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).

Breastfeeding, guilt, feminism, the media... and UNICEFs new report

As is normal for me, when new breastfeeding research is published and discussed widely in the media, I've found myself alternately depressed and encouraged by the response to the publication yesterday of UNICEFs report: Preventing disease and saving resources: the potential contribution of increasing breastfeeding rates in the UK.

There was certainly plenty of media attention for the story: newspaper articles, blogs, TV, news programmes. Having blogged about the report myself, I kept a close eye on how it was being reported by others. I found myself increasingly disappointed in the way it was handled (if not surprised). Lorraine Kelly, on ITV, framed discussion of the report as 'Is there too much pressure on women to breastfeed?' and a poll, conducted among viewers, concluded that 60% of respondents thought there was. (I linked yesterday to a great post on 'pressure': you can find it here). Lorraine's guest, Natalie Cassidy, was actually a great example of someone who was both culturally at a disadvantage when it came to breastfeeding (she explained how her father would not want to see her feeding, and how she'd felt, even among family, that she needed to go into another room) and the victim of poor support (she'd been told, and felt herself, that the latch was fine, but her story of cracked and bleeding nipples, and a baby with poor weight gain, suggested problems that could have been resolved with more skilled help). However, the context of the 'debate' meant that her contribution perpetuated many of the ideas that breastfeeding supporters are working hard to challenge - about breastfeeding as something that is difficult, time-consuming, painful, isolating. Dr Hilary Jones made a few points 'in favour' of breastfeeding, but the whole thrust of the discussion missed the point of the new report entirely (of which more below).

At 7pm on Channel 4 presenter Cathy Newman interviewed a breastfeeding mum feeding her three-week old baby on air, again questioning her on the 'pressure to breastfeed' angle, which she handled with aplomb, and Krishnan Guru-Murthy refereed a 'debate' between report author Prof. Mary Renfrew and Dr Ellie Lee from the Centre for Parenting Culture Studies in Kent (whose role was to present 'the other side'). This set-up did not make for illuminating discussion: it consisted of Dr Lee claiming that the report was one-sided, based on flimsy evidence and just one more stick to beat women with, while Prof Renfrew had to use up her minutes of air-time refuting these points rather than talking about the importance of the new report.

Have you spotted a trend? That trend continued... on Newsnight at 10pm three women were interviewed (very briefly!) about breastfeeding: one breastfeeding support worker, one bottle-feeder (again a good example of cultural barriers to breastfeeding: she explained how in her family two generations had bottle-fed, and she'd always thought of it as normal, and thus felt challenged and pressured when, during antenatal appointments, midwives explained the risks of bottle-feeding.) The third lady, calmly breastfeeding her young baby, explained how she'd planned to breastfeed and had welcomed the support she was given, although she qualified this by saying that the information she'd had 'was very biased in favour of breastfeeding.' Arguably this is spot on - breastfeeding and artificial feeding are not comparable. Gabrielle Palmer, in the Politics of Breastfeeding, sums this up very well:

'The infant feeding issue is often represented as one of individual choice between two parallel methods,"the breast or the bottle". Neither the products nor the method are equal and the true cost to society and the individual is seldom mentioned or measured [except, perhaps, in this new report?]. Women have the right to choose how they use their bodies and they cannot (and should not) be forced to breastfeed, but that does not mean that evidence about the risks of not breastfeeding should be censored.' (p7)

Newsnight then featured a 'debate' hosted by presenter Emily Maitliss between Rosie Dodds of the NCT, Francesca Entwhistle, a midwife and lecturer, and Charlotte Faircloth (of the aforementioned Centre for Parenting Culture Studies), who also had a piece in the Independent. (In which she said, among other things, that we spend enough money promoting breastfeeding already - £6m per year. Nestle spends £42m promoting its products.) It was an interesting discussion, although for me it was again derailed by the opposition set up between Faircloth (who described the report as one-sided and explained that as a feminist she believed we should not blame women for society's ills and  make them feel guilty about feeding; she also dismissed the notion that breastfeeding could address health inequalities) and the other contributors, who had to explain, again, that the report was not designed to make mothers feel guilty and that the evidence shows that 81% of women want to breastfeed and are forced by many circumstances to give up before they want to. Once again, the key message of the report played second fiddle to a different agenda.

A comment piece today by Victoria Summerley returns again to the question of guilt/pressure. It seems that despite the best efforts of the report's authors, and those of commentators welcoming the findings, we can't get away from these entrenched positions. Gabrielle Palmer again:

'I know that stating these facts can be painful or even enraging to some women who have not breastfed their children, but the continued denial of the risks of not breastfeeding and the value of breastmilk, supposedly to spare women's feelings, is a patronising deception. The whine about "not making mothers feel guilty" is such a cop-out... No woman need feel guilty for 'failing' to breastfeed, though she has the right to feel angry or sad for being denied support when she needed it.' (p85)

So what is the point of the report, and what is wrong with the way it's been covered so far? This is a report about the economics of breastfeeding. It presents information about infant feeding in a new way - we have not previously had these figures, of cost savings and potential returns on investment, available for the UK in this form. The report is a tool for the decision-makers who have to manage the limited resources of our health service in tight financial times.

Where were these decision-makers yesterday? Where were the health ministers, politicians, economists, health service bigwigs? Yesterday someone commented on my blog that her PCT had recently laid off three IBCLCs who had increased initiation and continuation rates in their locality. An interview with the person who made that decision would have been interesting in the light of the new report, surely? Where were the tough questions, the demands for assurance that the new report will be taken seriously? The report itself contains two fascinating case studies of areas that have implemented breastfeeding programmes that have improved breastfeeding rates and cut costs: Lancashire and Harrow (Harrow now has admissions for gastroenteritis of 16% below the national average). No one involved in these programmes was interviewed yesterday to explain how they had implemented change and seen results.

I think, so far, the mainstream media has taken the view that this new report on breastfeeding is a 'women's issue' and has covered it accordingly. I find that more than a little patronising. The report's main message, which is that programmes of breastfeeding support are cost-effective, improve public health and address health inequalities, is being lost among the bickering about 'guilt' and 'pressure'.

Some suggestions for what to do if you're irritated about this: Read the actual report - it's well worth it. Email your MP about it. Join Baby Milk Action - they are respected lobbyists in the political arena. Buy and read The Politics of Breastfeeding and become more aware of the issues. Support breastfeeding, and women who want to breastfeed, however you can - by doing it yourself or supporting those who do. It's perfectly possible to campaign for breastfeeding politically and be an enthusiastic, sympathetic and genuine supporter of women at an individual level as well.