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Vilar-Compte M, Hernández-Cordero S, Pérez-Escamilla R, Tomori C. Commercial milk formula marketing entry points: setting the course of infant and young child feeding trajectories. BMC Public Health 2024; 24:2653. [PMID: 39342250 PMCID: PMC11438275 DOI: 10.1186/s12889-024-19997-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 09/05/2024] [Indexed: 10/01/2024] Open
Abstract
BACKGROUND There is a limited understanding of the dynamic influences that shape infant and young child feeding (IYCF) decisions over time. We conducted an innovative qualitative study to reconstruct IYCF trajectories across early life course phases, in the context of the socioecological model (SEM) and the commercial determinants of IYCF. METHODS Women of different socioeconomic status were interviewed in two large metropolitan areas in Mexico. Our specific goal was to allow us to better understand if and how the commercial milk formula (CMF) marketing influenced breastfeeding decisions in a complex dynamic way involving the individual, relational, community and societal levels. RESULTS Hospitals, health professionals, and interactions with social media were key category entry points throughout the prenatal, perinatal, early infancy period and beyond. The CMF industry interfered by engaging a wide array of actors across the different layers of the SEM, most prominently the health care system and the workplace. Through its marketing strategies the CMF operates subconsciously and its messages are most effective when health institutions, health care providers, workplace spaces and social norms are weak in their support for breastfeeding. CONCLUSIONS The cases in our study highlight how, together with a weak breastfeeding counseling system, and health professionals who lack training in breastfeeding and normal infant behavior, lead to the opportunity for CMF marketing to shape infant feeding, and ultimately to the decision to feed formulas that some mothers were not planning to use and cannot afford.
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Affiliation(s)
| | - Sonia Hernández-Cordero
- Research Center for Equitable Development EQUIDE, Universidad Iberoamericana, Mexico, Mexico.
| | - Rafael Pérez-Escamilla
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, USA
| | - Cecília Tomori
- Johns Hopkins School of Nursing and Johns Hopkins Bloomberg School of Public Health, Johns Hopkins University, Baltimore, USA
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Cavalcanti MB, Silva IDCGD, Lamarca F, de Castro IRR. Research on commercial milk formulas for young children: A scoping review. MATERNAL & CHILD NUTRITION 2024:e13675. [PMID: 38956436 DOI: 10.1111/mcn.13675] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Revised: 05/10/2024] [Accepted: 05/14/2024] [Indexed: 07/04/2024]
Abstract
A scoping review of publications about commercial milk formulas intended for or consumed by children 12-36 months (CMF 12-36) was conducted. This review aimed to comprehensively map the existing literature, identify key concepts in the field and understand its evolution through time. A total of 3329 articles were screened and 220 were included, published between 1986 and 2024. Most works were published after 2016 (70.0%) and in high-income countries (71.8%). Original studies were the vast majority (81.8%) of publications. Most publications dealt with feeding practices or analysed the composition and/or contamination of specific products (44.1% and 35.9%), but since the late 2000s, publications about marketing, policy, legislation, and consumer perception started to appear. Most published works (65.5%) did not focus exclusively on CMF 12-36 and included formulas for other demographics or other foods. About half of the works (55.5%) did not consider CMF 12-36 to be a breast milk substitute. We found 81 distinct product denominations used to refer to CMF 12-36, Growing Up Milk was the most common (25.9%). CMF industry was involved in 41.8% of all analysed works, and industry participation and funding were not always clearly informed (22.5% lacked a conflict of interest statement, and 25.5% did not present any information about funding). In the last decade, publications about CMF 12-36 have increased in volume and diversified in scope and subject matter. CMF-industry participation has always been and still is present in the field, so possible vested interests should be taken into account when appreciating the literature.
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Affiliation(s)
| | | | - Fernando Lamarca
- Department of Applied Nutrition, Institute of Nutrition, State University of Rio de Janeiro, Rio de Janeiro, Brazil
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Richter APC, Grummon AH, Falbe J, Taillie LS, Wallace DD, Lazard AJ, Golden SD, Conklin JL, Hall MG. Toddler milk: a scoping review of research on consumption, perceptions, and marketing practices. Nutr Rev 2024; 82:425-436. [PMID: 37203416 PMCID: PMC10859688 DOI: 10.1093/nutrit/nuad057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023] Open
Abstract
Toddler milk is an ultra-processed beverage consisting primarily of powdered milk, caloric sweeteners, and vegetable oil. Pediatric health authorities do not support the use of toddler milk, and emerging evidence suggests that toddler-milk marketing practices may mislead consumers. However, studies have not synthesized the extent of toddler-milk marketing practices or how these practices affect parents' decisions about whether to serve toddler milk. We aimed to summarize the literature about toddler milk to identify what is known about: (1) parents' toddler-milk purchasing and feeding behaviors, (2) toddler-milk marketing, and (3) how marketing practices influence parents' beliefs and perceptions about toddler milk. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR), we systematically searched 8 databases (PubMed, APA PsycINFO, Scopus, Cochrane Central, Embase, CINAHL, Communication & Mass Media Complete, and Business Source Premier). We identified 45 articles about toddler milk. Studies were conducted in 25 countries across 6 continents. Five types of findings emerged: (1) consumption and feeding behaviors, (2) demographic correlates of toddler-milk purchasing and consumption, (3) misperceptions and beliefs, (4) increased sales, and (5) increased marketing and responses to marketing. The included articles suggested that toddler-milk sales are growing rapidly worldwide. Findings also revealed that toddler-milk packages (eg, labels, branding) resemble infant formula packages and that toddler-milk marketing practices may indirectly advertise infant formula. Purchasing, serving, and consumption of toddler milk were higher in Black and Hispanic populations than in non-Hispanic White populations, and parents with higher educational attainment and income were more likely to offer toddler milk to their children. Findings suggest a need for policies to prevent cross-marketing of toddler milk and infant formula, reduce provision of toddler milk to infants and toddlers, and prevent caregivers from being misled about toddler-milk healthfulness.
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Affiliation(s)
- Ana Paula C Richter
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Anna H Grummon
- Department of Nutrition, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, USA
- Department of Pediatrics, Stanford University School of Medicine, Palo Alto, California, USA
| | - Jennifer Falbe
- Department of Human Ecology, University of California (UC) Davis, Davis, California, USA
| | - Lindsey Smith Taillie
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Department of Nutrition, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Deshira D Wallace
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Allison J Lazard
- Hussman School of Journalism and Media, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Shelley D Golden
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Jamie L Conklin
- Health Sciences Library, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Marissa G Hall
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
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Conway R, Ritchie I, Esser S, Steptoe A, Smith AD, Llewellyn C. Perceived influence of commercial milk formula labelling on mothers' feeding choices in Great Britain: a qualitative study. Arch Dis Child 2023; 108:1008-1013. [PMID: 37541681 PMCID: PMC10715500 DOI: 10.1136/archdischild-2023-325767] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 07/19/2023] [Indexed: 08/06/2023]
Abstract
OBJECTIVE To understand how mothers use commercial milk formula (CMF) labels to inform their feeding choices and explore mothers' understanding of differences between CMF products. DESIGN Qualitative study with recruitment via social media. Online semistructured interviews, including a product mapping exercise and thematic analysis. PARTICIPANTS Mothers (n=25) using CMF for children <3 years living in Great Britain (GB). RESULTS Mothers were drawn to brands they recognised from years of exposure to CMF advertising. CMF products were assumed to vary according to brand and stage, but participants found on-pack information did not explain how. This added to anxiety about choosing 'the best one' and mothers would have liked guidance from healthcare professionals (HCPs). Wide availability of CMF for older infants and children, and on-pack messaging suggesting progression from one product to the next, led many to believe these products were necessary. There was confusion over the appropriate use of specialist products. While mothers rarely mentioned on-pack health and nutrition claims, they were attracted to the overall appearance of packs and messaging relating to science, research and nature. References to breast milk and a logo perceived to represent a breastfeeding mother were taken as indicators of closer similarity to breast milk. CONCLUSIONS CMF legislation in GB should be updated to restrict brand advertising and the use of on-pack text and images that mothers perceive as indicating products have a closer similarity to breast milk. Greater input from HCPs was desired by new mothers and would support them to make more informed choices about CMF.
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Affiliation(s)
- Rana Conway
- Research Department of Behavioural Science and Health, University College London, London, UK
| | - Isabel Ritchie
- Research Department of Behavioural Science and Health, University College London, London, UK
| | - Sara Esser
- Research Department of Behavioural Science and Health, University College London, London, UK
| | - Andrew Steptoe
- Research Department of Behavioural Science and Health, University College London, London, UK
| | - Andrea D Smith
- Research Department of Behavioural Science and Health, University College London, London, UK
- MRC Epidemiology Unit, University of Cambridge, Cambridge, UK
| | - Clare Llewellyn
- Research Department of Behavioural Science and Health, University College London, London, UK
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Fuchs GJ, Abrams SA, Amevor AA. Older Infant-Young Child "Formulas". Pediatrics 2023; 152:e2023064050. [PMID: 37860831 DOI: 10.1542/peds.2023-064050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/22/2023] [Indexed: 10/21/2023] Open
Abstract
The category of "formulas" directed at older infants and toddlers 6 to 36 months of age has increased in prominence over the last years but is characterized by lack of standardization in nomenclature and composition as well as questionable marketing practices. There has been uncertainty and misperception regarding some of the roles of these beverages in ensuring adequate childhood nutrition. The aim of this clinical report is to review the context, evidence, and rationale for older infant-young child formulas, followed by recommendations.
