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...

Why shouldn't formula companies sponsor training events for health workers?

An event is taking place in Manchester tomorrow - billed as a Journal of Family Health Care 'free conference bringing together health and social care professionals - designed to improve outcomes for mothers, babies and children.' Among the exhibitors are Nestle, HiPP Organic, and Danone Nutricia Early Life Nutrition; Nestle Nutrition UKs Head of Medical and Scientific Affairs, Dr Liz Greenstreet, is giving a presentation about 'optimal growth and feeding issues in the first 1000 days'. Other similar events take place regularly in the UK and elsewhere.

As a volunteer for and member of several impoverished organisations, I can understand how tempting it is to snap up funding that is on offer to make it easier to arrange events and training. It can be hard to see where the harm is; a sponsor pays for an expert speaker, the topic is not related to infant feeding, the sponsor may not even directly promote their products at the event. The sponsor is not the 'brand' itself, but their 'Nutrition Foundation', or educational or charitable arm, which has been set up, apparently, with the aim of providing high-quality education for health professionals. We all know that our NHS is underfunded and under threat. Why not use some money from private companies to fill in some of the gaps? Health workers work hard - long hours, modest pay and benefits. Who doesn't love a free lunch and a day out at a study day or conference? It's a welcome break from the stresses of working in a creaking organisation. The trouble is that there really is no such thing as that free lunch.

To understand the problems, we need to start by understanding the market for formula and baby food (for the purposes of this post I'm talking about the UK, but similar situations exist in many countries).

- the market for infant formula depends for its existence on women who do not or cannot breastfeed. When breastfeeding rates increase due to effective initiatives and good support, the market for formula milk decreases. More breastfeeding means fewer profits for the formula companies; it's a direct relationship.

- the formula companies are no different from most other companies - they exist to make money for their shareholders. To fulfil their duties to their shareholders they must maximise profits. This means that they must design marketing and sales strategies that aim to increase the market, and their share of that market. Job advertisements for posts at formula companies show this explicitly. (More on this, from Baby Milk Action, here.) Much like the energy companies that fight to drill for oil - although we know that burning the oil they produce will contribute to catastrophic climate change - formula companies must aggressively promote a product that is known to carry health risks in order to satisfy the demands of investors.

- formula companies are regulated by laws in many countries. The International Code of Marketing of Breastmilk Substitutes (and subsequent Resolutions), drafted by the World Health Organisation and adopted at the World Health Assembly by nearly every country in the world, forms the basis for the law; in the UK our laws do not fully implement the Code but they do restrict the marketing and promotion of first infant formula. Because they are limited by the law, companies must continually try to find new ways to market their products that get around the restrictions. Since they cannot market directly to mothers, they must target those who have contact with them - health workers. (Follow-on milk - an unnecessary product - was invented to get around these restrictions too. In countries where all formula advertising is restricted, follow-on milk does not exist.)

- formula companies are regulated because breastfeeding is the normal way to feed babies, and formula feeding carries known health risks for mothers and babies. Formula milk may be an infant's sole source of nutrition and must be suitable and nutritionally adequate (though it is not, and can never be, close or similar to breastmilk) so there are strict regulations about its composition. This means that the differences between products are very small, and often claimed differences do not stand up to scientific scrutiny. What really matters to companies is 'brand awareness'. What can they do to ensure that the buyer of formula, whoever that is, chooses one brand and not another? One answer is to get that brand, or information about it, on to materials that will be seen by their target market (which is hard, because they are restricted from marketing directly to mothers), or those that advise them - midwives, doctors, health visitors, community nurses and so on.

You might think that health workers should be immune to the effects of marketing - surely they know all this, and can make their own informed decisions? In fact research shows that none of us are immune to marketing. The effects of even small, trivial gifts such as pens and notepads have been shown to cause the recipient to feel good about the giver. Larger gifts, such as free study days (which delegates might otherwise have to pay for themselves, or apply to their employers for the money) have a greater effect. The speaker paid by the sponsor feels good about the sponsor too. Might that influence the content of what they say? It certainly suits a formula company to have both health workers and experts feeling good about their name or brand. When a health worker who attends a study day goes back to the office and tells colleagues about the event, might they mention the sponsor by name? Or show others the programme for the day that carries the sponsor's logo? It's only a short step from here to saying to a new mother, 'Well we're not supposed to give advice, but xxx is meant to be good'. (Hands up if you work in breastfeeding and have heard that one before?)

To sum up, sponsoring an event may benefit the sponsor in many ways:

- goodwill from the participants/organisers
- promotion of the name/logo/brand - on advertising for the event and materials given out
- networking opportunities for staff from the sponsor organisation who may attend the event
- product promotion (some events allow product promotion/stands by sponsors)
- the chance to obtain personal/workplace contact details from participants

Given the above, I think it's clear that formula companies should not be sponsoring training - any training, not just in breastfeeding - for health workers, and that organisations should have policies in place to avoid conflicts of interest.

