September 14, Dear Dr. Rasmussen and Committee members:

Transcription

1 September 14, 2015 Dr. Kathleen Rasmussen, Chair Committee to Review WIC Food Packages Institute of Medicine Keck Center 500 Fifth St. NW Washington, DC Dear Dr. Rasmussen and Committee members: The International Dairy Foods Association (IDFA) appreciates the opportunity to comment on the review of food packages in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC). WIC is a key federal nutrition program that helps introduce young children to nutritious choices and provides important nutritious foods and beverages, particularly those that are underconsumed. The International Dairy Foods Association (IDFA), Washington, D.C., represents the nation's dairy manufacturing and marketing industries and their suppliers, with a membership of 550 companies within a $125-billion a year industry. IDFA is composed of three constituent organizations: the Milk Industry Foundation (MIF), the National Cheese Institute (NCI) and the International Ice Cream Association (IICA). IDFA's nearly 200 dairy processing members run nearly 600 plant operations, and range from large multinational organizations to single-plant companies. Together these organizations represent more than 85 percent of the milk, cultured products, cheese, ice cream, and frozen desserts produced and marketed in the United States. IDFA s members are proud of the various dairy products that are included in the WIC food packages. In the recent report of the 2015 Dietary Guidelines Advisory Committee, dairy was identified as a food group that is being under consumed by almost all Americans.1/ This underconsumption is one of the reasons that it is vital to include dairy in the WIC program and encourage WIC participants to consume adequate dairy foods Dietary Guidelines Advisory Committee. Scientific Report of the 2015 Dietary Guidelines Advisory Committee: Advisory Report to the Secretary of Health and Human Services and the Secretary of Agriculture. First Print, February 2015.

2 Aligning with the Dietary Guidelines for Americans One goal of the current IOM committee review is to ensure that the food packages align with the official DGAs. IDFA believes that the final Dietary Guidelines for Americans (DGA) should be the basis of the WIC food packages. The 2010 DGA is the last official Dietary Guidelines published and should be the basis for WIC recommendations until the 2015 DGAs are released. However, the 2015 Dietary Guidelines Advisory Committee (DGAC) report is also now available. The focus of the 2010 DGAs is promoting healthy eating patterns, rather than setting requirements for specific foods. All of the eating plans identified as examples of those meeting the recommendations of the Dietary Guidelines, the DASH diet, Mediterranean diet, and vegetarian diets, include dairy products.2/ This same pattern remained in the 2015 DGAC report. The report endorsed vegetarian, Mediterranean and healthy US diets, which all included dairy. 3/ This demonstrates that dairy, along with other important foods and beverages form the core of healthy diets. The 2010 DGAs and 2015 DGAC report continued to identify low-fat and fat-free dairy foods as foods to encourage in Americans diets.4/ Most Americans are not consuming the recommended levels of dairy products. While many preschoolers do consume adequate amounts of dairy, it is vital that programs such as WIC keep dairy as an important component in order to continue this trend. The 2010 Dietary Guidelines Advisory Committee (DGAC) report highlighted children as a population group of particular concern because nutrition during childhood can affect the development of chronic disease later in life.5/ The 2010 DGAs noted the importance of increasing the intake of dairy products in children as they actively develop lifelong eating habits, which should include healthy choices such as low-fat and fat-free milk and yogurt rather than other, less nutrientdense options.6/ In addition to concerns that the American population at large is underconsuming dairy, there are also concerns that specific subgroups should be consuming more dairy foods. A joint report from the National Hispanic Medical Association and Latinos and Hispanics in Dietetics and Nutrition stated [l]ow dairy consumption is a growing problem as nonnutritive beverages may be displacing milk and milk consumption. 7 Nutrient density is a concept that originated in the 2005 DGAs and has been carried over into the 2010 DGAs and 2015 DGAC report. The importance of building an eating pattern around nutrientdense foods was highlighted in the speech given by Agriculture Secretary Vilsack at the release of the 2010 DGAs. He encouraged Americans to consider the nutrient density of the calories they consume, saying not every calorie is the same. 8/ 2 U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, th Edition, Washington, DC: U.S. Government Printing Office, December Dietary Guidelines Advisory Committee. Scientific Report of the 2015 Dietary Guidelines Advisory Committee: Advisory Report to the Secretary of Health and Human Services and the Secretary of Agriculture. First Print, February U.S. Department of Agriculture and U.S. Department of Health and Human Services. Dietary Guidelines for Americans, th Edition, Washington, DC: U.S. Government Printing Office, December Ibid. 6 Ibid. 7 Mercado F, C Pozo Fileti. Health Implications of Dairy Intake in US Hispanics: Opportunities for Nutrition Intervention and Education. October USDA Secretary Thomas Vilsack. Release of the 2010 Dietary Guidelines for Americans, January 31, 2011.Archived at March 18,

