Introduction by Croakey: On 28 March, The Lancet will launch a series on the commercial determinants of health, investigating how commercial entities are “responsible for escalating levels of avoidable ill health, planetary damage, and social and health inequity”.
The impact of one such industry, the baby milk formula industry, has also been in the spotlight in a three-paper 2023 Lancet Breastfeeding Series launched this month (watch a recording of the Australasia & Pacific Series launch event here).
Co-authors of the Series papers, Dr Phil Baker and Honorary Associate Professor Julie Smith, write below on behalf of The Lancet Breastfeeding Collaboration.
Phil Baker and Julie Smith write:
Babies are most likely to survive and grow to their full potential when breastfed. Breastfeeding protects infants against malnutrition, infectious diseases and death, promotes brain development, and reduces the risks of experiencing obesity and chronic diseases in later life.
Yet fewer than half of infants and young children globally are breastfed as WHO recommends. Although breastfeeding rates are improving in some countries and globally, rates remain far below levels practiced before the intensive marketing efforts of the baby milk formula industry began in the mid-20th Century.
In contrast, formula milk sales are booming worldwide, despite formula failing to offer the same nutrition, health and development benefits as breastfeeding. The global rise of milk formulas presents a major risk for infant and young child food security, evident in the recent United States formula shortage. The excessive marketing and production of milk formulas harms the environment, through greenhouse gas emissions, water pollution linked with dairy production, and packaging waste.
The 2023 Lancet Breastfeeding Series brings together new evidence on this long-standing global health challenge, developed over at least four years of investigation, by an international collaboration supported by the World Health Organization. The Series highlights the economic and political power of milk formula companies such as Nestle, Danone and Abbot, to drive milk formula sales well beyond basic human need, to block regulation intended to protect breastfeeding, and to commodify infant and young child feeding on a global scale.
The three papers show how marketing by milk formula companies exploits parents’ emotions and manipulates scientific information to generate sales, undermine breastfeeding and extract wealth. Marketing regulations need to be urgently strengthened and properly implemented, including through effective monitoring and stronger penalties for violators. To support and unite governments to do this, the authors call for an international legal treaty to end milk formula marketing, accompanied by more effective breastfeeding promotion and support worldwide.
Series co-author, Professor Nigel Rollins, WHO, says: “The sale of commercial milk formula is a multi-billion-dollar industry which uses political lobbying alongside a sophisticated and highly effective marketing playbook to turn the care and concern of parents and caregivers into a business opportunity. It is time for this to end. Women should be empowered to make choices about infant feeding which are informed by accurate information free from industry influence.”
Exploitative marketing playbook
In 1981, prompted by the publication of The Baby Killer investigative report into Nestle’s marketing practices in the Global South, WHO member states adopted the International Code of Marketing of Breast-milk Substitutes (the Code), since strengthened through ongoing World Health Assembly resolutions.
Yet today, the global reach and influence of the baby milk formula industry’s marketing to women and families, health professionals and policy-makers, is as powerful as ever. In fact, in the 40 years since the Code’s adoption, the industry has grown world formula sales 37-fold to $55 billion a year.
Violations of the Code have continued, and are widespread and common in many countries. In recent years, digital technologies have greatly increased the reach of marketing in ways that blur the difference between advertising and the provision of nutrition and care advice.
One key way in which the industry has achieved such remarkable growth, is through ‘widening the boundaries’ of milk formula markets. Beginning in the mid-1980s, companies have aggressively promoted formula products for older infants, young children and even pregnant and lactating mothers.
Follow-up formulas and toddler milks now comprise the bulk of the industry’s world sales, which is remarkable, given WHO considers these products as unnecessary, and unsuitable as breastmilk substitutes.
Industry marketing to health professionals, including through direct influence in the development of clinical guidelines, is strongly evident in the over-diagnosis of cows-milk protein allergy. The industry has also pathologised normal infant behaviours to sell products claiming to deliver solutions for healthcare providers and parents.
