-eligible
canned vegetables contain no added
sugars, fats, and oils remains
unchanged. This final rule clarifies that
home-canned and home-preserved fruits
and vegetables are not authorized.
f. Implementation of Fruit and Vegetable
Options
(1) Paying the difference with the
cash-value voucher. The interim rule
authorized State agencies the option to
allow participants to pay the difference
if the fruit and vegetable purchase
exceeds the value of the cash-value
voucher, a transaction known as ‘‘split
tender.’’ A total of 116 commenters (59
form letters) asked FNS to require all
State agencies to allow split tender
transactions to ensure that participants
are able to maximize use of their cashvalue voucher. Because it may be
difficult for participants to accurately
estimate the exact purchase price of the
fruit and vegetable selections,
particularly when fresh, canned, dried,
2 Institute of Medicine, National Academy of
Sciences. ‘‘Child and Adult Care Food Program:
Aligning Dietary Guidance for All,’’ 2010. Available
at Internet site: http://www.fns.usda.gov/child-andadult-care-food-program-aligning-dietary-guidanceall.

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or frozen items are combined in one
purchase or when items are purchased
in bulk, FNS agrees that all participants
should be allowed to pay the difference
when the purchase of allowable fruits
and vegetables exceeds the value of the
fruit/vegetable cash-value voucher.
Therefore, this final rule adds a
provision at 7 CFR 246.12(f)(4) to
require State agencies to allow split
tender transactions with the cash-value
voucher.
(2) Minimum vendor stocking
requirements. A technical oversight in
the interim rule has been corrected at 7
CFR 246.12(g)(3)(i) by clarifying that
authorized vendors must stock at least
two different fruits and two different
vegetables.
(3) Authorizing farmers’ markets. The
interim rule gave State agencies the
option to allow farmers at farmers’
markets to accept cash-value vouchers.
FNS received 29 comments (mostly
form letters) recommending that
farmers’ market organizations, rather
than the individual farmer, be
authorized to accept cash-value
vouchers, as is permitted under the WIC
Farmers’ Market Nutrition Program
(FMNP). Sixty-nine commenters (mostly
form letters) additionally recommended
that the WIC Program regulations be
more closely aligned with the FMNP.
Commenters stated that consistency
between the two programs would make
FMNP participation easier both for WIC
participants and authorized farmers.
Many of the comments suggested that
State agencies be allowed to authorize
farmers’ markets in addition to the
current provision (7 CFR 246.12(v)) that
allows State agencies the flexibility to
authorize farmers at farmers’ markets or
roadside stands. FNS finds merit in
such a provision; this also would
provide more consistency between WIC
and FMNP.
Seventy-eight comments went on to
suggest that the authorization of
farmers’ markets should be a Federal
requirement, rather than a State agency
option. FNS believes that State agencies
are in the best position to determine
what works for their individual benefit
delivery systems, taking into
consideration such factors as participant
access, the availability of farmers, and
the administrative burdens of
monitoring and authorization.
Therefore, the final rule amends 7 CFR
246.12 to allow WIC State agencies to
authorize farmers or farmers’ markets to
accept WIC cash-value vouchers, but
such authorization will remain as a
State agency option. As a result of the
addition of farmers’ markets,
conforming amendments have been

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made in 7 CFR 246.2, 246.4, 246.18, and
246.23.
A number of comments were received
recommending that the Federal WIC
regulations be modified to be consistent
with the fruits and vegetables eligible
for purchase under the FMNP. FNS
makes every effort to ensure that both
programs are aligned in most areas, to
the extent possible. However, each
program has different statutory
objectives. Thus, FNS is convinced that
it is critical for each program to
maintain its separate identity. As stated
previously, FNS found merit in allowing
farmers’ markets to redeem WIC cashvalue vouchers, an example of aligning
both programs. FNS finds no need to
make any further operational changes in
this area through this final rule. A
technical amendment is added to 7 CFR
246.4(a)(14) to correct a cross-reference
to 7 CFR 246.12 that addresses the State
agency options regarding vendor
sanctions.
2. Mature Legumes (Dry Beans, Peas and
Lentils) and Peanut Butter
a. Clarification of Allowable Mature
Legumes
Technical corrections have been made
to the list of authorized mature legumes
in Table 4 of 7 CFR 246.10(e)(12).
Refried beans, without added sugars,
fats, oils, vegetables or meat, have been
added to the examples of allowable
legumes in Table 4 of 7 CFR
246.10(e)(12). The specification in Table
4 also clarifies that mature legumes
issued via the WIC food instrument may
not contain added vegetables or fruits.

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b. Issuance of Mature Legumes (Dry
Beans and Peas)
The interim rule includes mature dry
beans, peas, or lentils in dry-packaged
or canned forms as a WIC food category.
Items in this food category are issued
via the regular WIC food instrument.
FNS provided technical assistance to
State agencies on the interim rule
clarifying that beans and peas that do
not qualify under this category may be
purchased only with the cash-value
voucher. A total of 23 commenters (8 of
which were form letters) asked FNS to
allow all mature varieties and forms of
dry beans and peas to be purchased
with both the cash-value voucher and
the WIC food instrument to eliminate
confusion on the part of participants
and vendors.
The nutritional profile of mature dry
legumes is different than that for
immature varieties and FNS believes it
is important to maintain this
distinction. Mature legumes are
excellent sources of plant protein, and

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also provide other nutrients such as iron
and zinc. Mature dry beans and peas are
similar to meats, poultry, and fish in
their contribution of these nutrients. In
WIC, they are offered as a separate food
category from the fruit and vegetable
category. Therefore, mature legumes in
dry-packaged and canned forms,
without added vegetables, fruits, meat,
sugars, fats, or oils, are the only dry
beans and peas authorized to be issued
via the WIC food instrument.
c. Disallowed Ingredients in Peanut
Butter
A technical oversight has been
corrected in Table 4 of 7 CFR
246.10(e)(12) to disallow peanut butter
with added marshmallows, honey, jelly,
chocolate/or similar ingredients.
3. Fruit and Vegetable Juice
Technical corrections have been made
in Table 4 of 7 CFR 246.10(e)(12) related
to the standard of identities for canned
fruit and vegetable juices. This final rule
corrects the specifications for WICeligible canned fruit juice and vegetable
juice to reflect that only those WICeligible juices that have a standard of
identity, as listed at 21 CFR Part 146
and 21 CFR Part 156, must conform to
these FDA standards of identity.
4. Milk and Milk Alternatives
a. Whole milk for participants greater
than 2 years of age. Under the interim
rule, and as recommended by the IOM,
whole milk is not authorized for
children greater than 2 years of age and
women in Food Packages IV–VII. Under
the interim rule, whole milk may be
issued to medically fragile children
older than 2 years of age and women
only in Food Package III for participants
with qualifying conditions. A total of
216 commenters, primarily local agency
WIC staff, asked FNS to allow the CPA
to prescribe whole milk for participants
in any food package if necessary for
participants who have medical or
nutritional reasons for requiring
additional calories.
FNS believes that WIC staff can assist
participants in Food Packages IV–VII in
meeting their nutritional needs through
fat-reduced milks and other foods.
Whole milk adds unnecessary saturated
fat and cholesterol to the diets of
participants. Nutrition education and
individual tailoring of the food package
within authorized parameters remain
the most effective tools for WIC staff to
use to help participants make
appropriate choices based on their
specific needs. Therefore, the provision
to authorize whole milk for children
greater than 2 years of age and women
only in Food Package III is retained in

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this final rule in Table 3 of 7 CFR
246.10(e)(11).
b. Fat-Reduced Milks for Children 12
Months to 2 Years of Age in Food
Package III and IV
Under the interim rule, children 12
months to 2 years of age may only be
issued whole milk. A total of 332
commenters (34 form letters) want
flexibility in this provision, citing
American Academy of Pediatrics (AAP)
policy,3 recommending fat-reduced
milks for children over the age of 1 for
whom overweight or obesity is a
concern.
In light of current AAP policy, FNS
will allow, at State agency option, fatreduced milks to be issued to 1-year-old
children (12 months to 2 years of age)
for whom overweight or obesity is a
concern. Under Food Package IV, FNS
will allow the CPA to make a
determination for the need for fatreduced milks for young children based
on an individual nutritional assessment
and consultation with the child’s health
care provider if necessary, as
established by State agency policy. FNS
will provide technical assistance for
issuing fat-reduced milks to children 12
months to 2 years of age in Food
Package IV. Due to the medically fragile
qualifying conditions of children 12
months to 2 years of age, FNS will
continue to require medical
documentation for issuance of WICeligible formula and foods, including
fat-reduced milks, under Food Package
III.
c. Fat Content of Milk for Children Over
2 Years of Age and Women
Under the interim rule, children ≥ 24
months of age and women may be
issued a variety of milk types (i.e.,
nonfat, lowfat (1%) and reduced fat
(2%) milk). Seven commenters
recommended the issuance of only
nonfat or lowfat (1%) milk to children
≥ 24 months of age and women to be
consistent with the Dietary Guidelines
for Americans. FNS notes that State
agencies already have policies to ensure
that CPAs issue the appropriate milk to
participants based on the assessed
nutritional needs of individual
participants. Since 1995 the Dietary
Guidelines for Americans have
recommended consumption of nonfat
and lowfat milk and milk products. In
technical assistance provided to State
agencies on the interim rule, FNS
supported and encouraged State
agencies to issue only nonfat and lowfat
3 American Academy of Pediatrics. Policy
Statement Lipid Screening and Cardiovascular
Health in Childhood, Pediatrics Vol. 122 No. 1 July
2008, pp. 198–208.

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milk to children and women unless
otherwise indicated by nutrition
assessment. As such, FNS finds merit in
adding a provision that nonfat and
lowfat (1%) milks are the standard
issuance for children ≥ 24 months of age
and women in Food Packages IV–VII.
Reduced fat (2%) milk is authorized
only for participants with certain
conditions, including but not limited to,
underweight and maternal weight loss
during pregnancy. The need for reduced
fat (2%) milk for children ≥ 24 months
of age (Food Package IV) and women
(Food Packages V, VI, VII) will be
determined as part of the careful
nutrition assessment completed by the
CPA, as established by State agency
policy.

authorized milk substitutes to fulfill the
maximum allowance. Because milk in
quart sizes has become more widely
available as States have implemented
the interim rule, and this final rule
allows the option of providing a quart
of yogurt for children and women (as
described in a subsequent section of this
preamble), and allows issuance of a 12
ounce can of evaporated milk to
substitute for the ‘‘dangling quart,’’ State
agency concerns about difficulty
providing the full milk benefit to
participants who substitute cheese for
milk should be alleviated. State agencies
also have the option to prescribe half
gallon containers of milk every other
month for participants in lieu of the
‘‘dangling quart.’’

d. Fortification of Whole Milk
This final rule clarifies the minimum
nutrient requirements for all milks
listed in Table 4 of 7 CFR 246.10(e)(12).
The table restates the milk
specifications to make it clearer that
vitamin A fortification is not required
for whole milk.

f. Cheese in Excess of Maximum
Substitution Rates
Under the interim rule, cheese may be
substituted for milk. The IOM set a
substitution rate for cheese for milk, but
put a cap on the amount that can be
substituted to control total and saturated
fat content of the food packages. Under
the interim rule, FNS allowed, with
medical documentation, additional
amounts of cheese to be issued beyond
the substitution rate to provide State
agencies with flexibility to
accommodate participants with lactose
intolerance. This accommodation was
made because, at the time, milk
alternatives for participants with lactose
intolerance were more limited. Few soybased beverages that met FNS’
nutritional standards were available,
and the interim rule did not authorize
yogurt, which had been recommended
by IOM as a milk substitute. Since that
time, more soy-based beverages that
meet the nutritional standards
established by FNS are available in the
marketplace, and this final rule
authorizes yogurt for children and
women. As a result, State agencies have
increased flexibility, in addition to
offering lower lactose milks, to
accommodate lactose intolerance with
substitutes other than cheese, as
recommended by the IOM. Therefore,
this final rule will no longer allow
cheese to be issued beyond established
substitution rates, even with medical
documentation, which is consistent
with the recommendation of the IOM.

e. Provision of Maximum Monthly
Allowance of Milk
Under the interim rule, the maximum
monthly allowance of milk must be
provided to participants, as the WIC
benefit to participants is the full
authorized amount. The interim rule
allows a substitution rate of 1 pound of
cheese for 3 quarts of milk, leaving a
quart of milk or milk substitute that
must be provided to participants issued
this option to fulfill the maximum
allowance in the food package.
A total of 17 commenters (6 of these
form letters) asked FNS to drop the
‘‘dangling quart’’ or allow State agencies
to round the quantity of milk up when
substituting cheese for milk because of
limited availability and higher costs of
milk in quart size containers. A total of
20 commenters (6 of these form letters)
asked FNS to allow State agencies to
issue 12 ounce cans of evaporated milk,
which are the largest size available in
the marketplace and which reconstitute
to 24 fluid ounces, as the ‘‘dangling
quart.’’
The IOM cited milk as an important
source of calcium and vitamin D for
WIC participants, and this food category
should not be shortchanged. Therefore,
the ‘‘dangling quart’’ may not be
ignored. This final rule will continue to
require that State agencies provide the
maximum allowance of milk to
participants if cheese is substituted for
milk in order for participants to obtain
their full milk benefit.
State agencies continue to have the
option to make available other

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g. Yogurt
The IOM recommended adding yogurt
to the WIC food packages as a partial
milk substitute for children and women.
However, under the interim rule, FNS
determined that the addition of yogurt
to the WIC food packages was cost
prohibitive. The interim rule solicited
comments from State agencies about the

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extent to which WIC participants would
benefit from the addition of yogurt, and
whether that addition could be achieved
in a cost-effective manner.
A total of 304 comment letters (63 of
these form letters) encouraged FNS to
allow yogurt as a milk substitute,
emphasizing that yogurt provides
priority nutrients and is convenient,
popular, and culturally acceptable to
WIC participants. Commenters also
cited a pilot study, conducted by the
California WIC Program in conjunction
with the National Dairy Council, which
demonstrated the feasibility of
providing yogurt in WIC food packages.4
The pilot study results cited participant
acceptance and ease of implementation.
FNS agrees that yogurt is a desirable
milk alternative for participants who
might not otherwise drink sufficient
amounts of fluid milk due to lactose
intolerance or other reasons. Therefore,
this final rule authorizes yogurt as a
substitute for milk for children and
women in Food Packages III–VII, at the
State agency’s option.
(1) Maximum Monthly Allowance of
Yogurt
At State agency option, 1 quart of
yogurt may be substituted for 1 quart of
milk for women and children in Food
Packages III–VII. No more than 1 quart
of yogurt is authorized per participant.
(2) Authorized Yogurts
As recommended by the IOM, yogurt
must conform to the standard of identity
for yogurt as listed in Table 4 of 7 CFR
246.10(e)(12) and may be plain or
flavored with ≤ 40 grams of total sugar
per 1 cup of yogurt. Only lowfat and
nonfat yogurts are authorized for
children over 2 years of age and women.
Whole fat yogurt is authorized only for
children less than two years of age. State
agencies have the option to determine
the container sizes of yogurt to
authorize on their food lists.
h. Tofu
Under the interim rule, calcium-set
tofu prepared only with calcium salts,
(e.g., calcium sulfate), and without
added fats, sugars, oils, or sodium, is
authorized. A technical correction has
been made in this final rule to clarify
that tofu must be calcium-set, i.e.,
contain calcium salts, but may also
contain other coagulants, i.e.,
magnesium chloride. This additional
flexibility allows State agencies to meet
the needs of WIC’s culturally diverse
participants. Tofu with only calcium
4 Fung, EB, et al. Randomized, controlled trial to
examine the impact of providing yogurt to women
enrolled in WIC. J Nutr Educ Behav. 2010 May–
Jun;42(3 Suppl):S22–9.

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sulfate may not be readily available in
the marketplace. Major tofu
manufactures with national distribution
make tofu with calcium sulfate alone or
in addition to magnesium chloride as a
coagulant. Magnesium chloride is not a
flavoring or preservative, and should
not be confused with sodium chloride,
which is not permitted. The calcium
content of various types of tofu, even
those set only with calcium salts, varies.
In choosing the brands and types of
calcium-set tofu to include on food lists,
State agencies should read the nutrition
labels and choose tofu with the highest
amount of calcium.
5. Breastfeeding Provisions
Under the interim rule, food packages
for infants and women are designed to
strengthen WIC’s breastfeeding
promotion and support efforts and
provide additional incentives to assist
mothers in making the decisions to
initiate and continue to breastfeed. The
provisions disallow routine issuance of
infant formula to partially breastfeeding
infants in the first month after birth to
help mothers establish milk production
and the breastfeeding relationship.
Overall, commenters expressed support
for the breastfeeding provisions, with 7
State agencies stating they have already
seen increases in breastfeeding rates
attributable to the interim rule
provisions. State agencies stressed that
adequate training of WIC staff and the
provision of appropriate counseling and
support to mothers is critical to the
success of the new food packages for the
breastfeeding mothers and their infants.