3 Dairy foods are nutrient-dense. Even those options that may contain naturally occurring solid fats, added sugar or sodium, have high nutrient density because of the levels of beneficial nutrients they provide. The overall focus of the program should be how to encourage the use of nutrient-dense foods to provide WIC participants with a nutritious basis for their meals and snacks. We believe that nutrient density is an important concept to encourage in WIC because a single nutrient-dense food choice can provide a variety of nutrients that are essential for health. Focusing WIC food packages on nutrient-dense foods encourages participants to include more nutrients in a lower calorie diet. This focus not only aids in the consumption of beneficial nutrients, but also assists in energy balance and weight control. Since the Committee is required to make recommendations that are cost-neutral, dairy products that are both nutrient-dense and affordable should be an important component of the food packages. Including dairy can help the WIC program provide underconsumed foods and nutrients while also containing costs to be able to serve as many people as possible. According to the Bureau of Labor Statistics, the average retail cost of a gallon of milk was $3.37 in June 2015, representing a total cost of 21 cents per one cup serving to provide 30% DV calcium, 10% DV vitamin A, 25% DV vitamin D, 11% DV of potassium and many other valuable nutrients.9/ Consumption of nutrient-dense foods, such as milk and yogurt, can be enhanced by the use of added sugars to increase palatability to WIC participants. This enhanced palatability increases the likelihood that people will consume nutrient-dense products and the important nutrients they provide. The 2010 DGAs emphasized this important role for added sugars, using low-fat and fat-free dairy as examples. The 2010 DGAs updated the nutrients of concern to just four: calcium, potassium, vitamin D and fiber, which have been continued in the 2015 DGAC report. These nutrients are of concern for children as well as adults. Dairy products are a significant source of calcium, potassium and vitamin D, three of the identified nutrients of concern. Milk is the number one source of all three of these nutrients in the American diet, while cheese and yogurt provide calcium and some are also good sources of vitamin D.10/ The 2015 DGAC report emphasized the unique nutrient profile of dairy foods and considered the impact of removing all dairy from the diet, and also the results of replacing fluid milk with other beverages. In the modeled situations where dairy or fluid milk was removed from the diet, the intake of a number of essential nutrients was significantly reduced, in many cases failing to meet the recommended levels of intake. Additionally, the 2015 DGAC report pointed out that common substitutes for fluid milk require additional calories to supply the same amount of calcium as provided through milk. These issues all point to the important nutritional role of dairy foods, such as milk, yogurt and cheese. However, some Americans that have lactose intolerance may incorrectly believe that they 9 Bureau of Labor Statistics. Consumer Price Index-Average Price Data for Milk, fresh, whole, fortified, per gallon. August 13, Dietary Guidelines Advisory Committee Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines for Americans, 2010, to the Secretary of Agriculture and the Secretary of Health and Human Services. U.S. Department of Agriculture, Agricultural Research Service, Washington, DC. 3