Such marketing techniques, serve to exploit parents’ anxieties about their child’s health and development. Inadequate or absent health professional training on breastfeeding creates marketing opportunities for industry delivered education and training, and sponsorships of health professional conferences and journals.
For instance, one common reason women and families introduce milk formula is interpreting unsettled baby behaviour, especially disrupted sleep and persistent crying, as a sign of insufficient breast milk. However, sleep patterns of babies are not the same as for adults, and unsettled baby behaviours are common. When mothers are appropriately supported by skilled and knowledgeable health professionals, concerns can be addressed successfully without the use of formula milk.
Professor Linda Richter, Wits University, South Africa says: “The formula milk industry uses poor science to suggest, with little supporting evidence, that their products are solutions to common infant health and developmental challenges. Adverts claim specialised formulas alleviate fussiness, help with colic, prolong night-time sleep, and even encourage superior intelligence.
“Labels use words like ‘brain’, ‘neuro’ and ‘IQ’ with images highlighting early development, but studies show no benefit of these product ingredients on academic performance or long-term cognition. This marketing technique violates the 1981 Code, which says labels should not idealise the use of formula, and exploits poor science to create an untrue story to sell more product.”
The claims used in milk formula marketing, promote a biomedical rather than a socially determined interpretation of infant nutrition, and promote beliefs among parents and caregivers that formula is equivalent to, or even superior than, breastmilk. Furthermore, the claims so often seen on formula product labels are based on little or even no supporting evidence, something that requires urgent scrutiny from government regulators.
The Series highlights examples of digital marketing such as industry-paid influencers sharing the difficulties of breastfeeding as preludes to formula milk marketing, and industry sponsored parenting apps with 24/7 chat services that enable product placement, offer free samples or deals, and promote online sales. The authors argue there is very little regulation of the formula milk industry online and there are regular violations of the Code in marketing to the public and to health professionals and their organizations.
The Series explains how formula milk marketing exploits the lack of support for breastfeeding by governments and society to use gender politics to sell its products. The authors describe how the industry’s marketing frames breastfeeding advocacy as a moralistic judgment that is anti-feminist and damaging to women, while presenting milk formula as a convenient and empowering solution for working mothers.
The formula milk lobby
The Series also draws attention to the power of the milk formula industry to influence national political decisions and interfere with international and national regulatory processes. The industry has established a network of trade associations and front groups, established and coordinated by the companies, to lobby against implementation of the Code, and other breastfeeding protection measures in many countries and internationally.
For example, in 2012, South Africa passed new national legislation to implement the Code into law; however, this took nine years with many setbacks resulting from industry lobbying. Formula milk manufacturers formed a new lobby group, the Infant Feeding Association, which applied pressure for amendments to the regulations.
The Philippines Government faced aggressive litigation by an industry lobby group, alongside coordinated lobbying targeting the President and various government agencies, when it attempted to introduce new regulation that would strengthen the countries Milk Code. The litigation led to a long delay in the adoption of the new regulations.
This outsourcing of lobbying to these front groups allows the corporations to avoid reputational damage, while simultaneously projecting an image of benevolence and corporate social responsibility, suggesting that they can adequately self-regulate through corporate policies on responsible marketing. However, their self-regulation falls far short of compliance to the Code. The tactics used to sway compliant governments to avoid industry regulation are similar to the lobbying and advertising techniques used by the discredited tobacco industry.
In a novel analysis, the Series also describes how profits made by the companies benefit shareholders located almost exclusively in high-income countries while, the social, economic and environmental harms are widely distributed, and most harmful in low and middle income countries.
The authors also reveal how the Australian and New Zealand governments, together with the US, EU and Canada, have frequently lobbied against other governments in the World Trade Organization, to weaken their efforts to regulate formula marketing. This goes completely against their supposed commitments to supporting breastfeeding women.
As well as influencing political organisations, the authors argue formula milk companies also draw on the credibility of science by sponsoring professional organisations, publishing sponsored articles in scientific journals, and inviting leaders in public health onto advisory boards and committees, leading to unacceptable conflicts of interest within public health.
