Tuesday, 15 November 2016

The WBTi report on breastfeeding in the UK - and why we need it

Since I got back from the Unicef Baby Friendly conference last week, it’s all been a bit eventful in the breastfeeding world – there was a poorly written and researched article published in New Scientist (the Unicef response is here), longer-term breastfeeding was discussed (again) on This Morning, with a GP who didn’t know her stuff on the subject, there was a furore in the Daily Mail and on social media over a mother refused a parking voucher from Tesco because she only bought infant formula (see Baby Milk Action’s excellent discussion of this here), and we discovered that the CPHVA conference, for health visitors, has sessions (and no doubt exhibition stands) sponsored by formula manufacturers. The publication of the WBTi (World Breastfeeding Trends Intiative) report on breastfeeding in the UK couldn’t be more timely – it’s abundantly clear that we need a strategy if we are to counter the anti-breastfeeding culture that we have in the UK.

The WBTi report, published today (15 November) and launched at the House of Commons tonight, is the culmination of two years of work by a huge number of people and organisations. Using a system developed by IBFAN, data has been collected for 10 ‘indicators’ – these correspond to policies and programmes recommended in the WHO Global Strategy for Infant and Young Child Feeding, which the UK supported when it was adopted by the World Health Assembly in 2002. In other words, although the WBTi system has been designed to be used internationally, it is very relevant for the UK and shows how we are doing against criteria that our government has signed up to. The idea is that the process is repeated every 3-5 years to track trends. On the international WBTi website you can see how other countries have scored.

The report begins with a series of 'Report Cards' that sum up the findings in a simple scorecard, with each country of the UK given a total out of 150, and an amalgamated score for the UK as a whole. The UK scored 81/150. England has the lowest score of all the four nations at 80.5/150; Scotland and Northern Ireland score much better, in part due to the fact that all their maternity units are Baby Friendly. For comparison, Afghanistan scored 80/150 in 2015. If like me you think that this isn't good enough, then the great thing about this report is that it offers a way forward. The work that's been done has identified the gaps in UK breastfeeding policy and made recommendations - that have been agreed upon by the contributors to the report (a host of breastfeeding organisations and public health bodies, among others) - that we could act on, right now.

The report's recommendations echo a growing consensus that currently, women in the UK who want to breastfeed are being failed - not only by a lack of skilled support for breastfeeding (the table in Indicator 5, which shows which health professionals have training in breastfeeding, is well worth a look), but also by an entire culture and society that undermines it. Other recent publications, including the Lancet series on breastfeeding, a special issue of Acta Paediatrica and Unicef's Call to Action make many of the same points. Dr Amy Brown, of Swansea University, has written extensively about the subject in her book Breastfeeding Uncovered.

Turning the situation around is not impossible. We know, from a mountain of published evidence, what works. The main problem - and one of the chief recommendations of this report - is that there is no national strategy on infant and young child feeding, no national coordinator and no means of sharing good practice UK-wide. To address this would be relatively simple and relatively cheap - what's needed is the political will to tackle it. From better national leadership on the issue, other improvements could follow: we could fully implement the Code, we could address gaps in the training of health professionals, we could collect better data, we could ensure that infant feeding is considered in the formation of other policy (like the obesity 'plan')... and then, as all these areas interact like cogs in a machine, we would see a shift in society's attitudes, increased breastfeeding rates, improved health outcomes and cost savings... and happier, better supported mothers. (This isn't just conjecture - see the breastfeeding gear model, which uses Brazil and Mexico as examples, on p68 of the report.)

This report, with its overview of the current situation, could be hugely important - it can inform what we do, and where we direct our campaigning efforts. Do read the whole thing if you can, and reflect on what you could do to make a difference.

Wednesday, 4 May 2016

Not #scientificandfactual at all – how UK breastmilk substitute ads to health workers break the rules

Most readers of my blog will know that in the UK infant formula (first stage, or from birth formula) cannot be marketed to parents, or be discounted or promoted in shops. Manufacturers use follow-on formula to get around these advertising restrictions, but there are still rules that they must follow and they can be pulled up by the Advertising Standards Agency for breaking them. When shops break the rules on infant formula promotion – by discounting it, or positioning it in premium spots in store – they can be reported to Trading Standards. It’s far from a perfect system; no prosecutions have been brought, and companies are not fined nor have to apologise for infringing the rules, but the principle of challenging misleading marketing does at least exist. Baby Milk Action, with the help of its members and the public, monitors advertising to parents and compiles a report ‘Look What They’re Doing in the UK’ to expose the companies' tactics.

