National Institute for Health and Clinical Excellence
PUBLIC HEALTH PROGRAMME GUIDANCE
Preventing obesity: whole system approaches
Consultation on the Draft Scope February 2010
The comments relating to infant and young child feeding are submitted on behalf of Baby Milk Action, the Baby Feeding Law Group, and the Breastfeeding Manifesto Coalition . Other more general comments relating to older children and education are from Baby Milk Action alone.
In 2008 the UK was called to answer questions from the UN Committee on the Rights of the Child (CRC) - 5 years after being told by the Committee to implement the Code. The Committee was unimpressed by the Government’s submission which claimed it had implemented the International Code. “The CRC Committee, while appreciating the progress made in recent years in the promotion and support of breastfeeding in the State party...is concerned that implementation of the International Code of Marketing of Breastmilk Substitutes continues to be inadequate and that aggressive promotion of breastmilk substitutes remains common.... The Committee recommends that the State party implement fully the International Code of Marketing of Breastmilk Substitutes.
The importance of regulating the baby food market
Many of the following comments focus on the importance of regulating food marketing rather than on strategies which focus on lifestyle and individual choice. The importance of this strategy is shown in the latest Euromonitor International analysis of the global baby food market, Global Packaged Food: Market Opportunities for Baby Food to 2013, which states: “Government Regulation a Growing Constraint….There are significant international variations in the regulations governing the marketing of milk formula, which are reflected in sales differences across countries.”
This is a clear indication that restricting marketing protects breastfeeding, so limiting market growth. “The industry is fighting a rearguard action against regulation on a country-by-country basis,” In industrialised countries the industry focus is on increasing value growth as well as volumes, through the promotion of added ingredients such as DHA and ARA (Long Chain Polyunsaturated Fatty Acids) and ‘probiotics’.
Promotion of breastfeeding is a concern to the industry, even in the US where formula advertising is unregulated: “The rising popularity of breast feeding and a low birth rate will combine to drag North American retail value growth down by a percentage point in 2008, to 5.9%.”
Organic baby foods are seen as a significant marketing strategy, but Euromonitor acknowledges: “In Western Europe, most parents are unaware that, as a result of stringent EU regulations on permitted levels of pesticide residues in baby food, there is very little difference between regular and organic baby food.”
The internet is portrayed as a major marketing opportunity and also promoting ‘good night milks’: “With an increasing number of mothers returning to work after giving birth, products that help babies sleep better could have a wide appeal.”
The Euromonitor report Global Packaged Food: Market Opportunities for Baby Food to 2013 is available at: euromonitor.com
Another report, Datamonitor’s Babies and Toddlers: Emerging Opportunities, shows the importance of Build brand loyalty early“Mothers are returning to a more traditional parenting technique of breastfeeding their children. This presents problems for the baby drinks industry, with the growth of formulas stunted as a consequence. Manufacturers must find ways of creating appeal without positioning drinks as a direct alternative, which creates ill-feeling among mothers. “Marketers are becoming more aware of the need to target parents as early as possible. Brand relationships and trust bonds can be formed during pregnancy when the child is not yet even born. This lifestage targeting will becoming increasingly important going forwards.” datamonitor.com
Question 1: What are the key societal, environmental and organisational factors operating at the local level that can lead to obesity? How do these factors interact with each other? Do they reflect social integration and connection with local or broader community and cultural institutions?
The contribution of high fat, high sugar, high calorie foods alongside reduced levels of physical exercise to rising levels of obesity is well established and acknowledged. The role of optimal infant and young child feeding (exclusive breastfeeding for six months, followed by continued breastfeeding alongside appropriate complementary foods) is less well acknowledged.
When considering ways to tackle this problem its important that the focus is moved away from individual ‘choice’ to providing an environment that supports good healthy decision making. Schemes that seek promote breastfeeding but fail to ensure that women receive adequate and consistent and objective support and advice at the time they need it and allow conflicting commercial messages to continue, are likely to back fire and create hostility.