The Guardian and Danone infant feeding roundtable - and why the politics of breastfeeding matter

A couple of weeks ago I Tweeted my disappointment that the Guardian had decided to run a roundtable discussion in association with Danone Nutricia; yesterday an article reporting on the debate appeared in the paper's society section; a full page, with the Danone Nutricia Early Life Nutrition logo clearly displayed, and an explanation that the content is editorially independent (which presumably means that the journalist, Joanna Moorhead, wrote her piece reporting on the discussion without having the text approved by Danone). As Helen Crichton, head of public affairs for Danone Early Life Nutrition took part in the discussion itself, and Danone was able to suggest topics to be included in the discussion, the term 'editorially independent' is at best only partially accurate.

Mike Brady, Baby Milk Action's campaigns coordinator, has already published an excellent response to the Guardian article; you can read it here. What follows is my personal response to the article, which attempts to explain some of the reasons it made me so uncomfortable/furious.

Participants
Paul Lindley, founder of Ella's Kitchen
Helen Crichton from Danone itself;
Judy More, freelance dietician. Her website reveals that she is on the editorial board of the Journal of Family Health Care, which runs training events sponsored by formula companies including Nestle, Danone and Hipp Organic, and that she has worked for the Infant and Toddler Forum:

"The Infant & Toddler Forum is supported by an educational grant from Danone Nutricia Early Life Nutrition. The views and outputs of the group, however, remain independent of Danone Nutricia Early Life Nutrition and its commercial interests."

Professor Paul Gately from Leeds Metropolitan University. He has previously been a speaker at an event sponsored by the Infant and Toddler Forum.

Four of seven panel members have a clear conflict of interest in the discussion, because they are currently, or have been in the past, paid by companies that make profits marketing and selling products aimed at babies and young children. Judy More and Paul Gately's conflicts of interest were not made clear in the article; I found their earlier links to Danone with a simple search.

A major problem with this sort of 'invitation' roundtable discussion sponsored by a formula company is panel selection. Anyone who's had any sort of training on the International Code of Marketing of Breastmilk Substitutes, who works in breastfeeding, public health or in a Baby Friendly accredited NHS Trust should refuse to be involved. (For more about health worker conflicts of interest, see here).

Content/discussion
Reading the article I found myself occasionally incredulous. Paul Lindley (Ella's Kitchen) is quoted as saying, 'Food is what brings people together, but they're not eating together very often and very young children aren't learning the art of conversation or the joy of eating with others.' This from a man who founded a company that makes pouches of ready-made pureed baby food that babies can slurp alone in their pushchairs without making a mess! Is it just me?

Dr Lucy Cooke said 'There's a lot of confusion about breastfeeding. The Department of Health says breastfeed to six months, but baby foods say 4-6 months on the jar'. Both Lindley and More, who should both surely understand the Code, the Department of Health guidelines and how information is given to new mothers, given their work, instead perpetuated the confusion, with Lindley appearing to advocate early weaning by saying that the earlier you give children vegetables, the more likely they are to eat them later on. What he didn't say was that early feeding (before six months) with pureed foods like apples, carrots and parsnips, which his company supplies in pouches, displaces breastmilk in a baby's diet and may reduce their overall nutrition rather than improve it.

I was also deeply uneasy about the suggestion that 'one change that would make a huge difference was to encourage better collaboration between the government and the food industry'. The food industry already has extensive access to contacts in government, and will lobby hard for its own interests. There is plenty of evidence that if companies are not regulated, then they will not restrain their marketing practices voluntarily. If the industry is so keen to do good, surely it should first put its own house in order: in the case of Danone, with 39 pages of marketing Code violations worldwide in the IBFAN Breaking the Rules, Stretching the Rules 2014 report, it would seem that the company has plenty of work to do before embarking on seemingly generous public health campaigns. Ella's Kitchen too could look at its early weaning guidance and labelling so that it better reflects the information that mothers are actually given.

And mothers are often given good information; but we didn't hear anyone talking about it in this debate because of the inherent conflict of interest. Health visitors, midwives and breastfeeding supporters could have painted another picture; one where UNICEF Baby Friendly and the First Steps Nutrition Trust are sources of clear, independent information for parents. The LIFIB (Lancashire Infant Feeding Information Board) is a great example of how information from companies can be critically reviewed and challenged before being passed on to health professionals (see @The_LIFIB).

I could go on, and on. I won't, but I will leave you with this quote from my forthcoming book with Gabrielle Palmer for Pinter and Martin Why The Politics of Breastfeeding Matter, which sums up my thoughts.