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a. Exclusive Breastfeeding
This final rule clarifies the intent of
the WIC Program that all women be
supported to exclusively breastfeed
their infants and to choose the fully
breastfeeding food package without
infant formula at 7 CFR 246.10(e).
Breastfeeding women who do not
exclusively breastfeed are to be
supported to continue breastfeeding to
the maximum extent possible through
minimum supplementation with infant
formula.
b. Clarification of Partially Breastfeeding
Terminology
Commenters asked FNS to address
terminology used to describe the
mother-infant pair who ‘‘partially’’
breastfeed (both breastfeed and formula
feed). Confusion exists because partially
breastfeeding is used to describe a
combination of any amounts of
breastfeeding and formula feeding.
However, under the interim rule, for the
purposes of food package issuance, the
partially breastfeeding food package is

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defined by a maximum quantity of
formula that assumes the mother is
substantially breastfeeding her infant.
Confusion also exists because WIC’s
definition of a breastfeeding woman is
the practice of feeding a mother’s breast
milk to her infant on the average of at
least once a day. This definition
determines the categorical eligibility of
a participant as a breastfeeding woman,
and did not change under the interim
rule revising the WIC food packages. All
women who meet this definition are
counted as breastfeeding women for
participation purposes, regardless of the
food package they are issued or the
amount of formula their infants receive.
Under the interim rule, three infant
feeding variations are defined for the
purposes of assigning food quantities
and types in Food Packages I and II for
infants: (1) Fully formula feeding, (2)
fully breastfeeding (the infant does not
receive formula from the WIC Program),
and (3) partially breastfeeding (the
infant is breastfed but also receives
some infant formula from WIC up to the
maximum allowance described for
partially breastfed infants in Table 1 of
7 CFR 246.10(e)(9)). Breastfeeding
assessment and the mother’s plans for
breastfeeding serve as the basis for
determining food package issuance.
Breastfed infants who are assessed to
need more formula than is allowed
under the food package for partially
breastfed infants are assigned to the
fully formula feeding package.
FNS agrees that terminology used to
describe food packages for the motherinfant pair that both breastfeed and
formula feed, regardless of amount from
either source, needs clarification.
Therefore, this final rule attempts to
minimize confusion about food package
issuance by parenthetically adding the
descriptor ‘‘mostly’’ breastfeeding to the
partially breastfeeding food package
designation established under the
interim rule.
c. Issuance of Formula to Breastfed
Infants
There has been some confusion about
the issuance of one can of powder infant
formula in the first month to breastfed
infants. For breastfeeding women who
do not receive the fully breastfeeding
package, WIC staff are expected to
individually tailor the amount of infant
formula based on the assessed needs of
the breastfeeding infant and provide the
minimal amount of formula that meets
but does not exceed the infant’s
nutritional needs. This is consistent
with long-standing FNS policy that
dates back to the 1980s. State agencies
should develop policies for handling
breastfeeding mothers’ formula requests

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that encourage substantial and
continued breastfeeding. This is true
whether the infant receives the fully
formula feeding package (although the
infant may be minimally breastfeeding)
or the partially (mostly) breastfeeding
food package. The full nutrition benefit
should not be used as the standard for
issuance unless the mother is not
breastfeeding the infant at all.
The interim rule strengthened the
WIC food packages to better enhance
breastfeeding promotion and support.
Food packages for partially (mostly)
breastfed infants and women were
created that provide additional foods for
mothers as incentives, to better meet
nutritional needs, and to provide less
infant formula to partially breastfed
infants than to infants who receive the
fully formula fed package.
The food packages for partially
(mostly) breastfed mothers and infants
are designed to provide for the
supplemental nutrition needs of the
breastfeeding pair, provide minimal
formula supplementation to help
mothers maintain milk production, and
provide incentives for continued
breastfeeding by way of a larger variety
and quantity of food than the full
formula/postpartum packages. FNS
emphasizes that the benefits of the
partially breastfed food packages are lost
if the breastfeeding mother-infant pair is
issued the full formula/postpartum
packages. Appropriate support and
counseling should be provided to
mothers to minimize the number of
breastfeeding infants receiving the full
formula packages.
This final rule clarifies at 7 CFR
246.10(b)(2)(ii)(C) that food package
quantities are to be issued based on
assessment of each participant’s
individual breastfeeding and nutritional
needs.
d. Issuance of Formula to Breastfed
Infants in the First Month After Birth
This final rule clarifies that the
issuance of any formula to breastfed
infants in the first month after birth is
a State agency option. If a State agency
chooses this option, it may issue one
can of powder infant formula in the
container size that provides closest to
104 reconstituted fluid ounces to
partially breastfed infants on a case-bycase basis. Breastfed infants who are
provided this option are considered
partially (mostly) breastfed. Breastfed
infants should not receive more than the
one can option in order to maintain the
mother’s milk production. State
agencies should not create food
packages that standardize issuance of
formula to partially (mostly) breastfed
infants in the first month after birth.

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e. Food Package VII for Fully
Breastfeeding Women
Under the interim rule, Food Package
VII is issued to three categories of WIC
participants—fully breastfeeding
women whose infants do not receive
formula from the WIC Program; women
pregnant with two or more fetuses, and
women fully or partially (mostly)
breastfeeding multiple infants. This
final rule clarifies that Food Package VII
is issued to partially (mostly)
breastfeeding mothers who are
breastfeeding multiples from the same
pregnancy.
A total of 12 commenters (4 form
letters) asked that partially breastfeeding
women who are also pregnant be
allowed to receive the more enhanced
Food Package VII. FNS agrees with
commenters that pregnant women who
are also partially (mostly) breastfeeding
singleton infants would benefit from the
increased quantity and variety of foods
in this food package. Therefore, this
final rule authorizes pregnant women
who are also partially (mostly)
breastfeeding to receive Food Package
VII.
Under the interim rule, women fully
breastfeeding multiples receive 1.5
times the maximum allowance of foods
authorized in Food Package VII to meet
their nutritional needs. A total of 36
commenters (8 form letters) asked FNS
to revise the food package quantities for
women fully breastfeeding multiples to
reflect a consistent amount each month
and to specify amounts in quantities
available in marketplace. In technical
assistance provided to State agencies on
the interim rule, FNS provided
flexibility to allow States to choose how
they will issue these quantities. Some
States have elected to issue foods in this
food package in amounts averaged over
a 2-month timeframe to eliminate
concern about providing quantities
available in the marketplace. Others
issue double the ‘‘regular’’ fully
breastfeeding package one month and
then issue the ‘‘regular’’ fully
breastfeeding package the next month.
FNS will allow State agencies to retain
the flexibility to determine how best to
issue food packages quantities for
women fully breastfeeding multiples
and therefore will not change the
provision to specify a set amount that
must be provided each month.
f. Human Milk Fortifier (HMF)
Fifteen commenters (4 form letters)
asked that partially (mostly)
breastfeeding women whose infants
receive human milk fortifier (HMF) be
considered fully breastfeeding.

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Issuance of HMF as a WIC formula is
allowed with medical documentation
under the interim rule, as it was under
previous WIC policy. A woman whose
infant receives HMF is considered
partially breastfeeding because her
infant is receiving formula from WIC.
HMF provides additional protein,
minerals, and vitamins that, when
added to breastmilk in the first
postpartum month for premature
infants, results in nutrient, mineral, and
vitamin concentrations similar to those
of the formulas developed for feeding
preterm infants. HMF is given in the
hospital, but most often is discontinued
prior to discharge. There is a limit on
how long HMF is necessary and the
need and length of time an infant
should remain on HMF should be
determined and monitored by the health
care provider.
Since HMF is to be used for only a
very short time, the woman can be
transitioned back to the fully
breastfeeding package as soon as the
infant is no longer receiving HMF from
WIC. The final rule will retain the
provision that Food Package VII is
issued only to women whose infants do
not receive formula from WIC, including
HMF.
6. Whole Wheat Bread and Whole Grain
Options
a. Authorized Breads
Under the interim rule, whole wheat
breads, rolls and buns that meet the
FDA standard of identity for whole
wheat bread (21 CFR 136.180) are
authorized. Some commenters asked
FNS to allow baked products that do not
meet the standard of identity for whole
wheat bread, e.g., English muffins and
bagels, if these products otherwise meet
the whole wheat requirements. FNS has
considered this request, but has
determined that identifying the WICeligibility of whole wheat bread
products that do not meet the standard
of identity would be complex given the
number of products in the marketplace.
Therefore, the requirement that whole
wheat breads meet the standard of
identity for whole wheat bread is
retained in this final rule in Table 4 of
7 CFR 246.10(e)(12).
b. Package Sizes of Whole Wheat/Whole
Grain Bread
The interim rule established a
maximum monthly allowance of two
pounds of whole wheat bread or other
whole grain options for children in
Food Packages III and IV; and one
pound of whole wheat bread or other
whole grain options for women in Food
Packages III, V and VII. Commenters

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asked that FNS authorize bread in the
more commonly available 20 ounce
package size.
Although the availability of bread in
package sizes to meet the WIC
maximum monthly amount of bread
authorized in WIC food packages was of
initial concern as State agencies
planned to implement the new food
packages and supply in the marketplace
may have been limited, bread
manufacturers have increasingly
produced WIC-eligible breads in 16
ounce package sizes to respond to the
changes in the WIC Program. As such,
all State agencies have breads in
appropriate size packages on their WIC
food lists. A greater number of WICeligible breads in 16 ounce package
sizes continue to be introduced by
manufacturers, which will further
increase the bread options available to
participants. Therefore, FNS believes
that this situation has been addressed
and the maximum allowance for whole
wheat and whole grain bread is
unchanged in this final rule.
c. Expansion of Whole Grain Options
Under the interim rule, whole grains
(brown rice, bulgur, oats, and whole
grain barley), as well as tortillas, are
authorized as substitutions for whole
wheat and whole grain bread. A total of
310 commenters (22 of these form
letters) asked FNS to consider
expanding the list of whole grain foods
available to participants. Suggestions
included whole grain pasta, whole
wheat English Muffins, and whole
wheat bagels.
To make available additional whole
grain foods to participants, this final
rule will add whole wheat pasta to the
list of whole wheat/whole grain bread
alternatives. Whole wheat macaroni
(pasta) products that meet the FDA
standard of identity (21 CFR 139.138)
and have no added sugars, fats, oils, or
salt (i.e., sodium) are WIC-eligible.
Other shapes and sizes that otherwise
meet the FDA standard of identity for
whole wheat macaroni (pasta) products
are also authorized (e.g. whole wheat
rotini, whole wheat penne).
d. Technical Corrections
In technical assistance provided to
State agencies on the interim rule, FNS
clarified that State agencies must offer
whole wheat and/or whole grain bread.
State agencies have the option to also
authorize the other whole grain options
listed in Table 4 of 7 CFR 246.10(e)(12).
This final rule clarifies this provision.
Also, consistent with technical
assistance provided to State agencies on
the interim rule, FNS clarifies in Table
4 of 7 CFR 246.10(e)(12) of this final

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rule that corn tortillas made from
ground masa flour (corn flour) using
traditional processing methods are WICeligible. FNS recognizes that a small
loss of corn kernel occurs during the
traditional processing of tortillas, and
therefore, such tortillas are not
considered whole grain. FNS
encourages State agencies to authorize
corn tortillas that have whole corn listed
as their primary ingredient. However, if
the market availability of such corn
tortillas is limited, FNS will allow State
agencies to authorize corn tortillas made
from ground masa flour using
traditional processing methods, due to
the high participant acceptance of corn
tortillas, especially among Hispanic
cultures. A technical clarification has
been made in Table 4 of 7 CFR
246.10(e)(12) to the minimum
requirements and specifications for
whole wheat tortillas to address the
types of flour authorized. This final rule
continues to require that whole grain
breads and cereals meet FDA labeling
requirements for making a health claim
as a ‘‘whole grain food with moderate
fat content.’’ However, for simplicity
and clarity, the final rule removes the
specifics of the labeling requirements
from Table 4 of 7 CFR 246.10(e)(12) and
instead refers readers and manufacturers
directly to the FDA health claim
notification for further reference at
http://www.fda.gov/food/
ingredientspackaginglabeling/
labelingnutrition/ucm073634.htm.
A technical clarification has been
made in Table 4 of 7 CFR 246.10(e)(12)
to the minimum requirements and
specification for whole wheat bread to
address consistency with the standard
of identity for whole wheat bread. For
additional clarity and to aid State
agencies and participants in identifying
WIC-eligible whole grain bread
products, a statement has been added to
the requirements noting whole grain
breads must conform to the FDA
standard of identity for bread, buns and
rolls.
7. Breakfast Cereals
Under the interim rule, at least one
half of all breakfast cereals on each State
agency’s authorized food list must meet
the whole grain requirements as
specified in Table 4 at 7 CFR
246.10(e)(12). This provision allows
certain corn and rice-based cereals to be
offered to participants who may have
allergies to whole grain cereals. FNS is
retaining this provision in this final
rule, but encourages State agencies to
issue whole grain cereals to participants
to the maximum extent possible,
reserving non-whole grain options for
those participants with allergies or other

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medical reasons where whole grains are
contraindicated. Participants should
receive nutrition education on the
benefits of whole grain in the diets to
reduce the risk of coronary heart disease
and type-2 diabetes, help with body
weight maintenance, and increase
intake of dietary fiber.
A technical correction has been made
in this final rule in Table 4 of 7 CFR
246.10(e)(12) to clarify that there is no
FDA standard of identity listed for
breakfast cereals.
8. Infant Foods in Food Packages II and
III
a. Fresh Bananas as Substitute for Jarred
Infant Foods
Under the interim rule, State agencies
have the option to offer fresh bananas as
a substitute for up to 16 ounces of infant
food fruit at a rate of one pound of
bananas per eight ounces of infant food
fruit via the regular WIC food
instrument. To ensure participants
receive the full food package benefit of
this provision, and to simplify the
transaction for vendors as well as
participants, FNS will also allow State
agencies the option to substitute fresh
bananas at a rate of one banana per four
ounces of jarred infant food fruit, up to
a maximum of 16 ounces, in Food
Packages II and III for infants 6 to 12
months of age. This is consistent with
recommendations of the IOM.
b. Cash-Value Voucher in Lieu of
Commercial Jarred Infant Foods
Under the interim rule, jarred infant
foods (fruits, vegetables, and meat) are
provided in Food Packages II and III for
infants 6 months through 11 months of
age. Although this provision overall has
been well received, concerns initially
made by commenters on the proposed
rule persist regarding this provision. A
total of 508 commenters on the interim
rule asked FNS to include a State option
to provide a cash-value voucher to older
infants receiving Food Packages II and
III in lieu of commercial jarred infant
food fruits and vegetables. Commenters
stated that foods for older infants should
be developmentally appropriate as
infants transition to toddler foods, and
noted the lack of availability of jarred
infant foods in appropriate textures for
the older infant. Commenters also stated
that the amount of jarred infant foods in
the WIC food packages is excessive for
some older infants who are progressing
in their feeding skills and transitioning
from infant foods to table foods
consumed during family meals.
FNS remains committed to IOM’s
recommendation that commercial jarred
infant foods be provided in the WIC

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food packages to ensure that infants
receive and consume fruits and
vegetables in developmentally
appropriate textures and in a variety of
flavors. The IOM also intended that
commercial jarred infant foods be
provided to ensure that these items are
consumed by infants and not other
participants or family members. Food
safety and nutrient content were also
considerations. FNS recognizes these
considerations and continues to provide
commercial jarred infant foods in this
final rule.
FNS acknowledges the preference for
alternative options for infants and
agrees that the lack of developmentally
appropriate infant foods available in the
marketplace may make it difficult for
State agencies to provide a range of
textures appropriate for infants at
different stages of development. This
void in the market is particularly noted
among infant food products for older
infants, and may compromise the
appropriate progression of an infant’s
feeding skills. The FNS Infant Nutrition
and Feeding Guide 5 indicates that at
around nine months of age, most infants
are developmentally ready to consume
foods of increased texture and
consistency. Such consistency should
progress from pureed to ground to forkmashed and eventually to diced.
Therefore, in light of these
considerations, under this final rule,
FNS will allow infants 9 months
through 11 months of age to receive a
cash-value voucher for the purchase of
fresh fruits and vegetables in lieu of a
portion of the infant food fruits and
vegetables provided in Food Packages II
and III. For partially breastfed infants
and fully formula fed infants,
participants may opt to receive a $4
cash-value voucher plus 64 ounces of
infant food fruits and vegetables; fully
breastfed infants may receive an $8
cash-value voucher plus 128 ounces of
infant food fruit and vegetables. The
decision to issue cash-value vouchers in
lieu of infant food fruits and vegetables
is a State agency option. If a State
agency chooses this option, it may not
categorically issue cash-value vouchers
to all infants of this age group. Instead,
the cash-value voucher is to be provided
to the participant only after a thorough
assessment by the CPA, as established
by State agency policy, and is optional
for the participant, i.e., the mother may
choose to receive either the maximum
allowance of jarred foods or the
combination of jarred foods and a fruit
5 Food and Nutrition Service 2009. Infant
Nutrition and Feeding: A Guide for Use in the WIC
and CSF Programs. Available at Internet site:
http://www.nal.usda.gov/wicworks/Topics/FG/
CompleteIFG.pdf.

