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

Rising risk of obesity among China’s ‘left behind children’

Boys in Rural ChinaThe December Nutrition Society paper of the month, is from Public Health Nutrition and is entitled, ‘A multi-level analysis of the relationship between parental migration and left-behind children’s macronutrient intakes in rural China.’

Some 61 million rural children left behind by parents moving to China’s booming urban centres are at risk from increased fat and reduced protein in their diets.

The study of 975 children from 140 rural villages in nine provinces carefully analysed nutritional intake and showed a particular risk to boys who were left behind in the care of grandparents or a mother who sought work away from home.

There are sound financial reasons why so many people move from rural to urban areas in China, but the benefits that more money brings to a family can often be at the expense of child nutrition. The Chinese government needs to recognise this growing problem among rural communities and this research provides some evidence to target health policies on encouraging a balanced diet.

The study finds that ‘left behind’ boys in particular consumed more fat and less protein than those from complete families, which potentially leaves them at increased risk of obesity and stunted growth. This has important policy implications in a specific cultural-context where son preferences are powerful.

Although the results of the study don’t provide reasons for this change in diet, we speculate that mothers moving away from home generally earn less, and that these lower earnings act in combination with grandparents’ poorer dietary knowledge or willingness to spend more on food.

Another factor at work could be that prices of protein-based foods such as eggs and meat have increased faster than many households’ incomes – meaning that even though money is being sent home from one or both parents, nutrition doesn’t always improve.

The process of parental migration is complex and the reasons for problems in boys’ nutrition are not straightforward, however we can see that both parents and grandparents in rural areas need to be educated about good diet.

Because raising children can fall on all members of the family, good care-giving practice needs to become more widespread.

The paper, ‘A multi-level analysis of the relationship between parental migration and left-behind children’s macronutrient intakes in rural China,’ was published in the journal, Public Health Nutrition and is available to read in full at http://journals.cambridge.org/ns/dec15

Authors Nan Zhang, Laia Bécares and Tarani Chandola

Funding- Economic and Social Research Council (ESRC) Postgraduate Scholarship

Do higher vitamin E levels have a protective effect on pulmonary condition in Cystic Fibrosis?

The  July Nutrition  Paper of the Month is entitled ‘Vitamin E intake, The affect of  levels and pulmonary function in children and adolescents with cystic fibrosis’

Cystic fibrosis (CF) is a life-threating genetic disorder, characterised by chronic pulmonary inflammation that causes a gradual, progressive decline in pulmonary function, partly due to oxidative stress. Most patients have pancreatic insufficiency, leading to intestinal malabsorption of fat and fat-soluble vitamins. Therefore, lifelong treatment with fat-soluble vitamins such as vitamin E has become standard care.

It has been suggested that higher vitamin E levels, expressed as serum α-tocopherol levels, have a protective effect on pulmonary condition in CF. However, serum α-tocopherol levels are compromised during a pulmonary exacerbation and recover with resolution of the inflammation. Likewise, chronic pulmonary inflammation may reduce levels, and the suggested association between vitamin E levels and pulmonary function might be secondary.

Whether current recommendations for vitamin E supplementation are optimal for preventing deficiency and whether higher serum α-tocopherol levels have beneficial effects on pulmonary function are subjects of debate. The present paper studied the association between vitamin E intake (dietary intake plus prescribed supplementation), the coefficient of fat absorption and chronic inflammation on serum α-tocopherol levels, and the long-term effect of both serum α-tocopherol levels and chronic inflammation on pulmonary function in paediatric patients with CF.

Results

In our study sample, we found no clear effect of vitamin E intake, the coefficient of fat absorption or chronic inflammation on serum α-tocopherol levels. Moreover, patients with CF received vitamin E supplementation at half the CF-specific recommended dosage; nevertheless, serum α-tocopherol levels were normal.

Furthermore, we found that chronic inflammation was inversely associated with pulmonary function and we found no association between serum α-tocopherol levels and pulmonary function. Paradoxically, we even found an overall trend towards a lower pulmonary function in those with higher serum α-tocopherol levels.

Conclusions

Our results suggest that the CF-specific vitamin E recommendations are higher than necessary to prevent deficiencies. Therefore, vitamin E dosages of 50% of the recommendations could be used, at least initially. We found no evidence that higher serum α-tocopherol levels had protective effects on pulmonary function in paediatric patients with CF. Moreover, the finding of higher serum α-tocopherol levels in patients with lower pulmonary function casts doubt on the hypothesis that vitamin E has therapeutic benefits.

This paper is freely acvailablke via the following link for one month: journals.cambridge.org/ns/jul15

Authors: Janna W. Woestenenk, Nancy Broos, Rebecca K. Stellato, Hubertus G. M. Arets, Cornelis K. van der Ent and Roderick H. J. Houwen

Nutrition Society Paper of the Month

Each month a paper is selected by one of the Editors of the five Nutrition Society Publications (British Journal of Nutrition, Public Health Nutrition, Nutrition Research Reviews, Proceedings of the Nutrition Society and Journal of Nutritional Science). This paper is freely available for one month.

