A formula for concern: The boom of milk-based formula sales

PHN Editorial Highlight: ‘Global trends and patterns of commercial milk-based formula sales: is an unprecedented infant and young child feeding transition underway?
Blog by Phillip Baker

To ensure children get the best start in life the World Health Organization recommends that infants are exclusively breastfed to six months of age with ongoing breastfeeding for up to two years of age and beyond. Yet worldwide the prevalence of infants exclusively breast fed to six months hovers at around 37% and has improved only marginally in recent decades.

In contrast, the study of 80 countries demonstrates that global milk-based formula sales are booming. In the five-years between 2008 and 2013 world total milk formula sales grew by 40.8% from 5.5 to 7.8kg per infant/child, a figure projected to increase to 10.8kg by 2018.

This global sales boom applies not only to infant formula (for consumption by infants aged 0-6 months) but also to follow-up (7-12 months) and toddler (13-36 months) formulas, which can displace ongoing breastfeeding if marketed and consumed inappropriately.

We describe this as indicative of a global ‘infant and young child feeding transition’ i.e. a shift from lower to higher formula diets at the population level. Although the idea of such a transition is not new, the rate and scale of change described in the study is potentially unprecedented.

Growth has been especially rapid in several industrialising countries in Asia: China, Indonesia, Malaysia, Vietnam and Thailand. As home to the world’s second largest infant/child population (~41 million aged 0-36 months in 2013) the most significant absolute change has been in China. Other highly-populated countries undergoing significant growth include South Africa, Iran, Turkey, Brazil and Peru.

These results are troubling because formula-fed children experience poorer health and developmental outcomes than breastfed children including an increased risk of death, pneumonia, diarrhoea, obesity and type-2 diabetes, ear infections and asthma. Formula feeding also harms mothers due to the forgone protective effects of breastfeeding against breast and ovarian cancer.

Infant and young child feeding is typically portrayed as an individual behaviour, as a matter of free parental choice. The study offers a counter-view – the observed results are likely to reflect transformations in wider social, economic and social systems that structure infant and young child feeding choices at the population level.

In this view, the global infant and young child feeding transition is driven largely by the expansion of transnational formula companies and more intensive formula marketing, the shift of labour and production out of the home (especially in Asia’s vast manufacturing centres where millions of women have become employed, often with no or limited maternity protections), and the failure of regulations and policies designed to promote, protect and support breastfeeding in these new contexts.

These findings are important for several reasons. The results raise serious concern that the rapid changes observed are not being captured in a timely manner by existing international nutrition monitoring systems.

Existing regulations intended to protect the health of children and mothers and to prevent unethical formula marketing are not working effectively. Renewed efforts towards the implementation, monitoring and enforcement of the International Code of Marketing of Breast-Milk Substitutes, including stronger accountability mechanisms for governments and industry are urgently needed.

Stronger maternity protections that enable breastfeeding (e.g. adequate maternity leave, paid lactation breaks, flexible working hours, and nursing facilities) are also urgently needed for millions of working mothers, especially in Africa and Asia.

This can only come about through greater political priority and strengthened governance mechanisms for infant and young child nutrition.

The paper, ‘Global trends and patterns of commercial milk-based formula sales: is an unprecedented infant and young child feeding transition underway?’ is published in the journalPublic Health Nutrition and is freely available until 12th June 2016.
Authors: Phillip Baker, Julie Smith, Libby Salmon, Sharon Friel, George Kent, Alessandro Iellamo, JP Dadhich, Mary J Renfrew.
Funding: This analysis was unfunded. However, the lead author was employed through an Australian Research Council Discovery Project (number 130101478).

Source: A formula for concern: The boom of milk-based formula sales – Cambridge Journals Blog

Free Content about the Zika Virus Now Available

33270_640x345_2

Just 8 days after the public health emergency was declared, this content regarding the Zika virus has been written, reviewed, edited, and released as a freely available resource.

On February 1st, the World Health Organization declared a Public Health Emergency of International Concern related to clusters of microephaly cases in some areas affected by the Zika virus. Like the Ebola virus, there had been very little funding and research on Zika until the recent emergency and associated media and scientific attention – there is therefore a dearth of information and there is neither a vaccine nor prophylactic pharmacotherapy available to prevent Zika virus infection.

In response to concern over the effects of Zika virus infection in pregnant women, the medical publishing team at Cambridge University Press commissioned a brief summary of current evidence and recommendations. Just 8 days after the public health emergency was declared, this content has been written, reviewed, edited and released as a freely available resource. The content has been provided by Professor Bernard Gonik, Fann S. Srere Chair of Perinatal Medicine, Wayne State University School of Medicine.

