Nutrition in an

International Perspective
- II

Shweta Chandnani
18 December 2017
SUSTAINABLE DEVELOPMENT GOALS & NUTRITION
INTERNATIONAL CODE OF MARKETING OF
BREASTMILK SUBSTITUTES
GLOBAL NUTRITION REPORT 2017

Shweta Chandnani
18 December 2017
SUSTAINABLE DEVELOPMENT GOALS

14 December 2017
“Nutrition is both a maker and a marker of development. Improved nutrition is the
platform for progress in health, education, employment, empowerment of women
and the reduction of poverty and inequality, and can lay the foundation for peaceful,
secure and stable societies.”
Ban Ki-moon, United Nations 8th Secretary General, a message for the SUN
Movement Strategy and Roadmap (2016-2020).

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SUSTAINABLE DEVELOPMENT GOALS & NUTRITION

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14 December 2017
 http://17goals.org/quiz-level-1/

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Infant and young child feeding

 Breastfeeding is the normal way of providing young infants

with the nutrients they need for healthy growth and
development. Virtually all mothers can breastfeed,
provided they have accurate information, and the support
of their family, the health care system and society at large.
 Colostrum, the yellowish, sticky breast milk produced at
the end of pregnancy, is recommended by WHO as the
perfect food for the newborn, and feeding should be
initiated within the first hour after birth.
 Exclusive breastfeeding is recommended up to 6 months
of age, with continued breastfeeding along with appropriate
complementary foods up to two years of age or beyond.

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Key facts
 Every infant and child has the right to good nutrition according to the "Convention on the Rights of the Child".
 Undernutrition is associated with 45% of child deaths.
 Globally in 2016, 155 million children under 5 were estimated to be stunted (too short for age), 52 million
were estimated to be wasted (too thin for height), and 41 million were overweight or obese.
 About 40% of infants 0–6 months old are exclusively breastfed.
 Few children receive nutritionally adequate and safe complementary foods; in many countries less than a
fourth of infants 6–23 months of age meet the criteria of dietary diversity and feeding frequency that are
appropriate for their age.
 Over 820 000 children's lives could be saved every year among children under 5 years, if all children 0–23
months were optimally breastfed. Breastfeeding improves IQ, school attendance, and is associated with
higher income in adult life. (1)
 Improving child development and reducing health costs through breastfeeding results in economic gains for
individual families as well as at the national level.


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Overview

 Undernutrition is estimated to be associated with 2.7 million child deaths annually

or 45% of all child deaths. Infant and young child feeding is a key area to
improve child survival and promote healthy growth and development. The first 2
years of a child’s life are particularly important, as optimal nutrition during this
period lowers morbidity and mortality, reduces the risk of chronic disease, and
fosters better development overall.
 Optimal breastfeeding is so critical that it could save the lives of over 820 000
children under the age of 5 years each year.

14 December 2017
WHO and UNICEF recommend:

 early initiation of breastfeeding within 1 hour of birth;

 exclusive breastfeeding for the first 6 months of life; and
 introduction of nutritionally-adequate and safe complementary (solid) foods at 6
months together with continued breastfeeding up to 2 years of age or beyond.
 However, many infants and children do not receive optimal feeding. For example,
only about 36% of infants aged 0–6 months worldwide were exclusively breastfed
over the period of 2007-2014.

14 December 2017
 However, many infants and children do not receive optimal feeding. For example,
only about 36% of infants aged 0–6 months worldwide were exclusively breastfed
over the period of 2007-2014.
 Recommendations have been refined to also address the needs for infants born
to HIV-infected mothers. Antiretroviral drugs now allow these children to
exclusively breastfeed until they are 6 months old and continue breastfeeding
until at least 12 months of age with a significantly reduced risk of HIV
transmission.

14 December 2017
 Exclusive breastfeeding for 6 months has many benefits for the infant and
mother. Chief among these is protection against gastrointestinal infections which
is observed not only in developing but also industrialized countries. Early
initiation of breastfeeding, within 1 hour of birth, protects the newborn from
acquiring infections and reduces newborn mortality. The risk of mortality due to
diarrhoea and other infections can increase in infants who are either partially
breastfed or not breastfed at all.