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Affiliation(s)
- George J Fuchs
- Department of Pediatrics, University of Kentucky College of Medicine and Department of Epidemiology, University of Kentucky College of Public Health, Lexington, Kentucky
| | - Steven A Abrams
- Department of Pediatrics, Dell Medical School at the University of Texas at Austin, Austin, Texas
| | - A Adjowa Amevor
- Beverly Knight Olsen Children's Hospital, Atrium Health, Macon, Georgia
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C Richter AP, W Duffy E, Higgins ICA, Barrington C, Martin SL, Aquilina KH, Avendaño-Galdamez MI, Hall MG. Toddler Milk Perceptions and Responses to Front-of-Package Claims and Product Warnings: A Qualitative Study of Caregivers of Toddlers. J Acad Nutr Diet 2023; 123:1568-1577.e3. [PMID: 37352928 PMCID: PMC10874641 DOI: 10.1016/j.jand.2023.06.281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 06/01/2023] [Accepted: 06/17/2023] [Indexed: 06/25/2023]
Abstract
BACKGROUND Toddler milk products are ultraprocessed milk-based beverages promoted for children aged 9 through 36 months. They often contain added sugars, which may contribute to unhealthy dietary habits. Aggressive promotion of toddler milk, particularly to the Latinx population, has likely led to rapid rises in sales. OBJECTIVE The study aims were to qualitatively explore caregivers' experiences with, beliefs about, and attitudes toward toddler milk; to explore caregivers' reactions to health claims and product warnings on toddler milk packaging; and explore whether perceptions of toddler milk differ by Latinx ethnicity. DESIGN Focus group discussions and in-depth interviews were conducted. PARTICIPANTS Fifteen online in-depth interviews and 4 online focus groups with US caregivers of children aged 9 through 36 months who reported serving toddler milk to their children were conducted in 2021. STATISTICAL ANALYSES PERFORMED Audio files were transcribed, coded, and analyzed in NVivo. A thematic analysis with a hybrid analytical approach of deductive and inductive coding was conducted. RESULTS Caregivers struggled to discern toddler milk from infant formula and perceived formula as a larger term that included toddler milk. Participants described offering toddler milk to their children for its convenience, nutritional profile, and perceived benefits tied to health claims present on the labels. Participants reported that health claims on toddler milk packaging attracted their attention; most participants did not express skepticism about the veracity of the claims. An "added sugar" warning increased understanding of the presence of added sugar in a toddler milk product. Latinx and non-Latinx participants largely reported similar perceptions, beliefs, and patterns of provision of toddler milk. CONCLUSIONS Health claims may lead caregivers to perceive toddler milk as a nutritionally adequate product. Research is needed to investigate caregiver-directed interventions for informing caregivers about the distinction between infant formula and toddler milk.
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Affiliation(s)
- Ana Paula C Richter
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina; Carolina Population Center, University of North Carolina, Chapel Hill, North Carolina
| | - Emily W Duffy
- Department of Nutrition, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina; Carolina Population Center, University of North Carolina, Chapel Hill, North Carolina
| | - Isabella C A Higgins
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina; Carolina Population Center, University of North Carolina, Chapel Hill, North Carolina
| | - Clare Barrington
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina; Carolina Population Center, University of North Carolina, Chapel Hill, North Carolina
| | - Stephanie L Martin
- Department of Nutrition, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina; Carolina Population Center, University of North Carolina, Chapel Hill, North Carolina
| | - Kathryn H Aquilina
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina; US Food and Drug Administration, Silver Spring, Maryland
| | | | - Marissa G Hall
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina; Carolina Population Center, University of North Carolina, Chapel Hill, North Carolina; Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina.
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7
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Champeny M, Yuen-Esco K, Juniza E, Sy NY, Kane R, Badham J, Mulder A, Pries AM. Accuracy of declared nutrient content on labels of commercial complementary food products in Cambodia, Indonesia and Senegal. MATERNAL & CHILD NUTRITION 2023; 19:e13504. [PMID: 36961253 DOI: 10.1111/mcn.13504] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 02/25/2023] [Accepted: 03/01/2023] [Indexed: 06/14/2023]
Abstract
Commercially produced complementary foods (CPCF) have the potential to fill nutritional gaps in the diets of older infants and young children. This study evaluated the accuracy of nutrient declarations on labels of 43 commonly available CPCF in three peri-urban/urban locations: Khsach Kandal district, Cambodia (n = 11); Bandung, Indonesia (n = 11) and Guédiawaye and Dakar departments, Senegal (n = 21). Label values (LV) from product nutrient declarations were compared to analytical values (AV) derived from laboratory nutrient analysis for macronutrients (carbohydrate, protein and total fat), nutrients of public health concern (saturated fat, total sugar and sodium), and micronutrients of interest (calcium, iron and zinc). European Union guidance for nutrition label accuracy was used to set tolerance ranges for each nutrient LV relative to AV. LV were missing for one or more nutrients in 88.4% (n = 38) of the CPCF products and no CPCF met EU tolerance thresholds for all nine nutrients assessed. Over half of products with LV for key micronutrients (55.6%, n = 10/18) and macronutrients (54.8%, n = 23/42) met tolerances for LV accuracy. Eighty-five percent (n = 11/13) of products with LV for nutrients of public health concern were determined to be accurate. Nutrient content claims for iron appeared on 19 (44.2%) of the 43 products. Of the products which made an iron content claim, 26.3% had inaccurate LV with the majority of these containing less iron than declared. Regulatory action is needed to ensure that CPCF labelling communicates complete and accurate nutrient content information that enables caregivers to make informed decisions for feeding older infants and young children.
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Affiliation(s)
| | | | - Eva Juniza
- Helen Keller International, New York, New York, USA
| | - Ndeye Y Sy
- Helen Keller International, New York, New York, USA
| | | | - Jane Badham
- JB Consultancy, Johannesburg, Gauteng, South Africa
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Rollins N, Piwoz E, Baker P, Kingston G, Mabaso KM, McCoy D, Ribeiro Neves PA, Pérez-Escamilla R, Richter L, Russ K, Sen G, Tomori C, Victora CG, Zambrano P, Hastings G. Marketing of commercial milk formula: a system to capture parents, communities, science, and policy. Lancet 2023; 401:486-502. [PMID: 36764314 DOI: 10.1016/s0140-6736(22)01931-6] [Citation(s) in RCA: 88] [Impact Index Per Article: 88.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 08/21/2022] [Accepted: 09/26/2022] [Indexed: 02/10/2023]
Abstract
Despite proven benefits, less than half of infants and young children globally are breastfed in accordance with the recommendations of WHO. In comparison, commercial milk formula (CMF) sales have increased to about US$55 billion annually, with more infants and young children receiving formula products than ever. This Series paper describes the CMF marketing playbook and its influence on families, health professionals, science, and policy processes, drawing on national survey data, company reports, case studies, methodical scoping reviews, and two multicountry research studies. We report how CMF sales are driven by multifaceted, well resourced marketing strategies that portray CMF products, with little or no supporting evidence, as solutions to common infant health and developmental challenges in ways that systematically undermine breastfeeding. Digital platforms substantially extend the reach and influence of marketing while circumventing the International Code of Marketing of Breast-milk Substitutes. Creating an enabling policy environment for breastfeeding that is free from commercial influence requires greater political commitment, financial investment, CMF industry transparency, and sustained advocacy. A framework convention on the commercial marketing of food products for infants and children is needed to end CMF marketing.
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Affiliation(s)
- Nigel Rollins
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, WHO, Geneva, Switzerland.
| | | | - Phillip Baker
- Institute for Physical Activity and Nutrition, Deakin University, Geelong, VIC, Australia
| | | | | | - David McCoy
- International Institute for Global Health, United Nations University, Kuala Lumpur, Malaysia
| | | | | | - Linda Richter
- University of the Witwatersrand, DSI-NRF Centre of Excellence in Human Development, Johannesburg, South Africa
| | - Katheryn Russ
- Department of Economics, University of California, Davis, CA, USA
| | - Gita Sen
- Public Health Foundation of India, Bangalore, India
| | - Cecília Tomori
- Johns Hopkins School of Nursing, Johns Hopkins University, Baltimore, MD, USA
| | - Cesar G Victora
- International Center for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
| | | | - Gerard Hastings
- Institute for Social Marketing, University of Stirling, Stirling, UK
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9
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Baker P, Smith JP, Garde A, Grummer-Strawn LM, Wood B, Sen G, Hastings G, Pérez-Escamilla R, Ling CY, Rollins N, McCoy D. The political economy of infant and young child feeding: confronting corporate power, overcoming structural barriers, and accelerating progress. Lancet 2023; 401:503-524. [PMID: 36764315 DOI: 10.1016/s0140-6736(22)01933-x] [Citation(s) in RCA: 63] [Impact Index Per Article: 63.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 08/21/2022] [Accepted: 09/26/2022] [Indexed: 02/10/2023]
Abstract
Despite increasing evidence about the value and importance of breastfeeding, less than half of the world's infants and young children (aged 0-36 months) are breastfed as recommended. This Series paper examines the social, political, and economic reasons for this problem. First, this paper highlights the power of the commercial milk formula (CMF) industry to commodify the feeding of infants and young children; influence policy at both national and international levels in ways that grow and sustain CMF markets; and externalise the social, environmental, and economic costs of CMF. Second, this paper examines how breastfeeding is undermined by economic policies and systems that ignore the value of care work by women, including breastfeeding, and by the inadequacy of maternity rights protection across the world, especially for poorer women. Third, this paper presents three reasons why health systems often do not provide adequate breastfeeding protection, promotion, and support. These reasons are the gendered and biomedical power systems that deny women-centred and culturally appropriate care; the economic and ideological factors that accept, and even encourage, commercial influence and conflicts of interest; and the fiscal and economic policies that leave governments with insufficient funds to adequately protect, promote, and support breastfeeding. We outline six sets of wide-ranging social, political, and economic reforms required to overcome these deeply embedded commercial and structural barriers to breastfeeding.
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Affiliation(s)
- Phillip Baker
- Institute for Physical Activity and Nutrition, Deakin University, Geelong, VIC, Australia
| | - Julie P Smith
- National Centre for Epidemiology and Population Health, Australian National University, Canberra, ACT, Australia
| | - Amandine Garde
- Law & Non-Communicable Diseases Unit, School of Law and Social Justice, University of Liverpool, Liverpool, UK
| | | | - Benjamin Wood
- Global Centre for Preventive Health and Nutrition, Deakin University, Geelong, VIC, Australia
| | - Gita Sen
- Ramalingaswami Centre on Equity and Social Determinants of Health, Public Health Foundation of India, Bangalore, India
| | | | - Rafael Pérez-Escamilla
- Department of Social and Behavioral Sciences, Yale School of Public Health, New Haven, CT, USA
| | | | - Nigel Rollins
- Department of Maternal, Newborn, Child and Adolescent Health and Ageing, Geneva, Switzerland
| | - David McCoy
- International Institute for Global Health, United Nations University, Kuala Lumpur, Malaysia.
