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.

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.