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 Breast-milk is also an important source of energy and nutrients in children aged
6–23 months. It can provide half or more of a child’s energy needs between the
ages of 6 and 12 months, and one third of energy needs between 12 and 24
months. Breast-milk is also a critical source of energy and nutrients during
illness, and reduces mortality among children who are malnourished.

14 December 2017
 Children and adolescents who were breastfed as babies are less likely to be
overweight or obese. Additionally, they perform better on intelligence tests and
have higher school attendance. Breastfeeding is associated with higher income
in adult life. Improving child development and reducing health costs results in
economic gains for individual families as well as at the national level.(1)

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Mothers and families need to be supported for their
children to be optimally breastfed. Actions that help
protect, promote and support breastfeeding include:
 adoption of policies such as the International Labour Organization’s "Maternity Protection Convention 183" and "Recommendation
No. 191", which complements "Convention No. 183" by suggesting a longer duration of leave and higher benefits;
 adoption of the "International Code of Marketing of Breast-milk Substitutes" and subsequent relevant World Health Assembly
resolutions;
 implementation of the "Ten Steps to Successful Breastfeeding" specified in the Baby-Friendly Hospital Initiative, including:
 skin-to-skin contact between mother and baby immediately after birth and initiation of breastfeeding within the first hour of life;
 breastfeeding on demand (that is, as often as the child wants, day and night);
 rooming-in (allowing mothers and infants to remain together 24 hours a day);
 not giving babies additional food or drink, even water, unless medically necessary;
 provision of supportive health services with infant and young child feeding counselling during all contacts with caregivers and
young children, such as during antenatal and postnatal care, well-child and sick child visits, and immunization; and
 community support, including mother support groups and community-based health promotion and education activities.
 Breastfeeding practices are highly responsive to supportive interventions, and the prevalence of exclusive and continued
breastfeeding can be improved over the course of a few years.

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Video Link
 https://www.ted.com/talks/katie_hinde_what_we_don_t_know_about_mother_s_
milk/footnotes#t-43661

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International Code of Marketing of
Breast-milk Substitutes

 The World Health Assembly adopted the International Code of Marketing of Breast-milk
Substitutes in 1981 to protect and promote breastfeeding, through the provision of adequate
information on appropriate infant feeding and the regulation of the marketing of breastmilk
substitutes, bottles and teats. In subsequent years additional resolutions have further defined
and strengthened the Code.
 The code stipulates that there should be absolutely no promotion of breastmilk substitutes,
bottles and teats to the general public; that neither health facilities nor health professionals
should have a role in promoting breastmilk substitutes; and that free samples should not be
provided to pregnant women, new mothers or families.
 All governments should adopt the Code into national legislation. Since 1981, 84 countries
have enacted legislation implementing all or many of the provisions of the Code and
subsequent relevant World Health Assembly resolutions. In addition, 14 countries have draft
laws awaiting adoption. The latest update of the state of the code by country provides an
overview of all countries. UNICEF is working with legislators and lawyers to ensure the Code
and maternity protection laws are implemented in more countries.

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Here are some of the innovative
strategies developed to implement
the Code
 In Iran, the Government has taken control of the import and sale of breastmilk
substitutes. Formula is available only by prescription, and the tins must carry a generic
label - no brand names, pictures or promotional messages are allowed.
 In India, legislation requires that tins of infant formula carry a conspicuous warning
about the potential harm caused by artificial feeding, placed on the central panel of the
label.
 In Papua New Guinea, the sale of feeding bottles, cups, teats and dummies is strictly
controlled, and there is a ban on advertising these products as well as breastmilk
substitutes.
 If you are interested in establishing or strengthening the Code in your country,
please contact your National Breastfeeding Committee, your local UNICEF
office, or UNICEF National Committee.

