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Infant & Young Child Feeding n Nutrition in Perspective
Breastfeeding - We Care Logo
Facebook Baby Friendly Hospital Initiative Hong Kong Association
 Aug  2018
 
  
Fighting Commercialisation for Health


Dr. Rachel Cheng
FHKAM (Community Medicine)
Specialist in Community Medicine

Dr Shirley Leung
FHKAM(Paed), FFPH(UK)
Specialist in Developmental Behavioural
Paediatrics

Marketing of Breastmilk Substitutes

Formula milk is one of the fastest growing food commodities nowadays. According to the Euromonitor International, about US$41 billion was spent on formula milk globally in 2013, with one-third on young child formulae, making it the largest formula milk category in the market.1 As sales in most Western countries have plateaued, the large emerging Asian markets are now being heavily targeted for promotion by the industry. Hong Kong is notable for being targeted by the industry’s increasingly aggressive marketing of breastmilk substitutes. In 2015, according to a local advertising database, the trade spent $2.8 billion on advertising formula milk for young children under 36 months of age, which was about 21 times the spending in 2001.2 More than 90% were spent by the multi-national formula milk companies. 

The effectiveness of marketing communications is a function of both “exposure” (of consumers to the marketing message) and “power” (the extent towhich the message achieves its objectives). Exposure, defined by “reach” (the proportion of target audience exposed to the marketing message) and “frequency” (the number of times the average audience is exposed to the message), is determined by the selection of communication channels; while power of the message is related to its creative content.3 The breastmilk substitutes industry makes enormous and increasing investments on marketing their products through extensive media channels and settings to increase the exposure of families to its marketing messages, and boost the “power” of the messages through creative strategies such as the promotion of close bonding and nurturing of smart kids, etc. Formula milk for infants and young children competes with and undermines breastfeeding and nutritious foods, which are the gold standard of infant and young child feeding, yet not subject to advertising.

Combating the Aggressive Marketing of Breastmilk Substitutes

Breastfeeding practices are affected by a multitude of modifiable factors, including socio-economic and cultural factors, policies and practices in specific setting such as health care facilities, workplaces and public venues, as well as characteristics of individuals. An International Comparison Study conducted by the University of Sydney reaffirmed the importance of implementing a comprehensive multi-pronged national policy to protect, promote and support breastfeeding. It concluded that “robust evidence presented in documents and recommendations by government agencies, high-quality systematic reviews and some randomized controlled trials indicate that multifaceted interventions and not just a single intervention have a cumulative and positive effect on the promotion and support of breastfeeding.”4  Among others, combating aggressive marketing of breastmilk substitutes is a key component of the comprehensive strategy.

The local scene

To address this important child public health issue, the Government launched the Hong Kong Code of Marketing of Formula Milk and Related Products, and Food Products for Infants & Young Children (HK Code)5 in July 2017 as part of a comprehensive strategy to protect, promote and support breastfeeding. The HK Code aims to protect healthy infant feeding practices, irrespective of whether the baby is breastfed or formula fed, from undue commercial influences of breastmilk substitutes, on the basis of adequate and unbiased information and through appropriate marketing. The HK Code covers formula milk, bottles and teats, and foods for infant and young children under 36 months of age. 

Other equally important elements of the strategy include implementing the baby-friendly initiative in health care facilities, promulgating breastfeeding-friendly workplaces and public premises, strengthening public education on breastfeeding, protecting breastfeeding women from discrimination and extending the maternity leave.


Evolving Marketing Strategies of the Industry since Launching of the HK Code

Prevailing advertising and promotion of breastmilk substitutes do impact mothers’ perception, feeding choices and practices, though insidiously. Since the launch of the HK Code a year ago, formula milk companies have tactfully adjusted their marketing strategy by promoting follow-up formula for older children (three years and above) and maternal formula for pregnant and lactating women, which have a similar look and feel as their infant and young child (under 36 months) counterparts.

Cross-promotion (brand extension) is a powerful marketing strategy in this instance. While marketed aggressively for older children, follow-up formula also effectively promotes infant formula, without the latter being overtly advertised. A survey conducted by the Department of Health in 2013 revealed that mothers could not easily distinguish between infant formula and follow-up formula in advertisements or promotions.6 According to overseas evidence, the industry has effectively used cross-promotion to circumvent the marketing Codes in a number of countries. A study showed that follow-on formula advertisements occurred more frequently in the United Kingdom where infant formula advertising is prohibited; and toddler milk advertisements appeared more frequently in Australia where infant and follow-on formula advertising is prohibited. 7

The Role of Follow-up and Young Child Formula: What do the Authorities Say?