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10
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Fleming‐Milici F, Phaneuf L, Harris JL. Marketing of sugar-sweetened children's drinks and parents' misperceptions about benefits for young children. MATERNAL & CHILD NUTRITION 2022; 18:e13338. [PMID: 35199914 PMCID: PMC9218304 DOI: 10.1111/mcn.13338] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 12/17/2021] [Accepted: 01/25/2022] [Indexed: 11/29/2022]
Abstract
Despite expert recommendations, US parents often serve sugar-sweetened children's drinks, including sweetened fruit-flavoured drinks and toddler milks, to young children. This qualitative research explored parents' understanding of common marketing tactics used to promote these drinks and whether they mislead parents to believe the drinks are healthy and/or necessary for children. We conducted nine focus groups in Washington, DC and Hartford, CT with parents of children (9-36 months) of diverse race/ethnicity and socioeconomic status (N = 50). Semistructured discussions elicited parents' responses to four concepts designed to correct common misperceptions about toddler milks and sweetened fruit-flavoured drinks (fruit drinks and flavoured waters) by providing information about drink ingredients and potentially misleading marketing tactics. Participants expressed widespread misperceptions about sweetened fruit-flavoured drinks and toddler milks, including perceived healthfulness and benefits for children and confusion between sweetened and unsweetened drink categories (sweetened fruit-flavoured drinks vs. juice, toddler milk vs. infant formula). They confirmed that common marketing strategies contributed to misperceptions, including front-of-package claims and marketing messages that imply benefits for children and/or hide problematic ingredients; cross-branding and product extensions from trusted brands; side-by-side shelf placement at retailers; lower price than healthier products; and targeted marketing to children and parents. Some parents expressed anger about deceptive marketing and supported increased regulation and consumer education campaigns. Findings support the need for policies to address potentially misleading marketing of sweetened fruit-flavoured drinks and toddler milks and revealed opportunities to reduce parents' provision of these drinks through countermarketing campaigns communicated via trusted sources.
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Affiliation(s)
| | - Lindsay Phaneuf
- Present address:
Waldo County General Hospital, MaineHealthBelfastMEUSA
| | - Jennifer L. Harris
- Rudd Center for Food Policy & HealthUniversity of ConnecticutHartfordConnecticutUSA
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11
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Vilar‐Compte M, Hernández Cordero S, Castañeda‐Márquez AC, Rollins N, Kingston G, Pérez‐Escamilla R. Follow‐up and growing‐up formula promotion among Mexican pregnant women and mothers of children under 18 months old. MATERNAL & CHILD NUTRITION 2022; 18 Suppl 3:e13337. [PMID: 35293129 PMCID: PMC9113472 DOI: 10.1111/mcn.13337] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 02/06/2022] [Accepted: 02/08/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Mireya Vilar‐Compte
- Department of Public Health Montclair State University Montclair New Jersey USA
| | - Sonia Hernández Cordero
- Research Institute for Equitable Development (EQUIDE) Universidad Iberoamericana Mexico City Mexico
| | | | - Nigel Rollins
- Department of Maternal, Newborn, Child and Adolescent Health Geneva Switzerland
| | | | - Rafael Pérez‐Escamilla
- Department of Social and Behavioral Sciences Yale School of Public Health New Haven Connecticut USA
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12
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Neves PAR, Barros AJD, Baker P, Piwoz E, Santos TM, Gatica-Domínguez G, Vaz JS, Rollins N, Victora CG. Consumption of breast milk, formula and other non-human milk by children aged under 2 years: analysis of eighty-six low- and middle-income countries. Public Health Nutr 2022; 25:680-688. [PMID: 33059789 PMCID: PMC9991621 DOI: 10.1017/s1368980020004061] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 09/21/2020] [Accepted: 10/12/2020] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To investigate the prevalence and socio-economic inequalities in breast milk, breast milk substitutes (BMS) and other non-human milk consumption, by children under 2 years in low- and middle-income countries (LMIC). DESIGN We analysed the prevalence of continued breast-feeding at 1 and 2 years and frequency of formula and other non-human milk consumption by age in months. Indicators were estimated through 24-h dietary recall. Absolute and relative wealth indicators were used to describe within- and between-country socio-economic inequalities. SETTING Nationally representative surveys from 2010 onwards from eighty-six LMIC. PARTICIPANTS 394 977 children aged under 2 years. RESULTS Breast-feeding declined sharply as children became older in all LMIC, especially in upper-middle-income countries. BMS consumption peaked at 6 months of age in low/lower-middle-income countries and at around 12 months in upper-middle-income countries. Irrespective of country, BMS consumption was higher in children from wealthier families, and breast-feeding in children from poorer families. Multilevel linear regression analysis showed that BMS consumption was positively associated with absolute income, and breast-feeding negatively associated. Findings for other non-human milk consumption were less straightforward. Unmeasured factors at country level explained a substantial proportion of overall variability in BMS consumption and breast-feeding. CONCLUSIONS Breast-feeding falls sharply as children become older, especially in wealthier families in upper-middle-income countries; this same group also consumes more BMS at any age. Country-level factors play an important role in explaining BMS consumption by all family wealth groups, suggesting that BMS marketing at national level might be partly responsible for the observed differences.
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Affiliation(s)
- Paulo AR Neves
- International Center for Equity in Health, Federal University of Pelotas, Rua Marechal Deodoro, 1160, 3rd floor, Pelotas96020-220, Brazil
| | - Aluísio JD Barros
- International Center for Equity in Health, Federal University of Pelotas, Rua Marechal Deodoro, 1160, 3rd floor, Pelotas96020-220, Brazil
| | - Phillip Baker
- Institute for Physical Activity and Nutrition, Deakin University, Melbourne, Australia
| | - Ellen Piwoz
- Global Development Program, The Bill & Melinda Gates Foundation, Seattle, WA, USA
| | - Thiago M Santos
- International Center for Equity in Health, Federal University of Pelotas, Rua Marechal Deodoro, 1160, 3rd floor, Pelotas96020-220, Brazil
| | - Giovanna Gatica-Domínguez
- International Center for Equity in Health, Federal University of Pelotas, Rua Marechal Deodoro, 1160, 3rd floor, Pelotas96020-220, Brazil
| | - Juliana S Vaz
- International Center for Equity in Health, Federal University of Pelotas, Rua Marechal Deodoro, 1160, 3rd floor, Pelotas96020-220, Brazil
| | - Nigel Rollins
- Department of Maternal, Newborn, Child and Adolescent Health, World Health Organization, Geneva, Switzerland
| | - Cesar G Victora
- International Center for Equity in Health, Federal University of Pelotas, Rua Marechal Deodoro, 1160, 3rd floor, Pelotas96020-220, Brazil
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Nguyen TT, Cashin J, Ching C, Baker P, Tran HT, Weissman A, Nguyen TT, Mathisen R. Beliefs and Norms Associated with the Use of Ultra-Processed Commercial Milk Formulas for Pregnant Women in Vietnam. Nutrients 2021; 13:4143. [PMID: 34836398 PMCID: PMC8621914 DOI: 10.3390/nu13114143] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 11/12/2021] [Accepted: 11/17/2021] [Indexed: 01/08/2023] Open
Abstract
Commercial milk formula for pregnant women (CMF-PW) is an expensive, ultra-processed food with a high concentration of sugar, the consumption of which may be linked to negative health outcomes. However, CMF-PWs are promoted as beneficial for pregnant women and lactating mothers as well as their children. To date, little is known about the factors associated with the use of CMF-PW among pregnant women. We performed this analysis to examine the association between the use of CMF-PW and related beliefs and norms among pregnant women in Vietnam. We interviewed 268 pregnant women in their second and third trimesters from two provinces and one municipality representing diverse communities in Vietnam. Multinomial (polytomous) logistic regression, structural equation modeling (SEM), and propensity score matching (PSM) analysis were used to examine associations between beliefs and social norms related to CMF-PW and reported consumption, characterized as occasional, recent, and never during the current pregnancy. Overall, 64.6% of pregnant women reported using CMF-PW during the current pregnancy and 34.7% consumed CMF-PW on the day prior to the interview. Strong beliefs that CMF-PW will make a child smart and healthy (53.7%) and the perception that use of CMF-PW is common (70.9%) were associated with increased use on the previous day (beliefs: aOR: 3.56; 95% Confidence Interval (95% CI): 1.65, 7.71; p < 0.01 and social norms aOR: 2.29; 95% CI: 1.13, 4.66; p < 0.05). SEM and PSM analyses confirmed these findings for both occasional and regular CMF-PW use. Results are consistent with observations of CMF-PW product labels and marketing tactics in Vietnam. The prevalent use of CMF-PW in Vietnam is associated with the belief that these products make children smart and healthy and the perceived social norm that most mothers use these products, which mirrors marketing messages and approaches employed by the CMF industry.
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Affiliation(s)
- Tuan T. Nguyen
- Alive & Thrive Southeast Asia, FHI 360, Hanoi 11022, Vietnam; (J.C.); (C.C.); (A.W.); (R.M.)
| | - Jennifer Cashin
- Alive & Thrive Southeast Asia, FHI 360, Hanoi 11022, Vietnam; (J.C.); (C.C.); (A.W.); (R.M.)
| | - Constance Ching
- Alive & Thrive Southeast Asia, FHI 360, Hanoi 11022, Vietnam; (J.C.); (C.C.); (A.W.); (R.M.)
| | - Phillip Baker
- Institute for Physical Activity and Nutrition, Deakin University, Geelong, VIC 3220, Australia;
| | - Hoang T. Tran
- Neonatal Unit and Human Milk Bank, Da Nang Hospital for Women and Children, Da Nang 50506, Vietnam;
| | - Amy Weissman
- Alive & Thrive Southeast Asia, FHI 360, Hanoi 11022, Vietnam; (J.C.); (C.C.); (A.W.); (R.M.)