See Protecting breastfeeding -Protecting babies fed on formula Why the UK government should fulfil its obligation to implement the International Code of Marketing of Breastmilk Substitutes and other papers:
Although the vast majority of women in the UK want to breastfeed, most are failed by the system and stop breastfeeding long before they wanted to because of problems that could have been avoided with proper support and care. Most give up long before they have to return to work.
Indeed the UK has one of the lowest breastfeeding rates in Europe – with less than 1 per cent of mothers in the UK exclusively breastfeeding at six months. The UK infant feeding survey 2005 (Bolling et al. 2007) showed that 78% of women in England breastfed their babies after birth but, by 6 weeks, the number had dropped to 50%. Only 26% of babies were breastfed at 6 months. Exclusive breastfeeding was practised by only 45% of women one week after birth and 21% at 6 weeks (Bolling et al. 2007).
As new formulas are promoted with lower protein levels, it is important to recognize that rapid early weight gain and later obesity is not only the result of the extra calories in formulas and baby foods. Breastfeeding and baby-led feeding is likely to influence the development of a taste receptors, fostering a preference for lower energy diets later on in life, and may help in developing appetite control mechanisms.
Evidence regarding breastfeeding
Epidemiological evidence strongly suggests that breastfeeding represents an ideal window of opportunity for obesity prevention. Systematic reviews on the association between breastfeeding and obesity show that breastfeeding acts as a protective factor in a dose-dependent and causal fashion Scientific research shows that many biological factors associated with obesity and chronic diseases may be programmed very early in life or even during pregnancy. Once a child becomes obese, it is quite likely that s/he will remain obese as an adult.
The report of the BMA Board of Science on Early life nutrition and lifelong health, February 2009 states that: “Breastfed infants have more control over the flow of milk than bottle-fed infants. Breastfeeding is therefore often described as an ideal ‘supply and demand’ regulation system. The feeding behaviour of the baby and the quality of the breast milk change with time in a way that may prevent overfeeding, teach the infant how to recognise satiety signals, and regulate energy intake differently from formula-fed infants. The role of leptin in breast milk may be of particular importance in the early development of both adipose tissue and appetite regulatory systems in the infant, and ultimately on propensity to obesity in later life. A recent study showed that administration of physiological levels of leptin to suckling rats caused a significantly lower body weight in adulthood.129 Observational studies have shown that breastfeeding is associated with lower rates of childhood obesity.130 Bearing in mind the absence of leptin in formula milk, this may have important implications for the prevention of obesity in children and in adults.”
The USA Centre for Disease Control and Prevention (CDC) considers that there are only two potential, cost-effective interventions that can be put into place immediately to deal with the childhood obesity epidemic: decreased television viewing and breastfeeding promotion. (Dietz WH. Breastfeeding may help prevent childhood overweight. JAMA. 2001; 285:2506
Excerpts from: Recommended Community Strategies and Measurements to Prevent Obesity in the United States Morbidity and Mortality Weekly Report
www.cdc.gov/mmwr July 24, 2009 / Vol. 58 / No. RR-7
This report describes the expert panel process that was used to identify 24 recommended strategies for obesity prevention and a suggested measurement for each strategy that communities can use to assess performance and track progress over time. The 24 strategies are divided into six categories including strategies to promote the availability of affordable healthy food and beverages; to support healthy food and beverage choices, and to encourage breastfeeding,
Strategy to Encourage Breastfeeding
Breastfeeding has been linked to decreased risk of pediatric overweight in multiple epidemiologic studies. Despite this evidence, many mothers never initiate breastfeeding and others discontinue breastfeeding earlier than needed. The following strategy aims to increase overall support for breastfeeding so that mothers are able to initiate and continue optimal breastfeeding practices. systematic reviews of epidemiologic studies indicate that breastfeeding helps prevent pediatric obesity: breastfed infants were 13%–22% less likely to be obese than formula-fed infants (77,78), and each additional month of breastfeeding was associated with a 4% decrease in the risk of obesity (79). Furthermore, one study demonstrated that infants fed with low (<20% of feedings from breastmilk) and medium (20%–80% of feedings from breastmilk) breastfeeding intensity were at least twice as likely to have excess weight from 6 to 12 months of infancy compared with infants who were breastfed at high intensity (>80% of feedings from breastmilk) (80).
