It’s time to disarm the formula industry

The WHO Code is turning 35, and this vital public health policy is more critical than ever. The World Health Organization Code of Marketing of Breast Milk Substitutes was passed in 1981 to regulate predatory marketing tactics by infant formula companies. After World War II, formula sales boomed in the US, reaching their apex in the 1970s – the year I was born, just 22 percent of babies were ever breastfed. As they saturated the US market, formula companies looked overseas to expand markets for their products. They promoted formula as a modern, advanced approach to infant feeding, and dressed up sales representatives as nurses in clinics, pushing their product in communities where breastfeeding had been the norm for generations, and where clean water was in short supply.

Companies raked in profits, and babies died in droves. International outrage led the World Health Organization to adapt the Code, which banned marketing of artificial breast milk substitutes to consumers.

The US has never adapted the code, but formula companies did not market directly to consumers until the late 1980s  – when, coincidentally, breastfeeding rates were rising in the US, cutting into formula profits. Today, families are inundated with formula marketing and free samples, and the formula market is big business in the US. Formula sales totaled US$4.8 billion in 2013 – that’s  $1220.69 in sales for each of the 3,932,181 babies born in the United States in 2013.

Formula manufacturers secure this lucrative market with pervasive marketing campaigns. In the 2005-2006 Infant Feeding Practices Survey II, 57.4% of participants reported having received a free formula sample in the mail. Formula companies spend 10-15% of their net sales on advertising and promotion. Conservatively, therefore, formula manufacturers spend $480 million (10% of net sales) each year marketing infant formula in the US. That’s more than six times the $68 million in total US federal government expenditures for breastfeeding support through the WIC Peer Counselor program ($60 million) and CDC initiatives ($8 million).

Both in the US and globally, the hottest growing market is for toddler “follow-on” formulas, dubbed “The Hello Kitty of Packaged Food” for its runaway success in Asian markets. According to the European Food Safety Authority, these products offer no additional value to a balanced diet, and many are sweetened with sugar or corn syrup, potentially contributing to the global obesity epidemic.

Aggressive formula marketing reaps profits for manufacturers at the expense of families. For example, corporations have long co-opted the credibility of hospitals and health professionals by distributing discharge packs stocked with samples of their most expensive formulas. A 1996 court case, Abbott Laboratories, Inc. v. Segura, provided a rare insight into detailing of health professionals: here’s what Abbott Labs told their sales representatives about nurses:

Ross Hospital Feeding System is designed to provide an early and convenient means of getting infants started on Similac … and ultimately sent home with instructions that they continue to use Similac.

Never underestimate the importance of nurses. If they are sold and serviced properly, they can be strong allies. A nurse who supports Ross is like an extra salesperson

In many US hospitals, postpartum nurses hand families a “gift bag” stocked with premium formula, implicitly suggesting that the top-shelf, newest formula was “recommended” by the maternity center.  I recently compared the cost of one of these premium formulas with a store-brand generic – the premium brand sold for $37.99, compared with $14.29 for the store-brand. Over a year of exclusive formula feeding, families that stuck with the fancy “hospital-recommended” brand would spend $2587.31, compared with $952.14 for store brand. Formula marketing in health facilities hurts formula-feeding families.

Hospital-based formula marketing pitches high-price, brand-name formula to families.

Companies also distribute “breastfeeding success” kits, which are meticulously engineered to undermine breastfeeding. A recent study by my colleagues at the Carolina Global Breastfeeding Institute found that pregnant women who reviewed formula company materials worried that their milk might not be as nutrient-rich as a commercial product:

But it still makes me wonder, then, is my breastmilk doing all those things too? Like I’m starting to feel a little bit of doubt because this is just…this covers everything. You know? I’m like “Well, actually I don’t know if my breastmilk will provide strong bones and brain and eye.” I don’t know. I’m feeling a little bit of doubt when I look at this.

And in Brazil earlier this year, Nestle funded an insidious campaign suggesting that mothers who did not eat a perfect diet were putting their babies at risk by breastfeeding, implicitly suggesting that formula feeding mothers have fewer constraints.

Companies use these tactics because rising breastfeeding rates are a well-recognized threat to formula manufacturers’ financial bottom line. Every time a baby goes to breast, a formula company loses a sale. In his Q1 2016 earnings call with shareholders, Mead Johnson CEO Peter Kasper Jakobsen stated:

The start to the year in our U.S. business was affected by market share losses from the highs we saw in the middle of 2015. On a positive note, we believe the strengthening labor market and workforce participation rates have caused a rise in breastfeeding rates to level off over the last four months or so. [italics added]

When CEOs celebrate “leveling off” of a health behavior, they profit at the expense of public health. It’s time for corporations to acknowledge that formula marketing, like promotion of sugar-sweetened beverages and high-fructose-corn syrup to children, is unacceptable. Families deserve non-commercial, unbiased information to enable each mother to make an informed decision regarding how to feed her infant.

Breastfeeding is under attack, in the US and around the world, by a burgeoning formula industry that is fighting a multi-million dollar battle for every infant’s first meal. This is a global battle, led by an industry with a retail value expected to exceed US$70.6 billion by 2019. As Alison McFadden and colleagues wrote in The Lancet earlier this year, “Promotion and marketing have turned infant formula, which should be seen as a specialised food that is vitally important for those babies who cannot be breastfed, into a normal food for any infant.”

To divert attention from this global offensive, the industry has deliberately conflated regulation of formula promotion with attacks on families who decide to formula feed. One is an issue of corporate governance and ethics; the other is a smokescreen, fueling the “mommy wars” to conceal predatory marketing tactics.

As an obstetrician-gynecologist, I passionately support each woman’s right to make her own informed reproductive decisions, including decisions to formula feed. For these decisions to be truly autonomous, women deserve accurate information about the risks and benefits of various feeding strategies. As the American College of Obstetricians and Gynecologists affirmed in their recent Committee Opinion:

Families should receive noncommercial, accurate, and unbiased information so that they can make informed decisions about their health care. Obstetric care providers should be aware that personal experiences with infant feeding may affect their counseling. In addition, pervasive direct-to-consumer marketing of infant formula adversely affects patient and health care provider perception of the risks and benefits of breastfeeding…

Obstetrician–gynecologists and other obstetric care providers should support each woman’s informed decision about whether to initiate or continue breastfeeding, recognizing that she is uniquely qualified to decide whether exclusive breast­feeding, mixed feeding, or formula feeding is optimal for her and her infant. (italics added)

Aggressive marketing of infant formula misleads families and derails informed decisions.

Indeed, much of the bile and vitriol around infant feeding is a direct consequence of pervasive formula marketing. We waste precious time and energy flinging pebbles at a $480 million marketing Goliath, rather than providing material support to help women make informed decisions and achieve their feeding goals. Against elegantly engineered narratives about “the sisterhood of motherhood,” our painstakingly crafted PSAs appear amateur, and our voices become so hoarse that we sound strident.

We can’t compete in a $480 million marketing arms race; instead, we need to disarm the formula industry.   Thirty-five years later, we need to #ProtectParentsAndBabies and enforce the WHO Code.

Alison Stuebe, MD, MSc, is a maternal-fetal medicine physician and breastfeeding researcher. She is an associate professor of Obstetrics and Gynecology at the University of North Carolina School of Medicine and Distinguished Scholar of Infant and Young Child Feeding at the Gillings School of Global Public Health. You can follow her on Twitter at @astuebe.

Posts on this blog reflect the opinions of individual ABM members, not the organization as a whole.