When it comes to advertising aimed at health professionals, however, the situation is very different. Many people don’t know that breastmilk substitutes can be marketed to healthcare professionals: in journals and magazines, on professional websites and at conferences and study days. Although the Department of Health has regulations stating that this advertising must be ‘scientific and factual’, there is no monitoring and no mechanism for reporting marketing that breaks the rules, other than to complain directly to the Department of Health.

First Steps Nutrition Trust’s recently published resource ‘Scientific and Factual – a review of breastmilk substitute advertising to health professionals’ looks more closely at the science used to back up the claims made in advertising in professional journals and magazines. We know from research that advertising is effective – why else would the companies spend vast sums on advertising space? – and that adverts that carry simple, easy-to-understand messages relating to the reader’s own scientific knowledge are very ‘believable’. The companies know this too, and they also know that few health workers will have the time or resources to investigate the references given in tiny print at the bottom of carefully crafted adverts. Graphs, charts and statistics create the appearance of ‘a scientific basis’, even when what they show is not scientifically correct or objective.

The resource looks in detail at adverts that appear in publications including the Journal of Family Health, the Journal of Health Visiting and Dietetics Today, but the same and similar adverts appear in many other publications aimed at health professionals in a wide range of fields. When the references given to support the claims made in the adverts are scrutinised, the findings are often shocking.

An advert for Cow & Gate Comfort milk, marketed as relieving colic, which shows an emotive image of an exhausted mother, appeared in the Journal of Health Visiting in March 2016. The main claim, in red type, is that ‘95% of paediatricians reported an improvement in common infant feeding problems with a formula like Cow & Gate Comfort1’ [italics added]. Closer reading of the reference given reveals that the study, funded by Numico (Danone) did not use Cow & Gate Comfort milk; the test formula had different energy, protein, carbohydrate and mineral content. NHS Choices says that there is no evidence for any treatment that is beneficial for colic, which resolves itself. The conclusion that the advert is deliberately misleading is inescapable.

SMA, now owned by Nestle, has been rolling out a new product, SMA PRO, and many stores have illegally cleared stock of the previous formula by marking it down in price to make way for the new product (lots of examples have been posted on the Baby Milk Action Facebook page). An extensive advertising campaign to health professionals has accompanied the roll-out. Dietetics Today carried two adverts for SMA PRO in March 2016, a shorter one-page ad and then a longer, more ‘scientific-looking’ ad – this in itself is a tactic designed to reassure the reader that the information given in the simpler advert is supported by the ‘science’ given in the more complex version. The main claim in the simpler advert is that SMA PRO is ‘Clinically proven1’. This is supported by one reference to a poster presentation given by Nestle employees at a conference – not a peer-reviewed publication as required by the Department of Health regulations. The poster reports a meta-analysis of four studies looking at infants fed with Nan milk (another Nestle product). It is not clear whether this Nan formula is the same as SMA PRO. It is impossible to know how the manufacturers can use this evidence to claim that SMA PRO is clinically proven, or what it is ‘clinically proven’ to do. That such shaky evidence can be used to support a headline claim on a new product shows just how confident the companies are that they will not be challenged.

There is much, much more detail in the resource, which has painstakingly reviewed all the scientific papers the companies have cited to support their claims. If, having read it, you’re outraged by how misleading these adverts are, there are plenty of suggestions for action on the First Steps Nutrition Trust website. Health professionals can demand change, by complaining to the journals and professional bodies that carry advertising and allow it at events, and writing to the Department of Health regulators. The Royal College of Paediatrics and Child Health voted at its AGM in April to ‘decline any commercial transactions or any other kind of funding or support from all companies that market products within the scope of the WHO Code on the marketing of breast milk substitutes’ – other professional organisations can be lobbied to pass similar resolutions. For more information, and links to further reading, see the campaign pages on the First Steps Nutrition Trust website. Baby Milk Action is urging the UK parliament to enforce marketing restrictions on the promotion of formula to parents too – see more on their website here or make a donation to support their work.

