Adriano Cattaneo
Hooking up parents and caregivers to sell breastmilk substitutes. This marketing is associated with a reduction in the prevalence and duration of breastfeeding, and therefore harm to health and nutrition. Revenue from these products grew from $1.5 billion in 1978 to $55.6 billion in 2019, a 37-fold increase in 40 years.
Since 2003, every 4-6 years, the Lancet has dedicated a series of articles to breastfeeding. The latest came out in the February 11, 2023 issue. It consists of three substantial main articles, an editorial and a commentary. As with previous series, it is to be expected that there will be more comments and numerous letters and replies in future issues, given the way the subject has been addressed. The three main lengthy articles are accompanied by appendices detailing the methods used and data sources. They have huge bibliographies: 174, 168 and 296 entries, respectively, for a total of 638 bibliographic references. You need to devote at least three days to reading the whole thing, including reading some bibliographic references that may have escaped even a fan of the subject, like me.
The first article begins with a brief and very up-to-date review of scientific knowledge on breast milk and breastfeeding.(1) After citing numerous studies on the still largely unknown properties of the hitherto known ingredients of breast milk, the authors conclude that “we are just beginning to understand the complex biology of this incomparable functional food, and the social and psychological implications of the interaction of breastfeeding”. They then go on to analyze the factors that hinder breastfeeding. The first is the reckless and abundant use of the so-called additions, which in populations with a western lifestyle are made up of more or less abundant quantities of formula, while in other populations they can also be represented by foods and liquids of a ritual nature. There isn’t much data on formula supplements in high-income countries, but in the US, for example, they are used routinely in two-thirds of maternity wards. In low- and middle-income countries, it is estimated that about one-third of newborns receive formula supplements. Research shows that supplement use in the first few days of life is associated with less exclusivity and duration of breastfeeding, with known consequences on the present and future health of mothers and infants.
The formula industry exploits many mechanisms to increase the use of additives, which obviously works in their favor. In addition to the marketing strategies aimed at healthcare systems and operators, which the second article in the series talks about, with marketing aimed at families, the industry conveys the idea that normal newborn behaviors, such as crying, restlessness, regurgitation and nocturnal awakenings are actually problems to be dealt with medically. And here many mothers, often encouraged by health professionals, begin to think that their milk is insufficient, or that it is not good. The solution is obviously at hand: a “normal” formula to complete breast milk, or a “special” formula to make the newborn sleep better, to prevent him from regurgitating, to reduce the risk of allergy to cow’s milk proteins . Protecting families from these marketing strategies is as essential as building and maintaining a health care system that promotes and supports breastfeeding, with competent professionals free from commercial interests.
The second article, in addition to analyzing the trend of sales, marketing and consumption of formula, shows how the industry uses scientific research and health professionals to build trust in its products, taking advantage of the weakness of health systems.(2) In response to demonstrations and boycotts in the second half of the 20th century, culminating in the passage of WHO and UNICEF’s International Code of Marketing of Breast-milk Substitutes in 1981, the industry created an extensive network of lobbyists, invented so-called corporate social responsibility, discouraged or prevented the development and enforcement of rules, invested to repair and beautify its image, and diversified its product range to continually escape the current laws. The sales of the 4 categories of formula (infant, up to 6 months; continuation, up to 12 months; so-called growth, up to 3 years; special, for often ill-defined conditions) grew from $1.5 billion in 1978 to $55.6 billion in 2019, a 37-fold increase in 40 years. A global market 60% controlled by six multinationals (Abbott, USA; Danone, France; Feihe, China; Freisland Campina, Holland; Nestlé, Switzerland; Reckitt Benckiser, Great Britain). Difficult to obtain from these, especially from those that produce thousands of other foods in addition to formula, data on marketing expenditure, but estimates vary from 1% to 33% of the annual sales proceeds. Data from a company that produces only formula report a marketing expenditure of 627 million dollars in 2016, 16.7% of sales (3743 million) and 46.7% of the cost of production (1341 million), compared with a net gain of 2402 million dollars.
