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Lo o k W h at T h e y ' r e D o i n g ! Monitoring Code Compliance in Alberta

Alberta Code Violations

A summary of violations of the International Code of Marketing of Breastmilk Substitutes and subsequent relevant WHA Resolutions in 2011 ? 2012.

An example of a six-pack box of Abbott Similac Advance liquid formula distributed free to a hospital in Saskatchewan

Mead Johnson information and coupon mailed to grandparents of a new baby in Alberta

Good Start promotional paraphernalia from Nestl? for health care facilities in Calgary and Edmonton: a crib card tear-off pad distributed to a hospital and a weighing scale cover found in a pediatrician's

office

Abbott goodie bag filled with products worth $57 handed out at Baby & Tot Fair

Heinz growth chart to watch baby grow

Idealising bottle feeding: Avent ad in Babies `R' Us 2011 Canada catalogue

Overview of Code & Resolutions

1. Aim: to "contribute to the provision of safe and adequate nutrition for infants, by the protection and promotion of breastfeeding, and by ensuring the proper use of breastmilk substitutes, when these are necessary, on the basis of adequate information and through appropriate marketing and distribution."

2. Scope: applies to breastmilk substitutes, including infant formula; to other milk products, follow-on milks, foods and beverages, when marketed or otherwise represented as a partial or total replacement for breastmilk up to two years; to feeding bottles and nipples (teats). It also applies to their quality and availability, and to information concerning their use.

3. Advertising: no advertising of above products to the public. No health claims on products.

4. Samples: no free samples to mothers, their families or health care workers.

5. Health care facilities: no promotion of products, i.e., no product displays, posters or distribution of promotional materials. No use of mothercraft nurses or similar company-paid personnel.

6. Health care workers: no gifts or samples to health care workers as these create a conflict of interest .

7. Supplies: no free or low-cost supplies of breastmilk substitutes to maternity wards and hospitals.

8. Information: information and education materials must explain the superiority of breastfeeding, the health hazards associated with bottle feeding, and the costs of using infant formula. Product information must be factual and scientific.

9. Labels: product labels must clearly state the superiority of breastfeeding, to use only on the advice of a health care worker, instructions for the appropriate preparation and a warning about the health hazards of inappropriate preparation, and for powdered baby milks, the risk of Enterobacter sakazakii. No pictures of infants, or other pictures or text idealising the use of infant formula.

10. Products: unsuitable products, such as sweetened condensed milk, should not be promoted for babies and products high in saturated or trans fats, free sugars and salts not marketed for children. All products should be of a highly-recognized standard.

This scan of Code violations in Alberta and Saskatchewan will educate health care professionals on marketing practices which catch them and their clients in a web of promotion of artificial milk and feeding products.This `web' influences initiation, exclusivity, and duration of breastfeeding. Marketers target those with high disposable income. In wealthy Canada health care workers must particularly be aware of, resist and educate the public on the danger of the dual Trojan horses of `free lunches' and marketing masquerading as science.

"A baby nursing at a mother's breast... is an undeniable affirmation of our rootedness in nature."

David Suzuki

Canada's Laws and Policies

Canada voted in favour of the Code at the World Health Assembly (WHA) in 1981 and supported all subsequent WHA resolutions on infant and young child nutrition but neither the Code nor resolutions has been incorporated into Canadian legislation. Only a few labelling laws, some specific to baby foods, have impact on marketing:

1. Neither comparisons to breastmilk nor health claims are permitted on foods for children under two years of age, including infant formulas, only nutrient content claims are allowed (B.01.503.(2));

2. Misleading labelling is prohibited. "No person shall label, package, treat, process, sell or advertise any food in a manner that is false, misleading or deceptive or is likely to create an erroneous impression regarding its character, value, quantity, composition, merit or safety". (B.25.061.(1))

The Canadian Food Inspection Agency, responsible for the implementation of legislation on labelling and claims has set out the labelling requirements for infant formula*, however, there still is no ban on advertising to the public, the cornerstone of the Code and resolutions.

Enforcement remains a problem. * inform/20070112e.shtml

On the social media front Companies are now directly contacting mothers through social media. Twitter parties, RSS feeds, and APPs for phones provide instant `advice' to moms that pays lip service to breastfeeding. These services play on the idea of `sharing' feeding responsibilities with dad and having time away from baby because ... `Mom, you deserve it.'

