Understanding the Marketing of Breastmilk Substitutes and Follow-up Formulas

1. When is a milk a breastmilk substitute? Manufacturers’ attempts to get around the International Code of Marketing of Breastmilk Substitutes and Subsequent World Health Assembly Resolutions. David Clark, Nutrition Specialist (Legal) UNICEF, New York Yeong Joo Kean, Legal Adviser, ICDC, Penang.

2. Before the Code Infant formula was the main BMS on the market and was promoted “from birth” without upper age limit. After six months, a non-breastfeeding mother would introduce complementary food and could continue with the infant formula. Nestle Nan Infant Food Formula, 1978

3. Code adopted in 1981 • Prohibits all forms of promotion of BMS • Preamble makes reference to a “legitimate market for infant formula” and “the proper use of infant formula”. • Although the scope refers to “breast-milk substitutes, including infant formula”, infant formula is the only BMS product mentioned and defined. • Manufacturers thought they could use this to argue that the Code only applies to infant formula, leaving them to invent new “formulas” that they could claim were not covered by the Code’s prohibition on promotion.

4. And then there were two … Age indication - Nan 1 – “from birth” Nan 2 - “from 6 months” with no upper age limit. Resulted in cross-promotion whereby mothers of newborns were targeted with promotion of the follow-up formula, since the packaging, branding and labelling so closely resemble that of the infant formula (also known as brand extension).

5. Follow-up milks pronounced “unnecessary” • In May 1986, WHA declared “the practice being introduced in some countries of providing infants with specially formulated milks (so-called follow-up milks) is not necessary”(WHA 39.28) Industry tries to fight back In 1987, Codex Alimentarius Standard adopted for follow-up formula which stated: “The products covered by this standard are not breast-milk substitutes and shall not be presented as such” (CODEX STAN 156-1987)

6. But Governments take action to protect their babies: • Countries like Benin (1997) Albania (1999) Ghana (2000) Brazil (2001) Botswana (2005) Gambia (2005) Nigeria 2005) Kyrgyzstan (2008), Fiji (2010), Madagascar 2011), Vietnam (2014), Kuwait (2014), Myanmar (2014) began to specifically include follow-up formulas in their national regulations. • How did the companies react? follow-on formulas now generally have an upper age limit of 12 months ... Allowing for further brand extension …..

7. With companies again claiming the new 1,2,3 milks (a.k.a. growing-up or toddler milks) don’t fall under the scope of the Code. Cross Promotion

8. Companies claim the No 3 milks (and 4) can be promoted and they do so aggressively… Increasing consumer demand for GUMS through • Innovative activities to instill perception that product is beneficial • Expansion of retail space like this baby race track Singapore

9. “Partly due to government restrictions of the marketing of baby formula, manufacturers are increasingly targeting toddler milk formula.”

10. Promotion of one GUM product over 2 decades Labelling 2011 - Bahrain 1999 – Malaysia 2016 - South Africa Clean label after law How companies behave depends on prevailing laws

11. Promotion in health care facilities 2000 - UAE 2013 - Ethiopia 1999 – Oman/ UAE From creating brand awareness to product premiumisation

12. Promotion to the public 2004 – Malaysia 2007 - Ghana “Brain development” “immunity” Help your child realise his full potential ? “Healthy Bones & Minds depend on the right milk”? 2007 - UAE “Enhanced your child’s mental development” In ads for the new millenium, claims became entrenched

13. Circa 2010 – more claims !! Indonesia/ Philippines / UAE Small eyes. Big Vision. Improved formulation to improve eye protection With AA & DHA to awaken the natural ability of your child Dha & AA to help visual acuity and brain development

14. Feed their potential? “Biofactors system – unique age appropriate combination of nutrients to support your child’s growth” 2013 - Ethiopia 2011 - Lebanon WHA 58.32 [2005] - nutrition and health claims are notpermitted for bmsexceptwhere specifically provided for in national legislation (reiterated in WHA 63.23 [2010] and extended to all foods for IYC )

15. Raising the alarm “These respondents clearly understood toddler milk advertisements to be promoting a range of products that included infant and follow-on formula and accepted their claims quite uncritically” Breastfeeding Review 2009; 17 (3): 21–30 A rapid evidence assessment: Does marketing of commercially available complementary foods affect infant and young child feeding? “The analysis of the primary question in this report reveals exploitation by marketers of confused distinctions by consumers between infant, follow-on and toddler milks, and this indicates an important area of focus for policy and regulation.

16. Guidance on Inappropriate Promotion of Foods for Infants and Young Children Recommendation 2: Breastmilk Substitutes World Health Assembly in May 2016 (A69/7) “Products that function as breastmilk substitutes should not be promoted. A breastmilk substitute should be understood to include any milks (including soy milk), in either liquid or powdered form, that are specifically marketed for feeding infants and young children up to the age of 3 years (including follow-up formula and growing-up milks) http://apps.who.int/gb/ebwha/pdf_files/WHA69/A69_7Add1-en.pdf/

17. 2016 - post guidance; ads & claims persist 2016– Malaysia

18. Look what they’re doing NOW ! India Are these breastmilk substitutes or complementary foods?

19. Danone GUM Promotion Today Formula for “1 -6 year olds “? What product is this?

20. Guidance on Inappropriate Promotion of Foods for Infants and Young Children Recommendation 5: Cross Promotion World Health Assembly in May 2016 (A69/7) • There should be no cross-promotion to promote breastmilk substitutes indirectly via the promotion of foods for infants and young children. • Companies that market breastmilk substitutes should refrain from engaging in the direct or indirect promotion of their other food products for infants and young children by establishing relationships with parents and other caregivers (for example through baby clubs, social media groups, childcare classes and contests). http://apps.who.int/gb/ebwha/pdf_files/WHA69/A69_7Add1-en.pdf/

21. What about cross-promotion through milks for mothers? Lookalike labels create brand recognition, trust and loyalty. Malaysia

22. Key takeaway messages • The promotion of follow-on formulas and growing up milks cross promotes the infant formulas of the same brand. • The Code covers all breastmilk substitutes i.e. any milks that are specifically marketed for feeding infants and young children up to the age of 3 years, irrespective of what they are called. • There should thus be no promotion of these products • In the absence of national Code regulations that are specific about the definition of BMS, companies will probably continue to try and promote GUMs. • Despite recommendations against cross-promotion of BMS indirectly via the promotion of foods for IYCF, can still occur through promotion of milks for pregnant and breastfeeding women.

24. Global baby food sales Milk Formula US$45.0 billion Likely to rise by 55% to US$ 70 billion by 2019 Big Money!!! Source: Euromonitor, 2013; WHO-UNICEF-IBFAN Joint Report on Implementation of the International Code, 2016

25. Formula milks US$45 billion Growing Up Milks: 50% of the absolute growth, strongest retail sales growth among all formula milk products (Euromonitor International, 2015)

26. Some Marketing Trends • Robust sales performance of toddler milk formula (GUMs) compared to the overall baby food market encourages manufacturers to focus on widening their target audience to older children, in order to retain their customer base for a longer period. • Toddler milk formula’s high sales per capita in large emerging markets, notably Indonesia and Thailand, are expected to remain major growth drivers. • The five largest markets for toddler milk formula in 2015 are all located in Asia Pacific. • Premiumisation is set to be a key factor for growth in developed markets.(Euromonitor International, 2015)