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and vegetable cash-value voucher for
her infant. State agencies must ensure
that appropriate nutrition education is
provided to the caregiver addressing
safe food preparation, storage
techniques, and feeding practices to
make certain participants are meeting
their nutritional needs in a safe and
effective manner.
States continue to have the option to
offer, via the regular WIC food
instrument, fresh bananas as a substitute
for infant food fruit in Food Packages II
and III for infants six to twelve months
of age as described in section IV.C.8.a of
this preamble.
This final rule clarifies that a fruit or
vegetable must be listed as the primary
(first) ingredient in WIC-eligible jarred
infant foods. Further, this final rule
clarifies that combinations of single
ingredients of fruits and/or vegetables
(e.g., peas and carrots, apples and
squash) are allowed in Food Package II
and III for infants 6 to 12 months of age.
c. White Potatoes in Jarred Infant Foods
White potatoes are excluded from
purchase with the cash-value voucher in
the WIC food packages. However, this
final rule clarifies that jarred infant
foods that meet the minimum
requirements and specifications for an
infant food product and include white
potatoes as an ingredient, but not the
primary ingredient, are allowed in Food
Packages II and III for infants 6 to 12
months of age.

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d. Infant Cereal
Under the interim rule, infant cereal
is provided in Food Packages II and III
for infants 6 months to 12 months of
age. A total of 223 commenters (16 form
letters) asked FNS to allow State
agencies the option to offer ‘‘adult’’
breakfast cereals, as appropriate, to
older infants to encourage
developmental feeding skills and
support the transition from infant foods
to appropriate table and finger foods.
Commenters stated that participants
report not purchasing infant cereal
because older infants prefer cereals they
can eat with their fingers.
The IOM recommended the provision
of iron-fortified infant cereal for infants
6 to 12 months of age as a quality source
of iron and zinc, nutrients needed by
infants for optimal growth and
development. Providing infant cereal for
infants 6 months through 11 months of
age is consistent with pediatric nutrition
guidelines. The FNS Infant Nutrition
and Feeding Guide 6 states that ready-to6 Food and Nutrition Service 2009. Infant
Nutrition and Feeding: A Guide for Use in the WIC
and CSF Programs. Available at Internet site:

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eat, iron-fortified cereals designed for
adults or older children are not
recommended for infants because they:
(1) often contain mixed grains; (2) tend
to contain more sodium and sugar than
infant cereals; and (3) typically contain
less iron per infant-sized serving. Food
safety is also of concern with the
provision of adult cereals to infants as
these products could cause choking if
the infant is not developmentally ready
to consume foods of this texture. For
these reasons, the provision of ironfortified infant cereal for infants 6
months of age through 12 months of age
in Food Packages II and III remains
unchanged in this final rule.
9. Canned Fish
The IOM recommended that a variety
of canned fish that do not pose a
mercury hazard be offered in Food
Package VII. In addition to canned light
tuna, canned salmon, and canned
sardines, the interim rule authorized
canned mackerel in Food Package VII
for fully breastfeeding women.
However, the two species of mackerel
specified in the interim rule—N.
Atlantic and Chub (Pacific)—are not
readily available in canned form in the
United States. FNS received 21
comments asking that canned Jack
mackerel also be authorized in Food
Package VII, citing its lower levels of
mercury and acceptance by WIC
participants.
To allow more variety and choice
among canned fish options, this final
rule authorizes Jack mackerel as a
canned fish option in Food Package VII.
King mackerel is not authorized in any
form. FNS encourages State agencies to
offer all authorized canned fish options,
i.e., tuna, salmon, sardines, and Jack
mackerel, to ensure variety and choice
for participants. This final rule also
clarifies that canned fish with added
sauces and flavorings, e.g., tomato
sauce, mustard, lemon, are authorized at
the State agency’s option.
10. Food Package III for Children and
Women With Qualifying Conditions
a. Infant Foods In Lieu of the CashValue Voucher
Under the interim rule, children and
women with qualifying conditions who
require the use of a WIC formula (i.e.,
infant formula, exempt infant formula or
WIC-eligible nutritional (formerly WICeligible medical food)) receive Food
Package III. Among the supplemental
foods provided to participants in this
food package is a cash-value voucher to
purchase fruits and vegetables. A total
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of 33 commenters requested the
substitution of commercial jarred infant
food fruit and vegetables in lieu of the
cash-value voucher for participants over
the age of one who have a qualifying
medical condition, such as prematurity,
developmental delays, and dysphasia
(swallowing disorders). Commenters
pointed out that these individuals
would benefit from the use of this
ready-to-feed form of pureed fruits and
vegetables over the purchase of fresh
fruits and vegetables.
Food Package III is reserved for
medically fragile participants who have
specific dietary needs that are dictated
by their medical condition. FNS is
committed to providing these
individuals with WIC Formula (i.e.,
infant formula, exempt infant formula
and WIC-eligible nutritionals) and
supplemental foods that best meet their
special dietary needs. Thus, FNS finds
merit in the argument that some
participants with certain qualifying
conditions may require a pureed form of
fruits and vegetables to meet their
nutritional needs, and would benefit
from the convenience of purchasing
jarred infant food fruits and vegetables.
As such, this final rule allows State
agencies the flexibility to provide
children and women in Food Package III
the option of receiving commercial
jarred infant food fruits and vegetables
in lieu of the cash-value voucher. The
quantity of commercial jarred infant
food fruits and vegetables is based on
the substitution ratio of 128 ounces of
infant food fruits and vegetables for the
$8 cash-value voucher for children and
160 ounces of infant food fruits and
vegetables for the $10 cash-value
voucher for women. The need for
commercial jarred infant food fruits and
vegetables in lieu of the cash-value
voucher will be determined by medical
documentation that meets the criteria
established in 7 CFR 246.10(d). Some
participants may prefer to purchase
fruits and vegetables via the cash-value
voucher and process/puree the fruits
and vegetables themselves; this remains
an option and is encouraged for those
who would benefit from this method of
modifying the consistency and texture
of foods to improve nutritional intake.
Some commenters asked FNS to allow
children in Food Package IV the option
to receive commercial jarred infant
foods in lieu of the cash-value voucher.
However, FNS believes it appropriate
that caregivers of children who do not
have qualifying conditions making them
eligible for Food Package III, and who
need modifications in food consistency,
receive nutrition education on choosing
and preparing foods that meet the
child’s needs, e.g., pureeing fruits and

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vegetables and/or choosing those with
soft texture/consistency.
b. Allowance of Infant Formula in Food
Package III for Infants
Food package III is reserved for
participants who have one or more
qualifying conditions that require an
exempt infant formula or WIC-eligible
nutritional (formerly WIC-eligible
medical food) to supplement their
nutrition needs, as determined by the
participant’s health care professional.
Infants who have a qualifying condition
and are successfully managed with an
infant formula are issued Food Package
I or II, as deemed appropriate for their
age and feeding method.
Under the interim rule, infants who
require a combination of infant formula
and a WIC-eligible nutritional or exempt
infant formula are not able to receive
both products through a WIC food
package. In addition, these infants at 6
months of age may not be
developmentally ready to consume solid
foods due to their medical condition
and would benefit from an increased
amount of formula in place of infant
foods at that timeframe. FNS received
74 comments requesting that infants
who are not developmentally ready to
consume solid foods be allowed
increased infant formula amounts in
lieu of infant foods in Food Package II.
FNS agrees that there are a small
percentage of infants who have a
qualifying condition, such as
prematurity, whose nutritional needs
may be successfully managed with
infant formula alone or a combination of
infant formula and WIC-eligible
nutritionals. These infants are
considered medically fragile and would
benefit from the close medical
supervision provided under Food
Package III. These infants may not be
ready to consume infant foods at 6
months of age, as would otherwise
generally healthy term infants, and they
may benefit from receiving additional
formula in lieu of infant foods at that
time. Therefore, this final rule expands
the type of formula authorized to infants
with qualifying conditions in Food
Package III to include infant formula.
The issuance of infant formula in Food
Package III would be strictly reserved
for those infants who are medically
fragile. Infants who do not have a
qualifying condition and are otherwise
generally healthy infants will continue
to receive Food Packages I and II, as
appropriate. In Food Package III, infants
greater than 6 months of age may
receive additional infant formula,
exempt infant formula or WIC-eligible
nutritionals (formerly WIC-eligible
medical food) in lieu of infant foods at

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the same maximum monthly allowance
as infants ages 4 through 5 months of
age of the same feeding option. As with
exempt infant formula and WIC-eligible
nutritionals, infants receiving infant
formula in Food Package III will need
medical documentation that meets the
criteria established in 7 CFR 246.10(d).
11. Liquid Concentrate Infant Formula
Amounts and Full Nutrition Benefit
Table 1 in 7 CFR 246.10(e)(9) of the
interim rule established the full
nutrition benefit and the maximum
monthly allowances of each physical
form of infant formula, for each food
package category and infant feeding
variation. The interim rule also
described the full nutrition benefit as
the reconstituted fluid ounce amounts
for liquid concentrate infant formula
(based on a 13 ounce can) which formed
the basis of substitution rates for other
physical forms of infant formula (i.e.,
powder and ready-to-feed infant
formula). Providing the full nutrition
benefit amounts ensure that participants
receive a comparable nutritional benefit
no matter which physical form of infant
formula they receive.
For decades, infant formula
manufacturers consistently provided
liquid concentrate and ready-to-feed
infant formula in container sizes or
packaging that evenly divide into the
maximum monthly allowance, while
powder infant formulas traditionally
vary in package size across
manufacturers. FNS has become aware
of a shift in the marketplace, such that
liquid concentrate and ready-to-feed
infant formula container sizes (i.e., 13
and 32-fluid ounces) are no longer
standard for all major infant formula
manufacturers. Because the maximum
monthly allowance amounts of liquid
infant formula under the interim rule
are evenly divisible by a 13 ounce
standard for liquid concentrate
(reconstituted) and a 32 ounce standard
of ready-to-feed infant formula, there is
little flexibility to accommodate changes
in the package size while still providing
the full nutrition benefit and not
exceeding the maximum monthly
allowance amount.
This final rule provides the technical
correction of revised maximum monthly
allowance amounts for liquid
concentrate and ready-to-feed infant
formula. The revision of maximum
monthly allowance amounts for liquid
infant formula (i.e., liquid concentrate
and ready-to-feed) is consistent with the
legislative authority granted to the
Secretary of Agriculture in Section 733
of Public Law 111–80 and reiterated in
Section 712 of Public Law 112–55, the
Consolidated and Further Continuing

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Appropriations Act, 2012 that
authorizes State Agencies to exceed the
current maximum amount of liquid
infant formula to ensure the full
nutrition benefit be provided to
participants. This will maintain
competition in the infant formula
market and address recent changes in
package size availability of liquid
concentrate and ready-to-feed infant
formula.
Liquid concentrate infant formula will
now have a separate maximum monthly
allowance amount different from the
full nutrition benefit to accommodate
market changes in packaging. This
provision does not change the full
nutrition benefit amounts as established
in the interim rule. The full nutrition
benefit will now be defined as the
minimum amount of reconstituted
liquid concentrate infant formula as
specified in Table 1 of 7 CFR
246.10(e)(9) of this rule for each food
package category and infant feeding
option (e.g., Food Package IA fully
formula fed, IA–FF).
Infant formula issuance, whether
using monthly issuance or rounding
methodology, should be based on
providing the amount of infant formula
that most closely provides the full
nutrition benefit to all infant
participants as deemed appropriate
based on breastfeeding assessment and
infant food package and feeding
method. At a minimum, State agencies
must provide the full nutrition benefit
to all non-breastfed infants. For
breastfed infants, even those receiving
the fully formula fed package, infant
formula amounts should be tailored
based on the assessed needs of the
breastfed infant and provide the
minimal amounts of formula that meets
but does not exceed the infant’s
nutritional needs. This final rule adds
the definition of full nutrition benefit at
7 CFR 246.2.
12. Infant Formula Requirements
Technical Correction
A technical correction has been made
to infant formula requirements in 7 CFR
246. 246.10(e)(1)(iii) to clarify the
qualifying conditions for the types of
supplemental foods (i.e., noncontract
brand infant formula and any contract
brand infant formula that does not meet
the requirements in Table 4 of 7 CFR
246.10(e)(12)) that may be issued in this
food package only with medical
documentation.

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Procedural Matters
Executive Order 12866 and Executive
Order 13563
Executive Orders 12866 and 13563
direct agencies to assess all costs and
benefits of available regulatory
alternatives and, if regulation is
necessary, to select regulatory
approaches that maximize net benefits
(including potential economic,
environmental, public health and safety
effects, distributive impacts, and
equity). Executive Order 13563
emphasizes the importance of
quantifying both costs and benefits, of
reducing costs, of harmonizing rules,
and of promoting flexibility.
This final rule has been designated a
‘‘significant regulatory action,’’ under
section 3(f) of Executive Order 12866.
Accordingly, the rule has been reviewed
by the Office of Management and
Budget.
Regulatory Impact Analysis Summary
As required for all rules that have
been designated as Significant by the
Office of Management and Budget, a
Regulatory Impact Analysis (RIA) was
developed for this final rule. The RIA
for this rule was published as part of
docket number FNS–2006–0037 on
www.regulations.gov. A summary of the
analysis follows:
Need for Action. This final rule
considers public comments submitted

in response to the interim rule revising
the WIC food packages published in
December 2007 (72 FR 68966). The
interim rule implemented the first
comprehensive revisions to the WIC
food packages since 1980. The interim
rule revised regulations governing the
WIC food packages to align them more
closely with updated nutrition science
and the infant feeding practice
guidelines of the American Academy of
Pediatrics, promote and support more
effectively the establishment of
successful long-term breastfeeding,
provide WIC participants with a wider
variety of food, and provide WIC State
agencies with greater flexibility in
prescribing food packages to
accommodate participants with cultural
food preferences.
This final rule addresses public
comments received on the interim rule
and makes adjustments that improve
clarity of the provisions set forth in the
interim rule.
Benefits. The revised food packages
were developed to better reflect current
nutrition science and dietary
recommendations, promote and support
more effectively the establishment of
successful long-term breastfeeding,
provide WIC participants with a wider
variety of food than do current food
packages, and provide WIC State
agencies with greater flexibility in
prescribing food packages to
accommodate participants with cultural
Estimate

food preferences. The final rule makes
additional administrative and food
package changes that will allow local
WIC agencies to better meet the
nutritional needs and dietary
preferences of program participants.
Costs. FNS estimates that the cost of
all mandatory and optional provisions
in this final rule will total $1.17 billion
over 5 years assuming State
implementation beginning May 1, 2014
(for all provisions except the split
tender and soy-based beverage for
children provisions, which have
effective dates of October 1, 2014) and
yogurt for women and children with an
effective date of April 1, 2015. If the
optional provisions are adopted by
fewer than all State agencies, then the
cost of the rule will be lower. The cost
of the mandatory provisions across all
State agencies, plus the cost of the
optional provisions by State agencies
that serve half of WIC participants, is
estimated to be $999 million over 5
years.
Accounting statement. The following
accounting statement gives the
estimated discounted, annualized costs
of the rule assuming full State agency
implementation of the rule’s mandatory
and optional provisions. The figures are
computed from the nominal 5-year
estimates developed in the full RIA. The
accounting statement contains figures
computed with 7 percent and 3 percent
discount rates.
Discount rate
(percent)

Year dollar

Period covered

Benefits
Qualitative: The final rule modifies several provisions of the interim rule based on comments from State and local agencies, interest groups, participants, and others. These modifications better fulfill the intent of the interim rule and the IOM recommendations that are the basis for the
WIC food package changes. The rule would increase the quantity of fruits and vegetables contained in the food packages for children to the
level recommended by the IOM. The rule also gives States and local agencies more flexibility to meet the medical needs and cultural preferences of WIC participants. Recent research on WIC participants indicates that changes in the WIC food package have resulted in increases
in consumption of healthful foods recommended by IOM (see RIA text). The effect of the rule, therefore is a benefit to participants and not
simply a transfer of Federal funds replacing costs that WIC participants would have incurred in the absence of this rule. Because we do not
quantify the value of the benefits in the impact analysis, and therefore cannot separate them from the estimated Federal transfer to WIC participants, we show our entire dollar impact under transfers. No longer requiring medical documentation for children to receive soy-based beverage and tofu as milk substitutes will save participants some time, although we believe the overall impact on that their time will be minimal
and the savings will be nominal. There may also be a benefit in that some WIC participants may not have been taking the soy-based beverage and tofu substitution because getting medical documentation was presenting a barrier. Providing a mechanism to access soy-based
beverage and tofu by working with a WIC Competent Professional Authority will help to remove that barrier and may result in nutrition benefits for this group of participants.

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Transfers
Annualized Monetized ................................................................................

$225.2

2014

($millions/year) ...........................................................................................

230.5

2014

FY2014–2018

Quantified: The rule contains a mix of mandatory provisions and State options. For purposes of this impact analysis we estimate the value of
both the mandatory and optional provisions assuming full implementation by all WIC State Agencies. The figures shown here are estimates of
the value of full implementation of mandatory and optional provisions assuming no offsetting savings. The figures shown here which are limited to the food benefit, are transfers from the Federal government to WIC participants.
Costs

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Estimate

Year dollar

Discount rate
(percent)

12287
Period covered

Qualitative: Local and State WIC agencies will incur some administrative costs, other than reporting and recordkeeping, to implement the final
rule. However, we are unable to quantify the potential increases in administrative burden due to the final provisions. These include the costs
of training WIC clinic and administrative staff and the periodic review and updating of WIC-approved food lists. The State option to authorize
farmers’ markets to accept WIC cash-value vouchers may introduce administrative costs, however in general, we anticipate that State Agencies and local WIC providers will be able to absorb the burden associated with implementing this rule with current NSA funds. State and local
agencies have substantial flexibility in how they spend their NSA funds and may need to reprioritize or postpone some initiatives to undertake
the implementation activities, as well as adapt to certain ongoing administrative requirements associated with the final rule. FNS will continue
to provide technical assistance to State and local agencies to assist them in implementing the new provisions of the final rule.