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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

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.
 And then there were two …

Age indication - Nan 2 - “from 6

Nan 1 – “from months” with
birth” 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).
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)
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 …..

 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
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
Singapore Expansion of retail space
like this baby race track
“Partly due to government
restrictions of the marketing of
baby formula, manufacturers
are increasingly targeting
toddler milk formula.”
Promotion of one GUM product over 2
decades
Labelling

2011 - Bahrain

1999 –
Malaysia 2016 - South Africa
Clean label after
How companies behave depends on law laws
prevailing
 Promotion in health care facilities

1999 – Oman/ UAE 2000 - UAE 2013 -

Ethiopia
From creating brand awareness to product
premiumisation
 Promotion to the public

2004 – Malaysia
2007 - Ghana
2007 -
“Brain development”
“Healthy Bones & UAE
“immunity” “Enhanced your
Minds depend on the
Help your child realise
right milk”? child’s mental
his full potential ? development”
In ads for the new millenium, claims became entrenched
 Circa 2010 – more claims !!
Indonesia/ Philippines / UAE

Small eyes. Big With AA & DHA Dha & AA to help

Vision. to awaken the visual acuity and
Improved natural ability of brain development
formulation to your child
improve eye
protection
 Feed their potential?

“Biofactors
system – unique
age appropriate
combination of
nutrients to
support your
child’s growth”

2011 - 2013 -
Lebanon Ethiopia

WHA 58.32 [2005] - nutrition and health claims are not permitted for bms except
where specifically provided for in national legislation
(reiterated in WHA 63.23 [2010] and extended to all foods for IYC )
Raising the alarm

“These respondents clearly understood toddler

milk advertisements to be promoting a range of A rapid evidence assessment:
products that included infant and follow-on Does marketing of
formula and accepted their claims quite commercially available
uncritically” complementary foods affect
Breastfeeding Review 2009; 17 (3): 21–30
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.
 Guidance on Inappropriate
Promotion of Foods for Infants
and Young Children
World Health Assembly in May 2016 (A69/7)
Recommendation 2: Breastmilk Substitutes
“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/
2016 - post guidance; ads & claims persist

2016– Malaysia
 Look what they’re doing NOW !

India

Are these breastmilk substitutes

or complementary foods?
 According to breastfeeding protection watchdog, Breastfeeding Promotion
Network of India (BPNI), the baby food industry has allegedly violated
the IMS Act at least 54 times if not more between 2008 and 2016 before being
brought it to the attention of the government regulatory authorities.

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 To understand the state of health services and formula feeding from the mothers'
perspective, an online survey was conducted within Breastfeeding Support for
Indian Mothers (BSIM), a 29000+ member strong Facebook group. More than
950 mothers who delivered in private hospitals responded.
 More than half were given artificial baby milk out of these two-third said it was
given without their consent. Analysis of the survey also revealed that children
were given formula without knowledge of women. Health workers often doubted
their ability to produce milk and undermined their confidence in breastfeeding.
 A number of violations have been identified by BPNI as a part of the monitoring
programme. Top violators include Nestle, Abbot, Heinz and Danone. These
companies have violated provisions of the IMS act in more than once and
continue to mislead mothers through various misleading tactics.

Vientiane, 2011
Danone GUM
Promotion
Today

Formula for
“1 -6 year olds “?
What product is
this?
 Guidance on Inappropriate
Promotion of Foods for Infants and
Young Children
World Health Assembly in May 2016 (A69/7)
Recommendation 5: Cross Promotion
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/
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.
GLOBAL NUTRITION REPORT
The Global Nutrition Report acts as a report card on the world's nutrition—
globally, regionally, and country by country—and on efforts to improve it. It
assesses progress in meeting Global Nutrition Targets established by the World
Health Assembly.

Vientiane, 2011
The Global Nutrition Report
2017 highlights
 the need for an urgent and integrated response to global nutrition if we are to
meet the Sustainable Development Goals of Agenda 2030.
 With almost every country in the world facing a serious nutrition-related
challenge, whether from undernutrition or obesity, the report authors call for a
critical change in the global response to malnutrition in all its forms and action
throughout the goals to tackle the many causes of malnutrition.