Released in advance as a freely accessible public resource, this content is part of High-Risk Pregnancy: Management Options – a forthcoming updateable online product from Cambridge University Press. Like all of the content in High-Risk Pregnancy: Management Options, the Zika section will be regularly updated as new information arises.

Read about the Zika Virus Here

 

Pregnant women lack guidance on iodine intake levels


Pregnant women are not getting enough information about the need to include iodine in their diets, despite high awareness of general advice for pregnancy nutrition.

While 96% of pregnant women surveyed by researchers were aware of general nutritional recommendations for pregnant women, only 12% were aware of iodine-specific advice.

The study, published in the British Journal of Nutrition, estimated the median intake of iodine during pregnancy was 190 micrograms (ug) per day, with 74% consuming less than the World Health Organisation (WHO) recommended intake of 250ug daily.

Iodine is required for the production of thyroid hormones, which are crucial for fetal development with links between iodine deficiency and developmental impairments.

Dr Emilie Combet, who led the reserch at the University of Glasgow, said: “Women aren’t receiving the message about the importance of iodine in pregnancy, meaning they cannot make informed choices to ensure they get the amount they require.”

Iodine deficiency affects 1.9 billion people globally and is the most preventable cause of intellectual disability. The UK is ranked 8th in a list of iodine-deficient countries in the world.

The main sources of iodine-rich foods are seafood and dairy products, and in some countries iodine-fortified salt or bread. In the UK, the Reference Nutrient Intake (RNI) for adults is 140ug per day, with no proposed increment for pregnant and lactating women.

Unborn children and young infants are entirely reliant on their mother for iodine supply, making babies and pregnant or lactating mothers the most vulnerable groups of the population.

At present there is no recommendation for routine iodine supplementation in the UK unlike folic acid and Vitamin D, or routine testing in pregnancy that would reflect iodine levels, as there is with iron.

The study surveyed 1,026 women across the UK who were pregnant or mothers of children aged up to 36 months. Participants were asked about their awareness of nutritional guidelines and completed a food frequency questionnaire.

Knowledge of iodine-rich foods was low, with 56% unable to identify any iodine-rich food and the majority wrongfully believing dark green vegetables and table salt had high levels. Most, 84% were unaware that iodine from diet is important for the healthy development of the unborn baby, and only 11% had heard about iodine from a healthcare professional.

Dr Combet said: “Iodine is crucial during pregnancy and the first months of life, to ensure adequate brain development, but achieving over 200ug a day of iodine through diet requires regular consumption of iodine-rich foods such as milk and sea fish. Not everyone will have the knowledge, means or opportunity to achieve this.

“There is an ongoing debate as to whether there should be some form of fortification of food with iodine. Iodine-fortified salt is common in other countries, but using salt as the delivery method has raised concerns since it is perceived to clash with public health messaging around reducing salt intake to combat high blood pressure. However, other countries have demonstrated that both measures could be held simultaneously. We need to work toward a solution.

“The most important issue to come from this study, however, was the lack of awareness of the important role iodine plays in fetal development and how to consume adequate levels of this essential mineral. This is something that needs to be addressed. Our current Yorkhill Children Charity – funded project us developing tools and resources for health care professionals and women either pregnant or planning a pregnancy.”

This paper is freely available for 2 weeks

Related links

Dr Emilie Combet: researcher profile

Media enquiries: stuart.forsyth@glasgow.ac.uk / 0141 330 4831

Pregnant women are exceeding weight gain guidelines

Mums-to-be are advised to watch their “overall food intake and takeaway consumption” following the results of a new study on the health behaviours and psychological well-being of pregnant women in Ireland.

The findings published in the scientific journal Public Health Nutrition reveal that almost two-thirds (62.5%) of women in Ireland exceed the recommended levels* of weight gain during pregnancy.

According to the study, pregnant women who report eating “a little more food” during their pregnancy are 60% more likely to gain excessive weight over the course of their pregnancy than those women who report eating “about the same” as before they became pregnant. It also shows that women who report eating “a lot more food” during their pregnancy are twice as likely to exceed weight gain guidelines.

The study identifies “increased food intake and takeaway consumption” as two key drivers of weight gain during pregnancy. To conduct the study researchers at University College Dublin and the National Maternity Hospital examined four health behaviours of almost 800 pregnant women: food intake, physical activity, sleep and smoking. They also assessed additional dietary behaviours including the frequency of takeaway and fried food consumption and the number of snacks eaten per day.

The findings show that foreign nationals living in Ireland are almost twice as likely as women born in Ireland to gain excessive weight over the course of their pregnancy.