A WHO Statement (2013) maintained that “follow-up formula is unnecessary and unsuitable when used as a breastmilk replacement from six months of age onwards, due to its content. It is marketed in a way that may cause confusion and have a negative impact on breastfeeding.”8 The 2016 WHO Guidance recommended that “products that function as breast-milk substitutes should not be promoted. A breast-milk substitute should be understood to include any milk, in either liquid or powdered form, that is specifically marketed for feeding infant and young children up to age of 3 years.”9 

In the Scientific Opinion on the Essential Composition of Infant and Follow-on Formulae (2014), the European Food Safety Authority (EFSA) Panel on Dietetic Products, Nutrition and Allergies considers that “young-child formula” (formula intended for young children aged between 1 and 3 years old) has no unique role in the diet of infants and young children. It concludes that young-child formula is not a necessity to satisfy the nutritional requirements of young children when compared with other foods that may be included in the normal diet of young children. Other foods, such as fortified cow’s milk, fortified cereals or the early introduction of meat and fish into complementary feeding and their regular consumption, are more appropriate alternatives to increase intakes of the critical nutrients such as iron, DHA, vitamin D and iodine. Infant formula can be continued beyond the first year in case mothers do not choose to breastfeed.10


Protecting the Health of Young Children: the Unique Roles of Health Professionals

Health professionals providing care for mothers, babies and young children are obliged to support families in making well-informed choices on infant feeding. They should provide correct and unbiased information from credible sources and assist families to achieve their goals with professional knowledge and skills.

Say “No” to Marketing Activities of Formula Milk Companies

Ample evidence has shown that food promotion influences food preferences, purchase requests and consumption patterns.11 When marketing occurs in health care facilities such as hospitals and clinics, the products or messages being promoted are likely to gain an implied professional endorsement. This effect would act synergistically with other marketing activities such as television advertising, resulting in an overwhelming influence on parents and families. It is the duty of health professionals to familiarise themselves with the aims and principles of the HK Code and ensure promotional messages, gifts and free samples of formula milk are NOT disseminated through health care facilities. 

 "There can be no keener revelation of a society's soul than the way in which it treats its children." Nelson Mandela, Former President of South Africa

Key Messages:

Prevailing advertising and promotion of breastmilk substitutes insidiously impact on mothers’ perception, feeding choices and practices.

鋪天蓋地的配方奶廣告及推廣渗入並左右了母親對餵哺孩子的觀感、選擇和做法。


Follow-up formula has no unique role in the diet of infants and young children from a nutritional perspective. However, it is marketed in a way that may cause confusion and have a negative impact on breastfeeding and healthy young child feeding practices.

從營養的角度來說，嬰幼兒並無必要吃較大嬰兒配方奶。然而，這些產品以混淆視聽的手法推廣，使推行母乳餵哺和健康嬰幼兒飲食的進展受挫。

Health professionals providing care for mothers, babies and young children are obliged to support families in making well-informed choices on infant feeding. They should provide correct and unbiased information from credible sources and assist families to achieve their goals with professional knowledge and skills. 

從事母嬰健康的醫護人員有義務通過可靠及中肯無誤的健康資訊，協助父母作出有關嬰兒餵哺的知情決定，並用專業知識及技能，幫助他們為孩子建立健康的飲食習慣。

It is the duty of health professionals to familiarise themselves with the aims and principles of the HK Code and ensure promotional messages, gifts and free samples of formula milk are NOT disseminated through health care facilities.

醫護人員應熟悉他們在香港守則下的責任，包括避免奶粉商在醫療機構內推廣或派發禮品和樣品。
 
Addendum:The Myth of “Human Milk Oligosaccharides” (HMO)



Formula milk with the additive “Human Milk Oligosaccharides” (HMO) has been made widely available after the European Food Safety Authority (EFSA) Panel on Dietetic Products, Nutrition and Allergiesi and US Food & Drug Administration (FDA)ii concluded their uses in food supplements was safe. Subsequently, HMO has been heavily marketed as “supporting infant immune systems” by formula milk companies.

Human breastmilk contains over 100 structurally different oligosaccharides (complex sugars). Breastfed infants are naturally exposed to high concentrations of complex and diverse combinations of oligosaccharides, the profiles of which are highly variable among mothers. Different oligosaccharide structures produce distinct functions, which include promoting the growth of good gut bacteria (the “prebiotic effect”), preventing infections by binding to pathogens and blocking their adhesion to the gut lining without inducing much inflammatory reactions, and antimicrobial effects, etc.iii

As additives to formula milk, the term “HMO” is extremely misleading to customers as the substance does not come from human milk nor is it functionally comparable to the oligosaccharides in human milk. The artificial oligosaccharides can be made by various means, including fermentation of genetically engineered bacteria and yeasts; chemical or enzymatic synthesis, or extraction from cow milk. Currently, only a few types of simple HMOs have been produced at a large scale.iv The oligosaccharides commonly added to infant formula, e.g. 2'-Fucosyllactose, are only analogues which are structurally similar to those naturally occurring in human milk. The available limited research evidence does not suggest that infants consuming formula milk supplemented with HMO develop immune functions similar to that of breast-fed infants, as claimed commercially.v

附錄:「母乳低聚醣」的迷思

自從歐洲食品安全局（EFSA）i和美國食品和藥物管理局（FDA）ii評審結果認為使用「母乳低聚醣」(HMO) 作為食品補充劑是安全的，含有 「母乳低聚醣」添加劑的配方奶便開始湧現市場。隨後，配方奶公司更大力宣傳「母乳低聚醣」可「支持嬰兒的免疫系統」。