Friday, 20 November 2015

UNICEF Baby Friendly conference 2015 - the morning after

I'm back at my desk after two days at the UNICEF Baby Friendly conference 2015 in Harrogate. Like last year I've come away enthused, inspired, outraged and with a whole heap of work to do...

The presentations by Christy Jo Hendricks, IBCLC, and Dr Helen Crawley of First Steps Nutrition, showed us examples of downright dishonest marketing from the formula companies, including a tin that made extravagant health claims for the product, with an asterisk(*). On the side of the tin, in tiny writing, it said '*study applies to an earlier version of this milk'! Even after years of breastfeeding advocacy it seems I (and many others in the audience) can still be shocked by this sort of thing. A US parent information leaflet, sponsored by a formula company, said on the first page 'most doctors* recommend...', while the wording below said '*in this publication doctors refers to midwives, obstetricians, paediatricians and any other health professional you trust'! This is unbelievably misleading. As Christy Jo memorably said: 'Don't go to a formula company for advice about breastfeeding. That's like going to the butcher to ask for advice about being vegetarian.'

Dr Helen Crawley getting the audience fired up.

On the issue of formula company sponsorship of health events aimed at professionals it was great to see some direct action as a result of the conference session. A health visitor in the audience reported that the CPHVA conference, sponsored by several formula companies and related organisations, was taking place in Manchester (overlapping with Baby Friendly - coincidence?). The result was a petition, to be delivered to CPHVA, that will carry the names and membership numbers of health visitors who were at the Baby Friendly conference, asking them to ditch the formula company sponsorship that is a clear conflict of interest for health professionals who want to work within the Code. Hopefully this, along with continued pressure on social media, will prompt a change in direction. National breastfeeding organisations like La Leche League, the ABM and the Breastfeeding Network, along with Baby Friendly, have shown that it is perfectly possible to organise Code-compliant conferences for large numbers of delegates without input from the formula industry.

If you came away from the conference angry, why not join Baby Milk Action? They campaign tirelessly against the formula companies, exposing the marketing tactics and bringing cases to the Advertising Standards Authority and Trading Standards on behalf of the parents who are paying for all this slick, misleading marketing when they buy formula. There's tons of information on the Baby Milk Action website, and if you work for a facility that would like training on the Code, you can contact them directly.

If I sound evangelical it's because I think organisations like Baby Milk Action and First Steps Nutrition are absolutely vital if we are to push back against the widespread, normalised use of formula - a theme that Professor Mary Renfrew explored in her presentation about shifting the curve: she suggested we turn our breastfeeding drop-off rate graph upside down, and look at reducing formula use instead. Between them the speakers had lots of solutions to the problem: tackling the media stance on breastfeeding, reinstating the Infant Feeding Survey in England, freeing research from company influence and forcing companies to release their research, implementing the Code and empowering mothers, through support and education, to resist the marketing and reduce dependency on formula. What's frustrating is that we know what works - the problem is getting the support and funding needed. Infant feeding in the UK is an issue with a unique set of political and social challenges, something that was highlighted when Sue Ashmore talked about the long-term sustainability of Baby Friendly; it's not a programme that can run and then stop. If that happened, our gains would be eroded because of the constant pressure from industry and a lack of political commitment, so what's needed is a way of embedding the Baby Friendly standards into the very bedrock of facilities; an advanced award. (The consultation about how to do this is here, do get involved if you can.)

With this in mind it was fantastic to see Alison Thewliss, MP at the conference. She's already secured and participated in debates about breastfeeding and a family-friendly parliament, and is setting up an All Party Parliamentary Group on Infant Feeding and Inequalities, which will meet for the first time on 24 November. I've written to my MP asking her to support this and encourage others to do the same.

Me on stage with Sue Ashmore and Robin Grille
Other personal highlights of the conference for me were chairing in the morning session on day two - I was nervous, but very happy to be representing the bloggers and Tweeters who campaign for breastfeeding on social media. I realised I will never, ever get bored of listening to Hollie McNish, and I helped out on the Pinter and Martin stand and talked to a lot of people about books (I love my job!). I came home with a new reading list of my own - Robin Grille's Heart to Heart Parenting landed on the mat this morning. Can't wait for next year in Birmingham...