This marketing is associated with a reduction in the prevalence and duration of breastfeeding, and therefore harm to health and nutrition. The authors of the article estimate that for every kg/child of formula sold, breastfeeding rates drop by 1.9%, with variability linked to the socio-economic situation of the country. And sales range from 1-2 kg/child in the poorest countries to peaks of 50 kg/child in the richest ones. However, the marketing strategies are the same and are well described and analyzed in two WHO reports published in the first half of 2022.(3,4) What is of greater concern and which is gradually supplanting conventional marketing is the marketing digital: it costs much less (per individual reached), it is more effective, and above all it can be customized and arrive at the right time (at 3 in the morning, if the newborn is crying at that time and the mother warns the mother-in-law via social media). Furthermore, it is more difficult to monitor (only the person who receives it knows) and control (it would take global rules, difficult both to agree and to apply). However, conventional marketing is not lacking, for example based on false claims on package labels (see cover image).
Healthcare professionals are a prime target for marketing breastmilk substitutes. Thanks to their exposure to the marketing of partially hydrolysed specialty formulas falsely claimed to be effective against allergies, their sales have increased hundreds of times in just a few years, without a parallel increase in the incidence of allergies.( 5) This marketing, which includes funding for research of questionable quality,(6) support for guideline development, and sponsorship of conferences and other educational activities, is presented as a form of professional collaboration; unfortunately many operators believe it. To demonstrate how important healthcare professionals are to the industry, an example from South Africa is worth citing. Years ago, a multinational corporation asked a marketing agency to map out the most important people and institutions to influence policies and guidelines, with the aim of increasing sales. The agency has produced a list of first and last names, with relative affiliations, divided by credibility and potential influence on peers, and propensity towards possible advances from the company. It goes without saying that the damages of not breastfeeding (for the health of mothers and children, for the family economy, for health systems, for the environment) are never mentioned in marketing activities.
The article concludes that the industry deploys a number of sophisticated and highly effective strategies to transform the concerns of families and healthcare professionals into business opportunities. In doing so, it systematically distorts science, ensnares parents and practitioners, skews public opinion, and influences policy makers.
Limiting this marketing is necessary, but not sufficient. It would also be necessary to modify or remove the structural and social barriers that make this possible. To do this, we need political commitment and investment, with the support of civil society. Meanwhile, health professionals and their associations could cut their ties, financial and otherwise, with industry, as the Royal College of Paediatrics and Child Health has done in Britain,(7) and in Italy the Cultural Association of Pediatricians (8).
Adriano Cattaneo, Epidemiologist, Trieste
Bibliography
- Pérez-Escamilla R, Tomori C, Hernández-Cordero S et al. Breastfeeding: crucially imporant, but increasingly challenged in a market-driven world. Lancet 2023; (published online Feb 7.) https://doi.org/10.1016/S0140-6736(22)01932-8
- Rollins N, Piwoz E, Baker P et al. Marketing of commercial milk formula: a system to capture parents, communities, science, and policy. Lancet 2023; (published online Feb 7) https://doi.org/10.1016/S0140-6736(22)01931-6
- M&C Saatchi World Services, WHO, UNICEF. Multi-country study examining the impact of marketing of breast-milk substitutes on infant feeding decisions and practices: commissioned report. Geneva: World Health Organization, United Nations Children’s Fund, 2022 https://apps.who.int/iris/handle/10665/354094
- WHO. Scope and impact of digital marketing strategies for promoting breastmilk substitutes. Geneva: World Health Organization, 2022 https://www.who.int/publications/i/item/9789240046085
- van Tulleken C. Overdiagnosis and industry influence: how cow’s milk protein allergy is extending the reach of infant formula manufacturers. BMJ 2018;363:k5056
- Helfer B, Leonardi-Bee J, Mundell A et al. Conduct and reporting of formula milk trials: systematic review. BMJ 2021;375:n2202
- Royal College of Paediatrics and Child Health. RCPCH statement on relationship with formula milk companies. Feb 13, 2019. https:// www.rcpch.ac.uk/news-events/news/rcpch-statement-relationship-formula-milk-companies
- Pediatrician Cultural Association. Commitment to self-regulation of relations with the industry. 2022 https://acp.it/it/codice-deontologico