Advertising infant formula - WHO cares?

Last month, online retailer Ocado distributed, in print and online, a magazine that carried a feature advertising first-stage infant formula. They've now (after an initial delay) amended the online version of the magazine, which you can see here. The article on p34 originally had an image of a box of six ready-to-feed SMA bottles in the 'S is for Sleep' section (see right) - in fact the whole section looked as though it spelt out S.M.A. The first problem? It's illegal in the UK to advertise first-stage infant formula: the relevant legislation is here.

So far, so simple. Ocado were pulled up on their mistake, and they responded with an apology:

The SMA First Infant Milk product was included in the feature by mistake. The mistake occurred purely through human error and we are satisfied this is an isolated incident. We are very sorry that this has happened and we have made some changes to the ocadolife production process to ensure this cannot happen again. We take compliance very seriously at Ocado and as a responsible retailer we have voluntarily approached the relevant authorities to discuss this matter with them. We can also confirm SMA did not provide any funding for the inclusion of their product in the feature and we also extend our apologies to them for our error.

An end to the matter? Not really. The whole incident brought some of the issues affecting infant feeding in the UK sharply into focus. So much is wrong with the picture. That this image of formula milk appeared in the 'sleep' section of the article reflects a common misconception that formula feeding aids infant sleep (when in fact it increases the risk of SIDS). That the image appeared at all demonstrates a worrying lack of awareness of the law among editors, copyeditors, proofreaders... And a storm of comments on Facebook (I saw them on the Association of Breastfeeding Mothers page, and on the Ocado page) demonstrated just how poorly the general public understand the law itself, and the reasons for it (which reminded me of the comments made about breastfeeding in swimming pools that I blogged about here.) A small selection:

I don't see what's wrong with this. Some people formula feed, so what!!!

In today's world of equality and freedom of choice its a disgrace that such a law even exists... it hits a bit of a raw nerve when I read so many people trying uphold a law that in my opinion should never have been passed.

...not allowing advertising of first milk is making some mothers' failure at breastfeeding even more apparent... don't we need to be looking at the nhs midwifery service and the support (or lack of) that new mothers receive rather than the advertising...?

If these infant formulas were actually bad for baby and caused harm... then they wouldn't be allowed to be produced never mind advertised.

Adverts are allowed for everything else under the sun claiming to be healthy such as high sugar cereals, breakfast bars and alcohol!!!... but adverts aren't allowed when it comes to offering choice or advice on formula milk!!!

So why is it illegal to advertise formula?

I just don't get why people are so up in arms about a very small picture in a publication.

The law exists because of pressure groups who don't feel that people should be allowed to make their own choices.

The problem with this law is that it prevents the balanced info that you claim you want parents to have. 

Let me make it clear. The law exists to protect mothers and young babies, whether breastfeeding or artificial feeding. We know (and by we, I mean that it is common knowledge) that breastfeeding is the normal way to feed human infants, and we know, thanks to an ever-expanding wealth of scientific research, that not doing so carries a host of increased health risks for both babies and their mothers. Yes, even in the UK. It seems logical then that the marketing of breastmilk substitutes for infants, which are artificially-fed babies' sole source of nutrition, should be subject to checks and controls.

It's also clear, from even the most cursory look at the advertising practices of the formula manufacturers, that they will go to great lengths to promote their products, often making pseudo-scientific claims that do not stand up to scrutiny (cases have been brought against them, and won), adding ingredients of unproven benefit and cynically targeting health care professionals when they are denied direct access to parents. Baby Milk Action, and the UK Baby Feeding Law Group, monitor the activities of the various formula companies: you can find a great deal of further reading on their websites (my most-read post ever is about this topic too, here.) It seems obvious that companies aiming to maximise their profits are not best placed to offer objective information about formula feeding.

The above has been known for some time, and is recognised worldwide. Hence WHO (the World Health Organisation) created the International Code of Marketing of Breast-milk Substitutes, adopted in 1981, the aim of which is to:

...contribute to the provision of safe and adequate nutrition for infants, by the protection and promotion of breast-feeding, and by ensuring the proper use of breast-milk substitutes, when these are necessary, on the basis of adequate information and through appropriate marketing and distribution.

Can anyone find anything there to disagree with? It sounds perfectly sensible. In 2003, WHO and UNICEF, as part of a global strategy for infant and young child feeding, called for governments to 'review progress in national implementation of the Code, and consider new legislation or additional measures as needed to protect families from adverse commercial influences.' Unfortunately, in the UK we have still only partially implemented the WHO Code, which, as Emma Pickett IBCLC, co-chair of the ABM, explains:

...could be argued to have done more harm than good. It has led directly to the 'invention' of follow-on formula, which is not subject to the same advertising controls as first-stage formula. In countries that have fully implemented the Code, there is no follow-on formula at all - if it really were a distinct and medically necessary product, as the manufacturers would have UK parents believe, surely it would be available worldwide? Here in the UK we have evidence from the Diet and Nutrition Survey that 32% of parents have given follow-on formula before six months: proof, if any more were needed, that advertising really works.