Regulatory Flexibility Act
This final rule has been reviewed
with regard to the requirements of the
Regulatory Flexibility Act (RFA) of
1980, (5 U.S.C. 601–612). Pursuant to
that review, FNS Administrator Audrey
Rowe certified that this rule would not
have a significant impact on a
substantial number of small entities.
State and local agencies and WIC
participants will be most affected by the
rule and WIC authorized vendors and
the food industry may be indirectly
affected.
Although not required by the RFA,
FNS prepared a Regulatory Flexibility
Analysis describing the impact of this
interim rule on small entities that
reflects comments that were received on
the Regulatory Flexibility Analysis that
was included in the WIC Food Package
interim rule published at 72 FR 68982,
December 6, 2007.

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Need for and Objectives of the Final
Rule
The interim rule, published in the
Federal Register on December 6, 2007
(72 FR 68966), revised the WIC food
packages. The revisions align the WIC
food packages with the Dietary
Guidelines for Americans and infant
feeding practice guidelines of the
American Academy of Pediatrics. The
interim rule revisions largely reflect
recommendations made by the Institute
of Medicine (IOM) of the National
Academies in its report, ‘‘WIC Food
Packages: Time for a Change,’’ with
certain cost containment and
administrative modifications found
necessary by the Department to ensure
cost neutrality. The interim rule allowed
FNS to obtain feedback on the major
changes as recommended by IOM, as
well as the implementation of
procedures, while allowing
implementation to move forward. State
agencies, including Indian Tribal
Organizations, were required to
implement the changes by October 1,
2009, and new food packages are now
being provided to WIC participants in
all States. The interim rule comment
period ended February 1, 2010. Public

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comments received on the interim rule
are reflected in the final rule.
The interim rule required substantial
changes by State and local agencies.
Overall, implementation proceeded
smoothly and all States have
successfully implemented the changes.
This final rule makes a much more
limited number of modifications than
those contained in the interim rule and
requires less significant changes in
response to the public comments
received. Therefore, the expected effects
are minimal for FNS and other Federal
Agencies. FNS will continue to provide
technical assistance to State and local
agencies to assist them in fully
implementing the changes. This rule
will require State and local agencies to
make further modifications to their
procedures that are far less substantial
than the changes required under the
Interim rule. Foreign countries will not
be affected.
Description and Estimate of Number of
Small Entities to Which the Final Rule
Would Apply
This final rule applies to WIC State
agencies with respect to their selection
of foods to be included on their food
lists. As a result, vendors will be
indirectly affected. The rule may have
an indirect economic affect on certain
small businesses because they may have
to carry a larger variety of certain foods
to be eligible for authorization as a WIC
vendor. Currently, approximately
46,000 stores are authorized to accept
WIC food instruments, some of which
are small businesses. With the high
degree of State flexibility allowable
under this final rule, small vendors will
be impacted differently in each State
depending upon how that State chooses
to meet the new requirements. Since
neither FNS nor the State agencies
regulate food producers under the WIC
Program, it is not known how many
small entities within that industry may
be indirectly affected by the final rule.
A 2011 evaluation conducted by
Altarum Institute 7 sought to understand
7 Altarum Institute 2011. Impact of the Revised
WIC Food Package on Small WIC Vendors: Insight
from a Four State Evaluation.

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the impact that the WIC food package
changes had on small stores. The study
demonstrated that most small WIC
stores were able to maintain their
authorization with the WIC Program
during the period the food package
changes were implemented. Small
stores appear to have added healthy
foods to their inventory in response to
the WIC food package changes. The
report concludes that adequate vendor
preparation likely factored into the
overall success of implementation, and
cites the need for ongoing engagement
of these and other WIC stakeholders.
Description of Projected Reporting,
Recordkeeping, and Other Compliance
Requirements
Modifications included in the final
rule to eliminate certain medical
documentation requirements imposed
by the interim rule will decrease the
Information Collection Burden
associated with this rule.
Steps Taken To Minimize Significant
Economic Impact on Small Entities, and
Significant Alternatives Considered
FNS considered significant
alternatives in developing the interim
rule including those that may reduce the
indirect impact on small business.
These considerations included (among
others) the establishment of differing
compliance or reporting requirements or
timetables that take into account the
resources available to small entities; the
clarification, consolidation, or
simplification of compliance and
reporting requirements under the rule
for small entities; the use of
performance, rather than design,
standards; and an exemption from
coverage of the rule, or any part thereof,
for small entities.
In general, the alternatives of
exempting small entities from the
requirements in the interim rule or
altering the requirements for small
entities were rejected. The WIC food
packages provide supplemental foods
designed to address the nutritional
needs of low-income pregnant,
breastfeeding, non-breastfeeding
postpartum women, infants and

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children up to age 5 who are at
nutritional risk. Exempting small
entities from providing the specific
foods intended to address the
nutritional needs of participants or
altering the requirements for small
entities would undermine the purpose
of the WIC Program and endanger the
health status of participants. Therefore,
this final rule retains those
requirements.
FNS did, however, modify the new
food provisions in an effort to mitigate
the impact on small entities. As in the
past, State agencies must establish
minimum requirements for the variety
and quantity of foods that a vendor must
stock in order to receive WIC Program
authorization. The interim rule added
new food items, such as fruits and
vegetables and whole grain breads,
which may require some WIC vendors,
particularly smaller stores, to expand
the types and quantities of food items
stocked in order to maintain their WIC
authorization. In addition, vendors also
have to make available more than one
food type from each WIC food category,
except for the categories of peanut
butter and eggs, which may be a change
for some vendors. To mitigate the
impact of the fruit and vegetable
requirement, the interim rule allowed
canned, frozen and dried fruits and
vegetables to be substituted for fresh
produce. These provisions are all
retained in this final rule.
The interim rule authorized State
agencies the option to allow participants
to pay the difference if the fruit and
vegetable purchase exceeds the value of
the cash-value voucher, a transaction
known as ‘‘split tender.’’ In response to
public comments received on the
interim rule, this final rule requires
State agencies to allow split tender
transactions with the cash-value
voucher.
Unfunded Mandates Reform Act
Title II of the Unfunded Mandates
Reform Act of 1995 (UMRA), Public
Law 104–4, establishes requirements for
Federal agencies to assess the effects of
their regulatory actions on State, local
and tribal governments and the private
sector. Under section 202 of the UMRA,
the Department generally must prepare
a written statement, including a cost
benefit analysis, for proposed and final
rules with ‘‘Federal mandates’’ that may
result in expenditures by State, local or
tribal governments, in the aggregate, or
the private sector, of $100 million or
more in any one year. When such a
statement is needed for a rule, Section
205 of the UMRA generally requires the
Department to identify and consider a
reasonable number of regulatory

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alternatives and adopt the most cost
effective or least burdensome alternative
that achieves the objectives of the rule.
This final rule contains no Federal
mandates (under the regulatory
provisions of Title II of the UMRA) for
State, local and tribal governments or
the private sector of $100 million or
more in any one year. Thus, the rule is
not subject to the requirements of
sections 202 and 205 of the UMRA.
Executive Order 12372
The WIC Program is listed in the
Catalog of Federal Domestic Assistance
Programs under 10.557. For the reasons
set forth in the final rule in 7 CFR part
3015, subpart V, and related Notice (48
FR 29115, June 24, 1983), this program
is included in the scope of Executive
Order 12372 which requires
intergovernmental consultation with
State and local officials.
Federalism Summary Impact Statement
Executive Order 13132 requires
Federal agencies to consider the impact
of their regulatory actions on State and
local governments. Where such actions
have federalism implications, agencies
are directed to provide a statement for
inclusion in the preamble to the
regulations describing the agency’s
considerations in terms of the three
categories called for under Section
(6)(b)(2)(B) of Executive Order 13121.
Prior Consultation With State Officials
Since publication of the interim rule
revising the WIC food packages, FNS
has obtained input from WIC State and
local agency staff about the provisions
and implementation of the changes.
Examples of the different forums and
methods FNS has used to solicit WIC
State and local agency staff input on the
WIC food packages include the
following:
• Hosting annual meetings of the
National Advisory Council on Maternal,
Infant and Fetal Nutrition that includes
WIC staff as members of the Council; the
Council develops recommendations for
FNS on how to improve operations of
WIC, including aspects related to the
authorized foods and food packages;
• Consulting and collaborating with
the National WIC Association (NWA) on
a wide variety of WIC issues, including
those related to the WIC food packages.
NWA is a non-profit organization that
was founded in 1983 by State and local
agencies that administer the WIC
Program. NWA’s paid membership
includes 72 of the 90 WIC State
agencies, 813 local agencies, 7 State
WIC Associations, and 27 sustaining
members (i.e., for-profit and non-profit
businesses or organizations).

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Functioning as a coalition of WIC
agencies, NWA is dedicated to
maximizing WIC resources through
effective management practices. NWA
also serves in a leadership role for WIC
agencies by developing position papers
on issues of concern to the WIC
community; and
• Regular meetings and consultation
with State health officials and other
WIC stakeholders, including the
medical community, advocacy groups,
and retailers.
Nature of Concerns and the Need To
Issue This Rule
This final rule considers public
comments submitted in response to the
interim rule revising the WIC food
packages published in December 2007
(72 FR 68966). The interim rule
implemented the first comprehensive
revisions to the WIC food packages
since 1980. This final rule addresses
public comments received on the
interim rule and makes adjustments that
improve clarity of the provisions set
forth in the interim rule.
Extent to Which We Meet Those
Concerns
FNS has considered the impact of
final rule on State and local agencies.
FNS believes that the rule is responsive
to the expressed concerns and requests
of commenters representing State and
local concerns.
Executive Order 12988
This final rule has been reviewed
under Executive Order 12988, Civil
Justice Reform. This final rule is not
intended to have preemptive effect with
respect to any State or local laws,
regulations or policies which conflict
with its provisions or which would
otherwise impede its full and timely
implementation. This rule is not
intended to have retroactive effect
unless so specified in the DATES
section of the final rule. Prior to any
judicial challenge to the provisions of
the final rule, all applicable
administrative procedures must be
exhausted.
Civil Rights Impact Analysis
The intent of this final rulemaking is
not to limit participation or to have an
adverse effect on current participants.
FNS does not expect any protected
populations to be adversely affected by
the implementation of the requirements
in this rule. State agencies must ensure
participant access to supplemental
foods. The foods available to WIC
participants as a result of this final rule
are intended to broaden the appeal of
the WIC food packages for all groups

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and encourage participation in WIC.
This final rule revises certain provisions
to better address the needs of
participants with certain medical
conditions, and provides State agencies
increased flexibility in prescribing
culturally appropriate packages for
diverse groups. FNS does not anticipate
this rulemaking will result in any
adverse civil rights impacts.
Executive Order 13175
Executive Order 13175 requires
Federal agencies to consult and
coordinate with tribes on a governmentto-government basis on policies that
have tribal implications, including
regulations, legislative comments or
proposed legislation, and other policy
statements or actions that have
substantial direct effects on one or more
Indian tribes, on the relationship
between the Federal Government and
Indian tribes, or on the distribution of
power and responsibilities between the
Federal Government and Indian tribes.
In late 2010 and early 2011, USDA
engaged in a series of consultative
sessions to obtain input by Tribal
officials or their designees concerning
the impact of this rule on the tribe or
Indian Tribal governments, or whether
this rule may preempt Tribal law. USDA
did not receive any input during these
sessions that this rule preempts any
Tribal law. Input received relative to
this rule included overall satisfaction
with the new WIC foods, especially the
fruits and vegetables and whole grains,
and changes related to supporting
breastfeeding mothers. Some tribes
reported that WIC participants who
were enrolled in WIC during the
transition from the previous food
packages to the revised food packages
expressed displeasure with issuance of
lower fat milks and less cheese. The
input from Indian tribes during these
sessions was consistent with the general
comments received for the interim rule,
and have been addressed in this final
rule. Reports from these consultations
will be made part of the USDA annual
reporting on Tribal Consultation and
Collaboration. USDA will respond in a
timely and meaningful manner to all
Tribal government requests for
consultation concerning this rule and
will provide additional venues, such as
webinars and teleconferences, to
periodically host collaborative
conversations with Tribal officials or
their designees concerning ways to
improve this rule in Indian country.
Paperwork Reduction Act of 1995
The Paperwork Reduction Act of 1995
(44 U.S.C. Chap. 35; see 5 CFR 1320)
requires that the Office of Management

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and Budget (OMB) approve all
collections of information by a Federal
agency before they can be implemented.
Respondents are not required to respond
to any collection of information unless
it displays a current valid OMB control
number. This final rule changes the
information collection burden
previously approved under OMB 0584–
0545. Implementation of the data
collection requirements resulting from
this final rule is contingent upon OMB
approval under the Paperwork
Reduction Act of 1995.
The proposed food package rule was
published in the Federal Register [71
FR 44784] with a 60-day notice on
August 7, 2006, which provided the
public an opportunity to submit
comments on the information collection
burden resulting from the proposed
rule. FNS received no public comments
in response to this solicitation. On
November 1, 2006, OMB filed comment
in accordance with 5 CFR 1320.11(c),
requiring FNS to review public
comments in response to the proposed
rule and address any such comments in
the preamble of the final rule.
The interim food package rule was
published in the Federal Register [72
FR 68966] on December 6, 2007, and
included an estimated annual
information collection burden of 14,919
burden hours, which was approved as
OMB Number 0584–0545. These
information collection burden hours
were merged into the information
collection, WIC Program Reporting and
Recordkeeping Requirements, OMB
Number 0584–0043, changing the total
approved burden hours for OMB
Number 0584–0043 from 3,595,075 to
3,609,994. Information collection OMB
Number 0584–0545 was then
discontinued. Information collection
OMB Number 0584–0043 was renewed
as of December 27, 2012, changing the
total approved burden hours from
3,609,994 to 4,024,697.
In this final rule, FNS will no longer
require a health care professional
licensed to write medical prescriptions
to provide documentation for children
to receive soy-based beverage and tofu
as milk substitutes. Also, FNS will no
longer require documentation from a
health care professional licensed to
write medical prescriptions for women
to receive tofu in excess of the
maximum substitution allowance. As a
result of this final rulemaking, the
overall information collection burden
associated with OMB Number 0584–
0043 is estimated to have decreased by
4,200 burden hours annually due to
program changes in this rulemaking.
The total estimated burden hours for

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OMB Number 0584–0043 will decrease
from 4,024,697 to 4,020,497.
The breakdown of the changes is
described below:
OMB Number 0584–0043;
WIC Program Reporting and
Recordkeeping Requirements;
expiration date December 31, 2015.
Type of Request: Revision of a
currently approved collection.
Abstract: Federal regulations at 7 CFR
246.10(d)(1)(vi) and (viii) require
medical documentation for the issuance
of soy-based beverage and tofu for
children, and tofu above the maximum
substitution amount for women. Federal
regulations at 7 CFR 246.10(d)(1)(v)
require medical documentation for the
issuance of supplemental foods to
participants who receive Food Package
III (for participants with qualifying
conditions).
Under the interim rule, medical
documentation by a health care
professional licensed to write medical
prescriptions is required for the
issuance of certain milk alternatives for
children and women. A total of 180
comment letters (53 of these form
letters) opposed this requirement,
primarily the documentation for
children to receive soy-based beverage.
Commenters stated that the provision is
unnecessary, costly and burdensome for
participants and physicians, creates
barriers to services, and undermines
FNS’ efforts to provide foods that meet
the cultural needs of participants. The
NWA and the American Dietetic
Association (now known as the
Academy of Nutrition and Dietetics)
stressed that WIC dietitians and
nutritionists are health professionals
trained and capable of doing a complete
nutrition assessment, selecting WIC
foods, and providing appropriate
education to participants and caregivers,
in consultation with the health care
provider when warranted.
Based on the experiences cited by
WIC State and local agencies related to
medical documentation throughout
implementation of the new food
packages, FNS will no longer require a
health care professional licensed to
write medical prescriptions to provide
documentation for children to receive
soy-based beverage and tofu as milk
substitutes. Also, FNS will no longer
require documentation from a health
care professional licensed to write
medical prescriptions for women to
receive tofu in excess of the maximum
substitution allowance.
Estimate of Burden
This final rule amends the
supplemental foods that require medical
documentation as described in 7 CFR

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246.10(d)(1) However, medical
documentation continues to be required
for issuance of supplemental foods in
Food Package III. After revising to
reflect the changes made by this final
rule, the total annual reporting and
recordkeeping burden estimated for
medical documentation is decreased by
4,200 hours.
FNS estimates that approximately 1
percent of participants (89,606) will be
issued supplemental foods under Food
Package III. FNS estimates that it will
take three minutes (0.05 hours) for the
documentation required to issue the
authorized foods, thus resulting in an
estimated reporting burden for
participants of 8,961 hours (89,606 total
participants × 0.05 person hours × 2
certification periods per year). This
results in a decrease in the approved
reporting burden under OMB 0584–
0043 for participants providing medical
documentation for supplemental foods
from 13,160 burden hours to 8,961
burden hours (a decrease of 4,200
burden hours).
FNS will submit an Information
Collection Request clearance package to
OMB based on the provisions of this
final rule. These amended information
collection requirements will not become
effective until approved by OMB. When
OMB has approved these information
collection requirements, FNS will
publish separate action in the Federal
Register announcing OMB approval.
E-Government Act Compliance
The Food and Nutrition Service is
committed to complying with the EGovernment Act, 2002, to promote the
use of the Internet and other
information technologies to provide
increased opportunities for citizen
access to Government information and
services, and for other purposes.
List of Subjects in 7 CFR Part 246

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Administrative practice and
procedure, Civil rights, Food assistance
programs, Grant programs-health, Grant
programs-social programs, Indians,
Infants and children, Maternal and child
health, Nutrition, Penalties, Reporting
and recordkeeping requirements,
Women.
■ For reasons set forth in the preamble,
7 CFR Part 246 is amended as follows:
PART 246—SPECIAL SUPPLEMENTAL
NUTRTION PROGRAM FOR WOMEN,
INFANTS AND CHILDREN
1. The authority citation for 7 CFR
part 246 continues to read as follows:

■

Authority: 42 U.S.C. 1786.
■

2. In § 246.2:

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a. Add a definition for ‘‘Farmers’
market’’ in alphabetical order;
■ b. Add a definition for ‘‘Full nutrition
benefit’’ in alphabetical order;
■ c. Remove the definition heading
‘‘WIC-eligible medical foods’’ and add
in its place ‘‘WIC-eligible nutritionals
for participants with qualifying
conditions (hereafter referred to as
‘‘WIC-eligible nutritionals)’’; and
■ d. Remove the term ‘‘WIC-eligible
medical foods’’ and add in its place the
term ‘‘WIC-eligible nutritionals’’
wherever it appears.
■ The revisions and additions read as
follows:
■

§ 246.2

Definitions.