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

Calorie-focused thinking when it comes to obesity may mislead and harm public health

Perhaps not all calories are created equal. A new paper, co-authored by Saint Luke’s Mid America Heart Institute cardiovascular research scientist James J. DiNicolantonio, PharmD, challenges the prevailing belief that all consumed calories—regardless of their sources—are equivalent, and that focusing on calories is a good thing.

Primarily authored by Sean C. Lucan, M.D., M.P.H., M.S., Department of Family and Social Medicine, Albert Einstein College of Medicine, the paper is titled “How calorie-focused thinking about obesity and related diseases may mislead and harm public health. An alternative,” and is being published in the journal Public Health Nutrition.

The paper discusses various problems with the idea that “a calorie is a calorie,” and with the primarily quantitative focus on food calories. Instead, the authors argue for a greater qualitative focus—paying more attention to the foods from which the consumed calories derive—and on the metabolic changes that result from consuming foods of different types. In particular, Lucan and DiNicolantonio consider how calorie-focused thinking is inherently biased against high-fat foods, many of which may be protective against obesity and related diseases (e.g. nuts, olive oil, oily fish, whole milk), and supportive of starchy and sugary replacements, which are likely detrimental.

The idea that “a calorie is a calorie” implies that any two different foods, which have equivalent amounts of potential energy, will produce identical biological effects with regard to body weight/body fatness when consumed. By this thinking, a calorie’s worth of salmon, olive oil, white rice, or vodka would each be equivalent and expected to have the same implications for body weight and body fatness.

But a calorie’s worth of salmon, which is largely protein, and a calorie’s worth of olive oil, which is purely fat, have very different biological effects than a calorie’s worth of white rice, a refined carbohydrate, or a calorie’s worth vodka, mostly alcohol—particularly with regard to body weight/body fatness. In fact, studies in humans have shown that calorie-providing proteins, fats, carbohydrates, and alcohol each have substantially different effects on a variety of physiologic pathways and hormones relevant to perceived fullness, subsequent food consumption, weight maintenance, and body composition.

The paper specifically discusses the harmful effects of rapidly absorbable carbohydrates—sugars and refined starches, such as white rice and foods consisting substantively of white flour. These foods cause blood sugar and insulin to rise quickly, which then causes a rapid drop in blood sugar. The result is food cravings, particularly for something sweet.

“The fact is that some calories will squelch a person’s appetite and promote energy utilization, while others will promote hunger and energy storage,” DiNicolantonio said. “So while some calories send messages to the brain and body that say ‘I’m full and ready to move,’ other calories are send messages that says ‘I’m still hungry and just want to lie down on the couch.’ Not all calories are the same, and in order to promote healthy weight and better health, we need to take special note of the calories we are choosing to consume.”

Lucan and DiNicolantonio stress in their paper that public health should work primarily to support the consumption of whole/minimally processed foods—which help protect against obesity-promoting energy imbalance and metabolic dysfunction—and not continue to promote calorie-directed messages that may create and blame victims and possibly exacerbate epidemics of obesity and related diseases.

Read the full article here until 24th December 2014.

Posted on behalf of Dr James DiNicolantonio,  Saint Luke’s Mid America Heart Institute

Poor breakfast in youth linked to metabolic syndrome in adulthood

Health_riskPost Author: Maria Wennberg

It is often said that breakfast is important for our health and a study conducted by Umeå University, published in Public Health Nutrition supports this claim.

The study revealed that adolescents who ate poor breakfasts displayed a higher incidence of metabolic syndrome 27 years later, compared with those who ate more substantial breakfasts.

Metabolic syndrome is a collective term for factors that are linked to an increased risk of suffering from cardiovascular disorders. Metabolic syndrome encompasses abdominal obesity, high levels of harmful triglycerides, low levels of protective HDL (High Density Lipoprotein), high blood pressure and high fasting blood glucose levels.

The study asked all students completing year 9 of their schooling in Luleå in 1981 (Northern Swedish Cohort) to answer questions about what they ate for breakfast. 27 years later, the respondents underwent a health check where the presence of metabolic syndrome and its various subcomponents was investigated.

The study shows that the young people who neglected to eat breakfast or ate a poor breakfast had a 68 per cent higher incidence of metabolic syndrome as adults, compared with those who had eaten more substantial breakfasts in their youth. This conclusion was drawn after taking into account socioeconomic factors and other lifestyle habits of the adolescents in question. Abdominal obesity and high levels of fasting blood glucose levels were the subcomponents which, at adult age, could be most clearly linked with poor breakfast in youth.

“Further studies are required for us to be able to understand the mechanisms involved in the connection between poor breakfast and metabolic syndrome, but our results and those of several previous studies suggest that a poor breakfast can have a negative effect on blood sugar regulation,” says Maria Wennberg, the study’s main author.

The study has been conducted by researchers at the Family Medicine Unit within Umeå University’s Department of Public Health and Clinical Medicine and has been published in the journal Public Health Nutrition.

This paper is freely available for 2 weeks via the following link: http://journals.cambridge.org/phn/umea

For more information, please contact Maria Wennberg.

Telephone: +46 (0)70-4953230

E-mail: maria.wennberg@umu.se

via Poor breakfast in youth linked to metabolic syndrome in adulthood « Journals in the News « Cambridge Journals Blog.

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