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

Socio-economic inequalities in diet in UK adults

The December Nutrition Society Paper of the Month is from British Journal of Nutrition and is entitled “Socio-economic dietary inequalities in UK adults: an updated picture of key food groups and nutrients from national surveillance data”.

Study written in the British Journal of Nutrition found that those higher up on the socio-economic ladder are generally healthier and are less likely to be obese, and what people eat varies across different social groups.  It’s a reasonable assumption that these two phenomena are connected, but in the UK social inequalities in diet have not been comprehensively assessed in recent years.  While plenty of studies have documented socioeconomic differences in fruit and vegetable consumption, less is known about other food groups and nutrients, including fish and processed meat.  We also need to better understand the extent to which inequalities in diet differ across different indicators of socioeconomic position such as income, education and occupation.  This matters because unless we can understand the social and economic pattern of diet we will struggle to find the right strategies to improve public health for everyone.

Our study examined foods and nutrients eaten in a nationally-representative sample of 1491 UK adults stratified by socioeconomic position (SEP).  Data came from the rolling programme of the National Diet and Nutrition Survey 2008-2011. We calculated average intakes of five foods and nutrients across three indicators of SEP: equivalised household income, occupational social class, and highest educational qualification. The choice of foods and nutrients for this study was informed by the Scientific Advisory Committee on Nutrition’s (SACN) 2008 report on the nutritional status of the British population. This report expressed concern over whether people in the UK were eating enough fruit, vegetables and oily fish; and whether they were eating too much red and processed meat, sugar and saturated fat.

We found that, not only did the sample as a whole not meet recommended intakes, those of a lower SEP fared the worst.  For the food groups, the least educated adults ate 128grams a day less fruit and vegetables than the most educated; the lowest occupational class consumed 26grams a day more red and processed meat than those in higher managerial occupations; and the highest income group were four times more likely than the lowest to have consumed any oily fish.  The amount of calories from sugars (non-milk extrinsic sugars) was around two percentage points higher in the lower SEP groups. No pattern of saturated fat consumption was found for any of the socio-economic indicators.

So, what does this mean for action to tackle health inequalities?  Our study provides up-to-date evidence about specific food groups  that are of concern for public health nutrition, and is a reminder of the importance of monitoring dietary trends in a time of entrenched and rising inequality. It also adds important detail in terms of how different aspects of life experience and social position can affect what we eat. For instance, income or occupation may affect our material ability to access a healthy diet, or education may equip us to make healthier choices. When developing policies and interventions to tackle unhealthy diet, it is vital to take into account these different aspects of our lives.

This paper is freely available for one month via the following link: journals.cambridge.org/ns/dec14

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

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