*
*
*
*
Farmers’ market means an association
of local farmers who assemble at a
defined location for the purpose of
selling their produce directly to
consumers.
*
*
*
*
*
Full nutrition benefit means the
minimum amount of reconstituted fluid
ounces of liquid concentrate infant
formula as specified in Table 1 of
§ 246.10(e)(9) for each food package
category and infant feeding variation
(e.g., Food Package IA fully formula fed,
IA–FF).
*
*
*
*
*
■ 3. In § 246.4:
■ a. Amend paragraph (a)(11)(iii) by
removing ‘‘§ 246.10(b)(1)’’ and adding in
its place ‘‘§ 246.10(b)(2)(i)’’.
■ b. Revise paragraph (a)(14)(iii);
■ c. Redesignate paragraphs (a)(14)(v)
through (xvii) as paragraphs (vi) through
(xviii) and add a new paragraph
(a)(14)(v);
■ d. Amend newly designated
paragraph (a)(14)(vi) by removing
‘‘§ 246.12(k)(1)(i)’’ and adding in its
place ‘‘§ 246.12(l)(1)(i)’’;
■ e. Revise newly designated paragraph
(a)(14)(xii); and
■ f. Amend paragraph (a)(18) by
removing the words ‘‘and food vendors’’
and adding in their place the phrase ‘‘,
food vendors, farmers and farmers’
markets’’.
The revisions and additions read as
follows:
§ 246.4

State plan.

(a) * * *
(14) * * *
(iii) A sample vendor, farmer and/or
farmers’ market, if applicable,
agreement. The sample vendor
agreement must include the sanction
schedule, the process for notification of
violations in accordance with
§ 246.12(l)(3), and the State agency’s
policies and procedures on incentive
items in accordance with

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§ 246.12(g)(3)(iv), which may be
incorporated as attachments or, if the
sanction schedule, the process for
notification of violations, or policies on
incentive items are in the State agency’s
regulations, through citations to the
regulations. State agencies that intend to
delegate signing of vendor, farmer and/
or farmers’ market agreements to local
agencies must describe the State agency
supervision and instruction that will be
provided to ensure the uniformity and
quality of local agency activities;
*
*
*
*
*
(v) Farmer monitoring. The system for
monitoring farmers and/or farmers’
markets within its jurisdiction, if
applicable, for compliance with
program requirements;
*
*
*
*
*
(xii) Vendor, farmer and/or farmers’
market training. The procedures the
State agency will use to train vendors
(in accordance with § 246.12(i)), farmers
and/or farmers’ markets (in accordance
with § 246.12(v)). State agencies that
intend to delegate any aspect of training
to a local agency, contractor, vendor or
farmer representative must describe the
supervision and instructions that will be
provided by the State agency to ensure
the uniformity and quality of vendor,
farmer and/or farmers’ market training;
*
*
*
*
*
■ 4. In § 246.10:
■ a. Remove the term ‘‘WIC-eligible
medical food’’ and add in its place the
term ‘‘WIC-eligible nutritional’’
wherever it appears; and remove the
term ‘‘WIC-eligible medical foods’’ and
replace it with ‘‘WIC-eligible
nutritionals’’ wherever it appears;
■ b. Revise paragraph (b)(1)(i);
■ c. Amend paragraph (b)(2)(ii)(C) by
removing the words ‘‘age and’’ before
‘‘nutritional’’ and adding the words
‘‘and breastfeeding’’ after ‘‘nutritional’’;
■ d. Amend paragraph (d)(1)(ii) by
removing the phrase ‘‘a child’’ and
adding in its place the phrase ‘‘an
infant, child,’’;
■ e. Remove paragraphs (d)(1)(vi)
through (d)(1)(viii);
■ f. Redesignate paragraph (d)(1)(ix) as
(d)(1)(vi);
■ g. Revise the heading of paragraph
(d)(2);
■ h. Amend paragraph (d)(2)(ii) by
adding a space between ‘‘formula’’ and
‘‘and’’;
■ i. Revise paragraph (d)(3)(i);
■ j. Revise paragraph (d)(4)(ii)(D);
■ k. Revise paragraphs (e) introductory
text through (e)(1)(iii);
■ l. Revise paragraph (e)(1)(v);
■ m. Revise paragraph (e)(2)(ii);
■ n. Revise paragraph (e)(2)(iv);
■ o. Revise paragraph (e)(3)(v);

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p. Revise paragraphs (e)(4)(ii) through
(e)(7)(ii); and
■ q. Revise paragraphs (e)(9) through
(e)(12).
The revisions and additions read as
follows:
■

§ 246.10

Supplemental foods.

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*
*
*
*
(b) * * *
(1) * * *
(i) Establish criteria in addition to the
minimum Federal requirements in Table
4 of paragraph (e)(12) of this section for
the supplemental foods in their States,
except that the State agency may not
selectively choose which eligible fruits
and vegetables are available to
participants. These State agency criteria
could address, but not be limited to,
other nutritional standards, competitive
cost, State-wide availability, and
participant appeal. For eligible fruits
and vegetables, State agencies may
restrict packaging, e.g., plastic
containers, and package sizes, such as
single serving, of processed fruits and
vegetables available for purchase with
the cash-value voucher. In addition,
State agencies may identify certain
processed WIC-eligible fruits and
vegetables on food lists where the
potential exists for vendor or participant
confusion in determining authorized
WIC-eligible items.
*
*
*
*
*
(d) * * *
(2) Medical documentation for other
supplemental foods. * * *
(3) * * *
(i) Made a medical determination that
the participant has a qualifying
condition as described in paragraphs
(e)(1) through (e)(7) of this section that
dictates the use of the supplemental
foods, as described in paragraph (d)(1)
of this section; and
*
*
*
*
*
(4) * * *
(ii) * * *
(D) The qualifying condition(s) for
issuance of the authorized supplemental
food(s) requiring medical
documentation, as described in
paragraphs (e)(1) through (e)(7) of this
section; and
*
*
*
*
*
(e) Food packages. There are seven
food packages available under the
Program that may be provided to
participants. The authorized
supplemental foods must be prescribed
from food packages according to the
category and nutritional needs of the
participants. Breastfeeding assessment
and the mother’s plans for breastfeeding
serve as the basis for determining food
package issuance for all breastfeeding

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women. The intent of the WIC Program
is that all breastfeeding women be
supported to exclusively breastfeed
their infants and to choose the fully
breastfeeding food package without
infant formula. Breastfeeding mothers
whose infants receive formula from WIC
are to be supported to breastfeed to the
maximum extent possible with minimal
supplementation with infant formula.
Formula amounts issued to breastfed
infants are to be tailored to meet but not
exceed the infant’s nutritional needs.
The seven food packages are as follows:
(1) Food Package I—Infants birth
through 5 months.—(i) Participant
category served. This food package is
designed for issuance to infant
participants from birth through age 5
months who do not have a condition
qualifying them to receive Food Package
III. The following infant feeding
variations are defined for the purposes
of assigning food quantities and types in
Food Packages I: Fully breastfeeding
(the infant doesn’t receive formula from
the WIC Program); partially (mostly)
breastfeeding (the infant is breastfed but
also receives infant formula from WIC
up to the maximum allowance
described for partially (mostly) breastfed
infants in Table 1 of paragraph (e)(9) of
this section; and fully formula fed (the
infant is not breastfed or is breastfed
minimally (the infant receives infant
formula from WIC in quantities that
exceed those allowed for partially
(mostly) breastfed infants).
(ii) Infant feeding age categories.—(A)
Birth to one month. Two infant food
packages are available during the first
month after birth—fully breastfeeding
and fully formula-feeding. State
agencies also have the option to make
available a third food package
containing not more than one can of
powder infant formula in the container
size that provides closest to 104
reconstituted fluid ounces to breastfed
infants on a case-by-case basis. The
infant receiving this food package is
considered partially breastfeeding. State
agencies choosing to make available a
partially breastfeeding package in the
first month may not standardize
issuance of this food package. Infant
formula may not be routinely provided
during the first month after birth to
breastfed infants in order to support the
successful establishment of
breastfeeding.
(B) One through 5 months. Three
infant food packages are available from
1 months through 5 months—fully
breastfeeding, partially (mostly)
breastfeeding, or fully formula-fed.
(iii) Infant formula requirements. This
food package provides iron-fortified
infant formula that is not an exempt

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infant formula and that meets the
requirements in Table 4 of paragraph
(e)(12) of this section. The issuance of
any contract brand or noncontract brand
infant formula that contains less than 10
milligrams of iron per liter (at least 1.5
milligrams iron per 100 kilocalories) at
standard dilution is prohibited. Except
as specified in paragraph (d) of this
section, local agencies must issue as the
first choice of issuance the primary
contract infant formula, as defined in
§ 246.2, with all other infant formulas
issued as an alternative to the primary
contract infant formula. Noncontract
brand infant formula and any contract
brand infant formula that does not meet
the requirements in Table 4 of
paragraph (e)(12) of this section may be
issued in this food package only with
medical documentation of the
qualifying condition. A health care
professional licensed by the State to
write prescriptions must make a
medical determination and provide
medical documentation that indicates
the need for the infant formula. For
situations that do not require the use of
an exempt infant formula, such
determinations include, but are not
limited to, documented formula
intolerance, food allergy or
inappropriate growth pattern. Medical
documentation must meet the
requirements described in paragraph (d)
of this section.
*
*
*
*
*
(v) Authorized category of
supplemental foods. Infant formula is
the only category of supplemental foods
authorized in this food package. Exempt
infant formulas and WIC-eligible
nutritionals are authorized only in Food
Package III. The maximum monthly
allowances, allowed options and
substitution rates of supplemental foods
for infants in Food Packages I are stated
in Table 1 of paragraph (e)(9) of this
section.
(2) * * *
(ii) Infant food packages. Three food
packages for infants 6 through 11
months are available — fully
breastfeeding, partially (mostly)
breastfeeding, or fully formula fed.
*
*
*
*
*
(iv) Authorized categories of
supplemental foods. Infant formula,
infant cereal, and infant foods are the
categories of supplemental foods
authorized in this food package. The
maximum monthly allowances, allowed
options and substitution rates of
supplemental foods for infants in Food
Packages II are stated in Table 1 of
paragraph (e)(9) of this section.
*
*
*
*
*
(3) * * *

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(v) Authorized categories of
supplemental foods. The supplemental
foods authorized in this food package
require medical documentation for
issuance and include WIC formula
(infant formula, exempt infant formula,
and WIC-eligible nutritionals), infant
cereal, infant foods, milk, cheese, eggs,
canned fish, fresh fruits and vegetables,
breakfast cereal, whole wheat/whole
grain bread, juice, legumes and/or
peanut butter. The maximum monthly
allowances, allowed options and
substitution rates of supplemental foods
for infants in Food Package III are stated
in Table 1 of paragraph (e)(9) of this
section. The maximum monthly
allowances, allowed options, and
substitution rates of supplemental foods
for children and women in Food
Package III are stated in Table 3 of
paragraph (e)(11) of this section.
*
*
*
*
*
(4) * * *
(ii) Authorized categories of
supplemental foods. Milk, breakfast
cereal, juice, fresh fruits and vegetables,
whole wheat/whole grain bread, eggs,
and legumes or peanut butter are the
categories of supplemental foods
authorized in this food package. The
maximum monthly allowances, allowed
options and substitution rates of
supplemental foods for children in Food
Package IV are stated in Table 2 of
paragraph (e)(10) of this section.
(5) Food Package V—Pregnant and
partially (mostly) breastfeeding
women.—(i) Participant category served.
This food package is designed for
issuance to women participants with
singleton pregnancies who do not have
a condition qualifying them to receive
Food Package III. This food package is
also designed for issuance to partially
(mostly) breastfeeding women
participants, up to 1 year postpartum,
who do not have a condition qualifying

them to receive Food Package III and
whose partially (mostly) breastfed
infants receive formula from the WIC
program in amounts that do not exceed
the maximum allowances described in
Table 1 of paragraph (e)(9) of this
section. Women participants partially
(mostly) breastfeeding more than one
infant from the same pregnancy,
pregnant women fully or partially
breastfeeding singleton infants, and
women participants pregnant with two
or more fetuses, are eligible to receive
Food Package VII as described in
paragraph (e)(7) of this section.
(ii) Authorized categories of
supplemental foods. Milk, breakfast
cereal, juice, fresh fruits and vegetables,
whole wheat/whole grain bread, eggs,
legumes and peanut butter are the
categories of supplemental foods
authorized in this food package. The
maximum monthly allowances, allowed
options and substitution rates of
supplemental foods for women in Food
Package V are stated in Table 2 of
paragraph (e)(10) of this section.
(6) Food Package VI—Postpartum
women.—(i) Participant category served.
This food package is designed for
issuance to women up to 6 months
postpartum who are not breastfeeding
their infants, and to breastfeeding
women up to 6 months postpartum
whose participating infant receives
more than the maximum amount of
formula allowed for partially (mostly)
breastfed infants as described in Table
1 of paragraph (e)(9) of this section, and
who do not have a condition qualifying
them to receive Food Package III.
(ii) Authorized categories of
supplemental foods. Milk, breakfast
cereal, juice, fresh fruits and vegetables,
eggs, and legumes or peanut butter are
the categories of supplemental foods
authorized in this food package. The
maximum monthly allowances, allowed

options and substitution rates of
supplemental foods for women in Food
Package VI are stated in Table 2 of
paragraph (e)(10) of this section.
(7) Food Package VII—Fully
breastfeeding.—(i) Participant category
served. This food package is designed
for issuance to breastfeeding women up
to 1 year postpartum whose infants do
not receive infant formula from WIC
(these breastfeeding women are
assumed to be exclusively breastfeeding
their infants), and who do not have a
condition qualifying them to receive
Food Package III. This food package is
also designed for issuance to women
participants pregnant with two or more
fetuses, women participants partially
(mostly) breastfeeding multiple infants
from the same pregnancy, and pregnant
women who are also partially (mostly)
breastfeeding singleton infants, and who
do not have a condition qualifying them
to receive Food Package III. Women
participants fully breastfeeding multiple
infants from the same pregnancy receive
1.5 times the supplemental foods
provided in Food Package VII.
(ii) Authorized categories of
supplemental foods. Milk, cheese,
breakfast cereal, juice, fresh fruits and
vegetables, whole wheat/whole grain
bread, eggs, legumes, peanut butter, and
canned fish are the categories of
supplemental foods authorized in this
food package. The maximum monthly
allowances, allowed options and
substitution rates of supplemental foods
for women in Food Package VII are
stated in Table 2 of paragraph (e)(10) of
this section.
*
*
*
*
*
(9) Full nutrition benefit and
maximum monthly allowances, options
and substitution rates of supplemental
foods for infants in Food Packages I, II
and III are stated in Table 1 as follows:

TABLE 1—FULL NUTRITION BENEFIT (FNB) AND MAXIMUM MONTHLY ALLOWANCES (MMA) OF SUPPLEMENTAL FOODS FOR
INFANTS IN FOOD PACKAGES I, II AND III
Fully formula fed (FF)

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Foods 1

WIC Formula

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45678

Partially (mostly) breastfed (BF/FF)

Food Packages
I–FF &
III–FF
A: 0 through 3
months
B: 4 through 5
months

Food Packages
II–FF &
III–FF
6 through 11
months

A: FNB=806 fl oz,
MMA=823 fl oz,
reconstituted liquid concentrate or
832 fl. oz. RTF or
870 fl oz reconstituted powder.

FNB=624 fl oz,
MMA=630 fl oz,
reconstituted liquid concentrate.
or 643 fl. oz RTF or
696 fl oz reconstituted powder.

