Thursday, March 15, 2007

UK health claims action example to the Philippines and the world

I have been looking at some of the discussion boards where people are commenting on the action by UK authorities to enforce the UK baby milk marketing regulations. See our press release from Monday:

For many this is great news. It has taken 12 years of campaigning to prompt this action since the Infant Formula and Follow-on Formula Regulations were adopted in 1995. See:

Some, however, see it as an attack on mothers who feed their infants with formula or an attack on the validity of infant formula for infant feeding. It should not be seen that way.

Infant formula manufactured in accordance with Codex standards is a valid alternative to breastmilk and comes, in the ideal scheme of things, after breastfeeding, feeding with expressed mother's milk and donor milk.

We have never called for formula to be banned, we call for it to be marketing appropriately, which means in accordance with World Health Assembly marketing requirements. These require that idealizing claims are not made, that companies do not seek direct or indirect contact with mothers and that information provided to health workers is scientific and factual.

The reason action is being taken in the UK is very simple: companies were breaking the law partially implementing the International Code of Marketing of Breastmilk Substitutes and subsequent, relevant World Health Assembly Resolutions.

The Code and Resolutions are intended to protect breastfeeding AND to ensure that breastmilk substitutes are used safely if needed. The UN Committee on the Rights of the Child calls for governments to implement the Code to help ensure a mother’s right to receive independent and correct information on infant feeding. The Committee called on the UK government to implement the Code in its last report in 2002 and the government will revise legislation this year.

One of the things required is an end to idealizing text and images on labels and a ban on all promotion. Health and nutrition claims for ingredients in breastmilk substitutes are invariably promotional. The UK legislation allows claims about ingredients to be made, in terms of the contents of the formula. For example, low sodium, sucrose free etc. Only specified claims are allowed and only in the terms set out in the annex to the law.

Claims such as ‘Omega 3 LCPs for development’ are not allowed. Firstly, Long Chain Polyunsaturated Fatty Acids (LCPs or LCPUFAs) are not on the current list (though they are likely to be added following revision of the EU Directive from which the law derives). Secondly, the claim goes beyond saying the formula contains LCPs.

These are the ingredients that Nestlé describes as ‘Brain Building Blocks’ on its formula labels in the Philippines (see below). Yet, as previously discussed in this blog, the Cochrane Library review of research found: “At present there is little evidence from randomised trials of LCPUFA supplementation to support the hypothesis that LCPUFA supplementation confers a benefit for visual or general development of term infant”. The European Union's expert Scientific Committee is allowing companies to add LCPs to formula, as there is no evidence they are unsafe, but is not making it a requirement, as there is insufficient evidence of any benefit. As investment experts said when LCPs were first synthesized with the brand name Formulaid by Martek for inclusion in formula : “Even if Formulaid had no benefit we think that it would be widely incorporated into most formulas as a marketing tool and to allow companies to promote their formula as 'closest to human milk.’”

This is exactly what has happened. See:

One of the illegal claims that the authorities are cracking down on, is that formula is ‘closer than ever to breastmilk’.

Where there is scientific evidence for benefits from ingredients, these are invariably based on company-sponsored research which is often not independently and systematically reviewed before products are placed on the market. The studies carried out by companies often don't have an exclusively-breastfed control so the results only compare one product over another.

When the results of these studies are translated into a claim it is invariably promotional and conveys the impression that the product is actually better, the same or almost the same as breastfeeding.

Even the industry self-regulatory body, the Advertising Standards Authority (ASA), has stepped in and instructed one of the companies to stop overstating the claim about the prebiotics it was adding to formula. Of course, if the ASA was doing its job properly, it would have said, as the authorities have just done, that any claim about prebiotics was in breach of the law because they are not on the permitted list. This is what the ASA did say:

“Because they had not sent evidence to show a direct link between an infant taking their formula and it helping to build defences against a number of everyday illnesses or conditions to which they were susceptible, we considered that Cow & Gate had not substantiated the claim. We told Cow & Gate to amend the ad to make clear that the product could help build "some" and not "all" natural defences."


The point I am trying to make is that companies will overstate or misrepresent the properties of their formula. Mothers need accurate information and companies with a vested interest in increasing sales, do not in practice provide it. That is why the principle that information is independent is so important.

The properties of breastmilk are still being discovered and technology can only synthesize a limited number of ingredients similar to those known to be in breastmilk. Ingredients do not necessarily function in the same way in a processed formula as they do in living breastmilk.

Our view is that only the highest quality substitutes should be placed on the market. So if an ingredient has been proven – through independently funded and reviewed research - to be safe and essential for infant health it should be a requirement for all formulas.