Systematic reviews indicate that support programs in health-care settings are effective in increasing rates of breastfeeding initiation and in preventing early cessation of breastfeeding. Training medical personnel and lay volunteers to promote breastfeeding decreases the risk for early cessation of breastfeeding by 10% (81) and that education programs increase the likelihood of the initiation of breastfeeding among low-income women in the United States by approximately twofold (75).
Age of introduction of complementary foods and drinks
Many baby foods and drinks in the UK are promoted as suitable from 4-months – (some even younger). This encourages the introduction of solid foods before the vast majority of babies are developmentally ready to eat family foods, and conflicts with the UK Government and WHO recommendations: Practices encouraging puree as first weaning foods also encourage parents to overfeed infants at too early an age.
WHA Resolution 54.2, adopted in 2001 URGES Member State: to improve complementary foods and feeding practices by ensuring sound and culture-specific nutrition counselling to mothers of young children, recommending the widest possible use of indigenous nutrient-rich foodstuffs.
It requests the Director-General to provide support to Member States in the identification, implementation and evaluation of innovative approaches to improving infant and young child feeding, emphasizing exclusive breastfeeding for six months as a global public health recommendation, taking into account the findings of the WHO expert consultation on optimal duration of exclusive breastfeeding (note 1), the provision of safe and appropriate complementary foods, with continued breastfeeding up to two years of age or beyond, and community-based and cross-sector activities.
According to the 2009 BMA Board of Science report, Early life nutrition and lifelong health, “The influence of the timing and nutritional content of complementary feeding and the specific effects of variations in quality of complementary feeding on current and later health in countries such as the UK are still to be determined. There are wide variations in infant size, weight gain, linear growth and body composition. There is increasing evidence that these influence the risk of developing obesity, diabetes, cardiovascular disease and other health outcomes in later life. The optimal pattern(s) of infant growth to minimise the risk of obesity, cardiovascular disease and diabetes need(s) to be determined…
Nutrition during infancy also determines later risk of obesity. Rates of overweight and obesity are lower in people who were breastfed, although there is debate as to whether this is a causal relationship. Rapid weight gain in infancy also predicts an increased risk of obesity.
According to a study in the American Journal of Clinical Nutrition, the age at which parents introduce foods to infants may influence his/her body mass indexes (BMI) in adulthood. Babies who are breastfed for longer seem to have lower BMIs in adulthood, and delaying the introduction of complementary foods reduces the risk of becoming overweight in the long run by 5 to 10 percent.
Harder T, Bergmann R, Kallischnigg G, Plagemann A. Duration of breastfeeding and risk of overweight: a meta-analysis. Am J Epidemiol 2005;162:397-403
Harder T, Schellong K, Plagemann A. Differences between meta-analyses on breastfeeding and obesity support causality of the association. Pediatrics 2006;117:987-8
Levitt NS, Lambert EV, Woods D, Hales CN, Andrew R, Seckl JR. Impaired glucose tolerance and elevated blood pressure in low birth weight, nonobese, young south african adults: early programming of cortisol axis. J Clin Endocrinol Metab 2000;85:4611-8 Harder T, Bergmann R, Kallischnigg G, Plagemann A. Duration of breastfeeding and risk of overweight: A meta-analysis. Am J Epidemiol. 2005;162:397-403. These findings strongly support a dose-dependent and significant association between longer duration of breastfeeding and decrease in risk of overweight.
Kalies H, Heinrich J, Borte N, et al and LISA Study Group. The effect of breastfeeding on weight gain in infants: results of a birth cohort study. Eur J Med Res, January 28, 2005; 10(1): 36-42. In this prospective cohort study healthy term neonates were followed up to age 2 years in Germany. Duration of exclusive breastfeeding was inversely associated with the risk of elevated weight gain in a strongly duration-dependent way.