- Asia Pacific Regional Office, FHI 360, Bangkok 10330, Thailand
| | - Thao T. Nguyen
- School of Biotechnology and Food Technology, Hanoi University of Science and Technology, Hanoi 11615, Vietnam;
| | - Roger Mathisen
- Alive & Thrive Southeast Asia, FHI 360, Hanoi 11022, Vietnam; (J.C.); (C.C.); (A.W.); (R.M.)
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Pries AM, Mulder A, Badham J, Sweet L, Yuen K, Zehner E. Sugar content and nutrient content claims of growing-up milks in Indonesia. MATERNAL & CHILD NUTRITION 2021; 17:e13186. [PMID: 33830660 PMCID: PMC8476439 DOI: 10.1111/mcn.13186] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Revised: 03/09/2021] [Accepted: 03/10/2021] [Indexed: 01/03/2023]
Abstract
'Growing-up milks' (GUMs)-breast-milk substitutes targeted for young children (aged 12-36 months)-are commonly consumed in Indonesia. The World Health Assembly has stated that GUMs are not necessary for proper growth and development, and recently, the American Academy of Pediatrics declared that such products are not recommended for young children due to their common use of sweeteners. To contribute to the evidence base on the composition of GUMs and their appropriateness for young child diets, this cross-sectional study documented the declared sugar content and presence of nutrient content claims of 99 GUMs newly launched in Indonesia between January 2017 and May 2019. Sugar content was evaluated against the draft 2018 Codex Alimentarius Standard for Follow-Up Formula guidance on sugar content and the United Kingdom Food Standard Agency's front-of-pack (UK FSA FOP) colour coding system for sugar. Almost all (97%) GUMs contained one or more added sugars. None of the products were fully compliant with all three sugar content recommendations in the draft Codex standard. Seventy-one per cent of GUMs were determined to have high sugar content according to the UK FSA FOP system. Nutrient content claims were found on 97% of GUMs. Median total sugar content was 7.3 g per 100 ml, similar to sugar content levels in sugar-sweetened beverages. Many GUMs available in Indonesia claim to offer nutritional benefits; however, the current levels of sugar content in GUMs are a serious concern and are inappropriate for inclusion in the diets of young children.
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Affiliation(s)
- Alissa M. Pries
- Helen Keller InternationalHeadquartersWashingtonDistrict of ColumbiaUSA
| | | | | | | | - Katelyn Yuen
- Helen Keller InternationalHeadquartersWashingtonDistrict of ColumbiaUSA
| | - Elizabeth Zehner
- Helen Keller InternationalHeadquartersWashingtonDistrict of ColumbiaUSA
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Nguyen TT, Tran HTT, Cashin J, Nguyen VDC, Weissman A, Nguyen TT, Kelly B, Mathisen R. Implementation of the Code of Marketing of Breast-Milk Substitutes in Vietnam: Marketing Practices by the Industry and Perceptions of Caregivers and Health Workers. Nutrients 2021; 13:2884. [PMID: 34445044 PMCID: PMC8399411 DOI: 10.3390/nu13082884] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 08/06/2021] [Accepted: 08/19/2021] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND The promotion of breastmilk substitutes (BMS) is an important barrier to successful breastfeeding. OBJECTIVE To examine the enactment and implementation of the Code of Marketing of Breast-Milk Substitutes (the Code) in Vietnam with a focus on marketing practices by the baby food industry and perceptions of caregivers, health workers, and policy makers. METHODS From May to July 2020, we conducted a mixed-method, cross-sectional study including a survey of 268 pregnant women and 726 mothers of infants aged 0-11 months and in-depth interviews with a subset of interviewed women (n = 39), policy makers, media executives, and health workers (n = 31). RESULTS In the previous 30 days, two mothers (out of 726) participating in the quantitative survey reported that health workers had recommended BMS, at private hospitals in both cases. In-depth interviews with health workers showed that hospitals have internal procedures to prevent the promotion of BMS by health workers. However, companies employed representatives to promote products not covered under the Code (e.g., commercial milk formula for pregnant women) at antenatal care visits and by gaining contact information from women and using this information to promote BMS outside the hospital, often on social media. In the 30 days preceding the survey, one-fifth of pregnant women were exposed to promotions of commercial milk formula for pregnant women and 7.1% to promotions of BMS. Among mothers of infants, 7.3% and 10.7% of respondents with infants aged 0-5 and 6-11 months, respectively, were exposed to some form of BMS promotion in the past 30 days. Around the time of birth, parents commonly brought BMS to maternity facilities (52.5%) or purchased it nearby (35.4%). CONCLUSIONS Although Vietnam has a strong regulatory environment for the protection, promotion, and support of breastfeeding, there are implementation, monitoring, and enforcement gaps. Stronger enforcement of national policies to regulate the presence of BMS industry representatives in health facilities-both public and private-and the promotion of BMS products on digital platforms are needed.
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Affiliation(s)
- Tuan T. Nguyen
- Alive & Thrive Southeast Asia, FHI 360, Hanoi 11022, Vietnam; (J.C.); (A.W.); (R.M.)
| | - Ha T. T. Tran
- Research and Training Center for Community Development, Hanoi 11616, Vietnam; (H.T.T.T.); (V.D.C.N.); (T.T.N.)
| | - Jennifer Cashin
- Alive & Thrive Southeast Asia, FHI 360, Hanoi 11022, Vietnam; (J.C.); (A.W.); (R.M.)
| | - Van D. C. Nguyen
- Research and Training Center for Community Development, Hanoi 11616, Vietnam; (H.T.T.T.); (V.D.C.N.); (T.T.N.)
| | - Amy Weissman
- Alive & Thrive Southeast Asia, FHI 360, Hanoi 11022, Vietnam; (J.C.); (A.W.); (R.M.)
- Asia Pacific Regional Office, FHI 360, Bangkok 10330, Thailand
| | - Trang T. Nguyen
- Research and Training Center for Community Development, Hanoi 11616, Vietnam; (H.T.T.T.); (V.D.C.N.); (T.T.N.)
| | - Bridget Kelly
- School of Health and Society, University of Wollongong, Wollongong, NSW 2522, Australia;
| | - Roger Mathisen
- Alive & Thrive Southeast Asia, FHI 360, Hanoi 11022, Vietnam; (J.C.); (A.W.); (R.M.)
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16
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Duffy EW, Taillie LS, Richter APC, Higgins ICA, Harris JL, Hall MG. Toddler milk perceptions and purchases: the role of Latino ethnicity. Public Health Nutr 2021; 24:2911-2919. [PMID: 33472718 PMCID: PMC8255274 DOI: 10.1017/s1368980021000264] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 01/07/2021] [Accepted: 01/18/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVES Toddler milk (i.e. a nutrient-fortified milk-based drink marketed for children 12-36 months old) is increasingly being marketed in the USA despite not being recommended for young children. There is evidence of targeted toddler milk marketing to Latinos in the USA. This study aimed to explore toddler milk perceptions and behaviours among Latino and non-Latino parents. DESIGN An online survey assessed toddler milk perceptions, behaviours and interpretations of nutrition-related claims. Multivariable logistic and linear regression explored socio-demographic correlates of parent reported past purchases and perceived healthfulness. SETTING Online. PARTICIPANTS National convenience sample of 1078 US parents of children aged 2-12 years (48 % Latino). RESULTS About half of parents (51 %) had previously purchased toddler milk and few (11 %) perceived toddler milk as unhealthy. Latino parents were more likely to have purchased toddler milk than non-Latino parents (P < 0·001), but there were no differences in perceived product healthfulness (P = 0·47). Compared to parents born in the USA, parents living in the USA 10 years or less were more likely to have purchased toddler milk (P < 0·001) and perceive toddler milk as healthier (P = 0·002). Open-ended interpretations of claims were primarily positive, suggesting 'health halo' effects. CONCLUSIONS Common misperceptions about toddler milk healthfulness suggest stronger labelling regulations are needed. Greater reported purchases by Latino parents and recent immigrants warrant further investigation.
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Affiliation(s)
- Emily W Duffy
- Department of Nutrition and Carolina Population Center, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Lindsey Smith Taillie
- Department of Nutrition and Carolina Population Center, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, NC, USA
| | - Ana Paula C Richter
- Department of Health Behavior and Carolina Population Center, University of North Carolina at Chapel Hill Gillings School of Global Public Health, 123 W. Franklin St., Suite 210, Chapel Hill, NC27516, USA
| | - Isabella CA Higgins
- Carolina Population Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jennifer L Harris
- University of Connecticut Rudd Center for Food Policy & Obesity, Hartford, CT, USA
| | - Marissa G Hall
- Department of Health Behavior and Carolina Population Center, University of North Carolina at Chapel Hill Gillings School of Global Public Health, 123 W. Franklin St., Suite 210, Chapel Hill, NC27516, USA
- UNC Lineberger Comprehensive Cancer Center, School of Medicine, CB #7295, Chapel Hill, NC27599, USA
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17
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Baker P, Russ K, Kang M, Santos TM, Neves PAR, Smith J, Kingston G, Mialon M, Lawrence M, Wood B, Moodie R, Clark D, Sievert K, Boatwright M, McCoy D. Globalization, first-foods systems transformations and corporate power: a synthesis of literature and data on the market and political practices of the transnational baby food industry. Global Health 2021; 17:58. [PMID: 34020657 PMCID: PMC8139375 DOI: 10.1186/s12992-021-00708-1] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 04/29/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The global milk formula market has 'boomed' in recent decades, raising serious concerns for breastfeeding, and child and maternal health. Despite these developments, few studies have investigated the global expansion of the baby food industry, nor the market and political practices corporations have used to grow and sustain their markets. In this paper, our aim is to understand the strategies used by the baby food industry to shape 'first-foods systems' across its diverse markets, and in doing so, drive milk formula consumption on a global scale. We used a theoretically guided synthesis review method, which integrated diverse qualitative and quantitative data sources. RESULTS Global milk formula sales grew from ~US$1.5 billion in 1978 to US$55.6 billion in 2019. This remarkable expansion has occurred along two main historical axes. First, the widening geographical reach of the baby food industry and its marketing practices, both globally and within countries, as corporations have pursued new growth opportunities, especially in the Global South. Second, the broadening of product ranges beyond infant formula, to include an array of follow-up, toddler and specialized formulas for a wider range of age groups and conditions, thereby widening the scope of mother-child populations subject to commodification. Sophisticated marketing techniques have been used to grow and sustain milk formula consumption, including marketing through health systems, mass-media and digital advertising, and novel product innovations backed by corporate science. To enable and sustain this marketing, the industry has engaged in diverse political practices to foster favourable policy, regulatory and knowledge environments. This has included lobbying international and national policy-makers, generating and deploying favourable science, leveraging global trade rules and adopting corporate policies to counter regulatory action by governments. CONCLUSION The baby food industry uses integrated market and political strategies to shape first-foods systems in ways that drive and sustain milk formula market expansion, on a global scale. Such practices are a major impediment to global implementation of the International Code of Marketing of Breastmilk Substitutes, and other policy actions to protect, promote and support breastfeeding. New modalities of public health action are needed to negate the political practices of the industry in particular, and ultimately to constrain corporate power over the mother-child breastfeeding dyad.