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Food Packages
I–BF/FF & III BF/FF
(A: 0 to 1 month 2 3)
B: 1 through 3
months
C: 4 through 5
months
A: 104 fl oz reconstituted powder.
B: FNB=364 fl oz,
MMA=388 fl oz,
reconstituted liquid concentrate or
384 fl oz RTF or
435 fl oz reconstituted powder.

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Food Packages
II–BF/FF & III
BF/FF
6 through 11
months
FNB=312 fl oz,
MMA=315 fl oz,
reconstituted liquid concentrate or
338 fl oz RTF or
384 fl oz reconstituted powder.

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Fully breastfed (BF)
Food
Package
I–BF
0 through 5
months

Food
Package
II–BF
6 through 11
months

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TABLE 1—FULL NUTRITION BENEFIT (FNB) AND MAXIMUM MONTHLY ALLOWANCES (MMA) OF SUPPLEMENTAL FOODS FOR
INFANTS IN FOOD PACKAGES I, II AND III—Continued
Fully formula fed (FF)
Food Packages
I–FF &
III–FF
A: 0 through 3
months
B: 4 through 5
months

Foods 1

Partially (mostly) breastfed (BF/FF)
Food Packages
I–BF/FF & III BF/FF
(A: 0 to 1 month 2 3)
B: 1 through 3
months
C: 4 through 5
months

Food Packages
II–FF &
III–FF
6 through 11
months

Fully breastfed (BF)

Food Packages
II–BF/FF & III
BF/FF
6 through 11
months

Food
Package
I–BF
0 through 5
months

Food
Package
II–BF
6 through 11
months

24 oz ......................
128 oz ....................

......................
......................

24 oz.
256 oz.

................................

......................

77.5 oz.

B: FNB=884 fl oz,
MMA=896 fl oz,
reconstituted liquid concentrate or
913 fl oz RTF or
960 fl oz reconstituted powder.

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Infant Cereal 9 11 .......
Infant food fruits and
vegetables
9 10 11 12 13.
Infant food meat 9 ....

................................
................................

24 oz ......................
128 oz ....................

C: FNB=442 fl oz,
MMA=460 fl oz,
reconstituted liquid concentrate or
474 fl oz RTF or
522 fl oz reconstituted powder.
................................
................................

................................

Table 1 footnotes: (Abbreviations in order of appearance in table): FF = fully formula fed; BF/FF = partially (mostly) breastfed; BF = fully
breastfed; RTF = Ready-to-feed; N/A = the supplemental food is not authorized in the corresponding food package.
1 Table 4 of paragraph (e)(12) of this section describes the minimum requirements and specifications for the supplemental foods. The competent professional authority (CPA) is authorized to determine nutritional risk and prescribe supplemental foods as established by State agency
policy in Food Packages I and II. In Food Package III, the CPA, as established by State agency policy, is authorized to determine nutritional risk
and prescribe supplemental foods per medical documentation.
2 State agencies have the option to issue not more than one can of powder infant formula in the container size that provides closest to 104 reconstituted fluid ounces to breastfed infants on a case-by-case basis.
3 Liquid concentrate and ready-to-feed (RTF) may be substituted at rates that provide comparable nutritive value.
4 WIC formula means infant formula, exempt infant formula, or WIC-eligible nutritionals. Infant formula may be issued for infants in Food Packages I, II and III. Medical documentation is required for issuance of infant formula, exempt infant formula, WIC-eligible nutritionals, and other supplemental foods in Food Package III. Only infant formula may be issued for infants in Food Packages I and II.
5 The full nutrition benefit is defined as the minimum amount of reconstituted fluid ounces of liquid concentrate infant formula as specified for
each infant food package category and feeding variation (e.g., Food Package IA-fully formula fed).
6 The maximum monthly allowance is specified in reconstituted fluid ounces for liquid concentrate, RTF liquid, and powder forms of infant formula and exempt infant formula. Reconstituted fluid ounce is the form prepared for consumption as directed on the container.
7 State agencies must provide at least the full nutrition benefit authorized to non-breastfed infants up to the maximum monthly allowance for
the physical form of the product specified for each food package category. State agencies must issue whole containers that are all the same size
of the same physical form. Infant formula amounts for breastfed infants, even those in the fully formula fed category should be individually tailored to the amounts that meet their nutritional needs.
8 State agencies may round up and disperse whole containers of infant formula over the food package timeframe to allow participants to receive the full nutrition benefit. State agencies must use the methodology described in accordance with paragraph (h)(1) of this section.
9 State agencies may round up and disperse whole containers of infant foods (infant cereal, fruits and vegetables, and meat) over the Food
Package timeframe. State agencies must use the methodology described in accordance with paragraph (h)(2) of this section.
10 At State agency option, for infants 6–12 months of age, fresh banana may replace up to 16 ounces of infant food fruit at a rate of 1 pound of
bananas per 8 ounces of infant food fruit. State agencies may also substitute fresh bananas at a rate of 1 banana per 4 ounces of jarred infant
food fruit, up to a maximum of 16 ounces.
11 In lieu of infant foods (cereal, fruit and vegetables), infants greater than 6 months of age in Food Package III may receive infant formula, exempt infant formula or WIC-eligible nutritionals at the same maximum monthly allowance as infants ages 4 through 5 months of age of the same
feeding option.
12 At State agency option, infants 9 months through 11 months in Food Packages II and III may receive a cash-value voucher to purchase
fresh (only) fruits and vegetables in lieu of a portion of the infant food fruits and vegetables. Partially (mostly) breastfed infants and fully formula
fed infants may receive a $4 cash-value voucher plus 64 ounces of infant food fruits and vegetables; fully breastfeeding infants may receive a $8
cash-value voucher plus 128 ounces of infant food fruit and vegetables.
13 State agencies may not categorically issue cash-value vouchers for infants 9 months through 11 months. The cash-value voucher is to be
provided to the participant only after an individual nutrition assessment, as established by State agency policy, and is optional for the participant,
i.e., the mother may choose to receive either the maximum allowance of jarred foods or a combination of jarred foods and a fruit and vegetable
cash-value voucher for her infant. State agencies must ensure that appropriate nutrition education is provided to the caregiver addressing safe
food preparation, storage techniques, and feeding practices to make certain participants are meeting their nutritional needs in a safe and effective manner.

(10) Maximum monthly allowances of
supplemental foods in Food Packages
IV through VII. The maximum monthly

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TABLE 2—MAXIMUM MONTHLY ALLOWANCES OF SUPPLEMENTAL FOODS FOR CHILDREN AND WOMEN IN FOOD PACKAGES
IV, V, VI AND VII
Children
Foods 1

Juice, single strength 6 .............
Milk, fluid ...................................
Breakfast cereal 13 ....................
Cheese .....................................
Eggs ..........................................
Fresh fruits and vegetables 14 15

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Whole wheat or whole grain
bread 16.
Fish (canned) ............................
Legumes, dry 17 and/or Peanut
butter.

Women

Food Package IV: 1
through 4 years

Food Package V: Pregnant and Partially
(Mostly) Breastfeeding
(up to 1 year
postpartum) 2

Food Package VI:
Postpartum (up to 6
months postpartum) 3

128 fl oz ..........................
16 qt 7 8 9 10 11 ...................
36 oz ...............................
N/A ..................................
1 dozen ...........................
$8.00 in cash-value
vouchers.
2 lb ..................................

144 fl oz ..........................
22 qt 7 8 9 10 12 ...................
36 oz ...............................
N/A ..................................
1 dozen ...........................
$10.00 in cash-value
vouchers.
1 lb ..................................

96 fl oz ............................
16 qt 7 8 9 10 12 ...................
36 oz ...............................
N/A ..................................
1 dozen ...........................
$10.00 in cash-value
vouchers.
N/A ..................................

144 fl oz.
24 qt 7 8 9 10 12.
36 oz.
1 lb.
2 dozen.
$10.00 in cash-value
vouchers.
1 lb.

N/A ..................................
1 lb or 18 oz ....................

N/A ..................................
1 lb and 18 oz .................

N/A ..................................
1 lb or 18 oz ....................

30 oz.
1 lb and 18 oz.

Food Package VII: Fully
Breastfeeding (up to 1
year post-partum) 4 5

Table 2 Footnotes: N/A = the supplemental food is not authorized in the corresponding food package.
1 Table 4 of paragraph (e)(12) of this section describes the minimum requirements and specifications for the supplemental foods. The competent professional authority (CPA) is authorized to determine nutritional risk and prescribe supplemental foods as established by State agency
policy.
2 Food Package V is issued to two categories of WIC participants: Women participants with singleton pregnancies; breastfeeding women
whose partially (mostly) breastfed infants receive formula from the WIC Program in amounts that do not exceed the maximum formula allowances, as appropriate for the age of the infant as described in Table 1 of paragraph (e)(9) of this section.
3 Food Package VI is issued to two categories of WIC participants: Non-breastfeeding postpartum women and breastfeeding postpartum
women whose infants receive more than the maximum infant formula allowances, as appropriate for the age of the infant as described in Table 1
of paragraph (e)(9) of this section.
4 Food Package VII is issued to four categories of WIC participants: Fully breastfeeding women whose infants do not receive formula from the
WIC Program; women pregnant with two or more fetuses; women partially (mostly) breastfeeding multiple infants from the same pregnancy; and
pregnant women who are also fully or partially (mostly) breastfeeding singleton infants.
5 Women fully breastfeeding multiple infants from the same pregnancy are prescribed 1.5 times the maximum allowances.
6 Combinations of single-strength and concentrated juices may be issued provided that the total volume does not exceed the maximum monthly allowance for single-strength juice.
7 Whole milk is the standard milk for issuance to 1-year-old children (12 through 23 months). At State agency option, fat-reduced milks may be
issued to 1-year-old children for whom overweight or obesity is a concern. The need for fat-reduced milks for 1-year-old children must be based
on an individual nutritional assessment and consultation with the child’s health care provider if necessary, as established by State agency policy.
Lowfat (1%) or nonfat milks are the standard milk for issuance to children ≥ 24 months of age and women. Reduced fat (2%) milk is authorized
only for participants with certain conditions, including but not limited to, underweight and maternal weight loss during pregnancy. The need for reduced fat (2%) milk for children ≥ 24 months of age (Food Package IV) and women (Food Packages V–VII) must be based on an individual nutritional assessment as established by State agency policy.
8 Evaporated milk may be substituted at the rate of 16 fluid ounces of evaporated milk per 32 fluid ounces of fluid milk or a 1:2 fluid ounce substitution ratio. Dry milk may be substituted at an equal reconstituted rate to fluid milk.
9 For children and women, cheese may be substituted for milk at the rate of 1 pound of cheese per 3 quarts of milk. For children and women in
Food Packages IV–VI, no more than 1 pound of cheese may be substituted. For fully breastfeeding women in Food Package VII, no more than 2
pounds of cheese may be substituted for milk. State agencies do not have the option to issue additional amounts of cheese beyond these maximums even with medical documentation. (No more than a total of 4 quarts of milk may be substituted for a combination of cheese, yogurt or tofu
for children and women in Food Packages IV–VI. No more than a total of 6 quarts of milk may be substituted for a combination of cheese, yogurt
or tofu for women in Food Package VII.)
10 For children and women, yogurt may be substituted for fluid milk at the rate of 1 quart of yogurt per 1 quart of milk; a maximum of 1 quart of
milk can be substituted. Additional amounts of yogurt are not authorized. Whole yogurt is the standard yogurt for issuance to 1-year-old children
(12 through 23 months). At State agency option, lowfat or nonfat yogurt may be issued to 1-year-old children for whom overweight and obesity is
a concern. The need for lowfat or nonfat yogurt for 1-year-old children must be based on an individual nutritional assessment and consultation
with the child’s health care provider if necessary, as established by State agency policy. Lowfat or nonfat yogurts are the only types of yogurt authorized for children ≥ 24 months of age and women. (No more than a total of 4 quarts of milk may be substituted for a combination of cheese,
yogurt or tofu for children and women in Food Packages IV–VI. No more than a total of 6 quarts of milk may be substituted for a combination of
cheese, yogurt or tofu for women in Food Package VII.)
11 For children, issuance of tofu and soy-based beverage as substitutes for milk must be based on an individual nutritional assessment and
consultation with the participant’s health care provider if necessary, as established by State agency policy. Such determination can be made for
situations that include, but are not limited to, milk allergy, lactose intolerance, and vegan diets. Soy-based beverage may be substituted for milk
for children on a quart for quart basis up to the total maximum allowance of milk. Tofu may be substituted for milk for children at the rate of 1
pound of tofu per 1 quart of milk. (No more than a total of 4 quarts of milk may be substituted for a combination of cheese, yogurt or tofu for children in Food Package IV.) Additional amounts of tofu may be substituted, up to the maximum allowance for fluid milk for lactose intolerance or
other reasons, as established by State agency policy.
12 For women, soy-based beverage may be substituted for milk on a quart for quart basis up to the total maximum allowance of milk. Tofu may
be substituted for milk at the rate of 1 pound of tofu per 1 quart of milk. (No more than a total of 4 quarts of milk may be substituted for a combination of cheese, yogurt or tofu for women in Food Packages V and VI. No more than a total of 6 quarts of milk may be substituted for a combination of cheese, yogurt or tofu for women in Food Package VII.). Additional amounts of tofu may be substituted, up to the maximum allowances for fluid milk, for lactose intolerance or other reasons, as established by State agency policy.
13 At least one-half of the total number of breakfast cereals on the State agency’s authorized food list must have whole grain as the primary ingredient and meet labeling requirements for making a health claim as a ‘‘whole grain food with moderate fat content’’ as defined in Table 4 of
paragraph (e)(12) of this section.

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14 Both fresh fruits and fresh vegetables must be authorized by State agencies. Processed fruits and vegetables, i.e., canned (shelf-stable), frozen, and/or dried fruits and vegetables may also be authorized to offer a wider variety and choice for participants. State agencies may choose to
authorize one or more of the following processed fruits and vegetables: canned fruit, canned vegetables, frozen fruit, frozen vegetables, dried
fruit, and/or dried vegetables. The cash-value voucher may be redeemed for any eligible fruit and vegetable (refer to Table 4 of paragraph
(e)(12) of this section and its footnotes). Except as authorized in paragraph (b)(1)(i) of this section, State agencies may not selectively choose
which fruits and vegetables are available to participants. For example, if a State agency chooses to offer dried fruits, it must authorize all WIC-eligible dried fruits.
15 The monthly value of the fruit/vegetable cash-value vouchers will be adjusted annually for inflation as described in § 246.16(j).
16 Whole wheat and/or whole grain bread must be authorized. State agencies have the option to also authorize brown rice, bulgur, oatmeal,
whole-grain barley, whole wheat macaroni products, or soft corn or whole wheat tortillas on an equal weight basis.
17 Canned legumes may be substituted for dry legumes at the rate of 64 oz. (e.g., four 16-oz cans) of canned beans for 1 pound dry beans. In
Food Packages V and VII, both beans and peanut butter must be provided. However, when individually tailoring Food Packages V or VII for nutritional reasons (e.g., food allergy, underweight, participant preference), State agencies have the option to authorize the following substitutions: 1
pound dry and 64 oz. canned beans/peas (and no peanut butter); or 2 pounds dry or 128 oz. canned beans/peas (and no peanut butter); or 36
oz. peanut butter (and no beans).

(11) Maximum monthly allowances of
supplemental foods for children and
women with qualifying conditions in

Food Package III. The maximum
monthly allowances, options and
substitution rates of supplemental foods

for participants with qualifying
conditions in Food Package III are stated
in Table 3 as follows:

TABLE 3—MAXIMUM MONTHLY ALLOWANCES (MMA) OF SUPPLEMENTAL FOODS FOR CHILDREN AND WOMEN WITH
QUALIFYING CONDITIONS IN FOOD PACKAGE III
Children
Foods 1
1 through 4 years
Juice, single strength 6 ........
WIC Formula 7 8 ...................
Milk ......................................
Breakfast cereal 15 16 ...........
Cheese ................................
Eggs ....................................
Fruits and vegetables 17 18 19

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Whole wheat or whole grain
bread 20.
Fish (canned) ......................
Legumes, dry 21 and/or Peanut butter.

Women

Pregnant and partially
breastfeeding (up to 1 year
postpartum) 2

Postpartum (up to 6 months
postpartum) 3

Fully breastfeeding, (up to 1
year post-partum) 4 5

128 fl oz .....................
455 fl oz liquid concentrate.
16 qt 9 10 11 12 13 ...........
36 oz ..........................
N/A .............................
1 dozen ......................
$8.00 in cash-value
vouchers.
2 lb .............................

144 fl oz ..............................
455 fl oz liquid concentrate

96 fl oz ................................
455 fl oz liquid concentrate

144 fl oz.
455 fl oz liquid concentrate.

22 qt 9 10 11 12 14 ....................
36 oz ...................................
N/A ......................................
1 dozen ...............................
$10.00 in cash-value vouchers.
1 lb ......................................

16 qt 9 10 11 12 14 ....................
36 oz ...................................
N/A ......................................
1 dozen ...............................
$10.00 in cash-value vouchers.
N/A ......................................

24 qt 9 10 11 12 14.
36 oz.
1 lb.
2 dozen.
$10.00 in cash-value vouchers.
1 lb.

N/A .............................
1 lb .............................
Or ...............................
18 oz ..........................

N/A ......................................
1 lb ......................................
And ......................................
18 oz ...................................

N/A ......................................
1 lb ......................................
Or ........................................
18 oz ...................................

