Does Formula Advertising Really Influence Anyone’s Decisions?

1. Does Formula Advertising Really Influence Anyone’s Decisions? Miriam H. Labbok, MD, MPH, IBCLC FACPM, FABM, FILCA Professor and CGBI Director and Kathy Parry, MPH, IBCLC CGBI Project Director August 21, 2013

2. Learning Objectives: At the end to the session attendees will be able to: • Discuss research findings on the impact of formula marketing on breastfeeding decisions and outcomes • Understand the research about formula marketing may affect women and their feeding practices • Discuss current efforts to counter negative impact of formula marketing • Consider the impact of your interactions, the issue of “guilt” or “shame,” and related structural influences No conflict of interest to declare. Acknowledgements: Research colleagues: Kathy Parry, Emily Taylor, Marsha Walker, and many others… Photo credits: Kathy Parry, Sheryl Abraham, NCBC, WIC, others

3. Outline • Brief review of why breastfeeding is vital for our future in the US. • Research on the influence of commercial formula advertising on breastfeeding • Consideration of guilt and shame • What can WIC do – what can I do – to make a difference?

4. Breastfeeding is the Heartbeat of Family Health: Infant and Young Child Nutrition Growth and Development Birth Spacing / Fertility Reduction Immunization / disease prevention Savings of Family Resources Oral Rehydration Reduced Maternal Cancer and Improved Health Reduced Child Cancer and Chronic Disease Logo, Breastfeeding Division, IRH; adapted and modified by CGBI

5. Current trends in rate of breastfeeding initiation for US population, and for WIC and Non-WIC populationsRoss Mothers Survey and CDC National Immunization Survey 2020 Goal

6. 1990 Innocenti Declaration“Four Pillars” • Government commitment • Health System -- Quality assurance=Ten Steps -- Education of health professionals • Control of formula marketing -- Media -- Health personnel --WIC • Workplace -- Paid leave and breaks -- Co-located child care 5. Community support with Demand Creation

7. Current trends in rate of breastfeeding initiation for US population, and for WIC and Non-WIC populationsRoss Mothers Survey and CDC National Immunization Survey 2020 Goal

8. Why the difference in continuation of EBF?Percent of U.S. breastfed children who consume infant formula in addition to human milk in the first two days of life - CDC NIS Early supplementation is associated with 3-7 times increased likelihood of stopping breastfeeding at 1-6 months. Bunik M et al. Academic Pediatrics. 2010; 10(1);21-28

9. Exclusive breastfeeding lags among WIC participants… Percent Exclusively Breastfeeding at 3 and 6 months EBF3 EBF6

10. Last issue: African Americans – on average - are least likely to breastfeed or to exclusively breastfeedANDAfrican Americans suffer high rates diseases impacted by breastfeeding White Hispanic Black • Breastfeeding initiation rates 76 81 58 • Exclusive breastfeeding: 3 months 33 31 20 • Infant mortality rates/1000 6 6 14 • % Diabetes 9 9 13 • Breast Cancer Deaths/100,000 25 20 33 CDC 2007 data; 2005 National Diabetes statistics; 2005 Vital Statistics

11. Outline • Brief review of why breastfeeding is vital for our future in the US. • Research on the influence of commercial formula advertising on breastfeeding • Consideration of guilt and shame • What can WIC do – what can I do – to make a difference?

12. Expectations can be created… for anything Toilet paper is like a sweet puppy dog? Like Family?! • “At XXXXXXXXXXX, we care • about the important things in life. • We care about family • We care about kids • We care about the community • We care about the environment” And what, exactly, does all this have to do with breastfeeding?

13. What is Promised?What is Exploited?

14. Which image is modern and youthful and sexy?

15. Significant effort is made to sell products, and to sell products that make us buy more products…

16. “For discomfort due to persistent feeding issues” • “If your baby is experiencing discomfort due to persistent feeding issues, XXX may help. It has partially broken-down protein for easy digestion. In addition to having DHA/ARA, XXX has Lutein, an important nutrient babies can get from breast milk and XXX. It's especially helpful now, during this critical time of your baby's brain and eye development. • For healthy infants who are not exclusively breastfed and who have a family history of allergy, feeding 100% whey-protein partially hydrolyzed infant formula, like XXX. Protect from birth up to 4 months of age instead of a formula containing intact cow's milk proteins may reduce the risk of developing atopic dermatitis throughout the first year of life. • Reduces fussiness, gas and crying within 24 hours; Has gentle protein for sensitive tummies; Provides complete nutrition for healthy growth during baby's first year