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Affiliation(s)
- Phillip Baker
- Institute for Physical Activity and Nutrition, Deakin University, Geelong, Australia
| | | | | | - Thiago M. Santos
- International Centre for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
| | - Paulo A. R. Neves
- International Centre for Equity in Health, Federal University of Pelotas, Pelotas, Brazil
| | - Julie Smith
- Research School of Population Health, Australian National University, Canberra, Australia
| | - Gillian Kingston
- Centre for Primary Care and Public Health, Queen Mary University, London, UK
| | - Melissa Mialon
- Trinity Business School, Trinity College Dublin, Dublin, Ireland
| | - Mark Lawrence
- Institute for Physical Activity and Nutrition, Deakin University, Geelong, Australia
| | - Benjamin Wood
- School of Health and Social Development, Deakin University, Geelong, Australia
| | - Rob Moodie
- Melbourne School of Population and Global Health, University of Melbourne, Melbourne, Australia
| | - David Clark
- Independent Consultant on Public Health Law, New York, USA
| | - Katherine Sievert
- School of Exercise and Nutrition Sciences, Deakin University, Geelong, Australia
| | - Monique Boatwright
- School of Exercise and Nutrition Sciences, Deakin University, Geelong, Australia
| | - David McCoy
- School of Exercise and Nutrition Sciences, Deakin University, Geelong, Australia
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Baker P, Santos T, Neves PA, Machado P, Smith J, Piwoz E, Barros AJD, Victora CG, McCoy D. First-food systems transformations and the ultra-processing of infant and young child diets: The determinants, dynamics and consequences of the global rise in commercial milk formula consumption. MATERNAL & CHILD NUTRITION 2021; 17:e13097. [PMID: 33145965 PMCID: PMC7988871 DOI: 10.1111/mcn.13097] [Citation(s) in RCA: 75] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/03/2020] [Revised: 09/25/2020] [Accepted: 09/27/2020] [Indexed: 12/12/2022]
Abstract
The inappropriate marketing and aggressive promotion of breastmilk substitutes (BMS) undermines breastfeeding and harms child and maternal health in all country contexts. Although a global milk formula 'sales boom' is reportedly underway, few studies have investigated its dynamics and determinants. This study takes two steps. First, it describes trends and patterns in global formula sales volumes (apparent consumption), by country income and region. Data are reported for 77 countries, for the years 2005-19, and for the standard (0-6 months), follow-up (7-12 m), toddler (13-36 m), and special (0-6 m) categories. Second, it draws from the literature to understand how transformations underway in first-food systems - those that provision foods for children aged 0-36 months - explain the global transition to higher formula diets. Total world formula sales grew by 115% between 2005 and 2019, from 3.5 to 7.4 kg/child, led by highly-populated middle-income countries. Growth was rapid in South East and East Asia, especially in China, which now accounts for one third of world sales. This transition is linked with factors that generate demand for BMS, including rising incomes, urbanisation, the changing nature of woman's work, social norms, media influences and medicalisation. It also reflects the globalization of the baby food industry and its supply chains, including the increasing intensity and sophistication of its marketing practices. Policy and regulatory frameworks designed to protect, promote and support breastfeeding are partially or completely inadequate in the majority of countries, hence supporting industry expansion over child nutrition. The results raise serious concern for global child and maternal health.
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Affiliation(s)
- Phillip Baker
- Institute for Physical Activity and NutritionDeakin UniversityGeelongVictoriaAustralia
- School of Exercise and Nutrition SciencesDeakin UniversityGeelongVictoriaAustralia
| | - Thiago Santos
- International Center for Equity in HealthFederal University of PelotasPelotasBrazil
| | - Paulo Augusto Neves
- International Center for Equity in HealthFederal University of PelotasPelotasBrazil
| | - Priscila Machado
- Institute for Physical Activity and NutritionDeakin UniversityGeelongVictoriaAustralia
| | - Julie Smith
- Research School of Population HealthAustralian National UniversityCanberraAustralian Capital TerritoryAustralia
| | - Ellen Piwoz
- Bill and Melinda Gates Foundation, SeattleWashingtonUSA
| | - Aluisio J. D. Barros
- International Center for Equity in HealthFederal University of PelotasPelotasBrazil
| | - Cesar G. Victora
- International Center for Equity in HealthFederal University of PelotasPelotasBrazil
| | - David McCoy
- Centre for Primary Care and Public HealthQueen Mary UniversityLondonUK
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Harris JL, Pomeranz JL. Infant formula and toddler milk marketing: opportunities to address harmful practices and improve young children's diets. Nutr Rev 2021; 78:866-883. [PMID: 31968101 DOI: 10.1093/nutrit/nuz095] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Children's diets in their first 1000 days influence dietary preferences, eating habits, and long-term health. Yet the diets of most infants and toddlers in the United States do not conform to recommendations for optimal child nutrition. This narrative review examines whether marketing for infant formula and other commercial baby/toddler foods plays a role. The World Health Organization's International Code of Marketing Breast-milk Substitutes strongly encourages countries and manufacturers to prohibit marketing practices that discourage initiation of, and continued, breastfeeding. However, in the United States, widespread infant formula marketing negatively impacts breastfeeding. Research has also identified questionable marketing of toddler milks (formula/milk-based drinks for children aged 12-36 mo). The United States has relied exclusively on industry self-regulation, but US federal agencies and state and local governments could regulate problematic marketing of infant formula and toddler milks. Health providers and public health organizations should also provide guidance. However, further research is needed to better understand how marketing influences what and how caregivers feed their young children and inform potential interventions and regulatory solutions.
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Affiliation(s)
- Jennifer L Harris
- UConn Rudd Center for Food Policy and Obesity, Allied Health Sciences, University of Connecticut, Hartford, Connecticut, USA
| | - Jennifer L Pomeranz
- Department of Public Health Policy and Management, College of Global Public Health, New York University, New York, New York, USA
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Willcox JC, Februhartanty J, Satheannoppakao W, Hutchinson C, Itsiopoulos C, Worsley A. Commercial growing up milks: usage frequency and associated child and demographic factors across four Asia Pacific countries. J Hum Nutr Diet 2021; 34:524-533. [PMID: 33406319 DOI: 10.1111/jhn.12851] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Revised: 10/31/2020] [Accepted: 11/18/2020] [Indexed: 01/21/2023]
Abstract
BACKGROUND Commercial growing up milks (GUMs) targeted at children from 12 to 36 months of age are a rapidly growing industry, particularly across the Asia Pacific. METHODS The present study assessed the frequency of use and socio-demographic and child associations of commercial GUM feeding in children, aged between 12 and 36 months, in capital cities in four Asia Pacific countries. Mothers of children aged between 12 and 36 months were surveyed, assessing GUM feeding frequency in the past month. A market research company database was used to survey across Asia Pacific urban cities, including Bangkok Thailand, Jakarta Indonesia, Singapore and Australian Capital Cities (ACC). RESULTS More than 1000 women (n = 1051) were surveyed (Bangkok, n = 263; Jakarta, n = 275; ACC, n = 252; Singapore, n = 261). The mean (SD) age of mothers was 32.4 (5.3) years and that of children was 23.6 (6.7) months. In total, 62.7% of the children were fed GUMs more than once per week with significant country variance. In comparison with ACC, Asian countries were significantly more likely to feed GUMs ≥once per week: Bangkok [odds ratio (OR) = 5.7, 95% confidence interval (CI) = 3.8-8.6]; Jakarta (OR = 3.5, 95% CI = 2.3-5.5); and Singapore (OR = 7.4, 95% CI = 4.9-11.1). Associations of GUM feeding included: maternal tertiary education; mothers younger than 30 years; working full time; and feeding of commercial infant formula under 12 months. CONCLUSIONS This is the first published study to explore commercial GUM feeding in and between countries. The incidence of GUM feeding, in contrast to international recommendations, signals the need for further research into the drivers for GUM feeding and its contribution to the diet.