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14 December 2017
1. Grave nutrition situation
 Hunger statistics are going in the wrong direction: now 815 million people are
going to bed hungry, up from 777 million in 2015.
 Indeed, an estimated 38 million people are facing severe food insecurity in
Nigeria, Somalia, South Sudan and Yemen while Ethiopia and Kenya are
experiencing significant droughts.
 Exclusive breastfeeding of infants aged 0–5 months has marginally increased,
but progress is too slow (up 2% from baseline).
 inexorable rise in the numbers of children and adults who are overweight and
obese continues. The probability of meeting the internationally agreed targets to
halt the rise in obesity and diabetes by 2025 is less than 1%.

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 Too many people are being left behind from the benefits of improved nutrition.
Yet when we look at the wider context, the opportunity for change has never
been greater. The SDGs, adopted by 193 countries in 2015, offer a tremendous
window of opportunity to reverse or stop these trends.
 First, it means focusing on inequities in low, middle and high-income countries
and between them, to ensure that everyone is included in progress, and
everyone is counted.
 Second, it means that the time of tackling problems in isolation is well and truly
over. If we want to transform our world, for everyone, we must all stop acting in
silos, remembering that people do not live in silos.
 The SDGs are telling us loud and clear: we must deliver multiple goals through
shared action. Nutrition is part of that shared action. Action on nutrition is needed
to achieve goals across the SDGs, and, in turn, action throughout the SDGs is
needed to address the causes of malnutrition

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2. five core areas that run through the SDGs which
nutrition can contribute to, and in turn, benefit from:

1. Good nutrition can drive greater environmental sustainability. Agriculture

and food production is the backbone of our diets and nutrition. Food production
uses 70% of the world’s freshwater supply and 38% of the world’s land. Current
agriculture practices produce 20% of all greenhouse gas emissions, and livestock
uses 70% of agricultural land. Eating better is necessary to ensure that food
production systems are more sustainable
2. Good nutrition is infrastructure for economic development. Stunting
disrupts the critical ‘grey matter infrastructure’ – brain development – that builds
futures and economies. Investing in this infrastructure supports human
development throughout life and enhances mental and productive capacity, offering
a $16 return for every $1 invested.
Nutrition is linked to GDP growth: the prevalence of stunting declines by an
estimated 3.2% for every 10% increase in income per capita, and a 10% rise in
income translates into a 7.4% fall in wasting.

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2. five core areas that run through the SDGs which
nutrition can contribute to, and in turn, benefit from:

3. Good nutrition means less burden on health systems. Health is indivisible

from nutrition. Good nutrition means less sickness and thus less demand on
already-stretched health systems to deliver prevention and treatment.
4. Good nutrition supports equity and inclusion, acting as a platform for better
outcomes in education, employment, female empowerment and poverty reduction.
Well-nourished children are 33% more likely to escape poverty as adults, and each
added centimetre of adult height can lead to an almost 5% increase in wage rate.
Nutritious and healthy diets are associated with improved performance at school.
Children who are less affected by stunting early in their life have higher test scores
on cognitive assessments and activity level.
5. Good nutrition and improved food security enhances peace and stability.
More evidence is needed to better understand how poor nutrition and food
insecurity influence conflict.
available evidence indicates that investing in food and nutrition resilience also
promotes less unrest and more stability.

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14 December 2017
4. There is significant opportunity for financing a
more integrated approach to improving nutrition
universally.

 Malnutrition has a high economic and health cost, yet not enough is spent on
improving nutrition.
 New analysis this year shows domestic spending on undernutrition varies from
country to country, with some spending over 10% of their budget on nutrition and
others far less.
 Spending on prevention and treatment of obesity and diet-related NCDs
represented 0.01% of global ODA spending to all sectors in 2015, even though
the global burden of these diseases is huge.
 considerably more investment needs to be put on the table.
 The world simply cannot afford not to think about a more integrated approach to
investing in nutrition.