19. Infant Formula Marketing: Pervasive and Expensive • 1989 – first TV commercial • $$ spent annually jumped from 29 million to over 46 million in 5 years from 1999 – 2004 (in US alone) • Retail prices vastly exceed cost of production and outpace inflation in every state • Response: Social Marketing - funding? Abrahams SW. Milk and social media: online communities and the International Code of Marketing of Breast-milk Substitutes.J Hum Lact. 2012 Aug;28(3):400-6. doi: 10.1177/0890334412447080. Epub 2012 Jun 6.

20. How Does This Commercial Advertising Affect Women and their Partners? • Cumulative impact of long-term exposure to various formula marketing techniques over a lifetime

21. How Does This Particularly Affect Pregnant and Postpartum Women? • Exposure to infant formula marketing in the hospital is associated with early supplementation and weaning • Little research on effects of other types and times of marketing • Substantial misunderstanding persists(IFPS II 2005 Survey) • Breastfeeding is best way to feed an infant • 33% Did Not Agree • Infant formula is as good as breastmilk • 28% Agreed

23. Study Designed to Increase Understanding of How Women Perceive Formula Marketing 4 Focus Groups divided by reproductive status • Planning 1st pregnancy within 3 years • Pregnant with first child • Exclusively breastfed within past three years • Any formula fed within past three years Exposed to 5 Advertisements • Hospital“breastfeeding discharge bag”s • Color image of infant formula package • Website and magazine ads

24. Population in Focus Groups

27. Selected Themes that Emerged from Focus Group Research • Confusion about superiority of human milk • Formula seen as a treatment or solution • Expectation of failure with breastfeeding • Greater influence when from healthcare sites

28. All Groups Understood Formula to be a Solution to Many Problems + = • Formula Group: “You can’t change your milk but I can change my formula and maybe that will solve my problem.” • Pregnant Group: “This is something that formula can do that your breastmilk necessarily can’t do.” • Preconception: “… it’s kind of like you’re fault because you’re not feeding the right thing.”

29. Pregnant Women in Particular Became Confused About Superiority of Human Milk • “…is my breast milk doing all those things too? … I’m feeling a little bit of doubt when I look at this.” • “I don’t know how much DHA goes through breast milk, and so it almost makes me feel like, ‘Wow. That’s something that the formula has that I don’t even know.’” ?

30. Pregnant Women Expressed Increased Expectation of Failure • “I’m getting the impression that there’s a pretty good chance that I might want to use formula at some point.” • “They expect you to breastfeed. But then they’re almost like sort of expecting you to fail, and so when that time comes, you know, if you’ve got all these samples, well, what are you going to start using?”

31. Direct Support Needed:Pregnancy as a Unique Time • Women in “Pregnant” Focus Group were more likely to mention feelings of self-doubt, confusion and disempowerment in our research • Hormones/Emotional Receptivity • Feeding Decisions • Research – Type of infant feeding information given at first prenatal visit makes a difference

32. Prenatal Education • Evidence supports both one-on-one and group sessions; limited research on specific type of education • UNCH/UNC Health Care Prenatal Education • Skin-to-Skin, Rooming-In, Feeding on Demand • Recommendations and Benefits/Risks • Breastfeeding Norms in First Days and Weeks • Signs of Problems / Where to Find Answers and Help

33. AND - it makes a difference when the formula comes from health providers • Pregnant: “But seeing it out of context in the hospital, given to you by your doctor, that’s where it gets really confusing for me.” • Pregnant: “I don’t think the doctor would give it to me if it wasn’t recommended or, if they thought the information in it was wrong.”

34. Discussion • These themes underscore that, at best, these materials are very concerning, and, at worst, they actively mislead for profit • Given the ubiquity of direct-to-consumer advertising of infant formula– protection and support are needed • WIC staff has a unique and special role to play in offering an unbiased discussion of infant feeding - one that is not market driven

35. CDC NIH Breastfeeding Data for Children Born 2000-2009

36. How advertising supports first supplementation Perceptions from Exposure to Advertisements Reasons for First Supplement In-hospital – primarily due to lack of confidence/ unnecessary medical intervention Overwhelmed by caring for their newborns due to inadequate preparation and support Lack of knowledge about the realities and constraints of breastfeeding Belief that formula was the solution to problem • Confusion about superiority of human milk and breastfeeding • Formula seen as a treatment or solution • Expectation of failure with breastfeeding • Greater influence when ad/formula comes from healthcare outlets • Perception of inadequate supply