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Affiliation(s)
- J C Willcox
- School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, VIC, Australia
| | - J Februhartanty
- Southeast Asian Ministers of Education Organization Regional Centre for Food and Nutrition (SEAMEO RECFON)/Pusat Kajian Gizi Regional (PKGR), Universitas Indonesia, Jakarta, Indonesia
| | - W Satheannoppakao
- Department of Nutrition, Faculty of Public Health, Mahidol University, Bangkok, Thailand
| | - C Hutchinson
- Department of Nutrition, Faculty of Public Health, Mahidol University, Bangkok, Thailand
| | - C Itsiopoulos
- School of Allied Health, Human Services and Sport, La Trobe University, Melbourne, VIC, Australia.,College of Science, Health, Engineering and Education, Murdoch University, Murdoch, WA, Australia
| | - A Worsley
- Institute for Physical Activity and Nutrition, Deakin University, Waurn Ponds, VIC, Australia
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Laillou A, Gerba H, Zelalem M, Moges D, Abera W, Chuko T, Getahun B, Kahsay H, Chitekwe S. Is the legal framework by itself enough for successful WHO code implementation? A case study from Ethiopia. MATERNAL & CHILD NUTRITION 2021; 17:e13059. [PMID: 32841521 PMCID: PMC7729794 DOI: 10.1111/mcn.13059] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 06/03/2020] [Accepted: 06/17/2020] [Indexed: 12/28/2022]
Abstract
Since 2016, Ethiopia has passed several proclamations and directives to regulate the promotion of commercial breastmilk substitute (BMS). Ethiopia's market potential will undoubtedly be the gravitating point for international infant formula companies due to growing urbanization, purchasing power, population, and the relatively low use of BMS to-date. The aim of this review is to assess the strengths and weaknesses of the existing laws, standards, and monitoring documents used to regulate the marketing of BMSs in Ethiopia and make future recommendations. The study findings highlighted that the regulation on marketing are comprehensive and strong to limit the promotion of infant formula. On the other hand, the regulation on marketing of follow-up formulas, complementary foods, and growing-up milk by manufacturers and distributors, media houses, and communication and advertisement agencies are underregulated, especially with regards to the international 69.9 regulation. The monitoring and enforcement of the existing marketing regulations remain limited in the absence of a formal coordination mechanism. Several violations of the national BMS regulations were observed. Forty-one percent of mothers reported observing the BMS advertising and logos were detected in 36% of health facilities assessed. In 100% of cases, the infant formula labels contained violations. As the lead national authority mandated to regulate food safety, the Ethiopian Food and Drug Authority needs to update its regulations related to the marketing of BMS to fill the loopholes and revise the national law in line with the international code of marketing of BMSs to protect breastfeeding.
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Affiliation(s)
| | - Heran Gerba
- Ethiopian Food and Drug AdministrationAddis AbabaEthiopia
| | - Meseret Zelalem
- Department for Maternal, Child Health and NutritionFederal Ministry of HealthAddis AbabaEthiopia
| | | | | | | | - Betre Getahun
- Ethiopian Food and Drug AdministrationAddis AbabaEthiopia
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Romo-Palafox MJ, Pomeranz JL, Harris JL. Infant formula and toddler milk marketing and caregiver's provision to young children. MATERNAL AND CHILD NUTRITION 2020; 16:e12962. [PMID: 32157807 PMCID: PMC7296786 DOI: 10.1111/mcn.12962] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 01/14/2020] [Accepted: 01/16/2020] [Indexed: 11/30/2022]
Abstract
The World Health Organization International Code of Marketing of Breast‐milk Substitutes prohibits claims and other marketing that may confuse caregivers about benefits of formula and other milk‐based drinks for infants and toddlers, but such marketing is common in the United States. This study assessed caregivers' provision of milk‐based products to their infants and toddlers and potential confusion about product benefits and appropriate use. Online survey of 1,645 U.S. caregivers of infants (6–11 months) and toddlers (12–36 months). Respondents identified infant formula and toddler milk products they served their child (ren) and provided relative agreement with common marketing claims. Logistic regression assessed relationships between agreement and serving these products, controlling for individual characteristics. Over one‐half of caregivers of infants (52%) agreed that infant formula can be better for babies' digestion and brain development than breastmilk, and 62% agreed it can provide nutrition not present in breastmilk. Most caregivers of toddlers (60%) agreed that toddler milks provide nutrition toddlers do not get from other foods. Some caregivers of infants (11%) reported serving toddler milk to their child most often. Agreement with marketing claims increased the odds of serving infant formula and/or toddler milks. For caregivers of toddlers, odds were higher for college‐educated and lower for non‐Hispanic White caregivers. Common marketing messages promoting infant formula and toddler milks may mislead caregivers about benefits and appropriateness of serving to young children. These findings support calls for public health policies and increased regulation of infant formula and toddler milks.
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Affiliation(s)
- Maria J Romo-Palafox
- Rudd Center for Food Policy and Obesity, University of Connecticut, Hartford, Connecticut
| | | | - Jennifer L Harris
- Rudd Center for Food Policy and Obesity, University of Connecticut, Hartford, Connecticut
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23
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Abstract
AbstractObjective:Extensive marketing of ‘toddler milks’ (sugar-sweetened milk-based drinks for toddlers) promotes unsubstantiated product benefits and raises concerns about consumption by young children. The present study documents trends in US toddler milk sales and assesses relationships with brand and category marketing.Design:We report annual US toddler milk and infant formula sales and marketing from 2006 to 2015. Sales response models estimate associations between marketing (television advertising spending, product price, number of retail displays) and volume sales of toddler milks by brand and category.Setting:US Nielsen retail scanner sales and advertising spending data from 2006 to 2015.Participants:Researchers analysed all Universal Product Codes (n 117·4 million) sold by seven infant formula and eight toddler milk brands from 2006 to 2015.Results:Advertising spending on toddler milks increased fourfold during this 10-year period and volume sales increased 2·6 times. In contrast, advertising spending and volume sales of infant formulas declined. Toddler milk volume sales were positively associated with television advertising and retail displays, and negatively associated with price, at both the brand and category levels.Conclusions:Aggressive marketing of toddler milks has likely contributed to rapid sales increases in the USA. However, these sugar-sweetened drinks are not recommended for toddler consumption. Health-care providers, professional organizations and public health campaigns should provide clear guidance and educate parents to reduce toddler milk consumption and address misperceptions about their benefits. These findings also support the need to regulate marketing of toddler milks in countries that prohibit infant formula marketing to consumers.
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Champeny M, Hou K, Diop EI, Sy Gueye NY, Pries AM, Zehner E, Badham J, Huffman SL. Prevalence, duration, and content of television advertisements for breast milk substitutes and commercially produced complementary foods in Phnom Penh, Cambodia and Dakar, Senegal. MATERNAL & CHILD NUTRITION 2019; 15 Suppl 4:e12781. [PMID: 31225708 PMCID: PMC6617818 DOI: 10.1111/mcn.12781] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 12/07/2018] [Accepted: 01/09/2019] [Indexed: 11/28/2022]
Abstract
Promotion of breast milk substitutes (BMS) and inappropriate marketing of commercially produced complementary foods (CPCF), including through television, can negatively influence infant and young child feeding. The World Health Organization International Code of Marketing of Breast-milk Substitutes and subsequent relevant World Health Assembly (WHA) resolutions prohibit such advertising and require manufacturers and distributors to comply with its provisions; however, such regulations at national level may vary. Advertisements require Ministry of Health approval in Cambodia but are not regulated in Senegal. Television stations were monitored for 13 months in Phnom Penh and for 3 months in Dakar to assess advertisements for BMS and CPCF. Ten television channels (out of 16) in Phnom Penh and four (out of 20) in Dakar aired advertisements for BMS. Three and five channels, respectively, aired advertisements for CPCF. All BMS advertised in Phnom Penh were for children over 1 year of age. BMS products for children 6+ months of age and 1+ years of age were advertised in Dakar. Average air time for BMS advertisements was 189.5 min per month in Phnom Penh and 29.7 min in Dakar. Air time for CPCF advertisements averaged 3.2 min per month and 13.6 min, respectively. Fewer than half of BMS advertisements and three quarters of CPCF advertisements explicitly stated an age of use for products. Nutrition and health claims were common across BMS advertisements. This study illustrates the need to adopt, regulate, monitor, and enforce legislation prohibiting BMS promotion, as well as to implement regulations to prevent inappropriate promotion of CPCF.
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Affiliation(s)
| | - Kroeun Hou
- Helen Keller InternationalNew YorkNew YorkUSA
| | | | | | - Alissa M. Pries
- Helen Keller InternationalNew YorkNew YorkUSA
- London School of Hygiene and Tropical MedicineLondonUK
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25
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Zehner E, Champeny M, Huffman SL. Marketing and infant and young child feeding in rapidly evolving food environments. MATERNAL & CHILD NUTRITION 2019; 15 Suppl 4:e12810. [PMID: 31225711 PMCID: PMC6618061 DOI: 10.1111/mcn.12810] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 03/13/2019] [Accepted: 03/13/2019] [Indexed: 01/16/2023]
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26
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Hadihardjono DN, Green M, Stormer A, Agustino, Izwardy D, Champeny M. Promotions of breastmilk substitutes, commercial complementary foods and commercial snack products commonly fed to young children are frequently found in points-of-sale in Bandung City, Indonesia. MATERNAL & CHILD NUTRITION 2019; 15 Suppl 4:e12808. [PMID: 31225709 PMCID: PMC6617717 DOI: 10.1111/mcn.12808] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 03/04/2019] [Accepted: 03/15/2019] [Indexed: 01/08/2023]
Abstract
Few studies have documented the marketing of commercial foods and beverages for infants and young children in West Java, Indonesia. To assess the prevalence of promotions at points-of-sale for commercially produced products commonly fed to young children in Bandung City, 43 small and large stores were visited in 2017. Promotions for breastmilk substitutes (BMS), commercially produced complementary foods (CPCF), and select types of commercial snack products were photographed and information recorded on promotion characteristics. There were 402 and 206 promotions observed with BMS and CPCF products, respectively. Sixteen promotions with BMS products for infants under 12 months were found in 42.9% of stores selling BMS, violating national regulations. Almost all BMS promotions (98.3%) included BMS products for ages 1 year and above ("growing-up milks"). Of all BMS products available for sale, half of all infant/follow-up formula and 77.2% of growing-up milks were promoted. CPCF were found in 97.7% of stores, and 81.0% of these stores had promotions; 70.5% of all available CPCF products were promoted. Of the 2,451 promotions observed for commercial snack products, 17.3% used promotional techniques targeting young children or caregivers. Joint-promotions were common, with BMS and CPCF marketed in combination with commercial snack products; 49.0% of BMS promotions were joint BMS-snack promotions, and 80.0% or more of infant/follow-up formula promotions included a commercial snack. Revising and enforcing infant food and beverage marketing regulations to ensure consistency with global standards are necessary to protect and promote optimal infant and young child feeding in Indonesia.