Akobeng AK, Heller RF. Assessing the population impact of low rates of breast feeding on asthma, coeliac disease and obesity: the use of a new statistical method. Archives of Disease in Childhood 2007;92:483-485. In the population of the 596,122 babies born in England and Wales in 2002, the number of cases of asthma, coeliac disease and obesity that could be prevented over 7–9 years if all babies were breastfed was 33 100 (95% CI 17 710 to 47 543), 2655 (95% CI 1937 to 3343) and 13639 (95% CI 7838 to 19308), respectively.
[Further supporting references on obesity:]
Bergmann KE, Bergmann RL, Von Kries R, Böhm O, Richter R, Dudenhausen JW, Wahn U. Early determinants of childhood overweight and adiposity in a birth cohort study: role of breast-feeding. Int J Obes Relat Metab Disord. 2003 Feb;27(2):162-72.
Gillman MW, Rifas-Shiman SL, Berkey CS, et al. Breast-feeding and overweight in adolescence: within-family analysis [corrected] Epidemiology. 2006 Jan;17(1):112-4.
Gillman MW, Rifas-Shiman SL, Camargo CA Jr, Berkey C, Frazier AL, Rockett HRH, et al. Risk of overweight among adolescents who had been breast fed as infants. JAMA 2001;285:2461–7.
Hediger ML, Overpeck MD, Kuczmarski RJ, Ruan WJ. Association between infant breastfeeding and overweight in young children. JAMA 2001;285:2453–60.
von Kries R, Koletzko B, Sauerwald T, Von Mutius E, Barnert D, Grunert V, et al. Breast feeding and obesity: cross sectional study. BMJ 1999;319:147–50.
Toschke AM, Vignerova J, Lhotska L, Osancova K, Koletzko B, von Kries R. Overweight and obesity in 6- to 14-year-old Czech children in 1991: protective effect of breast-feeding. J Pediatr 2002;141:764–9.
When the US Department of Health (HSS) broadcast advertisements promoting breastfeeding in the period 2003-5, the industry brought in powerful lobbyists who succeeded in getting the ads toned down. At the same time, the industry substantially increased its own advertising as soon as the Government campaign was launched. According to a 2006 report by the Government Accountability Office, formula companies spent about $30 million in 2000 to advertise their products. In 2003 and 2004, when the campaign was underway, infant formula advertising increased to nearly $50 million.: The result was a fall in breastfeeding rates:“the proportion of mothers who breast-fed in the hospital after their babies were born dropped from 70 percent in 2002 to 63.6 percent in 2006, according to statistics collected in Abbott Nutrition’s Ross Mothers Survey, an industry-backed effort that has been measuring breast-feeding rates for more than 30 years.” 2
The Baby Feeding law Group is a coalition of 23 leading health professional and lay organisations working to bring UK and EU legislation into line with International Code of Marketing of Breast-milk Substitutes and subsequent relevant World Health Assembly Resolutions.
BFLG Member organisations: Association of Breastfeeding Mothers - Association for Improvements in the Maternity Services - Association of Radical Midwives - Baby Milk Action - Best Beginnings – Breastfeeding Community - Breastfeeding Network - Caroline Walker Trust - Community Practitioners and Health Visitors’ Association - Food Commission - Lactation Consultants of Great Britain - La Leche League (GB) - Little Angels - Midwives Information and Resource Service - National Childbirth Trust - Royal College of Midwives - Royal College of Nursing - Royal College of Paediatrics and Child Health - The Baby Café - UK Association for Milk Banking - Unicef UK Baby Friendly Initiative - UNISON - Women’s Environmental Network.
The Breastfeeding Manifesto Coalition has 33 member organizations and calls for action in 7 areas to protect, promote and support breastfeeding. http://www.breastfeedingmanifesto.org.uk
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