37. The Case for Increasing UnbiasedPrenatal Infant Feeding Education Susceptibility to formula ads and products confirmed by research Reasons for First Time Supplementation Feeding Decisions Often Made During Pregnancy or earlier BFHI Step 3 Understanding baby’s cues/ language WIC counseling for breastfeeding Self-Efficacy to improves duration CDC Guide to BF Interventions ABM Protocols 3, 14, 19 and others

39. What else is Being Done to Protect Women? • The FTC, The Code, BFHI • AAP resolutions • ABM protocols 3: Supplementation, 14: The Breastfeeding-Friendly Physicians' Office Part 1: Optimizing Care for Infants and Children, 19: Breastfeeding Promotion in the Prenatal Setting • NABA, IBFAN, Public Citizen, Ban the Bags • Other Breastfeeding Organizations • USBC, State Coalitions • MomsRising, Best for Babes • Facebook Groups (Friends of WHO Code) • Blogs (Lamaze’s Science and Sensibility, The Leaky Boob, Human Milk News, Nestlé Boycott, PhD in Parenting)

40. WIC CAN MAKE A REAL DIFFERENCE

41. USG Report Confirms: • Too few U.S. infants breastfeed and miss out on the health benefits esp. low-income children, costing us billions for unnecessary health care • Advertising is increasing: e.g., • hospital discharge packs, TV ads, • direct to the public • Companies use the WIC acronym • in their marketing efforts; WIC • participants are misled; FNS should • protect its trademarks • All State WIC contracts should • restrict the use of WIC trademarks

42. Outline • Brief review of why breastfeeding is vital for our future in the US. • Research on the influence of commercial formula advertising on breastfeeding • Consideration of guilt and shame • What can WIC do – what can I do – to make a difference?

43. The Reality of External Pressures… Comic used with Courtesy of Neil

44. Definitions: What is Guilt? What is Shame? • Accepted usage: • You feel guilty for what you did not do, • Ashamed of having failed. • If not addressed and expunged, shame may “mature” into guilt. • Cultural anthropology: • Shame is the failure to realize one’s own or society’s expectations, • Guilt is the set of feelings when one feels that one has done wrong, or has violated internal values.

45. When we lack confidence or have been purposefully confused, we need others to help and to support us to achieve an expectation.If we do not achieve the expectation, and feel shamed we need to learn that it is acceptable to have not achieved an expectation. If we do not feel accepted, we will create within us feelings of guiltGUILT is a self-created set of feelings if our shame is not addressed

46. Maternal guilt is ubiquitous... If breastfeeding is something ‘Good’ and, therefore, something that must be done, then Do mothers alone bear the responsibility and, hence, the guilt?

47. Who should be bearing the burden of guilt? From the Rights Perspective: • Family, community, and, in the bigger picture, States parties From the System Perspective: • Providers • Three aspects that influence clinician actions and communications: • 1) science; • 2) personal experience; • 3) lack of professional experience GUILTY!!

48. What can be done by WIC workers to ‘treat’ guilt? • Guilt is a natural response to loss: when we do not achieve expectations: • Traumatic birth experience • Infant disability or “defect” • Inability to, or choosing not to, breastfeed • “Failure” to breastfeed may be experienced as shame, maturing into guilt, AND, by mammalian physiology, as a loss approximating the loss of the child • Leads to predictable emotional and psychological stages • Fully experiencing and accepting all feelings is essential to the healing process

49. Factors that may hinder the healing process: • Avoidance or minimization of the mother’s feelings and emotions. • Maternal use of alcohol or drugs to self-medicate. • Maternal “over-function”, whether in mothering or at work, to avoid feelings.

50. Suggestions for the mother: • Allow time to experience thoughts and feelings openly to self. • Acknowledge and accept all feelings, both positive and negative. • Suggest she • use a journal to document the healing process. • Confide in a trusted individual; tell the story of the loss. • Express feelings openly. Crying offers a release. • Identify any unfinished business and try to come to a resolution. • There are religious, social and psychological groups provide an opportunity to share grief with others who have experienced similar loss. • If the healing process becomes too overwhelming, return for referral for professional help. • Summary: The same constructs for dealing with loss or depression may be used to prevent and ameliorate guilt.