Breastfeeding is best for infants. The companies say they accept that. The health benefits of breastfeeding, or, put another way, the negative impact of formula feeding, are well known. I won’t go through them here, but here are some rounded up on the IBFAN website.

The problem with an open and honest discussion of the advantages of breastfeeding and disadvantages of formula feeding, is that it is sometimes seen as an attack on mothers who formula feed. Or it is depressing to mothers who fed formula in the belief that ‘close to breastmilk’ meant virtually the same.

So it is a discussion that has to be had as sensitively as possible. I imagine that most mothers who have formula-fed did so either because they believed it to be for the best for their child given their circumstances (for example, they had been unable to overcome breastfeeding problems) or because they were misled into believing formula feeding was the same or almost the same (according to the Department of Health, that is the view of 34% of women) and so really just a lifestyle choice. I don't believe these mothers should feel guilty for their decision. Angry at the failure of support systems and at companies who promote their products with idealising claims and the authorities who have failed to stop them, perhaps.

A mother can only make an informed decision about how she will feed her baby if she has sufficient accurate and independent information and misinformation is stopped. That is the aim of the World Health Assembly marketing requirements and the crackdown on illegal health and nutrition claims in the UK.

In the UK formula-fed infants are at increased risk of short and long-term sickness than breastfed infants, but they are unlikely to die because there is access to health care. Without the same access to health care, however, infants are more likely to die if not breastfed and 1.5 million die around the world every year. The need to stop misleading information is the same in these countries. The crackdown in the UK is an example to other countries.

In the Philippines 16,000 infants die every year because of inappropriate infant feeding. There the government has introduced regulations to try to stop idealizing promotion. Unlike in the UK, where companies immediately agreed to comply when contacted by the regulatory authorities, in the Philippines the companies took the government to court and succeeded in blocking the regulations. See:

I have written previously how mothers who have now become aware they were misled by health and nutrition claims have demonstrated at the Supreme Court and are looking at suing the companies. See:

On Tuesday I received a copy of a news report from the Philippines, which appeared in the Manila Bulletin. You can download a scan by clicking here.

It is headlined ‘Department of Health sad over decision on milk code regulations’ and in it the Health Secretary comments on why they introduced the regulations:

----Quotes begin
In a crusade to improve the health of mothers and children, Health Secretary Francisco Duque III said that “the facts remain that the World Health Organisation (WHO) has estimated that 16,000 Filipino children unnecessarily die each year because they are not breastfed”

“They are not breastfed because many milk companies engage in aggressive, profit-oriented marketing of expensive milk substitutes and infant formula that adversely affect breastfeeding behavour of mothers,” he said.

“Each day of delay in the implementation of the revised Implementing Rules translates to a day where mothers get more half truths or even whole lies in the guise of informed choice. We believe that more teeth to the code, through the RIRR, will save lives,” Duque said.

“True, informed choice highlights the benefits of breast milk over infant formula and other milk substitutes and tells mothers that they can breastfeed despite working, despite having breast or nipple problems, despite illnesses for both mother and child, and many other issues raised,” Duque said.
---quotes end.

Of course, information is not enough in itself. The mothers most distressed when the advantages of breastfeeding and risks of formula feeding are highlighted as in the recent coverage are those who knew this already, but had difficulties with breastfeeding and were unable to overcome them. They should not feel guilty about this, but angry that the health care system fails too many mothers.

In the UK Infant Feeding Surveys it is found that in the early weeks when breastfeeding rates fall rapidly, very few mothers who stopped (around 1%) said they wanted to stop. They stopped because they experienced problems with breastfeeding. In countries where there is support, few women stop because of problems – problems are overcome.

Why the health system fails is, in part, due to the influence of baby food companies. We have highlighted this in our pamphlet ‘Hard Sell Formula’. See:

We have also exposed how Nestlé is trying to break into the UK market by recruiting midwives to act as their cheerleaders and leaders of a campaign for Nestlé-sponsored materials. Their efforts to reverse the negative image of Nestlé amongst UK health workers are shockingly dishonest. It would be a disaster if they get their way. See:

We want to see World Health Assembly marketing requirements implemented and enforced. We want to see a health care system that promotes and supports breastfeeding, while providing support to mothers who formula feed (and we recommend the leaflets produced by UNICEF Baby Friendly Initiative to this end).

The enforcement of the UK law is a small step in the right direction. Let us hope the Supreme Court in the Philippines will support the authorities there in protecting their mothers and infants.

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