30 oz.
1 lb.
And.
18 oz.

Table 3 Footnotes: N/A=the supplemental food is not authorized in the corresponding food package.
1 Table 4 of paragraph (e)(12) of this section describes the minimum requirements and specifications for the supplemental foods. The competent professional authority (CPA), as established by State agency policy, is authorized to determine nutritional risk and prescribe supplemental
foods per medical documentation.
2 This food package is issued to two categories of WIC participants: Women participants with singleton pregnancies and breastfeeding women
whose partially (mostly) breastfed infants receive formula from the WIC Program in amounts that do not exceed the maximum formula allowances as appropriate for the age of the infant as described in Table 1 of paragraph (e)(9) of this section.
3 This food package is issued to two categories of WIC participants: Non-breastfeeding postpartum women and breastfeeding postpartum
women whose breastfed infants receive more than the maximum infant formula allowances as appropriate for the age of the infant as described
in Table 1 of paragraph (e)(9) of this section.
4 This food package is issued to four categories of WIC participants: Fully breastfeeding women whose infants do not receive formula from the
WIC Program; women pregnant with two or more fetuses; women partially (mostly) breastfeeding multiple infants from the same pregnancy, and
pregnant women who are also partially (mostly) breastfeeding singleton infants.
5 Women fully breastfeeding multiple infants from the same pregnancy are prescribed 1.5 times the maximum allowances.
6 Combinations of single-strength and concentrated juices may be issued provided that the total volume does not exceed the maximum monthly allowance for single-strength juice.
7 WIC formula means infant formula, exempt infant formula, or WIC-eligible nutritionals.
8 Powder and ready-to-feed may be substituted at rates that provide comparable nutritive value.
9 Whole milk is the standard milk for issuance to 1-year-old children (12 through 23 months). Fat-reduced milks may be issued to 1-year old
children as determined appropriate by the health care provider per medical documentation. Lowfat (1%) or nonfat milks are the standard milks for
issuance for children ≥ 24 months of age and women. Whole milk or reduced fat (2%) milk may be substituted for lowfat (1%) or nonfat milk for
children ≥ 24 months of age and women as determined appropriate by the health care provider per medical documentation.
10 Evaporated milk may be substituted at the rate of 16 fluid ounces of evaporated milk per 32 fluid ounces of fluid milk or a 1:2 fluid ounce
substitution ratio. Dry milk may be substituted at an equal reconstituted rate to fluid milk.
11 For children and women, cheese may be substituted for milk at the rate of 1 pound of cheese per 3 quarts of milk. For children and women
in the pregnant, partially breastfeeding and postpartum food packages, no more than 1 pound of cheese may be substituted. For women in the
fully breastfeeding food package, no more than 2 pounds of cheese may be substituted for milk. State agencies do not have the option to issue
additional amounts of cheese beyond these maximums even with medical documentation. (No more than a total of 4 quarts of milk may be substituted for a combination of cheese, yogurt or tofu for children and women in the pregnant, partially breastfeeding and postpartum food packages. No more than a total of 6 quarts of milk may be substituted for a combination of cheese, yogurt or tofu for women in the fully breastfeeding
food package.)

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12 For children and women, yogurt may be substituted for fluid milk at the rate of 1 quart of yogurt per 1 quart of milk; a maximum of 1 quart of
milk can be substituted. Additional amounts of yogurt are not authorized. Whole yogurt is the standard yogurt for issuance to 1-year-old children
(12 through 23 months). Lowfat or nonfat yogurt may be issued to 1-year-old children (12 months to 23 months) as determined appropriate by
the health care provider per medical documentation. Lowfat or nonfat yogurts are the standard yogurt for issuance to children ≥ 24 months of
age and women. Whole yogurt may be substituted for lowfat or nonfat yogurt for children ≥ 24 months of age and women as determined appropriate by the health care provider per medical documentation. (No more than a total of 4 quarts of milk may be substituted for a combination of
cheese, yogurt or tofu for children and women in the pregnant, partially breastfeeding and postpartum food packages. No more than a total of 6
quarts of milk may be substituted for a combination of cheese, yogurt or tofu for women in the fully breastfeeding food package.)
13 For children, soy-based beverage and tofu may be substituted for milk as determined appropriate by the health care provider per medical
documentation. Soy-based beverage may be substituted for milk on a quart for quart basis up to the total maximum allowance of milk. Tofu may
be substituted for milk for children at the rate of 1 pound of tofu per 1 quart of milk. (No more than a total of 4 quarts of milk may be substituted
for a combination of cheese, yogurt or tofu for children.) Additional amounts of tofu may be substituted, up to the maximum allowance for fluid
milk for children, as determined appropriate by the health care provider per medical documentation.
14 For women, soy-based beverage may be substituted for milk on a quart for quart basis up to the total maximum monthly allowance of milk.
Tofu may be substituted for milk at the rate of 1 pound of tofu per 1 quart of milk. (No more than a total of 4 quarts of milk may be substituted for
a combination of cheese, yogurt or tofu for women in the pregnant, partially breastfeeding and postpartum food packages. No more than a total
of 6 quarts of milk may be substituted for a combination of cheese, yogurt or tofu for women in the fully breastfeeding food package.) Additional
amounts of tofu may be substituted, up to the maximum allowances for fluid milk, as determined appropriate by the health care provider per
medical documentation.
15 32 dry ounces of infant cereal may be substituted for 36 ounces of breakfast cereal as determined appropriate by the health care provider
per medical documentation.
16 At least one half of the total number of breakfast cereals on the State agency’s authorized food list must have whole grain as the primary ingredient and meet labeling requirements for making a health claim as a ‘‘whole grain food with moderate fat content’’ as defined in Table 4 of
paragraph (e)(12) of this section.
17 Both fresh fruits and fresh vegetables must be authorized by State agencies. Processed fruits and vegetables, i.e., canned (shelf-stable), frozen, and/or dried fruits and vegetables may also be authorized to offer a wider variety and choice for participants. State agencies may choose to
authorize one or more of the following processed fruits and vegetables: canned fruit, canned vegetables, frozen fruit, frozen vegetables, dried
fruit, and/or dried vegetables. The cash-value voucher may be redeemed for any eligible fruit and vegetable (refer to Table 4 of paragraph
(e)(12) of this section and its footnotes). Except as authorized in paragraph (b)(1)(i) of this section, State agencies may not selectively choose
which fruits and vegetables are available to participants. For example, if a State agency chooses to offer dried fruits, it must authorize all WIC-eligible dried fruits.
18 Children and women whose special dietary needs require the use of pureed foods may receive commercial jarred infant food fruits and
vegetables in lieu of the cash-value voucher. Children may receive 128 oz of commercial jarred infant food fruits and vegetables and women
may receive 160 oz of commercial jarred infant food fruits and vegetables in lieu of the cash-value voucher. Infant food fruits and vegetables
may be substituted for the cash-value voucher as determined appropriate by the health care provider per medical documentation.
19 The monthly value of the fruit/vegetable cash-value vouchers will be adjusted annually for inflation as described in § 246.16(j).
20 Whole wheat and/or whole grain bread must be authorized. State agencies have the option to also authorize brown rice, bulgur, oatmeal,
whole-grain barley, whole wheat macaroni products, or soft corn or whole wheat tortillas on an equal weight basis.
21 Canned legumes may be substituted for dry legumes at the rate of 64 oz. (e.g., four 16-oz cans) of canned beans for 1 pound dry beans. In
Food Packages V and VII, both beans and peanut butter must be provided. However, when individually tailoring Food Packages V or VII for nutritional reasons (e.g., food allergy, underweight, participant preference), State agencies have the option to authorize the following substitutions: 1
pound dry and 64 oz. canned beans/peas (and no peanut butter); or 2 pounds dry or 128 oz. canned beans/peas (and no peanut butter); or 36
oz. peanut butter (and no beans).

(12) Minimum requirements and
specifications for supplemental foods.

Table 4 describes the minimum
requirements and specifications for

supplemental foods in all food
packages:

TABLE 4—MINIMUM REQUIREMENTS AND SPECIFICATIONS FOR SUPPLEMENTAL FOODS
Categories/foods
WIC FORMULA:
Infant formula ................

Exempt infant formula ...

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WIC-eligible
nutritionals.1.

Minimum requirements and specifications

All authorized infant formulas must:
(1) Meet the definition for an infant formula in section 201(z) of the Federal Food, Drug, and Cosmetic Act (21
U.S.C. 321(z)) and meet the requirements for an infant formula under section 412 of the Federal Food, Drug
and Cosmetic Act, as amended (21 U.S.C. 350a) and the regulations at 21 CFR parts 106 and 107;
(2) Be designed for enteral digestion via an oral or tube feeding;
(3) Provide at least 10 mg iron per liter (at least 1.5 mg iron/100 kilocalories) at standard dilution;
(4) Provide at least 67 kilocalories per 100 milliliters (approximately 20 kilocalories per fluid ounce) at standard dilution.
(5) Not require the addition of any ingredients other than water prior to being served in a liquid state.
All authorized exempt infant formula must:
(1) Meet the definition and requirements for an exempt infant formula under section 412(h) of the Federal Food,
Drug, and Cosmetic Act as amended (21 U.S.C. 350a(h)) and the regulations at 21 CFR parts 106 and 107;
and
(2) Be designed for enteral digestion via an oral or tube feeding.
Certain enteral products that are specifically formulated to provide nutritional support for individuals with a qualifying condition, when the use of conventional foods is precluded, restricted, or inadequate. Such WIC-eligible
nutritionals must serve the purpose of a food, meal or diet (may be nutritionally complete or incomplete) and
provide a source of calories and one or more nutrients; be designed for enteral digestion via an oral or tube
feeding; and may not be a conventional food, drug, flavoring, or enzyme.

MILK AND MILK ALTERNATIVES:

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TABLE 4—MINIMUM REQUIREMENTS AND SPECIFICATIONS FOR SUPPLEMENTAL FOODS—Continued
Categories/foods
Cow’s milk 2 ......................

Goat’s milk ...........................

Cheese .................................

Yogurt (cow’s milk) ...............

Tofu ......................................

Soy-based beverage ............

JUICE ...................................

EGGS ...................................

BREAKFAST CEREAL
(READY-TO-EAT AND INSTANT AND REGULAR
HOT CEREALS).

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FRUITS AND VEGETABLES
(FRESH AND PROCESSED) 4 5 6 8 9.

WHOLE WHEAT BREAD,
WHOLE GRAIN BREAD,
AND WHOLE GRAIN OPTIONS:
Bread .............................

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Minimum requirements and specifications
Must conform to FDA standard of identity for whole, reduced fat, lowfat, or nonfat milks (21 CFR 131.110). Must
be pasteurized. May be flavored or unflavored. May be fluid, shelf-stable, evaporated (21 CFR 131.130), or dry.
Dry whole milk must conform to FDA standard of identity (21 CFR 131.147). Nonfat dry milk must conform to
FDA standard of identity (21 CFR 131.127).
Cultured milks must conform to FDA standard of identity for cultured milk, e.g. cultured buttermilk, kefir cultured
milk, acidophilus cultured milk (21 CFR 131.112).
Acidified milk must conform to FDA standard of identity for acidified milk, e.g., acidified kefir milk, acidified acidophilus milk or acidified buttermilk (21 CFR 131.111).
All reduced fat, lowfat, and nonfat cow’s milk types and varieties must contain at least 400 IU of vitamin D per
quart (100 IU per cup) and 2000 IU of vitamin A per quart (500 IU per cup).
Must be pasteurized. May be flavored or unflavored. May be fluid, shelf-stable, evaporated or dry (i.e., powdered).
All reduced fat, lowfat, and nonfat goat’s milk must contain at least 400 IU of vitamin D per quart (100 IU per cup)
and 2000 IU of vitamin A per quart (500 IU per cup).
Domestic cheese made from 100 percent pasteurized milk. Must conform to FDA standard of identity (21 CFR
part 133); Monterey Jack, Colby, natural Cheddar, Swiss, Brick, Muenster, Provolone, part-skim or whole Mozzarella, pasteurized process American, or blends of any of these cheeses are authorized.
Cheeses that are labeled low, free, reduced, less or light in sodium, fat or cholesterol are WIC eligible.
Yogurt must be pasteurized and conform to FDA standard of identity for whole fat (21 CFR 131.200), lowfat (21
CFR 131.203), or nonfat (21 CFR 131.206); plain or flavored with ≤40 g of total sugars per 1 cup yogurt. Yogurts that are fortified with vitamin A and D and other nutrients may be allowed at the State agency’s option.
Yogurts sold with accompanying mix-in ingredients such as granola, candy pieces, honey, nuts and similar ingredients are not authorized. Drinkable yogurts are not authorized.
Calcium-set tofu prepared with calcium salts (e.g., calcium sulfate). May not contain added fats, sugars, oils, or
sodium. Tofu must be calcium-set, i.e., contain calcium salts, but may also contain other coagulants, i.e., magnesium chloride.
Must be fortified to meet the following nutrient levels: 276 mg calcium per cup, 8 g protein per cup, 500 IU vitamin A per cup, 100 IU vitamin D per cup, 24 mg magnesium per cup, 222 mg phosphorus per cup, 349 mg potassium per cup, 0.44 mg riboflavin per cup, and 1.1 mcg vitamin B12 per cup, in accordance with fortification
guidelines issued by FDA. May be flavored or unflavored.
Must be pasteurized 100% unsweetened fruit juice. Must contain at least 30 mg of vitamin C per 100 mL of juice.
Must conform to FDA standard of identity as appropriate (21 CFR part 146) or vegetable juice must conform to
FDA standard of identity as appropriate (21 CFR part 156). With the exception of 100% citrus juices, State
agencies must verify the vitamin C content of all State-approved juices. Juices that are fortified with other nutrients may be allowed at the State agency’s option. Juice may be fresh, from concentrate, frozen, canned, or
shelf-stable. Blends of authorized juices are allowed.
Vegetable juice may be regular or lower in sodium.
Fresh shell domestic hens’ eggs or dried eggs mix (must conform to FDA standard of identity in 21 CFR 160.105)
or pasteurized liquid whole eggs (must conform to FDA standard of identity in 21 CFR 160.115).
Hard boiled eggs, where readily available for purchase in small quantities, may be provided for homeless participants.
Must contain a minimum of 28 mg iron per 100 g dry cereal.
Must contain ≤21.2 g sucrose and other sugars per 100 g dry cereal (≤6 g per dry oz).
At least half of the cereals authorized on a State agency’s food list must have whole grain as the primary ingredient by weight AND meet labeling requirements for making a health claim as a ‘‘whole grain food with moderate fat content’’.3
Any variety of fresh (as defined by 21 CFR 101.95) whole or cut fruit without added sugars.
Any variety of fresh (as defined by 21 CFR 101.95) whole or cut vegetable, except white potatoes, without added
sugars, fats, or oils (orange yams and sweet potatoes are allowed).
Any variety of canned fruits (must conform to FDA standard of identity as appropriate (21 CFR part 145)); including applesauce, juice pack or water pack without added sugars, fats, oils, or salt (i.e., sodium). The fruit must
be listed as the first ingredient.
Any variety of frozen fruits without added sugars, fats, oils, or salt (i.e., sodium).
Any variety of canned or frozen vegetables, except white potatoes (orange yams and sweet potatoes are allowed); without added sugars, fats, or oils. Vegetable must be listed as the first ingredient. May be regular or
lower in sodium. Must conform to FDA standard of identity as appropriate (21 CFR part 155).
Any type of dried fruits or dried vegetable, except white potatoes (orange yams and sweet potatoes are allowed);
without added sugars, fats, oils, or salt (i.e., sodium).
Any type of immature beans, peas, or lentils, fresh or in canned 5 forms.
Any type of frozen beans (immature or mature). Beans purchased with the CVV may contain added vegetables
and fruits, but may not contain added sugars, fats, oils, or meat as purchased. Canned beans, peas, or lentils
may be regular or lower in sodium content.
State agencies must allow organic forms of WIC-eligible fruits and vegetables.

Whole wheat bread must conform to FDA standard of identity (21 CFR 136.180). (Includes whole wheat buns
and rolls.) ‘‘Whole wheat flour’’ and/or ‘‘bromated whole wheat flour’’ must be the only flours listed in the ingredient list.

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TABLE 4—MINIMUM REQUIREMENTS AND SPECIFICATIONS FOR SUPPLEMENTAL FOODS—Continued

Categories/foods

Whole Grain Options ....

FISH (CANNED) 5 ................

MATURE LEGUMES (DRY
BEANS AND PEAS) 7.

PEANUT BUTTER ...............

INFANT FOODS:
Infant Cereal .................
Infant Fruits ...................
Infant Vegetables ..........

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Infant Meat ....................