“Excessive weight gain during pregnancy has significant implications for infant growth and obesity, with potential implications for later adult health,” says Fionnuala McAuliffe, Professor of Obstetrics and Gynaecology at UCD School of Medicine & Medical Science, University College Dublin, and the National Maternity Hospital, Holles Street, Dublin, who co-authored the study.

“With these findings, public health campaigns can be better designed to target the types of dietary changes required to bring weight gain during pregnancy into line with the recommended guidelines.”

Women who were overweight before they became pregnant were also shown to be the most likely to gain excessive weight during their pregnancy. This matches findings from many other studies in this area. “To our knowledge, this is the first study to find an independent association between consumption of takeaway meals and weight gain during pregnancy,” says Dr Emily Heery of the UCD School of Public Health, Physiotherapy and Population Science, University College Dublin, the lead author of the study. 53% of the women who took part in the study were first time mums-to-be, 30% were foreign nationals, and almost half (47%) had obtained at least a degree qualification. Over half (55%) of the women had private health insurance.

The article is freely available until 27 February 2015.

– Dr Emily Heery

Explore the online archive of AGMG

AGMG cover-1
Cambridge University Press and Twin Research and Human Genetics (TRHG) are proud to announce the release of the online archive of AGMG, the predecessor journal to TRHG. AGMG was the official journal of the International Society for Twin Studies (ISTS) from 1952-1998 when TRHG took over this role. However, both journals have always had a wider interest in the field of human genetics.

Twins can provide unique and powerful opportunities to study genetic and environmental factors that make people differ in how they look, behave and how healthy they are. Monozygotic [identical] twins share all their genetic variation and dizygotic [non-identical] twin pairs, on average, share about 50% of their genetic variation. Both types of twin pairs often but not always share similar pre- and post-natal environments as well. Having twins participate in these studies helps to continue important research for common human conditions such as diseases, health, and behaviors, leading to advances in science, medicine and future potential therapies.

Much effort has gone into creating this digitised archive and making it available online to the research community because we believe that many of the classic papers published in AGMG reveal the academic foundations of the subject and still have relevance today. Below is a link to the 20 most cited papers from the AGMG archive to demonstrate the wide scope of interest. We encourage you to explore and enjoy this fascinating resource.

View the 20 most-cited papers from the AGMG archive here .

The papers cover a wide spectrum of topics and include the following articles:

  • Population-Based Twin Registries: Illustrative Applications in Genetic Epidemiology and Behavioral Genetics from the Finnish Twin Cohort Study (1990)
  • Resting Metabolic Rate in Monozygotic and Dizygotic Twins (1985)
  • Causes of Variation in Drinking Habits in a Large Twin Sample (1984)
  • The Vanishing Twin (1982)

 

Sociology, Stigma and Innovation – Sam Rowlands on editing a book about abortion

Abortion Care Cover

After last month’s article about the journey of a medical book from an author’s perspective, this month we hear from Sam Rowlands, editor of Abortion Care, about editing a book which boasts more than 40 contributors – and which is about a particularly emotive topic…

There aren’t many medical books dedicated to abortion care. I felt there was a gap in the market for a smaller book that could be easily carried around. I wanted to produce a book that had all the conventional ingredients such as the methods of abortion, complications and so on but also looked at abortion from a wider perspective.

I drew up a list of around 30 chapters and identified potential authors for each. Cambridge were keen for the book to have international appeal so I endeavoured to select recognised specialists from around the world. I am fortunate to have met many of these personally through my career in sexual and reproductive health but still I was delighted (and surprised) that most of the colleagues I chose readily agreed despite their very busy schedules. I was then intrigued by how many chapter authors (15) asked to collaborate with their selected colleagues. This has resulted in an even richer authorship.

I had originally thought I might ask a couple of collaborators to co-edit with me but on reflection decided to edit the book on my own. The advantage of this was that I could be in control and do things my way, especially as I had by now a clear view of how the book would look. The downside was that when more than 20 chapter manuscripts arrived in a rather short space of time, I felt a bit overwhelmed! The lead chapter authors are all authorities in their fields. Some are academics and some are skilled practical clinicians, some both. Some are neither of these, just incredibly knowledgeable and wise. All authors developed their chapters in their own way; I encouraged them but tried not to steer them in any particular direction.

Although the book is mainly for readers with a medical bent, I have tried to include chapters to stretch their minds on topics that they might not necessarily otherwise tackle. Sociological topics are included but the authors of these were banned from using inaccessible terminology! There are two chapters with an epidemiological flavour which are not too daunting even to the numerically-challenged. There are two chapters written by lawyers which really flow, despite references to statute and case law.