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Affiliation(s)
| | | | - Ame Stormer
- Helen Keller InternationalNew YorkNew YorkUSA
| | - Agustino
- Helen Keller InternationalNew YorkNew YorkUSA
| | - Doddy Izwardy
- Direktorat Gizi Masyarakat‐Kementerian Kesehatan RIJakartaIndonesia
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27
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Spizzirri UG, Puoci F, Iemma F, Restuccia D. Biogenic amines profile and concentration in commercial milks for infants and young children. Food Addit Contam Part A Chem Anal Control Expo Risk Assess 2019; 36:337-349. [PMID: 30722764 DOI: 10.1080/19440049.2018.1563306] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Commercial milks for infants and young children (CMIYC) received much attention during last years for their impact on the nutritional status, health and development of the new-born and babies. Among possible contaminants contained in these foods, biogenic amines (BAs) have rarely been determined although they can exert toxic effects in humans if ingested at high concentrations. Spermine, spermidine, putrescine, histamine, tyramine, β-phenylethylamine and cadaverine have been quantified in CMIYC samples by LC-UV after derivatisation with dansyl-chloride. Once optimised in terms of linearity (R2 ≥ 0.989), recovery percentages (92.9-97.3), LOD (0.2-0.4 μg g-1 or 0.03-0.05 μg mL-1 depending on the samples), LOQ (0.5-1.0 μg g-1 and 0.08-0.13 μg mL-1 depending on the samples) and repeatability (0.1-0.2 intra-day; 0.2-0.4 inter-day), the method has been applied to real samples. Very low total BAs concentrations have been found in reconstituted (1.18-3.12 mg L-1) and liquid milks (0.33-2.30 mg L-1), with different biogenic amine profiles and distributions. A risk assessment based on the available information regarding Acute Reference Doses of histamine and tyramine, as well as the application of common Biogenic Amine Indexes, showed that none of the analysed samples represented a possible risk for babies, also considering a worst case evaluation. These findings confirmed the strict safety and quality protocols adopted during the production of CMIYC. Chemical compounds studied in this article: Ammonium chloride (PubChem CID: 25517); Cadaverine hydrochloride (PubChem CID: 5351467); Hydrochloridric acid (PubChem CID: 313); Histamine dihydrochloride (PubChem CID: 5818); Phenylethylamine hydrochloride (PubChem CID: 9075); Putrescine dihydrochloride (PubChem CID: 9532); Sodium hydroxide (PubChem CID: 14798); Spermine tetrahydrochloride (PubChem CID: 1103); Spermidine trihydrochloride (PubChem CID: 1102); Tyramine hydrochloride (PubChem CID: 66449).
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Affiliation(s)
- U Gianfranco Spizzirri
- a Department of Pharmacy, Health and Nutritional Sciences , University of Calabria , Arcavacata di Rende CS , Italy
| | - Francesco Puoci
- a Department of Pharmacy, Health and Nutritional Sciences , University of Calabria , Arcavacata di Rende CS , Italy
| | - Francesca Iemma
- a Department of Pharmacy, Health and Nutritional Sciences , University of Calabria , Arcavacata di Rende CS , Italy
| | - Donatella Restuccia
- a Department of Pharmacy, Health and Nutritional Sciences , University of Calabria , Arcavacata di Rende CS , Italy
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28
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Michaud‐Létourneau I, Gayard M, Pelletier DL. Translating the International Code of Marketing of Breast-milk Substitutes into national measures in nine countries. MATERNAL & CHILD NUTRITION 2019; 15 Suppl 2:e12730. [PMID: 30793543 PMCID: PMC6519018 DOI: 10.1111/mcn.12730] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 07/26/2018] [Accepted: 08/14/2018] [Indexed: 01/13/2023]
Abstract
The International Code of Marketing of Breast-milk Substitutes (the Code) adopted by the World Health Assembly (WHA) in 1981 and regularly updated through subsequent WHA resolutions, represents the international policy framework for protecting breastfeeding against inappropriate marketing practices. By March 2016, at least 135 countries had some measures covering provisions of the Code in their legislation. The translation of the International Code into national measures was investigated in the context of the advocacy efforts undertaken by the Alive & Thrive (A&T) initiative with UNICEF and partners. A real-time evaluation was carried out over 22 months in seven Southeast Asian countries (Cambodia, Indonesia, Lao People's Democratic Republic [Lao PDR], Myanmar, Thailand, Vietnam, and Timor-Leste) and two African countries (Burkina Faso and Ethiopia). Drivers of policy change and progress were examined. Two theory-based approaches were used: developmental evaluation and contribution analysis. Data collection methods included participant observation, key informant meetings, in-depth interviews, reflective practice, and desk review. Overall, countries made significant progress in translating the International Code into national measures and in moving forward throughout the policy cycle. The main driver of policy change was the creation of a strategic group, which engaged key relevant actors and supported the government in the performance of 15 critical tasks, which the analysis reveals is a second driver. Those critical tasks are described in this paper and could help public health advocates to anticipate the stages and challenges of policy change and develop more effective strategies to translate the Code into their legal framework.
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Affiliation(s)
- Isabelle Michaud‐Létourneau
- Department of Social and Preventive Medicine, School of Public HealthUniversité de MontréalMontrealQuebecCanada
- Department of Family Medicine and Emergency MedicineUniversité de SherbrookeLongueuilQuebecCanada
| | - Marion Gayard
- Department of Family Medicine and Emergency MedicineUniversité de SherbrookeLongueuilQuebecCanada
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29
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Theurich MA. World Health Assembly Resolution 69.9 Calls for an End to Unethical Marketing of "Baby Foods". J Hum Lact 2018; 34:272-275. [PMID: 29462567 DOI: 10.1177/0890334418754783] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Melissa Ann Theurich
- 1 Department for Metabolic and Nutritional Medicine, Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University of Munich, Munich, Bavaria, Germany
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30
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Wallingford JC. Perspective: Structure-Function Claims on Infant Formula. Adv Nutr 2018; 9:183-192. [PMID: 29767697 PMCID: PMC5952939 DOI: 10.1093/advances/nmy006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Accepted: 01/23/2018] [Indexed: 11/12/2022] Open
Abstract
In the context of a food product label, the term "claim" refers to information that attributes value to the product. The term extends to many different types of information, from product identity, descriptors of intended use, and identification of characteristic properties to the physiologic effects in the body of substances in the food, including the reduction of risk of disease. Food labeling, which includes claims, provides information that consumers want and use to improve their diets. Consumers prefer short statements on the front label claims to longer, more detailed information, including ingredients statements and a nutrition panel. Three types of claims are permitted in the United States. Nutrient content claims describe the level of the nutrient in the food relative to an established daily value, e.g., "Excellent source of choline," and are subject to composition limits for other nutrients, such as total fat, saturated fat, and cholesterol. Health claims describe the relation between a food substance and the risk of disease, e.g., "Adequate calcium and vitamin D throughout life, as part of a well-balanced diet, may reduce the risk of osteoporosis." They must undergo a premarket evaluation by the FDA to ensure that there is significant scientific agreement about the relation in question. The third type of claim, structure-function (SF) claims, has recently come under scrutiny, particularly regarding their use on infant formula. Such claims represent a food's effect on the structure or function of the body for maintenance of good health and nutrition. These claims must be truthful and not misleading, but are not subject to premarket approval before use. The purpose of this perspective is to describe the origins and unique niche of SF claims, and to comment on recent proposals to further regulate such claims on infant formula.
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Affiliation(s)
- John C Wallingford
- Nutrispectives, LLC, Spokane, WA,Address correspondence to JCW (e-mail: )
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31
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Pomeranz JL, Romo Palafox MJ, Harris JL. Toddler drinks, formulas, and milks: Labeling practices and policy implications. Prev Med 2018; 109:11-16. [PMID: 29339115 DOI: 10.1016/j.ypmed.2018.01.009] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2017] [Revised: 12/21/2017] [Accepted: 01/08/2018] [Indexed: 10/18/2022]
Abstract
Toddler drinks are a growing category of drinks marketed for young children 9-36 months old. Medical experts do not recommend them, and public health experts raise concerns about misleading labeling practices. In the U.S., the toddler drink category includes two types of products: transition formulas, marketed for infants and toddlers 9-24 months; and toddler milks, for children 12-36 months old. The objective of this study was to evaluate toddler drink labeling practices in light of U.S. food labeling policy and international labeling recommendations. In January 2017, we conducted legal research on U.S. food label laws and regulations; collected and evaluated toddler drink packages, including nutrition labels and claims; and compared toddler drink labels with the same brand's infant formula labels. We found that the U.S. has a regulatory structure for food labels and distinct policies for infant formula, but no laws specific to toddler drinks. Toddler drink labels utilized various terms and images to identify products and intended users; made multiple health and nutrition claims; and some stated there was scientific or expert support for the product. Compared to the same manufacturer's infant formula labels, most toddler drink labels utilized similar colors, branding, logos, and graphics. Toddler drink labels may confuse consumers about their nutrition and health benefits and the appropriateness of these products for young children. To support healthy toddler diets and well-informed decision-making by caregivers, the FDA can provide guidance or propose regulations clarifying permissible toddler drink labels and manufacturers should end inappropriate labeling practices.