Invite to `mOmma Twitter Party' by Lansinoh

The Alberta situation

In Alberta breastfeeding initiation rates

were 92.7% in 2005, 92% in 2007/2008, and 90.8% in 2009/20101. In Calgary

(pop. 1m) in 2012 exclusivity drops

precipitously to 44% at first public health visit2. Although 2009/2010

statistics show exclusive breastfeeding

at six months or more in Alberta

to be 29%, in Edmonton (pop. 800

000) exclusive breastfeeding at six months was at 9% in 20083.The initiation drop off and relatively low

Al Sahab B, Laness A, Feldman M,Tamim H. Prevalence and predictors of 6-month exclusive breastfeeding among Canadian women: a national survey. BMC Pediatrics 2010, 10:20

exclusive breastfeeding rates are largely attributable to aggressive marketing in the

public realm and in hospitals. Mothers do not get sufficient breastfeeding support

and receive instead advice on formula feeding against a background of formula supplementation during their hospital stay where as many as 47.9%4 of infants

receive formula milk.These are recognized risk factors for early breastfeeding cessation.5 This report shows how companies selling commercial baby foods,

feeding bottles and nipples contribute further to the decline of breastfeeding by

enticing health workers and mothers through various promotional tactics in health

facilities and the public arena.

1. Public Health Agency of Canada. Perinatal Health Indicators for Canada 2011. Ottawa, 2012. 2. Breastfeeding Data April 2012,Alberta Health Services, Calgary Zone 3. Breastfeeding Data May 2008,Alberta Health Services, Edmonton Zone 4. Yang Q,Wen SW, Dubois L Chen Y,Walker MC, Krewski D. Determinants of breast-feeding and weaning in Alberta, Canada. J Obstet

Gynaecol Can 2004. Nov;26(11):975-81 5. Chalmers B, Levitt C, Hearman M. et al. Breastfeeding rates and hospital breastfeeding practices in Canada: a national survey of women.

BIRTH 2009;36(2):122-132

The violations

Promotion to the public and in shops Article 5 of the Code prohibits all forms of promotion to the general public: advertising, samples and gifts, promotional devices at the retail level and contact by marketing personnel

Since the Code has not been implemented as law in Canada, promotion to the public is rife and unregulated. Examples include gifts at baby fairs and coupons in catalogues,`harvesting' of names and addresses of mothers from maternity stores and baby clubs to be used for distribution of free samples, promotions, invitations and growth charts.

Lansinoh's response to complaints

about its mOmma Twitter Party was that it is their corporate mission to support all breastfeeding mothers and that includes talking to moms directly. So much for ethical marketing in the spirit of the WHO Code as the company claims to be doing.

An Abbott dietitian signs up a participant for a baby club at the Calgary Alberta Baby and Tot Fair.

Abbott Nutrition gift bag handed out at baby fairs in Calgary,Alberta and Saskatoon, Saskatchewan. The bag shows the Similac brand name and logo with the promotional slogan `Little Treasures Need Protecting'. Picture of the infant on the gift bag does not reflect safe sleep guidelines.

Retailers such as pharmacies have programmes targeting all women of childbearing age.These retailers often recruit formula companies to provide samples for their programmes. Product information and samples of formula such as Enfamil are given to mothers from time to time.

Pharmacy website advertises a programme for women to ask questions about pregnancy and child care. Formula samples are provided in the process.

Promotion in health care facilities and to health workers

Article 7 of the Code prohibits gifts to health care workers as the practice creates conflicts of interest. (Article 7; WHA Resolutions 47.5 [1994], 49.15 [1996], 58.32 [2005] and 61.20 [2008])

Promotion for commercial baby foods in Canadian health care facilities is ubiquitous. Company and brand names are seen prominently on utility items such as measuring tapes, blankets, crib cards, baby tags and posters.These items are used by health workers in the presence of mothers and sometimes passed on to them. When company presence is so visible, there is implicit professional endorsement which is extremely valuable for marketing. Companies constantly find new ways of positioning themselves and their products.

Hospitals deluged with promotion of baby foods

From Mead Johnson...

Measuring tape found in Alberta Health Services...

Nestle Good Start advertising seen on an infant weighing scale in a pediatrician's office in Edmonton, Alberta.

Medela Calma bottle given to NICU nurse., with an information booklet that is more promotional than scientific and factual.

... and crib cards in Edmonton AB Hospital

Abbott Similac Advance 6-pack cartons distributed free to hospitals in Saskatchewan.

Under the table ? all kinds of samples in a physician's office in Edmonton.

Dangerous liaisons: the health worker?industry relationship

WHA resolution 49.15 [1996] cautions about conflict of interests when financial support is given for professionals working in infant and young child health.The warning about conflicts of interest was extended in WHA resolution 58.32 [2005] to cover programmes.

It is the responsibility of health workers to promote breastfeeding. There is potential for conflict of interest when health workers accept gifts and other incentives from companies.There is a risk that these health workers may exploit their professional or official capacity for their personal or organisational benefit to the detriment of breastfeeding. Breastfeeding advocates have protested against collaboration between companies and health workers where some form of sponsorship is involved but these events continue.