Although the book is about a controversial subject and is bound to be serious in most of its content it is written in language that I hope is accessible and uses a lighter touch at times, for example a quote from Monty Python in the ethics chapter. The historical chapter provides a wonderful backdrop, painting a vivid picture of days gone by with some poignant examples of tragic cases. Stigma is a theme that runs through the book. Half a chapter is dedicated to this but reference is also made elsewhere, particularly in the chapter on staff. Although we all know that abortion is stigmatised, it’s only quite recently that it’s been written about and even measured.

I tried to include some innovations in the book and two chapters come up trumps in this respect. One covers abortion care provided by personnel other than doctors, showing that all the evidence points to this being not only safe but actually preferred by many women. The other looks to the future and shows how telemedicine can be applied to facilitate communication and treatment when the clinician and the woman are not in the same place, which has potential to improve access in more rural areas or in those parts of the world with restrictive regimes.

I’ve found it very rewarding to head up this project but don’t claim it is perfect. I invite anyone to make suggestions for a second edition.

Sam Rowlands MBBS, MD, LLM, FRCGP, FFSRH, Clinical Lead in Community Sexual and Reproductive Health, Dorset HealthCare and Visiting Professor, School of Health & Social Care, Bournemouth University

Sam Rowlands is the editor of Abortion Care (out now).

Early versus delayed cord clamping at birth: in sickness and in health

cord clamping

Written by : David J R Hutchon FRCOG
Past president of the North of England Obstetrical and Gynaecological Society

Early cord clamping, often within 10 seconds of the birth of the baby, is a common obstetric and midwifery intervention largely based now on habit. Originally thought to be important for preventing post partum haemorrhage, the intervention has persisted since it was shown to be unnecessary by the WHO.

A major reason why early cord clamping has persisted in both term and preterm births is a poor understanding of the details of fetal to neonatal transition together with the impression that the intervention is benign and may even assist transition of the baby from placental to pulmonary respiration. Early cord clamping is the intervention, not delaying the clamp until the umbilical circulation has ceased, and therefore approximating to the natural physiology. The immediate effects of early clamping on the circulation may not be obvious but when poor condition of the baby after early cord clamping occurs it is always attributed to other reasons such as intrapartum hypoxia.

Recent studies in Melbourne by  Bhatt et al[i]  have shown that in lambs there was a marked bradycardia after early cord clamping, which was followed by a marked hypotension with a fall in cardiac output and cerebral circulation. In humans the bradycardia can be seen in the standard normal newborn heart rate charts (Dawson et al[ii]) with the mean heart rate at one minute after birth of 80bpm ( range 20 to 140). All these babies had standard obstetric 3rd stage management of early cord clamping. By 3 minutes the cardiovascular system had recovered and the heart rate was 160bpm. Thus from the normal fetal heart rate of 110 to 160bpm the bradycardia was the result of something occurring at birth.

A study in 1964 by Brady et al[iii] attributed the bradycardia directly to early cord clamping and a very recent study published at the Birmingham conference showed no significant bradycardia after late cord clamping[iv].

Such a severe insult on the neonatal circulation cannot be acceptable, and may have adverse effects on both healthy and sick neonates. Randomised controlled studies show the significant harm of early cord clamping in the vulnerable preterm neonate. In theory early clamping will lead to hypoxia and ischaemia in the cerebral circulation and incomplete vasodilatation in the pulmonary circulation. Most babies recover and appear to tolerate the insult which results failure of randomised controlled trials to find any serious outcomes. Most babies recover which is the reason so little attention has been given to the intervention of early cord clamping.

The perceived need for resuscitation usually in the form of initiation of ventilation on a remote resuscitaire is currently preventing wider abandonment of early cord clamping. The paper shows how resuscitation with the cord intact at the side of the mother can be achieved. Arguments are put forwards to show other drivers for early cord clamping, the need for cord blood gases, the need for cord blood banking and the risk of jaundice are not logical and are put into perspective.

This opinion paper, published in Fetal and Maternal Medicine Review, is freely available for one month via the following link:  http://journals.cambridge.org/fmr/clamping13


Endnotes:
[i]
 Bhatt S, Alison BJ, Wallace EM, Crossley KJ, Gill AW, Kluckow M, et al. Delaying cord clamping until ventilation onset improves cardiovascular function at birth in preterm lambs. J Physiol 2013 591(Pt 8): 2113–26.
[ii] Dawson JA, Kamlin COF, Wong C, te Pas AB, Vento M, Cole TJ, et al. Changes in heart rate in the first minutes after birth. Arch Dis Child Fetal Neonatal Ed 2010 95: F177–81
[iii] Brady J P and James LS American Journal of Obstetrics and Gynaecology, vol 84 number 1 July 1 1962, pages 1 – 12
[iv] Hutchon DJR. Cutting the Cord: an International Conference INFANT; 2013 9(5): 162. This was referenced in the original paper
%d bloggers like this: