Thursday, 23 April 2015

The Guardian and Danone infant feeding roundtable - and why the politics of breastfeeding matter

A couple of weeks ago I Tweeted my disappointment that the Guardian had decided to run a roundtable discussion in association with Danone Nutricia; yesterday an article reporting on the debate appeared in the paper's society section; a full page, with the Danone Nutricia Early Life Nutrition logo clearly displayed, and an explanation that the content is editorially independent (which presumably means that the journalist, Joanna Moorhead, wrote her piece reporting on the discussion without having the text approved by Danone). As Helen Crichton, head of public affairs for Danone Early Life Nutrition took part in the discussion itself, and Danone was able to suggest topics to be included in the discussion, the term 'editorially independent' is at best only partially accurate.

Mike Brady, Baby Milk Action's campaigns coordinator, has already published an excellent response to the Guardian article; you can read it here. What follows is my personal response to the article, which attempts to explain some of the reasons it made me so uncomfortable/furious.

Paul Lindley, founder of Ella's Kitchen
Helen Crichton from Danone itself;
Judy More, freelance dietician. Her website reveals that she is on the editorial board of the Journal of Family Health Care, which runs training events sponsored by formula companies including Nestle, Danone and Hipp Organic, and that she has worked for the Infant and Toddler Forum:
"The Infant & Toddler Forum is supported by an educational grant from Danone Nutricia Early Life Nutrition. The views and outputs of the group, however, remain independent of Danone Nutricia Early Life Nutrition and its commercial interests."
Professor Paul Gately from Leeds Metropolitan University. He has previously been a speaker at an event sponsored by the Infant and Toddler Forum.

Four of seven panel members have a clear conflict of interest in the discussion, because they are currently, or have been in the past, paid by companies that make profits marketing and selling products aimed at babies and young children. Judy More and Paul Gately's conflicts of interest were not made clear in the article; I found their earlier links to Danone with a simple search.

A major problem with this sort of 'invitation' roundtable discussion sponsored by a formula company is panel selection. Anyone who's had any sort of training on the International Code of Marketing of Breastmilk Substitutes, who works in breastfeeding, public health or in a Baby Friendly accredited NHS Trust should refuse to be involved. (For more about health worker conflicts of interest, see here).

Reading the article I found myself occasionally incredulous. Paul Lindley (Ella's Kitchen) is quoted as saying, 'Food is what brings people together, but they're not eating together very often and very young children aren't learning the art of conversation or the joy of eating with others.' This from a man who founded a company that makes pouches of ready-made pureed baby food that babies can slurp alone in their pushchairs without making a mess! Is it just me?

Dr Lucy Cooke said 'There's a lot of confusion about breastfeeding. The Department of Health says breastfeed to six months, but baby foods say 4-6 months on the jar'. Both Lindley and More, who should both surely understand the Code, the Department of Health guidelines and how information is given to new mothers, given their work, instead perpetuated the confusion, with Lindley appearing to advocate early weaning by saying that the earlier you give children vegetables, the more likely they are to eat them later on. What he didn't say was that early feeding (before six months) with pureed foods like apples, carrots and parsnips, which his company supplies in pouches, displaces breastmilk in a baby's diet and may reduce their overall nutrition rather than improve it.

I was also deeply uneasy about the suggestion that 'one change that would make a huge difference was to encourage better collaboration between the government and the food industry'. The food industry already has extensive access to contacts in government, and will lobby hard for its own interests. There is plenty of evidence that if companies are not regulated, then they will not restrain their marketing practices voluntarily. If the industry is so keen to do good, surely it should first put its own house in order: in the case of Danone, with 39 pages of marketing Code violations worldwide in the IBFAN Breaking the Rules, Stretching the Rules 2014 report, it would seem that the company has plenty of work to do before embarking on seemingly generous public health campaigns. Ella's Kitchen too could look at its early weaning guidance and labelling so that it better reflects the information that mothers are actually given.

And mothers are often given good information; but we didn't hear anyone talking about it in this debate because of the inherent conflict of interest. Health visitors, midwives and breastfeeding supporters could have painted another picture; one where UNICEF Baby Friendly and the First Steps Nutrition Trust are sources of clear, independent information for parents. The LIFIB (Lancashire Infant Feeding Information Board) is a great example of how information from companies can be critically reviewed and challenged before being passed on to health professionals (see @The_LIFIB).

I could go on, and on. I won't, but I will leave you with this quote from my forthcoming book with Gabrielle Palmer for Pinter and Martin Why The Politics of Breastfeeding Matter, which sums up my thoughts.
"When ‘knowledge’ comes from company promotion [which is what Danone-sponsored activities are] and poorly trained or corrupt health workers, parents and children suffer. Knowledgeable and supported families, who are aware that breastfeeding is normal, that artificial feeding carries risks, and that cheaper, safer baby foods can be made from locally available ingredients, end up healthier and less poor. The Code states that governments are responsible for ensuring that objective and consistent information on infant and young child feeding is provided. But it is hopeless to invest public money in providing such information if it is eclipsed by promotional untruths."

Thursday, 5 March 2015

Nutrimum: new product, same old formula company tactics

This morning the First Steps Nutrition Trust newsletter hit my inbox (if you don't get this already I highly recommend it). They've issued a statement on nutrimum, a new product on the market that I'd heard about thanks to a Facebook post from Michael Walne at Your Nutrition Matters (who is busy writing evidence-based nutrition books for the Pinter and Martin Why It Matters series at the moment).

Nutrimum is a range of cereal bars and granola aimed at pregnant and breastfeeding women, made by Nutricia, owned by Danone, which makes Cow & Gate and Aptamil infant formula. The new products are currently available through Boots stores and are heavily marketed on the Boots website, with advertorials accompanied by 'buy now' prompts. The advertorials stress the importance of maternal nutrition during pregnancy and breastfeeding; the clear implication is that the nutrimum bars and cereals can form part of the healthy diet that is being discussed. Associating general nutrition information with specific products is a deliberate strategy. Marketing products that combine food
and supplements through a store such as Boots, which although it has dropped 'the chemist' from its name still has a reputation for selling pharmacy products, also helps to support the idea that these products are somehow 'scientific' or 'beneficial' (they aren't). Using partner organisations for 'reputation transfer' is a tactic often used by formula manufacturers: for example in 2013 Danone sponsored a 'Big Toddle' in aid of Barnardos to promote its Cow & Gate brand.

The First Steps Nutrition Trust statement on nutrimum explains how the products undermine public health by stating that women should stop taking other supplements (which will have been recommended to them by midwives or health visitors in accordance with current guidelines) while consuming the products. Folic acid (which is recommended for those who are planning a pregnancy and pregnant women) and vitamin D (recommended for all pregnant and breastfeeding women) supplements are widely available in supermarkets and pharmacies at low cost, or may be free on the Healthy Start scheme. The nutrimum products are expensive: the cereal bars cost £4.99 for five bars, or £1 a day. A large part of the cost of the product will go on marketing. (As with infant formula, the marketing is paid for by those who buy the product.) Equivalent vitamin D and folic acid supplements cost just pennies per day. The cereal bars and granola are highly processed and high in sugar; the main ingredient (listed first in the ingredients list) in the bars is glucose syrup (sugar). A crucial difference between granola/cereal bars and vitamin supplements is that the granola/bars are food - they will fill you up, and increase your blood sugar levels, potentially displacing more nutritious foods (vegetables, fruit, nuts, eggs, meat) in your diet. Tablets and liquid supplements do not have this effect.

When formula companies stress the importance of nutrition while breastfeeding, they do so in order to make breastfeeding seem difficult, expensive and inconvenient - an unachievable ideal. Mothers who doubt the quality of their breastmilk may turn to formula for 'reassurance' that their babies are getting all that they need. In reality there is little difference in the nutritional profile of breastmilk worldwide: mothers everywhere, despite wide variations in diet, produce milk that will nourish their babies and keep them healthy. A mother needs good food for her own health, not to support breastfeeding. Mothers in the UK (where nutrimum is marketed) have access to better, cheaper food than these highly processed cereal products that are high in sugar and expensive. As First Steps Nutrition say:
'Good nutrition from food is perfectly possible for pregnant and breastfeeding mums and we show how nutrient requirements can be met through simple, cost effective menu choices in practical eating well resources. The money spent on these supplements could be more wisely used buying fresh and minimally processed foods for the household.'
Formula companies target medical and health workers to promote their products. Perhaps the most disturbing part of the First Steps Nutrition statement on nutrimum is the section about how company representatives have contacted infant feeding coordinators and NHS staff. An email to an infant feeding coordinator in February 2015 states that the product is:
‘designed to meet all the nutritional requirements for mum during pregnancy…and that neonatal nurses are particularly interested in Nutrimum for breastfeeding mums with babies in special care baby units’
It's this that makes me actually want to scream. For the last few months I've been working on a short book about the politics of breastfeeding, and this type of contact with health professionals, implying that the product is beneficial for mums breastfeeding special care babies (for which there is certainly no evidence), is reminiscent of all the marketing abuses I've been writing about. That this isn't infant formula doesn't matter. These products offer no benefits, play on fears mothers have about their own and their babies' nutrition, and the profits will line the pockets of the world's second biggest baby milk manufacturer. Thank goodness for the work of First Steps Nutrition and other organisations like Baby Milk Action that scrutinise and monitor the companies. Do visit their websites and join or donate to support their work if you can. And if you work with mothers, tell them that these products are unnecessary, expensive and heavily marketed (and that if they buy them, they are paying for the marketing).

Friday, 28 November 2014

BabyFriendly 2014: a conference report

I've just got back from the UNICEF BabyFriendly Conference in Newcastle. I'm full of thoughts, ideas and inspiration and wanted to mention a few points before I get caught up in other work again.
Dr Kasja Brimdyr speaking at BabyFriendly conference

Breastfeeding and politics are never far apart, and the opening address was a reminder of that. Dr Dan Poulter, MP is the Parliamentary Under Secretary of State at the Department of Health and the Conservative MP for Central Suffolk and North Ipswich. He spoke about the vital importance of the first few years of a child's life in terms of development, health and longer-term outcomes, about relationship-building supported by the BabyFriendly standards, and he talked about increased numbers of midwives in training and money that's been invested in improving the environments of maternity facilities.

Unfortunately for Dr Poulter, I wasn't really in the mood for his carefully-worded speech. Earlier in the week I'd read this article about Newcastle - the host city - which explains the utter hopelessness of the city's financial situation and the impact cuts are having on family services (spending on children and family services, via Children's Centres, has been cut by 40%). When asked how much worse it will get, the city council leader replies '[With cuts to] transport for kids with special educational needs and disabilities. That is in the pipeline.' The day before conference I had read this article too, about how families with disabled children are being forced into grinding poverty - the article itself is hard enough to bear, but read the comments for many more real-life examples. Closer to home I've been filling in consultation documents about cuts to family services in my own area. As volunteer peer supporters affiliated to the Children's Centres we deliver our breastfeeding groups, hold our training sessions and support families there. Recently I've also been supporting Cambridge Breastfeeding Alliance's campaign to secure funding to continue their incredibly valuable breastfeeding drop-ins, the victim of cuts to children's services in Cambridge, as well as the RCMs campaign for fair pay for midwives (Dr Poulter told us - again - that more midwives are in training, but - again - didn't address the question of whether there would be jobs for them when they graduate...)

He went on to talk about breastfeeding statistics - another area of concern for me: I've been emailing the Department of Health, writing to my MP and signing this petition to contest the decision to cancel the Infant Feeding Survey 2015. This survey is of immense value to anyone working in breastfeeding as it gives detailed information about national breastfeeding rates, introduction of solids, continued breastfeeding, use of formula milk and so on. Many of the conference speakers referenced the survey in their presentations. According to Dr Poulter the government will be improving the quality, quantity and timeliness of breastfeeding statistics at targeted local level - I'm not sure how, or how the national picture will be monitored, and he didn't elaborate.

So far, so depressing... fortunately, the rest of the conference was a genuine celebration: of 20 years of the BabyFriendly initiative, of accreditations across the country, of the hard work and dedication to supporting mothers and babies that underpins the whole thing, and looking ahead to how the achievements of BabyFriendly can be made sustainable into the future. It's hard to pick out my personal highlights, but I particularly loved Dr Nikk Conneman's presentation about gentle, baby-centred neo-natal care that fully involves the parents: when asked how he handled ward rounds in his unit (when parents are often asked to leave their baby's bedside), he replied 'I don't do ward rounds' and the audience broke into spontaneous applause: I think because it's so refreshing to meet someone so prepared to change the system if it isn't working for the babies and parents. Laurel Wilson's engaging talk about the emerging new science of epigenetics and breastfeeding was described by someone sitting near me as 'mindblowing'; we now know that how a baby is fed can influence the way their genes are expressed, and that breastmilk is packed with genetic material (the only way that this can be transmitted other than through sexual reproduction). It's a topic I can't wait to read more about, and it's closely linked to the work that's going on into the microbiome.

Dr Kasja Brimdyr talked about skin-to-skin in the first hour after birth - there was so much in her presentation that I found fascinating, particularly her observations about the effect of epidural fentanyl on infant responsiveness in the first hour (which ties in with a post I wrote about the effect of epidural on breastfeeding). The fentanyl (a commonly used epidural drug) delays the stages a baby must go through to find the way to the breast and latch on. It doesn't mean they won't or never will, but it may take longer, and those babies need even more skin-to-skin time to facilitate it. She cautioned against paying 'lip-service' to skin-to-skin; it shouldn't be interrupted or hurried if at all possible. Kerstin Uvnas Moberg touched on epidural too - explaining how it blocks the release of oxytocin, causing subtle changes that may affect breastfeeding behaviour.

There's so much more I could mention, but my take-home message was one of positivity and belief that the work we're all doing in breastfeeding really matters. One delegate asked how, given the daily pressures on midwives and breastfeeding supporters, we could give mothers and babies the best possible care? It's a frustration we all share at times, and the answer Sue Ashmore gave was simple but inspiring: keep doing your best, keep trying, keep the BabyFriendly standards at the heart of what you do, and it will be good enough. We don't need to be perfect to make a difference.

Were you at the conference? I'd love to know what your personal highlights were. Leave a comment below...