Leading Australian public health nutritionist Dr Rosemary Stanton said Australian policymakers must urgently commit to the recommendations laid out in the papers. “We have been concerned about marketing of infant formula and toddler milks for years and we addressed the issue in the last Infant Feeding Guidelines in 2012. But the problem is even worse now with digital marketing”.
“There is no doubt that the papers’ recommendations should be supported. At a global level we must have governments adopting a framework convention on the marketing of foods for infants and young children, and in Australia and New Zealand this must be given teeth.”
Society-wide changes needed
In addition to ending the marketing tactics and industry influence of formula milk companies, broader actions across workplaces, healthcare systems, governments, and communities are needed to more effectively support women and families who want to breastfeed.
This includes structural transformations in how society values the immense productivity and effort of breastfeeding women. Perversely, the current economic paradigm views milk formula growth as contributing to economic productivity and growth (i.e. GDP) whereas the vital contributions to sustainable food systems by breastfeeding women goes unmeasured.
The authors call for transformative change, including governments adopting gender-sensitive fiscal reforms and gender budgeting principles and analytical approaches such as time-use accounting for unpaid work, and incorporating breastfeeding and breastmilk production into national accounting systems.
Half a billion working women globally are not entitled to adequate maternity protection. A systematic review of studies found women with a minimum of three months maternity leave, paid or unpaid, were at least 50 percent more likely to continue breastfeeding compared to women returning to work within three months of giving birth.
The authors call for governments and workplaces to recognise the value of care work done by breastfeeding women, and to enable their capabilities to breastfeed, through actions such as extending paid maternity leave duration to align with the six month WHO recommended duration of exclusive breastfeeding.
Women also face a lack of breastfeeding promotion, protection and support within healthcare systems due to limited public budgets, skilled support by health workers, influence from milk formula industry and an absence of care that is culturally appropriate and led by the needs of women.
The authors argue that breastfeeding outcomes improve when health systems actively empower women and enable experienced peers to support women during pregnancy, childbirth and onwards. Currently under-funded maternity services, pervasive corporate influence and conflicts of interest, and a health system culture that privileges commercial technologies and biomedical interventions has promoted milk formula sales and undermined the agency of breastfeeding women.
Dr Penny Haora, a midwife and public health researcher at Charles Darwin University, said: “The experience of First Nations women in Australia illustrate resilience and resistance against the political, economic and other power structures which determine feeding practices and whether women’s birthing rights are respected, and which deny many the woman-centred, culturally appropriate and mid-wife led maternity care they desire.”
A linked editorial published in The Lancet says, “Women and families make decisions about infant feeding based on the information they receive, and a criticism of the CMF industry’s predatory marketing practices should not be interpreted as a criticism of women. All information that families receive on infant feeding must be accurate and independent of industry influence to ensure informed decision making.”
See the Twitter thread by Dr Phil Baker
Author details
Dr Phil Baker (BSc, MHSc (nutrition), PhD (population health) is an Australian Research Council Future Fellow, at the Institute for Physical Activity and Nutrition, Deakin University. His research focuses on understanding global food systems change, and the implications for human and planetary health. Recent work covers the global rise of ultra-processed foods, the political economy of food systems, and the commercial determinants of infant and young child nutrition. The current focus of his research is on ‘healthy and sustainable first-food systems’, including the influences of commercial actors and forces on breastfeeding, complementary feeding and food security for women, infants and young children.
Dr Julie Smith (B Ec (Hons)/B A (Asian Studies), PhD, is an awarded Australian Research Council Future Fellow and Honorary Associate Professor and feminist economist. Her research focuses on gender analysis, taxation policy, and economic aspects of breastfeeding, with more than 45 peer-reviewed articles, book chapters and books. She has been an expert advisor to the World Health Organization and the US Department of Health and Human Services, the Australian Department of Health, and to national and international NGOs. She is a co-founder of WBTi Australia, and Honorary Member of the Australian Breastfeeding Association.
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