4 cannot consume any dairy products. The predominance of lactose maldigestion is a real concern for many Americans, especially among certain sub-groups of the population. The 2010 DGAC, along with a National Institute of Health expert committee, urged Americans who think they may be lactose intolerant to get tested before they unnecessarily eliminate dairy foods from their diet.11/ The 2010 DGAC report also recommended low-lactose or lactose-reduced dairy products such as lactose-reduced milk, yogurt and cheese, as a way for individuals to avoid lactose, yet still obtain the nutritional benefits of dairy.12/ This advice is doubly important when considering the 2015 DGAC s findings that a diet without dairy is lower in a variety of essential nutrients and that many other products marketed as dairy substitutes do not have the same nutrient package as milk and in fact, many have higher levels of added sugars and calories than cow s milk. Lastly, as pointed out by the 2015 DGAC report Dairy foods are excellent sources of nutrients of public health concern, including vitamin D, calcium- and potassium. Consumption of dairy foods provides numerous health benefits including lower risk of diabetes, metabolic syndrome, cardiovascular disease and obesity. 13/ IDFA supports the inclusion of a variety of dairy products such as fluid milk, yogurt and cheese in WIC food packages. We also support flexibility of dairy substitutions by recommending that WIC participants be permitted to allocate their dairy substitutions in a way that adequately satisfies their individual preference, as recommended in the IOM s 2005 report, WIC Food Packages: Time for a Change. 14/ As with all foods and beverages, the nutritional benefits are only realized if the product can be acquired at a reasonable cost and are available in a useful and likeable format. Overall, the dairy group provides excellent nutrient value, is available in many flavors, container sizes and forms to meet a wide variety of consumers preferences. However, there are specific situations where one type of milk or yogurt may be easier for WIC participants to find in their neighborhood stores. Fluid Milk IDFA agrees that milk should continue as an important component of the WIC food packages. Milk provides nine essential nutrients, including three of the four nutrients identified as nutrients of concern in the 2010 DGAs and 2015 DGAC report calcium, vitamin D and potassium.15/ Milk is the number one source of these three nutrients of concern for Americans. 11 Suchy FJ, Brannon PM, Carpenter TO, Fernandez JR, Gilsanz V, Gould JB, Hall K, Hui SL, Lupton J, Mennella J, Miller NJ, Osganian SK, Sellmeyer DE, Wolf MA. NIH Consensus Development Conference Statement: Lactose Intolerance and Health. NIH Consens State Sci Statements Feb 22-24; 27(2): Dietary Guidelines Advisory Committee Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines for Americans, 2010, to the Secretary of Agriculture and the Secretary of Health and Human Services. U.S. Department of Agriculture, Agricultural Research Service, Washington, DC Dietary Guidelines Advisory Committee. Scientific Report of the 2015 Dietary Guidelines Advisory Committee: Advisory Report to the Secretary of Health and Human Services and the Secretary of Agriculture. First Print, February Committee to Review the WIC Food Packages, Food and Nutrition Board, Institute of Medicine of the National Academies. WIC Food Packages: Time for a Change. The National Academies Press: Washington DC U.S. Department of Agriculture and U.S. Department of Health and Human Services..Dietary Guidelines for Americans, th Edition, Washington, DC: U.S. Government Printing Office, December

5 In the 2015 DGAC report, modeling showed that replacing milk with other beverages made significant reductions in diet quality. As an example of what occurs when milk is replaced by other beverages, the DGAC indicated that when milk and milk products are removed from sample diets in the USDA Food Patterns, calcium, vitamin A, vitamin D, choline, magnesium, phosphorus, and potassium become deficient.16/ The overall trend of milk consumption in the American population is moving away from whole milk and toward reduced-fat, low-fat and fat-free milk. However, the increases in these lower fat milks have not made up for the reduction in whole milk.17/ In 1975, one of the first years of the WIC program and the first year for which consumption of low-fat and reduced-fat milk was reported separately, Americans consumed per capita gallons of fluid milk, covering gallons of whole milk, 4.7 gallons of reduced-fat milk, 1.48 gallons of low-fat milk, 1.33 gallons of skim milk and 1.2 gallons of flavored milk. In 2013, the last year for which data is available, American s per capita consumption of total fluid milk dropped to gallons. There was a gradual shift towards lower milk fat levels. Per capital consumption in 2013 was 5.13 gallons of whole, 6.74 of reducedfat, 2.73 gallons of low-fat and 2.67 gallons of skim. As consumption of whole milk has decreased, reduced-fat milk has become the most widely consumed variety in America today. Per Capita Fluid Milk Sales by Fat Level Compared to gallons 1975 % 2013 gallons 2013 % Change % Whole milk Reduced-fat milk Low-fat milk Skim/non-fat milk Flavored milk Total milk Dietary Guidelines Advisory Committee. Scientific Report of the 2015 Dietary Guidelines Advisory Committee: Advisory Report to the Secretary of Health and Human Services and the Secretary of Agriculture. First Print, February Total fluid sales data from USDA Economic Research Service, per capita calculations by IDFA 5