人類母乳含有多於100種不同結構的低聚醣，讓母乳餵養的嬰兒自然地接觸到多樣而複雜的低聚醣組合，而每個母親所產生的組合可以有很大差異。不同的低聚醣結構會產生明顯不同的功用，包括促進嬰兒良好的腸道細菌生長(「益生纖維」效應)；阻止病原體黏附腸壁，減少感染和有關的炎症；以及抗菌作用等。iii

添加於配方奶粉的「母乳低聚醣」這術語極其誤導顧客，因為該物質並不是來自母乳，也不能與母乳中的低聚醣在功能上相媲美。這些人造低聚醣是用不同方法製成，包括基因工程改造細菌和酵母的發酵、化學或發酵合成、或從牛乳中提煉。目前投入大量生產的只有幾種簡單的所謂「母乳低聚醣」。iv 通常加入配方奶的人造低聚醣(如2'-Fucosyllactos) 僅是天然的母乳低聚醣的類似物。雖然商界聲稱嬰兒食用添加HMO的配方奶，會產生類似母乳餵養的嬰兒的免疫功能，但目前的有限研究卻未有證據支持。v


References on Fighting Commercialisation for Health

  1. Bandy L. Toddler Milk Formula: The Hello Kitty of Packaged Food. 2014.Link: https://blog.euromonitor.com/2014/02/toddler-milk-formula-the-hello-kitty-of-packaged-food.html (Accessed on 6 August 2018)
     
  2. 衞生署健康促進交流會<提防宣傳陷阱> : 保護兒童的健康… 向配方奶推廣說 “不” 。2017年6月9日
     
  3. A Framework for Implementing the set of recommendations on the marketing of foods and non-alcoholic beverages to children. World Health Organization. 2012.
     
  4. An International Comparison Study into the implementation of the WHO Code and other breastfeeding initiatives. NHMRC Clinical Trials Centre, University of Sydney. 2011.
     
  5. A Summary of Hong Kong Code of Marketing of Formula Milk and Related Products, and Food Products for Infants & Young Children. Link: http://hkcode.gov.hk/en/the-hk-code-summary.html (Accessed on 6 August 2018)
     
  6. Survey on Mothers'Views of Formula Milk Promotion and Information on Infant and Young Child Feeding.
    Family Health Service, Department of Health, HKSAR. 2013. Link:
    http://www.fhs.gov.hk/english/archive/files/reports/
    Survey_on_Mothers_views_on_FM_promotion_full_2016_final.pdf
    (Accessed on 6 August 2018)
     
  7. Berry, N. J., Jones, S. C. & Iverson, D. C. 2012. Circumventing the WHO Code? An observational study. Archives of Disease in Childhood, vol. 97, no. 4, pp. 320-325.
     
  8. Information concerning the use and marketing of follow-up formula. World Health Organization. 2013.
     
  9. Guidance on ending the inappropriate promotion of foods for infants and young children. World Health Organization. 2016.
     
  10. Scientific Opinion on the essential composition of infant and follow-on formulae. EFSA Panel on Dietetic Products, Nutrition and Allergies (NDA), European Food Safety Authority (EFSA), Parma, Italy. EFSA Journal 2014;12(7):3760.
     
  11. The Extent, nature and effects of food promotion to children. World Health Organization. 2008.

References on The Myth of “Human Milk Oligosaccharides” (HMO)

    i.Statement on the safety of lacto-N-neotetraose and 2'-O-fucosyllactose as novel food ingredients in food supplements for children. EFSA Panel on Dietetic Products, Nutrition and Allergies (NDA), European Food Safety Authority (EFSA), Parma, Italy. EFSA Journal 2015;13(11):4299.

    ii.GRAS Exemption Claim for 2'-O-Fucosyllactose (2’-FL). GRAS Notice (GRN) No. 650. US Food and Drug Administration. April 2016. Link:
    http://www.fda.gov/Food/IngredientsPackagingLabeling/GARS/
    NoticeInventory/default.htm

    iii.Bode L. The functional biology of human milk oligosaccharides. Early Hum Dev. 2015 Nov ;91(11):619-22. doi: 10.1016/j.earlhumdev.2015.09.001.

    iv. Ravindran S. Producing Human Milk Sugars for Use in Formula. SPLASH! milk science update: October 2015. International Milk Genomics Consortium.
    http://milkgenomics.org/article/producing-human-milk-sugars-for-use-in-formula/

    v.Bode L and Jantscher-Krenn E. Structure-Function Relationships of Human Milk Oligosaccharides. Adv Nutr. 2012 May; 3(3): 383S–391S.
Views expressed in this article are the author's and do not necessarily reflect the
opinion or positio of the BFHIHKA.

作者在本文章表達的見解,未必代表愛嬰醫院香港協會的意見或立場

Editor-in-Chief: Dr Shirley SL Leung
Editorial Team: Dr Rachel PY Cheng, Mr Gordon CL Cheung, Dr Annie OL Fok,
Ms Miranda HS Leung, Dr Rosanna MS Wong
Illustration: Ms Cheryl Young

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