"When ‘knowledge’ comes from company promotion [which is what Danone-sponsored activities are] and poorly trained or corrupt health workers, parents and children suffer. Knowledgeable and supported families, who are aware that breastfeeding is normal, that artificial feeding carries risks, and that cheaper, safer baby foods can be made from locally available ingredients, end up healthier and less poor. The Code states that governments are responsible for ensuring that objective and consistent information on infant and young child feeding is provided. But it is hopeless to invest public money in providing such information if it is eclipsed by promotional untruths."

Nutrimum: new product, same old formula company tactics

This morning the First Steps Nutrition Trust newsletter hit my inbox (if you don't get this already I highly recommend it). They've issued a statement on nutrimum, a new product on the market that I'd heard about thanks to a Facebook post from Michael Walne at Your Nutrition Matters (who is busy writing evidence-based nutrition books for the Pinter and Martin Why It Matters series at the moment).

Nutrimum is a range of cereal bars and granola aimed at pregnant and breastfeeding women, made by Nutricia, owned by Danone, which makes Cow & Gate and Aptamil infant formula. The new products are currently available through Boots stores and are heavily marketed on the Boots website, with advertorials accompanied by 'buy now' prompts. The advertorials stress the importance of maternal nutrition during pregnancy and breastfeeding; the clear implication is that the nutrimum bars and cereals can form part of the healthy diet that is being discussed. Associating general nutrition information with specific products is a deliberate strategy. Marketing products that combine food
and supplements through a store such as Boots, which although it has dropped 'the chemist' from its name still has a reputation for selling pharmacy products, also helps to support the idea that these products are somehow 'scientific' or 'beneficial' (they aren't). Using partner organisations for 'reputation transfer' is a tactic often used by formula manufacturers: for example in 2013 Danone sponsored a 'Big Toddle' in aid of Barnardos to promote its Cow & Gate brand.

The First Steps Nutrition Trust statement on nutrimum explains how the products undermine public health by stating that women should stop taking other supplements (which will have been recommended to them by midwives or health visitors in accordance with current guidelines) while consuming the products. Folic acid (which is recommended for those who are planning a pregnancy and pregnant women) and vitamin D (recommended for all pregnant and breastfeeding women) supplements are widely available in supermarkets and pharmacies at low cost, or may be free on the Healthy Start scheme. The nutrimum products are expensive: the cereal bars cost £4.99 for five bars, or £1 a day. A large part of the cost of the product will go on marketing. (As with infant formula, the marketing is paid for by those who buy the product.) Equivalent vitamin D and folic acid supplements cost just pennies per day. The cereal bars and granola are highly processed and high in sugar; the main ingredient (listed first in the ingredients list) in the bars is glucose syrup (sugar). A crucial difference between granola/cereal bars and vitamin supplements is that the granola/bars are food - they will fill you up, and increase your blood sugar levels, potentially displacing more nutritious foods (vegetables, fruit, nuts, eggs, meat) in your diet. Tablets and liquid supplements do not have this effect.

When formula companies stress the importance of nutrition while breastfeeding, they do so in order to make breastfeeding seem difficult, expensive and inconvenient - an unachievable ideal. Mothers who doubt the quality of their breastmilk may turn to formula for 'reassurance' that their babies are getting all that they need. In reality there is little difference in the nutritional profile of breastmilk worldwide: mothers everywhere, despite wide variations in diet, produce milk that will nourish their babies and keep them healthy. A mother needs good food for her own health, not to support breastfeeding. Mothers in the UK (where nutrimum is marketed) have access to better, cheaper food than these highly processed cereal products that are high in sugar and expensive. As First Steps Nutrition say:

'Good nutrition from food is perfectly possible for pregnant and breastfeeding mums and we show how nutrient requirements can be met through simple, cost effective menu choices in practical eating well resources. The money spent on these supplements could be more wisely used buying fresh and minimally processed foods for the household.'

Formula companies target medical and health workers to promote their products. Perhaps the most disturbing part of the First Steps Nutrition statement on nutrimum is the section about how company representatives have contacted infant feeding coordinators and NHS staff. An email to an infant feeding coordinator in February 2015 states that the product is:

‘designed to meet all the nutritional requirements for mum during pregnancy…and that neonatal nurses are particularly interested in Nutrimum for breastfeeding mums with babies in special care baby units’

It's this that makes me actually want to scream. For the last few months I've been working on a short book about the politics of breastfeeding, and this type of contact with health professionals, implying that the product is beneficial for mums breastfeeding special care babies (for which there is certainly no evidence), is reminiscent of all the marketing abuses I've been writing about. That this isn't infant formula doesn't matter. These products offer no benefits, play on fears mothers have about their own and their babies' nutrition, and the profits will line the pockets of the world's second biggest baby milk manufacturer. Thank goodness for the work of First Steps Nutrition and other organisations like Baby Milk Action that scrutinise and monitor the companies. Do visit their websites and join or donate to support their work if you can. And if you work with mothers, tell them that these products are unnecessary, expensive and heavily marketed (and that if they buy them, they are paying for the marketing).