Minimum requirements and specifications
OR
Whole grain bread must conform to FDA standard of identity (21 CFR 136.110) (includes whole grain buns and
rolls).
AND
Whole grain must be the primary ingredient by weight in all whole grain bread products.
AND
Must meet FDA labeling requirements for making a health claim as a ‘‘whole grain food with moderate fat content’’.3
Brown rice, bulgur, oats, and whole-grain barley without added sugars, fats, oils, or salt (i.e., sodium). May be instant-, quick-, or regular-cooking.
Soft corn or whole wheat tortillas. Soft corn tortillas made from ground masa flour (corn flour) using traditional
processing methods are WIC-eligible, e.g., whole corn, corn (masa), whole ground corn, corn masa flour, masa
harina, and white corn flour. For whole wheat tortillas, ‘‘whole wheat flour’’ must be the only flour listed in the
ingredient list.
Whole wheat macaroni products. Must conform to FDA standard of identity (21 CFR 139.138) and have no added
sugars, fats, oils, or salt (i.e., sodium). ‘‘Whole wheat flour’’ and/or ‘‘whole durum wheat flour’’ must be the only
flours listed in the ingredient list. Other shapes and sizes that otherwise meet the FDA standard of identity for
whole wheat macaroni (pasta) products (139.138), and have no added sugars, fats, oils, or salt (i.e., sodium),
are also authorized (e.g., whole wheat rotini, and whole wheat penne).
Canned only:
Light tuna (must conform to FDA standard of identity (21 CFR 161.190));
Salmon (Pacific salmon must conform to FDA standard of identity (21 CFR 161.170));
Sardines; and
Mackerel (N. Atlantic Scomber scombrus; Chub Pacific Scomber japonicas; Jack Mackerel 10
May be packed in water or oil. Pack may include bones or skin. Added sauces and flavorings, e.g., tomato
sauce, mustard, lemon, are authorized at the State agency’s option. May be regular or lower in sodium content.
Any type of mature dry beans, peas, or lentils in dry-packaged or canned 5 forms. Examples include but are not
limited to black beans, black-eyed peas, garbanzo beans (chickpeas), great northern beans, white beans (navy
and pea beans), kidney beans, mature lima (‘‘butter beans’’), fava and mung beans, pinto beans, soybeans/
edamame, split peas, lentils, and refried beans. All categories exclude soups. May not contain added sugars,
fats, oils, vegetables, fruits or meat as purchased. Canned legumes may be regular or lower in sodium content.11
Baked beans may only be provided for participants with limited cooking facilities.11
Peanut butter and reduced fat peanut butter (must conform to FDA Standard of Identity (21 CFR 164.150));
creamy or chunky, regular or reduced fat, salted or unsalted forms are allowed. Peanut butters with added
marshmallows, honey, jelly, chocolate or similar ingredients are not authorized.
Infant cereal must contain a minimum of 45 mg of iron per 100 g of dry cereal.12
Any variety of single ingredient commercial infant food fruit without added sugars, starches, or salt (i.e., sodium).
Texture may range from strained through diced. The fruit must be listed as the first ingredient.13
Any variety of single ingredient commercial infant food vegetables without added sugars, starches, or salt (i.e.,
sodium). Texture may range from strained through diced. The vegetable must be listed as the first ingredient.14
Any variety of commercial infant food meat or poultry, as a single major ingredient, with added broth or gravy.
Added sugars or salt (i.e. sodium) are not allowed. Texture may range from pureed through diced.15

Table 4 Footnotes: FDA = Food and Drug Administration of the U.S. Department of Health and Human Services.
1 The following are not considered a WIC-eligible nutritional: Formulas used solely for the purpose of enhancing nutrient intake, managing body
weight, addressing picky eaters or used for a condition other than a qualifying condition (e.g., vitamin pills, weight control products, etc.); medicines or drugs, as defined by the Food, Drug and Cosmetic Act (21 U.S.C. 350a) as amended; enzymes, herbs, or botanicals; oral rehydration
fluids or electrolyte solutions; flavoring or thickening agents; and feeding utensils or devices (e.g., feeding tubes, bags, pumps) designed to administer a WIC-eligible formula.
2 All authorized milks must conform to FDA standards of identity for milks as defined by 21 CFR part 131 and meet WIC’s requirements for vitamin fortification as specified in Table 4 of paragraph (e)(12) of this section. Additional authorized milks include, but are not limited to: calciumfortified, lactose-reduced and lactose-free, organic and UHT pasteurized milks. Other milks are permitted at the State agency’s discretion provided that the State agency determines that the milk meets the minimum requirements for authorized milk.
3 FDA Health Claim Notification for Whole Grain Foods with Moderate Fat Content at http://www.fda.gov/food/ingredientspackaginglabeling/
labelingnutrition/ucm073634.htm
4 Processed refers to frozen, canned,5 or dried.
5 ‘‘Canned’’ refers to processed food items in cans or other shelf-stable containers, e.g., jars, pouches.
6 The following are not authorized: herbs and spices; creamed vegetables or vegetables with added sauces; mixed vegetables containing noodles, nuts or sauce packets, vegetable-grain (pasta or rice) mixtures; fruit-nut mixtures; breaded vegetables; fruits and vegetables for purchase
on salad bars; peanuts or other nuts; ornamental and decorative fruits and vegetables such as chili peppers on a string; garlic on a string;
gourds; painted pumpkins; fruit baskets and party vegetable trays; decorative blossoms and flowers, and foods containing fruits such as blueberry muffins and other baked goods. Home-canned and home-preserved fruits and vegetables are not authorized.
7 Mature legumes in dry-packed or canned forms may be purchased with the WIC food instrument only. Immature varieties of fresh or canned
beans and frozen beans of any type (immature or mature) may be purchased with the cash-value voucher only. Juices are provided as separate
food WIC categories and are not authorized under the fruit and vegetable category.
8 Excludes white potatoes, mixed vegetables containing white potatoes, dried white potatoes; catsup or other condiments; pickled vegetables;
olives; soups; juices; and fruit leathers and fruit roll-ups. Canned tomato sauce, tomato paste, salsa and spaghetti sauce without added sugar,
fats, or oils are authorized.
9 State agencies have the option to allow only lower sodium canned vegetables for purchase with the cash-value voucher.
10 FDA defines jack mackerel as any of the following six species: Trachurus declivis, trachurus japonicas, trachurur symmetricus, trachurus
murphyi, trachurus novaezelandiae, and trachurus lathami in The Seafood List at http://www.fda.gov/Food/GuidanceRegulation/
GuidanceDocumentsRegulatoryInformation/Seafood/ucm113260.htm. King mackerel is not authorized.

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11 The following are not authorized in the mature legume category: soups; immature varieties of legumes, such as those used in canned green
peas, green beans, snap beans, yellow beans, and wax beans; baked beans with meat, e.g., beans and franks; and beans containing added
sugars (with the exception of baked beans), fats, oils, meats, fruits or vegetables.
12 Infant cereals containing infant formula, milk, fruit, or other non-cereal ingredients are not allowed.
13 Mixtures with cereal or infant food desserts (e.g., peach cobbler) are not authorized; however, combinations of single ingredients (e.g.,
apple-banana) and combinations of single ingredients of fruits and/or vegetables (e.g., apples and squash) are allowed.
14 Combinations of single ingredients (e.g., peas and carrots) and combinations of single ingredients of fruits and/or vegetables (e.g., apples
and squash) are allowed. Mixed vegetables with white potato as an ingredient (e.g., mixed vegetables) are authorized. Infant foods containing
white potatoes as the primary ingredient are not authorized.
15 No infant food combinations (e.g., meat and vegetables) or dinners (e.g., spaghetti and meatballs) are allowed.

5. In § 246.12:
a. Remove the phrase ‘‘WIC-eligible
medical foods’’ and add in its place
‘‘WIC-eligible nutritionals’’ wherever it
appears;
■ b. Amend paragraph (a)(1) by
removing the words ‘‘and farmers’’ after
‘‘vendors’’ in the second sentence and
adding in their place the phrase ‘‘,
farmers and farmers’ markets,’’;
■ c. Amend paragraphs (f)(2)(ii) and
(f)(2)(iv) by removing the word
‘‘vouchermay’’ and adding in its place
the words ‘‘voucher may’’ whenever it
appears in these paragraphs;
■ d. Add a new paragraph (f)(4);
■ e. Amend paragraph (g)(3)(i) by
removing the words ‘‘varieties of’’ in
both places that it appears in the second
sentence and adding in their place the
word ‘‘different’’;
■ f. Amend paragraph (h)(3)(i) by
removing the word ‘‘vouchersonly’’ and
adding in its place the words ‘‘vouchers
only’’;
■ g. Amend paragraph (h)(3)(vii) by
adding the words ‘‘, or cash-value
vouchers’’ after the word ‘‘instruments’’;
■ h. Revise the heading and the first two
sentences of paragraph (h)(3)(viii);
■ i. Amend paragraph (h)(3)(x) by
removing the last sentence of the
paragraph;
■ j. Redesignate paragraphs (h)(3)(xi)
through (h)(3)(xxv) as paragraphs
(h)(3)(xii) through (h)(3)(xxvi) and add a
new paragraph (h)(3)(xi);
■ k. Amend paragraph (l)(1)(ii)(A) by
adding the words ‘‘, or cash-value
vouchers,’’ after the word
‘‘instruments’’;
■ l. Revise paragraph (o);
■ m. Amend paragraphs (r)(3) and (t) by
adding the phrase ‘‘, farmers’ markets,’’
after the word ‘‘farmer’’;
■ n. Amend paragraph (u)(5) by adding
the words ‘‘, farmers, farmers’ markets,’’
after the word ‘‘contractors’’;
■ o. Revise the heading and
introductory text of paragraph (v);
■ p. Amend paragraph (v)(1) by adding
the words ‘‘or farmers’ market’’ after the
word ‘‘farmer’’;
■ q. Revise paragraph (v)(1)(iv);
■ r. Amend paragraphs (v)(2) through
(v)(6) by adding the words ‘‘or farmers’
market’’ after the word ‘‘farmer’’
wherever it occurs;
■ s. Revise paragraph (v)(3);

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■
■

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t. Redesignate paragraphs (v)(4)
through (v)(6) as paragraphs (v)(5)
through (v)(7), and add a new paragraph
(v)(4); and
■ u. Add a new paragraph (v)(8).
The revisions and additions read as
follows:
■

§ 246.12

Food delivery systems.

*
*
*
*
(f) * * *
(4) Split tender transactions. The
State agency must implement
procedures that allow the participant,
authorized representative or proxy to
pay the difference when a fruit and
vegetable purchase exceeds the value of
the cash-value vouchers.
*
*
*
*
*
(h) * * *
(3) * * *
(viii) Food instrument and cash-value
voucher redemption. The vendor must
submit food instruments and cash-value
vouchers for redemption in accordance
with the redemption procedures
described in the vendor agreement. The
vendor may redeem a food instrument
or cash-value voucher only within the
specified time period. * * *
(xi) Split tender for cash-value
vouchers. The vendor must allow the
participant, authorized representative or
proxy to pay the difference when a fruit
and vegetable purchase exceeds the
value of the cash-value vouchers (also
known as a split tender transaction).
*
*
*
*
*
(o) Participant parent/caretaker,
proxy, vendor, farmer, farmers’ market,
and home food delivery contractor
complaints. The State agency must have
procedures to document the handling of
complaints by participants, parents or
caretakers of infant or child
participants, proxies, vendors, farmers,
farmers’ markets, home food delivery
contractors, and direct distribution
contractors. Complaints of civil rights
discrimination must be handled in
accordance with § 246.8(b).
*
*
*
*
*
(v) Farmers and farmers’ markets. The
State agency may authorize farmers,
farmers’ markets, and/or roadside stands
to accept the cash-value voucher for
eligible fruits and vegetables. The State
agency must enter into written

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agreements with all authorized farmers
and/or farmers’ markets. The agreement
must be signed by a representative who
has legal authority to obligate the farmer
or farmers’ market and a representative
of the State agency. The agreement must
be for a period not to exceed 3 years.
Only farmers or farmers’ markets
authorized by the State agency may
redeem the fruit and vegetable cashvalue voucher. The State agency must
require farmers or farmers’ markets to
reapply at the expiration of their
agreements and must provide farmers or
farmers markets with not less than 15
days advance written notice of the
expiration of the agreement.
*
*
*
*
*
(1) * * *
(iv) Redeem the cash-value voucher in
accordance with a procedure
established by the State agency. Such
procedure must include a requirement
for the farmer or farmers’ market to
allow the participant, authorized
representative or proxy to pay the
difference when the purchase of fruits
and vegetables exceeds the value of the
cash-value vouchers (also known as a
split tender transaction);
*
*
*
*
*
(3) Neither the State agency nor the
farmer or farmers’ market has an
obligation to renew the agreement. The
State agency, the farmer, or farmers’
market may terminate the agreement for
cause after providing advance written
notification.
(4) Farmer agreements for State
agencies that do not authorize farmers.
Those State agencies which authorize
farmers’ markets but not individual
farmers shall require authorized
farmers’ markets to enter into a written
agreement with each farmer within the
market that is authorized to accept cashvalue vouchers. The State agency shall
set forth the required terms for the
written agreement as defined in
§ 246.12(v)(1) and (v)(2), and provide a
sample agreement for use by the
farmers’ market.
*
*
*
*
*
(8) Monitoring farmers and farmers’
markets.—(i) The State agency must
design and implement a system for
monitoring its authorized farmers and
farmers’ markets for compliance with

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program requirements. The State agency
must document, at a minimum, the
following information for all monitoring
visits: name(s) of the farmer, farmers
market, or roadside stand; name(s) and
signature(s) of the reviewer(s); date of
review; and nature of problem(s)
detected.
(ii) Compliance buys. For compliance
buys, the State agency must also
document:
(A) The date of the buy;
(B) A description of the farmer (and
farmers’ market, as appropriate)
involved in each transaction;
(C) The types and quantities of items
purchased, current retail prices or prices
charged other customers, and price
charged for each item purchased, if
available. Price information may be
obtained prior to, during, or subsequent
to the compliance buy; and
(D) The final disposition of all items
as destroyed, donated, provided to other
authorities, or kept as evidence.
■ 6. In § 246.16, revise paragraph (j)(2)
to read as follows:
§ 246.16

Distribution of funds.

*
*
*
*
(j) * * *
(2) Base value of the fruit and
vegetable voucher. The base year for
calculation of the value of the fruit and
vegetable voucher is fiscal year 2008.
The base value to be used equals:
(i) $8 for children; and
(ii) $10 for women.
*
*
*
*
*
■ 7. In § 246.18:
■ a. Revise paragraph (a)(4);
■ b. Amend paragraphs (b), (d), (e), and
(f) by adding the phrase ‘‘or farmers’
market’’ after the word ‘‘farmer’’
whenever it appears;
■ c. Revise the first sentence in
paragraph (b)(9);
■ d. Amend paragraph (c) introductory
text by adding the phrase ‘‘, farmer, or
farmers’ market’’ after the word
‘‘vendor’’ in the last sentence; and

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e. Revise paragraph (c)(2);
The revisions and additions read as
follows:

■

§ 246.18 Administrative review of State
agency actions.

(a) * * *
(4) Farmer or farmers’ market
appeals.—(i) Adverse actions. The State
agency shall provide a hearing
procedure whereby farmers or farmers’
markets adversely affected by certain
actions of the State agency may appeal
those actions. A farmer or farmers’
market may appeal an action of the State
agency denying its application to
participate, imposing a sanction, or
disqualifying it from participation in the
program. Expiration of an agreement is
not subject to appeal.
(ii) Effective date of adverse actions
against farmers or farmers’ markets. The
State agency must make denials of
authorization and disqualifications
effective on the date of receipt of the
notice of adverse action. The State
agency must make all other adverse
actions effective no earlier than 15 days
after the date of the notice of the adverse
action and no later than 90 days after
the date of the notice of adverse action
or, in the case of an adverse action that
is subject to administrative review, no
later than the date the farmer receives
the review decision. The State agency
must make all other adverse actions
effective no earlier than 15 days after
the date of the notice of adverse action
and no later than 90 days after the date
of the notice of adverse action or, in the
case of an adverse action that is subject
to an administrative review, no later
than the date the farmer or farmers’
market receives the review decision.
(b) * * *
(9) Written notification of the review
decision, including the basis for the
decision, within 90 days from the date
of receipt of the request for an
administrative review from a vendor,
farmer, or farmer’s market, and within

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60 days from the date of receipt of a
local agency’s request for an
administrative review. * * *
(c) * * *
(2) A decision-maker who is someone
other than the person who rendered the
initial decision on the action and whose
determination is based solely on
whether the State agency has correctly
applied Federal and State statutes,
regulations, policies, and procedures
governing the Program, according to the
information provided to the vendor,
farmer, or farmers’ market concerning
the cause(s) for the adverse action and
the response from the vendor, farmer, or
farmers’ market.
*
*
*
*
*
■ 8. In § 246.23:
■ a. Amend paragraph (a)(1) by
removing the words ‘‘or food
instruments’’ and by adding in its place
the phrase ‘‘food instruments, or cashvalue vouchers’’; and
■ b. Revise paragraph (a)(2).
The revisions read as follows:
§ 246.23

Claims and penalties.

(a) * * *
(2) If FNS determines that any part of
the Program funds received by a State
agency; or supplemental foods, either
purchased or donated commodities; or
food instruments or cash-value
vouchers, were lost as a result of thefts,
embezzlements, or unexplained causes,
the State agency shall, on demand by
FNS, pay to FNS a sum equal to the
amount of the money or the value of the
supplemental foods, food instruments,
or cash-value vouchers so lost.
*
*
*
*
*
Dated: February 20, 2014.
Janey Thornton,
Acting Under Secretary, Food, Nutrition, and
Consumer Services.
[FR Doc. 2014–04105 Filed 2–28–14; 8:45 am]
BILLING CODE 3410–30–P

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File Type	application/pdf
Author	Bush, Alexander - FNS
File Modified	2022-01-11
File Created	2020-07-28