She also describes a situation that breastfeeding supporters everywhere will recognise:

You meet mothers every day who use formula alongside breastfeeding and end exclusive breastfeeding because the messages they receive from advertising are far more powerful than the information they are drily given about the benefits of exclusive breastfeeding. The TV adverts stick in the mind long after someone mumbling something about gut flora and allergy prevention.

It's grimly ironic that those parents complaining about the law against advertising first-stage formula are the very same parents that are being ripped off, both financially and through misinformation, by the formula manufacturers. Rough calculations (companies won't reveal their figures) suggest that of an annual spend by parents of £436.54 on Aptamil powdered formula, for example, between £231 and £349 goes on marketing and profit. Still think the companies are acting in the best interests of consumers?

As for where parents should go for better information, UNICEF, First Steps Nutrition, Which? and others all have guides to artificial feeding for those who need them, freely available on the internet.

But there's even more to it than this. Want to see how deep the rabbit-hole goes? In this post on the Alpha Parent James Akre describes our culture of acceptance of formula feeding thus (my italics):

Given the mass of compelling scientific and epidemiological evidence about the harm caused by routine artificial feeding, it’s hardly farfetched to qualify as collective delusion the unquestioned faith that the general public and health professionals alike in many settings continue to place in infant formula...

...Infant formula will sustain life in a pinch, and thank goodness this is so. But as I describe elsewhere, from a nutritional and developmental standpoint, most people do not understand just how hugely inferior it is to breast milk...The idealized view of normalized infant formula feeding that manufacturers are so adept at portraying – and, regrettably, so many consumers, health professionals and politicians are inclined to accept – doesn’t allow for even a hint of this disenchanting reality.

Given all the evidence, why do you think we haven't fully implemented the Code in the UK? And why don't we make more use of the laws we have? Don't be fooled into thinking that the reasons have anything to do with any doubts about the benefits, in terms of public health, of doing so. It's an uncomfortable truth that we cannot rely on governments to act as they should, even in the face of overwhelming evidence and firm guidance from WHO (which has no power to compel countries to implement the Code). The pressure, on governments and other organisations, from vested interests within the baby food industry and elsewhere, is immense: the power of corporations, at the highest levels of politics and policy-making, cannot be dismissed as conspiracy theory. When so much profit is at stake, the interested parties will do all they can to exert an influence. This month a letter appeared in the Journal of the World Public Health Nutrition Association about conflicts of interest in the area of infant nutrition:

...concerned with the equally deep penetration of the transnationals and their associated or supportive organisations, into the scientific community, into nutrition policy-making at the highest level, and into public health programmes that affect the health and lives of hundreds of millions of people.
We see this largely as a consequence of the failure of elected governments to fulfil their first duty, which is to govern. We also feel that some policy-makers and many scientists, including those working at the highest level, underestimate or overlook the consequences of their own actions.
The influence of Big Food can be subtle, and may, in the opinion of reasonable people, be seen to affect the judgement of public policy agenda-setters who act in good faith and whose personal integrity is not at issue. We are not questioning the motives of any of the people mentioned in this letter. We are though, deeply concerned about the possible effects of their activities.

Our specific situation in the UK is part of a global issue that has far-reaching implications for mothers and babies. Just today Baby Milk Action posted this press release on their website about formula companies bribing hospitals in China - yes, those same formula companies that advertise and sell products in the UK.

I've covered a lot of ground: from a tiny image of first-stage formula in an Ocado magazine, to global politics, nutrition policy and economics, in one helter-skelter ride. And really, this is still only scratching the surface. I just hope I have gone some way towards showing how that one little article is part of a much bigger picture that should concern us all.

Baby milk shortages - formula manufacturers, the politics of infant feeding, breastfeeding

The news that Danone, which makes Aptamil and Cow & Gate formula milks, has imposed sales restrictions on parents in the UK has been all over the media this week. Shoppers are now limited to purchasing two packs of powdered infant formula per day. Supposedly this is to prevent bulk buying and informal export of formula to China - at least, that is the explanation that Danone have given on the brands' respective websites, in a letter from managing director John Sykes.

However, there can be no denying that the story has generated massive publicity for the brands involved. For example, in this segment on the BBC website the mother is filmed using Aptamil formula, and this article from the Daily Mail carries a prominent shot of both Danone brands on supermarket shelves, complete with shelf-edge explanation of the buying restrictions.

What better way to add cachet to the Danone brand than to let its UK market know how highly prized its products are in China? The fact that millions of Chinese consumers (in a country beset by formula milk scandals, where formula advertising is aggressive and unregulated, and breastfeeding rates are on the way down) trust the brand and will pay inflated sums for it is surely something worth (from Danone's perspective) instilling in the minds of UK consumers. In addition, products in short supply have 'rarity value' - it's like must-have toys at Christmas, or petrol, or limited-edition designer handbags - that 'value', in the minds of consumers, is great news for retailers and manufacturers. Crucially, 'news' stories are not seen as 'advertising', although in practice, as anyone involved in the media knows, they fulfil the same function - there is truth in the old maxim 'all publicity is good publicity'.

