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


Pupils choose grab-and-go foods at schools

children eating lunch

New research from nutrition experts at the University of Sheffield has revealed that sandwiches, pizza and puddings are the most popular dishes with pupils.

The pioneering study, published in Public Health Nutrition, discovered that despite secondary schools offering a number of freshly prepared hot meal options pupils are disregarding these in favour of foods such as sandwiches and pizza.

However the research, which involved 2,660 pupils from two large Yorkshire secondary schools, also found that children entitled to Free School Meals (FSM) were more likely to pick nutritionally valuable freshly prepared dishes of the day.

The FSM programme, which provides a free school meal for children from low-income families, can make an important contribution to the diet of poorer children, especially where there may be little guarantee of nutritious food at home.

Obesity in childhood is fast becoming a global epidemic and within the UK is at unprecedented levels with 28 per cent of girls and 31 per cent of boys aged between two-15 years being classified as obese or overweight.

Nutrition and obesity are public health priorities due to their links with chronic and life-threatening diseases as well as huge associated costs for the NHS.

School meals can substantially affect a pupil’s diet and overall health and wellbeing. There are more than eight million school children in England and more than three million eat a school meal every day, contributing to 590 million school lunches consumed every year.

Lead author Hannah Ensaff, from the University’s Department of Oncology, said: “Eating behaviour is learnt early on and food preferences established in childhood and adolescence tend to persist into adult life, with related consequences for long-term health.

“Healthy eating habits are crucial to reducing children’s risk of health problems, both long and short-term. The school food environment is an obvious public health intervention, particularly as children today seem to rely more on school food than decades ago.”

Over recent years food-based and nutrient-based standards have improved the provision of school food, most notably through the prohibition and restriction of sources of high fat and sugar such as confectionary, crisps and carbonated soft drinks.

These findings however show a large discrepancy between foods comprising the theoretical menu cycle and the actual grab-and-go choices made by pupils, which highlight the need to consider children’s food choice behaviour, as well as take the opportunity to improve the nutrient density of these popular food items.

Dr Margo Barker, Senior Lecturer in Nutritional Epidemiology, said: “The patterns of food choice of students receiving free school meals with those that pay for them are of particular interest. Students receiving free school meals made nutritionally superior choices in the school canteen, although surveys show that their overall diet is lacking.

“This anomaly seems to be evidence for those calling for policy to extend free school meals beyond those families of lowest income.”

Meeting school food standards – students’ food choice and free school meals
Hannah Ensaff, Jean Russell and Margo E Barker

This paper is freely available online for two weeks

Nudge children to eat more vegetables

Children in lunchline

The November Nutrition Society Paper of the Month is from Public Health Nutrition and is entitled ‘Vegetable variety: an effective strategy to increase vegetable choice in children’

Do you remember the last time you were at a buffet and regretted not trying everything? All of the tempting varieties of foods to try make resistance difficult! Researchers from the ETH Zürich have now shown that exactly this effect can be used strategically to improve children’s food choices: variety truly is the spice of life, even when it comes to vegetables! When given a variety of healthy choices, children choose a more balanced and nutrient-rich meal.

For this recent study, 100 children aged 7 to 10 years old were invited to the laboratory to select and serve themselves a meal from a small buffet of fake foods (The Fake Food Buffet*). The foods on the “buffet” included chicken strips and pasta, along with the vegetable choices of cooked carrots and beans. Children were randomly assigned to the experimental conditions: they could either serve one vegetable with the meal or they were offered both vegetables.

The children in the group that were offered two vegetables instead of only one served themselves significantly more vegetables. Interestingly, however, they did not serve themselves a meal with higher calorie content. This means that the children offered two vegetables had a higher proportion of energy from vegetables, composing a more nutrient-dense meal. Even children that reported not liking these vegetables served themselves more veggies if they were offered two types rather than one.

So why did children choose more vegetables when offered two instead of only one? Researchers explain that this occurs due to a ‘consumption norm’. This theory suggests that if children are presented with several different foods to choose and serve from, they will serve themselves at least a taste of all of the dishes. Thus, when children are given the choice of more varieties of healthy foods, in the end, they serve themselves a more nutrient-rich meal.

Researchers conclude from this experiment that offering a variety of vegetables to children might be a simple and effective strategy to nudge them to eat more vegetables and healthier meals, not just at home, but also in school cafeterias.

*The Fake Food Buffet is a validated and novel method that allows for the study of environmental influences on food choice under well-controlled laboratory conditions. Dr. Bucher together with the team at the ETH Zürich, developed this method and conducts ongoing research to explore the influence of environmental changes on meal composition in adults and children.

This paper is freely available for one month via the following link: journals.cambridge.org/ns/nov13

Posted on behalf of Tamara Bucher

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 NutritionPublic Health NutritionNutrition Research ReviewsProceedings of the Nutrition Society and Journal of Nutritional Science). This paper is freely available for one month.

Statistical Modeling for Biomedical Researchers – online resources and class notes

Blog Post by William D. Dupont, PhD, Professor of Biostatistics and Preventive Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA

I teach a course in intermediate-level biostatistics as part of the Master of Public Health program at Vanderbilt University.  This program is targeted at clinical fellows who are interested in academic careers in population-based medicine.  Class notes for this course are posted at http://biostat.mc.vanderbilt.edu/BiostatisticsTwoClassPage in both pdf and MS-PowerPoint formats.  This web site also contains the data files used in this course and log files illustrating the analyses performed in the lecture notes.  These notes are based on my text: Statistical Modeling for Biomedical ResearchersThe goal of both this text and these notes is to provide hands-on instruction in modern multi-variable statistical analysis while using a minimum of mathematics.  My web page for this text may be found at http://biostat.mc.vanderbilt.edu/dupontwd/wddtext/Read more of this post

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