6 In addition to the population as a whole, Hispanics as a subgroup tend to purchase more whole and reduced-fat milk due to their perception that these are more nutritious and wholesome. A taste test found that Hispanic adults prefer the taste of reduced-fat milk to fat-free milk.18/ Education efforts on the nutritional benefits of low-fat and fat-free dairy have been undertaken by both USDA and the dairy industry, but the consumer preference for reduced-fat milk has continued. When considering changes to the WIC food package, it is important to allow participants to be able to choose milk that they enjoy and would normally consume, such as reduced-fat milk. Reduced-fat milk has 2% milk fat, compared to 1% or low-fat milk. Low-fat milk contains 314 mg calcium, 397 mg potassium, 2.4 micrograms vitamin D and 8.5 grams of protein, with 105 kilocalories and 2.38 grams of fat per cup.19/ Reduced-fat milk contains similar levels of protein, calcium, vitamin D and potassium as low-fat milk, with 122 kilocalories and 4.83 grams of fat per one cup serving.20/ Each cup of reduced-fat milk has 17 additional calories and 2.45 additional grams of fat, but the small increase in calories and fat can be greatly outweighed by the powerhouse of essential nutrients that milk provides, if participants choose not to drink milk when 2% milk is not an available option. 18 Mercado F, C Pozo Fileti. Health Implications of Dairy Intake in US Hispanics: Opportunities for Nutrition Intervention and Education. October National Agriculture Library, United States Department of Agriculture. Basic Report: 01083, Milk, lowfat, fluid, 1% milkfat, with added nonfat milk solids, vitamin A and vitamin D, National Nutrient Database for Standard Reference, Release 27 qlookup=milk. Accessed August 13, National Agriculture Library, United States Department of Agriculture. Basic Report: 01080, Milk, reduced fat, fluid, 2% milkfat, with added nonfat milk solids and vitamin A and vitamin D, National Nutrient Database for Standard Reference, Release 27 Accessed August 13,

7 In order to benefit from the nutrients in milk, particularly the nutrients of concern- calcium, vitamin D and potassium- WIC participants must be able to purchase milk allowed in the WIC food package. However, depending on where they live, it might be more difficult to find low-fat or fat-free milk in stores in their neighborhood. One recently published study showed that stores in Hispanic-majority neighborhoods and in low-income neighborhoods were less likely to carry low-fat milk.21/ We have concerns that the WIC final rule s recent removal of reduced-fat milk as options for the women and older children from the WIC food packages may have reduced milk consumption by WIC participants. One survey of WIC food package redemption in Kentucky, Michigan and Nevada showed that whole milk prescriptions were fully redeemed 44.7% of the time, while low-fat milk prescriptions were fully redeemed 37.6% of the time.22/ This indicates that with low-fat milk, WIC participants are not receiving all of the milk they are eligible for and could be missing out on important nutrients provided by milk. Even a minor reduction in milk consumption on a daily basis makes a big difference. While IDFA is not promoting whole milk in the WIC program, a study that compared beverage choices for children in the WIC program before and after the removal of whole milk from the program showed that when whole milk was eliminated, WIC children consumed one-third of a cup less milk, from 2.63 cups per day to 2.33 cups per day.23/ Even a reduction of one-third of a cup of milk represents a loss of 10% DV of calcium, 8% DV of vitamin D and 3% DV of potassium. Recent data from the Texas WIC Agency before and after the transition away from reduced-fat milk for older children and women, indicates a small increase in low-fat milk, but not enough to make up for the loss of reduced-fat milk. In March 2014, 1,257,078 gallons of reduced-fat milk were sold through WIC, along with 51,965 gallons of low-fat and 19,729 gallons of skim milk, for 1,328,772 total gallons of milk. One year later, after reduced-fat milk was removed from the WIC food packages for older children and women, 1,096,261 total gallons of milk were sold, 1,044,087 gallons of low-fat and 52,174 gallons of skim milk.24/ This is a total loss of 232,511 gallons, or a reduction of 17.5%. This rate of reduction is more than the reduction in program participation; participation in March 2015 was 2.8% lower for women, 5.6% lower for children and 4% lower for all participants than participation in March / IDFA supports the inclusion of 1% and nonfat in the WIC food packages for women and children over two. But due to data indicating declines in redemption and consumption, we believe it should be easier for participants to request 2% milk. IDFA recommends that women participating in WIC 21 Rimkus L et al. Disparities in the Availability and Price of Low-fat and Higher-fat Milk in US Food Stores by Community Characteristics. J Acad Nutr Diet, Phillips D, L Bell, R Morgan and J Pooler. Transition to EBT in WIC: Review of Impact and Examination of Participant Redemption Pattern: Final Report Published online: Accessed August 8, Ishdorj A, O Capps Jr. Rural vs. Urban Texas WIC Children Food Choices and Intakes Before and After Changes in the Food Benefits. Accessed August 28, Texas Department of State Health Services, Women, Infants and Children (WIC) Program. 25 Texas Department of State Health Services, Women, Infants and Children (WIC) Program. WIC Participation History Accessed August 13,

8 be able to receive reduced-fat milk as a fluid milk option for themselves and their children over the age of 24 months by making a written request to WIC staff. Yogurt Yogurt is a nutrient-dense food that is a natural source of high quality protein. Most yogurt available in the United States is of either low-fat or fat-free varieties. In addition to protein, yogurt is also a good source of calcium, potassium, riboflavin, vitamin B12 and phosphorous. Many yogurts have vitamins A and D added. Additionally, yogurt is naturally low in lactose as a result of the culturing process. Many individuals who have trouble consuming large amounts of fluid milk due to lactose intolerance, can often enjoy yogurt comfortably, making this a food that is healthy and appropriate for many children and adults. IDFA also urges the inclusion of yogurt in the food package for infants between the ages of six months and one year of age. Consumption of yogurt by infants six months and older is supported by the National Association of Pediatric Nurse Practitioners26/ while the American Academy of Pediatrics recommends the introduction of yogurt between the ages of nine and twelve months.27/ The Infant Feeding Guide for WIC includes yogurt in a list of protein-rich foods that are appropriate to introduce to children between the ages of 6 and 8 months of age.28/ These references attest to the place yogurt has as a first food for infants over the age of 6 months and it should be included in WIC food packages for these children. Yogurt, including flavored yogurts, is a nutrient-dense food for both children and adults. For many people, flavored yogurt is more attractive, meaning that they are more likely to consume the calcium, protein, potassium, vitamins A and D, and other important nutrients present in each serving of yogurt. For people that have lactose intolerance, many find that yogurt is a dairy food that they can consume. The 2010 DGAC report did recommend yogurt as a way for individuals to avoid lactose, yet still obtain the nutritional benefits of dairy.29/ Based on the nutrient package that is unique to dairy foods and the absence of nutrients when dairy is not consumed, the WIC program should encourage yogurt, along with lactose-reduced milk and cheese as the first choice for lactose intolerant individuals. Yogurt helps provide additional variety in the dairy category. Yogurt is a source of needed dairy nutrition, but with different flavors and different uses than milk or cheese. When included as part of the WIC food packages, yogurt can help meet nutrient recommendations for children and women. To encourage WIC participants to select and consume yogurt, WIC-approved yogurt should be available in container sizes and flavors that participants can easily find in their grocery stores. The 26 National Association of Pediatric Nurse Practitioners and International Food Information Council Foundation. Starting Solids: Nutrition Guide for Infants and Children 6 to 18 Months of Age. Found at: Accessed April 10, Dietz, WH and Stern L, Ed. Nutrition: What Ever Parent Needs to Know, 2 nd edition. American Academy of Pediatrics, United States Department of Agriculture, Food and Nutrition Service. Infant Nutrition and Feeding: A Guide for Use in the WIC and CSF Programs. Revised March Dietary Guidelines Advisory Committee Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines for Americans, 2010, to the Secretary of Agriculture and the Secretary of Health and Human Services. U.S. Department of Agriculture, Agricultural Research Service, Washington, DC. 8