The knock-on effects of all this on our culture of infant feeding on the UK are more subtle. A slew of articles about formula feeding normalises it further - a shortage that affects millions of parents across the UK gives the message that 'everyone' is using formula as opposed to breastfeeding. Images of specific brands accompanying the articles make it more likely that parents, faced with a shelf full of products and with little access to accurate, unbiased information about infant formula, will reach for the product they recognise. As shown by the Daily Mail article mentioned above, a focus in the media on formula feeding can bring with it a wave of anti-breastfeeding feeling. The author of the article claims that "the breastapo are out in force, berating the formula feeding pariahs who feed our babies this manufactured 'poison'." I don't believe this or see any evidence of it; all this article shows is that, given a convenient peg to hang it on (news of a formula shortage), the same tired elements of a FF v BF argument that helps no one and only serves to divide women and line the pockets of the formula manufacturers, can be trotted out yet again.

(A separate, but I suspect related, article in the Mirror about vitamin D deficiency mentioned Cow & Gate Growing Up Milk by name, causing me to wonder whether the article had been 'inspired' by a Danone press release... the formula companies are very keen for parents to know that children consuming more than 450ml of first stage or follow-on formula per day do not need vitamin D supplements.)

Consider the context of all this. We already know from the Infant Feeding Survey 2010 that in the UK many parents are unaware of the differences between infant (first stage) formula and follow-on formula (suitable from six months) - the latter being an unnecessary product specifically designed to circumvent the restrictions on marketing infant formula imposed by the WHO code on the marketing of breastmilk substitutes, which is not even fully implemented in the UK. We also know that the formula companies will battle incessantly for market share with a huge array of marketing tactics (carelines, baby clubs, marketing to health professionals, roadshows... the list goes on). All this is funded by marketing budgets, paid for by formula consumers. Increased market share means increased profits. In this sort of climate a shortage of product makes perfect sense as an aggressive marketing ploy.

In case you think I'm overstating the case here, I'd like to highlight the work of Baby Milk Action, which has recently published a new report Look What They're Doing in the UK!. In the press release that accompanies the report Mike Brady, Campaigns and Networking Coordinator, says:

"Given the massive production capacity that Danone has in nearby Ireland there is something about this story that does not ring true: it is surely more likely Danone that is prioritising other markets than people exporting supermarket stocks. Danone is locked in fierce competition with Nestlé, particularly in Asia. Danone is gaining massive publicity for its products on the back of this shortage scare, but parents who use formula can heed Department of Health advice and switch to other brands. Claims made that one particular brand is better than another do not stand up to scrutiny. As our Look What They're Doing in the UK report demonstrates, companies are endlessly imaginative in how they push their products."

In the BBC report on the issue, Nestle, the second largest formula manufacturer in the UK market, said that it had not seen an increase in demand due to unofficial exports, and that there was no shortage of its products. (Nevertheless, some supermarkets are limiting sales of Nestle brands too.)

It seems to me that what's needed, as usual in reference to infant feeding, is wider access to clear, unbiased information that doesn't come from the formula manufacturers themselves, and this article in the Telegraph made the same point. UNICEFs Babyfriendly initiative publishes A guide to infant formula for parents who are bottle-feeding, which is a great place to start. Another good source (aimed at health professionals, but anyone can download the report) is Infant Milks in the UK.

It's also not unreasonable, as part of the ongoing discussion, to talk about breastfeeding. It's not shaming of those who use formula to point out that, on a population level, increased breastfeeding would mean both improved public health and less reliance on commercially-driven formula milk manufacturers. The 'shortage' story could be seen as demonstrating perfectly some of the most amazing qualities of breastfeeding: most mothers can produce hundreds of litres of breastmilk (incomparable to formula) for a zero carbon footprint - no food miles, no energy costs of manufacture or reconstitution, no supply-chain issues. 

I've been considering the implications of all this for breastfeeding support. I had a conversation with a formula-feeding mother while I was planning this article: she asked me what, as a breastfeeding peer supporter, I would do if someone asked me about formula feeding. I thought hard about what I could do in this situation, aside from talking to the mother about her reasons for switching to see if there was anything I could help her with before she stopped breastfeeding, and discussing the option of mixed feeding (on the grounds that any breastfeeding is better than none). I realised there's a lot of information I can give, although I would be upfront about my lack of personal experience of bottle or formula feeding. I do, however, know about the most recent guidelines for making up bottles and the reasons for them, and am happy to talk to mothers about them. I have also read the guides above and feel that I could tell a mother that since the composition of formula in the UK is regulated, and claims about differences between brands don't hold water, her decision can be based on price and what her child seems to prefer, and she needn't be restricted to one brand. I'd hope, in doing this, to leave the mother feeling better-informed about her options, and not let-down by a sudden lack of support when her circumstances change. I'd love to hear what other breastfeeding supporters think about this.