14 December 2017
5. To leave no one behind, we must fill gaps
and change the way we analyse and use
data.
 National averages are not enough to see who is being left behind. We need
disaggregated data for all forms of malnutrition, in all countries as nutritional
levels can vary even within households. This is needed if we are to ensure that
marginalised, vulnerable populations are not left behind in the SDG agenda.
 Two notable data gaps are around adolescents and dietary intake. Better data on
adolescents is needed if we are to hold the world accountable for tackling
nutrition in such a critical part of the life course. Likewise, if we do not know what
people are eating, we will not be able to design effective interventions to improve
diets.
 Beyond just collecting data, we need to actively use this data to make
better choices and inform and advocate decision-making at the policy
level. We need data to be collected, collated and used to build the
dialogues, partnerships, actions and accountability needed to end
malnutrition in all its forms.

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14 December 2017
6. Commitments
 To begin with this means ensuring we can hold governments, multilateral
agencies, civil society and businesses accountable for delivering their
commitments – and this means making sure they are SMART (specific,
measurable, achievable, relevant and time-bound).
 Commitments must be ambitious and relevant to the problem. Also critical are
commitments that aim to achieve multiple goals and ensure no one is left behind.
 The bottom line is that nutrition needs some staying power. We need a
world where having suboptimal nutrition is considered completely
unacceptable and good nutrition is the global social norm. Accountability
mechanisms should be designed carefully to ensure they promote this
deeper level of commitment byall stakeholders.

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7. There is an exciting opportunity to achieve global
nutrition targets while catalysing other development goals
through ‘double duty’ and ‘triple duty’ actions.

 There is an opportunity to identify – and take – ‘double duty’ actions which tackle more than
one form of malnutrition at once.
 For example, actions to promote and protect breastfeeding in the workplace produce
benefits for both sides of the double burden of malnutrition;
 Eg Scaling up access to efficient cooking stoves would improve households’ nutritional
health, improve respiratory health, save time, preserve forests and associated ecosystems,
and reduce greenhouse gas emissions.
 School meal programmes could be more effectively structured to reduce undernutrition,
ensure children are not unduly exposed to foods that increase risk of obesity, provide income
to farmers, and encourage children to stay in school and/or learn better when at school.
 Urban food policies and strategies can be designed to reduce climate change, food waste,
food insecurity and poor nutrition. Humanitarian assistance could be used as a platform to
promote quality, nutritious diets while also rebuilding resilience via local institutions and
support networks

14 December 2017
Changing the way we work also means that
the nutrition community must transform the
way it speaks to other sectors.
 We must reach out to ask others “what can we do to help you?” “how can we
help you achieve your goals?”, and not just say “you should be helping us.” To
make us stronger, the different communities who work on nutrition – on
undernutrition, obesity, diet-related NCDs, maternal and child health and
humanitarian relief – must come together with a stronger voice.
 And we must put people at the centre of everything we do, by inspiring and
rallying around this fundamental right that impacts every single one of us and our
families.

14 December 2017
TAKE AWAY MESSAGES
 ending malnutrition in all its forms will catalyse improved outcomes across
the SDGs.
 We can make a difference to achieving the SDGs, and you can help end
malnutrition.
 You can stop the trajectory towards at least one in three people suffering
from malnutrition. The challenge is huge, but it is dwarfed by the
opportunity.

14 December 2017
Videos
 https://www.youtube.com/watch?v=5TNIwypQThs

 https://www.youtube.com/watch?v=zGFFcsPY2ow

 https://video.ucdavis.edu/media/The+Sustainable+Development+GoalsA+where
+does+nutrition+fit+inF/0_l2occ0en

Vientiane, 2011
Resources
 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.2016
 WHO infant and young child feeding practices 2016
 https://brandequity.economictimes.indiatimes.com/news/business-of-
brands/baby-food-industry-unethically-market-to-mothers-in-india-
study/55805305

14 December 2017