9 majority of yogurt is sold in single serving containers, such as 4 to 6 ounce cups, and a wider variety of flavors and calorie content is available in these container sizes. We urge the Committee to encourage states to be more flexible on container sizes and flavors for yogurt. We would also urge the Committee to clarify that yogurts with low-calorie sweeteners are included in the WIC food packages. These products meet FDA s standards of identity for yogurt and provide an option for women who are trying to control their calorie intake and manage their weight. Cheese Cheese, like fluid milk and yogurt, is a nutrient-dense food, providing a good source of protein, calcium and phosphorous to children. Due to the high quality naturally occurring protein in cheese, it is included as a meat alternate in CACFP, along with the school meals programs. In addition to being a nutritious and healthy snack, cheese is also naturally low in lactose. Cheese is an excellent way of providing the nutrition of dairy foods to students who may not regularly consume fluid milk products because of their lactose content. One important benefit of cheese that cannot be overlooked is to help increase consumption of other nutrient-dense foods. A study of children s consumption of foods in a school cafeteria setting demonstrated that visible cheese served with a food, such as a vegetable, increased consumption of that food. While foods to encourage were increased during the study, the overall caloric intake in the meal was not increased.30/ Cheese should continue as an option within WIC food packages. It is a versatile food that can be served on its own as either a snack or side, or as part of a main entrée for breakfast, lunch or dinner. It is a source of high-quality dairy protein, while also contributing to dairy intake. Infant Formula WIC s regulatory requirements for caloric density of infant formula should be updated to reflect current understanding of the caloric value of breastmilk. USDA regulations dating back to 1976 required that infant formula must provide at least 67 kilocalories per 100 milliliters (approximately 20 kilocalories per fluid ounce) at standard dilution. 31/ However, IOM s 2005 Dietary Reference Intakes report found that the average caloric density of human breastmilk is 650 kilocalories per liter, or 19.2 kilocalories per fluid ounce.32/ Additionally, the American Academy of Pediatrics (AAP) supports a range of 18.9 to 21 kilocalories per fluid ounce of infant formula.33/ 30 Joseph E. Donnelly, EdD; Debra K. Sullivan, PhD, RD, LD; Bryan K. Smith, PhD; et al J Child Nutrition and Management, Vol 34:1, Spring The Effects of Visible Cheese on the Selection and Consumption of Food Groups to Encourage in Middle School Students. 31 Federal Register 41:7 (January 12, 1976) p Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein and Amino Acids, A Report of the Panel on Macronutrients. Subcommittees on Upper Reference Levels of Nutrients and Interpretation and Uses of Dietary Reference Intakes, and the Standing Committee on the Scientific Evaluation of Dietary Reference Intakes, ISBN ; p American Academy of Pediatrics, Committee on Nutrition. Pediatric Nutrition Handbook. Kleinman RE, Greer FR, ed. 7 th ed. Elk Grove Village IL: American Academy of Pediatrics,

10 Accordingly, some infant formulas have been reformulated to more accurately reflect the caloric density of human breast milk, with less than 20 calories per fluid ounce. However, many of these reformulated formulas are not allowed as part of the WIC program, unless physician approval is granted to individual participants. We believe that infant formulas available to infants participating in WIC should reflect current understanding of the caloric content of human breastmilk. Conclusion IDFA members are proud of the range of nutritious dairy products they provide for both children and adults. We make the following recommendations for dairy products in the WIC food packages: The 2010 DGAs should serve as the basis for WIC recommendations until the 2015 DGAs are released. Dairy is an under-consumed food group for most Americans according to the DGA, and thus rates of milk redemption in the WIC program should be considered in any program modifications that lower milk consumption. IDFA supports the inclusion of a variety of dairy products in the WIC food packages, including fluid milk, yogurt and cheese, in order to allow WIC participants to select the dairy products they prefer and will consume. Women participating in the WIC program should be allowed to request reduced-fat milk for themselves and their children. Yogurt is a nutrient-dense dairy food and should be available in a variety of flavors, container sizes and with non-nutritive sweeteners. Cheese should remain as an alternative in the WIC packages as it contributes to dairy consumption while providing a number of important nutrients with a lower lactose content. Infant formula in WIC should reflect current understanding of caloric content of breastmilk. We urge the Committee to continue to encourage a wide range of dairy products, including milk, both flavored and unflavored, yogurt and cheese, in the WIC food packages. Sincerely, Constance Tipton President & CEO Michelle Albee Matto, MPH, RDN Nutrition Consultant to IDFA 10