Nestl?'s contribution to the National Dietitians Mead Johnson Physician Seminar in North

of Canada Conference 2011 in Edmonton

Battleford, Saskatchewan.

Activists abort Abbott dinner but webcast goes ahead

In January 2012, Canadian activists along with the Breastfeeding Action Committee of Edmonton protested against an Abbott dinner in Edmonton and managed to get it cancelled.The event was to celebrate the launch of a national webcast regarding the `importance' of certain ingredients found in Abbott products. The national webcast program went ahead. Activists logged in and asked questions on essential fatty acids and lutein added to infant formula--presenters confirmed there is no research to support the `benefits'!

Honourary Doctorate for former Nestl? CEO

Despite vociferous protests, the Chair of the University of Alberta, Dr. Indira Samarasekera, awarded a doctorate of laws to Chairman and former CEO of the Nestl? Group, Peter Brabeck-Letmathe, on 1 March 2012. Hundreds of e-mails, letters and pleas of protests were sent; a demonstration by the Breastfeeding Action Committee of Edmonton and the Council of Canadians was staged but to no avail. The University's decision pointed to the lack of awareness of the public, educators, and the press on the track record of Nestle in many areas, in particular the continuous violation of the International Code and relevant WHA resolutions.

Labelling

Article 9 of the Code requires labels to NOT discourage breastfeeding; or contain idealising pictures or text

The Code specifically prohibits pictures of infants on labels of infant formula. For many years, there were no more labels with baby pictures anywhere in the world. Canada has the dubious distinction of being the first country where such baby pictures have made a comeback. No attempt has apparently been made by authorities to rectify the situation.

Claims galore

Although the Food and Drug Act of Canada precludes inclusion of unsubstantiated claims on labels, companies continue to brandish labels with health or nutritional claims that `premiumize' the product. Claims idealise a product. Hence they are promotional by nature and prohibited by the Code. Claims are specifically banned by WHA 58.32 [2005] unless allowed by national laws.

Enfamil A+ ? idealising image of mom and baby on the label, with claims to boot ? only in Canada and nowhere else

Similac Advance contains `special nutrients found in breastmilk'

Good Start protect ... for Complete Nutrition, Easy Digestion and Advanced Immune Support

Feeding bottles, nipples, soothers and pacifiers

Step 9 of the BFHI says, "Give no artificial nipples or pacifiers (dummies or teats) to breastfeeding babies."

Monitoring in Alberta and Saskatchewan exposed the disregard that manufacturers and distributors of feeding bottles and teats have for the Code in Canada. Promotion of bottles and teats undermines efforts to protect, promote and support breastfeeding. Publicity materials display idealising text and messages. Like baby food companies, sellers of feeding bottles spare no effort in projecting the message that their products are `close to mommy', and are able to solve many of the common infant feeding problems babies have.This is reaffirmed by evidence under Step 9 of the BFHI `Give no artificial nipples or pacifiers to breastfeeding babies'.

A picture of a mother and baby sleeping snugly together portrays how a Tommee Tippee bottle `Works beautifully. Just like mom.'

Recommendations

This Gerber NUK ad above says `Grow With Us' because `generations of mums have trusted NUK. Various products for different stages of baby's growth are featured including feeding bottles and teats .

This Playtex ad promotes the image of bonding between mom and baby with the slogan, `Love every moment'. Among other things, the ad claims that Playtex products `mimic breastfeeding'. Most appealing of all,`mum' purportedly 'enjoyed my first full night's sleep now that my husband can feed her.'

Ample studies have shown that the health of babies can be improved by breastfeeding. For breastfeeding to thrive, there has to be a level playing field and the competition by promotion of commercial baby foods and feeding bottles and teats has got to be removed. Health care professionals in Alberta should: n Give effect to the Code and subsequent relevant World Health Assembly resolutions in Canada by advocating government for

legislation. n Advocate the Canadian government for enforcement of existing laws which prohibit claims. n Support monitoring activities by continuing to report violations to the offender and national (INFACT Canada) and interna-

tional (IBFAN-ICDC) monitoring agencies.

This pamphlet is prepared by Jennifer Peddlesden on behalf of the Alberta Breastfeeding Committee with support from INFACT Canada and IBFAN-ICDC. It forms part of a series of IBFAN pamphlets which highlight Code violations in selected areas around the world. The benchmark standards are the International Code of Marketing of Breastmilk Substitutes and subsequent relevant World Health Assembly resolutions.

Alberta Breastfeeding Committee (ABC) general@breastfeedingalberta.ca breastfeedingalberta.ca

INFACT Canada/ IBFAN North America

info@infactcanada.ca infactcanada.ca

IBFAN-ICDC Penang P.O. Box 19, 10700 Penang, Malaysia. Tel: +60 4 890 5799 ? Fax: +60 4 890 7291 ibfanpg@.my ?

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