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Affiliation(s)
- Jennifer L Pomeranz
- College of Global Public Health, New York University, NY, New York, United States.
| | - Maria J Romo Palafox
- Rudd Center for Food Policy & Obesity, University of Connecticut, Hartford, CT, United States
| | - Jennifer L Harris
- Rudd Center for Food Policy & Obesity, University of Connecticut, Hartford, CT, United States
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32
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Abstract
Young child formulae (YCF) are milk-based drinks or plant protein-based formulae intended to partially satisfy the nutritional requirements of young children ages 1 to 3 years. Although widely available on the market, their composition is, however, not strictly regulated and health effects have not been systematically studied. Therefore, the European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) Committee on Nutrition (CoN) performed a systematic review of the literature to review the composition of YCF and consider their role in the diet of young children. The review revealed limited data but identified that YCF have a highly variable composition, which is in some cases inappropriate with very high protein and carbohydrate content and even high amounts of added sugars. Based on the evidence, ESPGHAN CoN suggests that the nutrient composition of YCF should be similar to that of follow-on formulae with regards to energy and nutrients that may be deficient in the diets of European young children such as iron, vitamin D, and polyunsaturated fatty acids (n-3 PUFAs), whereas the protein content should aim toward the lower end of the permitted range of follow-on formulae if animal protein is used. There are data to show that YCF increase intakes of vitamin D, iron, and n-3 PUFAs. However, these nutrients can also be provided via regular and/or fortified foods or supplements. Therefore, ESPGHAN CoN suggests that based on available evidence there is no necessity for the routine use of YCF in children from 1 to 3 years of life, but they can be used as part of a strategy to increase the intake of iron, vitamin D, and n-3 PUFA and decrease the intake of protein compared with unfortified cow's milk. Follow-on formulae can be used for the same purpose. Other strategies for optimizing nutritional intake include promotion of a healthy varied diet, use of fortified foods, and use of supplements.
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Grummer-Strawn LM, Zehner E, Stahlhofer M, Lutter C, Clark D, Sterken E, Harutyunyan S, Ransom EI. New World Health Organization guidance helps protect breastfeeding as a human right. MATERNAL AND CHILD NUTRITION 2017; 13. [PMID: 28795484 PMCID: PMC5638108 DOI: 10.1111/mcn.12491] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Revised: 05/22/2017] [Accepted: 06/18/2017] [Indexed: 12/18/2022]
Abstract
Written by the WHO/UNICEF NetCode author group, the comment focuses on the need to protect families from promotion of breast‐milk substitutes and highlights new WHO Guidance on Ending Inappropriate Promotion of Foods for Infants and Young Children. The World Health Assembly welcomed this Guidance in 2016 and has called on all countries to adopt and implement the Guidance recommendations. NetCode, the Network for Global Monitoring and Support for Implementation of the International Code of Marketing of Breast‐milk Substitutes and Subsequent Relevant World Health Assembly Resolutions, is led by the World Health Organization and the United Nations Children's Fund. NetCode members include the International Baby Food Action Network, World Alliance for Breastfeeding Action, Helen Keller International, Save the Children, and the WHO Collaborating Center at Metropol University. The comment frames the issue as a human rights issue for women and children, as articulated by a statement from the United Nations Office of the High Commissioner for Human Rights.
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Affiliation(s)
| | | | | | - Chessa Lutter
- School of Public Health, University of Maryland, College Park, MD, USA
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34
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Media audit reveals inappropriate promotion of products under the scope of the International Code of Marketing of Breast-milk Substitutes in South-East Asia. Public Health Nutr 2017; 20:1333-1342. [PMID: 28294089 DOI: 10.1017/s1368980016003591] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To review regulations and to perform a media audit of promotion of products under the scope of the International Code of Marketing of Breast-milk Substitutes ('the Code') in South-East Asia. DESIGN We reviewed national regulations relating to the Code and 800 clips of editorial content, 387 advertisements and 217 Facebook posts from January 2015 to January 2016. We explored the ecological association between regulations and market size, and between the number of advertisements and market size and growth of milk formula. SETTING Cambodia, Indonesia, Myanmar, Thailand and Vietnam. RESULTS Regulations on the child's age for inappropriate marketing of products are all below the Code's updated recommendation of 36 months (i.e. 12 months in Thailand and Indonesia; 24 months in the other three countries) and are voluntary in Thailand. Although the advertisements complied with the national regulations on the age limit, they had content (e.g. stages of milk formula; messages about the benefit; pictures of a child) that confused audiences. Market size and growth of milk formula were positively associated with the number of newborns and the number of advertisements, and were not affected by the current level of implementation of breast-milk substitute laws and regulations. CONCLUSIONS The present media audit reveals inappropriate promotion and insufficient national regulation of products under the scope of the Code in South-East Asia. Strengthened implementation of regulations aligned with the Code's updated recommendation should be part of comprehensive strategies to minimize the harmful effects of advertisements of breast-milk substitutes on maternal and child nutrition and health.
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35
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Pereira C, Ford R, Feeley AB, Sweet L, Badham J, Zehner E. Cross-sectional survey shows that follow-up formula and growing-up milks are labelled similarly to infant formula in four low and middle income countries. MATERNAL AND CHILD NUTRITION 2017; 12 Suppl 2:91-105. [PMID: 27061959 PMCID: PMC5071731 DOI: 10.1111/mcn.12269] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
This cross-sectional survey assessed the characteristics of labels of follow-up formula (FUF) and growing-up milk (GUM) compared with infant formula (IF), including cross-promotion practices between FUF/GUM and IF manufactured by the same company, sold in Phnom Penh, Cambodia; Kathmandu Valley, Nepal; Dakar Department, Senegal; and Dar es Salaam, Tanzania. All products were imported. A wide recommended age/age range for introduction was provided by manufacturers across all sites, with products with an age recommendation of 0-6 months being most prevalent in three sites, representing over a third of all products. Various age categories (e.g. 1, 1+ and Stage 1) commonly appeared on labels. A number of descriptive names (e.g. infant formula and milk formula) per category of age of introduction were used with some appearing across more than one category. Images of feeding bottles were found on most labels across all age categories, but prevalence decreased with older age categories. The majority of FUF/GUM manufactured by IF companies across all sites displayed at least one example of cross-promotion with one or more of the company's IF: two-thirds or more contained similar colour schemes/designs and similar brand names; 20-85% had similar slogans/mascots/symbols. A wide and potentially confusing range of ages/categories of introduction and descriptive names were found, and cross-promotion with IF was common on FUF/GUM labels. Global guidance from normative bodies forms the basis of most low and middle income countries policies and should provide specific guidance to prohibit cross-promotion between FUF/GUM and IF, and all three categories should be classified as breastmilk substitutes.
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Lampl M, Mummert A, Schoen M. Promoting Healthy Growth or Feeding Obesity? The Need for Evidence-Based Oversight of Infant Nutritional Supplement Claims. Healthcare (Basel) 2016; 4:E84. [PMID: 27845744 PMCID: PMC5198126 DOI: 10.3390/healthcare4040084] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2016] [Revised: 10/10/2016] [Accepted: 10/27/2016] [Indexed: 12/28/2022] Open
Abstract
The Developmental Origins of Health and Disease (DOHaD) model recognizes growth in infancy and childhood as a fundamental determinant of lifespan health. Evidence of long-term health risks among small neonates who subsequently grow rapidly poses a challenge for interventions aiming to support healthy growth, not merely drive weight gain. Defining healthy growth beyond "getting bigger" is essential as infant and young child feeding industries expand. Liquid-based nutritional supplements, originally formulated for undernourished children, are increasingly marketed for and consumed by children generally. Clarifying the nature of the evidentiary base on which structure/function claims promoting "healthy growth" are constructed is important to curb invalid generalizations. Evidence points to changing social beliefs and cultural practices surrounding supplementary feeding, raising specific concerns about the long-term health consequences of an associated altered feeding culture, including reduced dietary variety and weight gain. Reassessing the evidence for and relevance of dietary supplements' "promoting healthy growth" claims for otherwise healthy children is both needed in a time of global obesity and an opportunity to refine intervention approaches among small children for whom rapid subsequent growth in early life augments risk for chronic disease. Scientific and health care partnerships are needed to consider current governmental oversight shortfalls in protecting vulnerable populations from overconsumption. This is important because we may be doing more harm than good.
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Affiliation(s)
- Michelle Lampl
- Center for the Study of Human Health, Emory University, Atlanta, GA 30322, USA.
- Department of Anthropology, Emory University, Atlanta, GA 30322, USA.
| | - Amanda Mummert
- Department of Anthropology, Emory University, Atlanta, GA 30322, USA.
| | - Meriah Schoen
- Center for the Study of Human Health, Emory University, Atlanta, GA 30322, USA.
- Department of Nutrition, Georgia State University, Atlanta, GA 30302, USA.
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Feeley AB, Ndeye Coly A, Sy Gueye NY, Diop EI, Pries AM, Champeny M, Zehner ER, Huffman SL. Promotion and consumption of commercially produced foods among children: situation analysis in an urban setting in Senegal. MATERNAL & CHILD NUTRITION 2016; 12 Suppl 2:64-76. [PMID: 27061957 PMCID: PMC5071683 DOI: 10.1111/mcn.12304] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
This study assessed the promotion of commercially produced foods and consumption of these products by children less than 24 months of age in Dakar Department, Senegal. Interviews with 293 mothers of children attending child health clinics assessed maternal exposure to promotion and maternal recall of foods consumed by the child on the preceding day. Promotion of breastmilk substitutes and commercially produced complementary foods outside health facilities was common with 41.0% and 37.2% of mothers, respectively, reporting product promotions since the birth of their youngest child. Promotion of commercially produced snack food products was more prevalent, observed by 93.5% of mothers. While all mothers reported having breastfed their child, only 20.8% of mothers breastfed their newborn within the first hour after delivery, and 44.7% fed pre-lacteal feeds in the first 3 days after delivery. Of children 6-23 months of age, 20.2% had consumed a breastmilk substitute; 49.1% ate a commercially produced complementary food, and 58.7% ate a commercially produced snack food product on the previous day. There is a need to stop the promotion of breastmilk substitutes, including infant formula, follow-up formula, and growing-up milks. More stringent regulations and enforcement could help to eliminate such promotion to the public through the media and in stores. Promotion of commercial snack foods is concerning, given the high rates of consumption of such foods by children under the age of 2 years. Efforts are needed to determine how best to reduce such promotion and encourage replacement of these products with more nutritious foods.
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Affiliation(s)
| | | | | | | | - Alissa M. Pries
- Helen Keller International, Asia Pacific Regional OfficePhnom PenhCambodia
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