Does Formula Advertising Really Influence Anyone’s Decisions?

Miriam H. Labbok, MD, MPH, IBCLC FACPM, FABM, FILCA

Professor and CGBI Directorand

Kathy Parry, MPH, IBCLCCGBI Project Director

August 21, 2013

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

Outline1. Brief review of why breastfeeding is vital for

our future in the US.2. Research on the influence of commercial

formula advertising on breastfeeding3. Consideration of guilt and shame4. What can WIC do – what can I do – to make a

difference?

Breastfeeding is the Heartbeat of Family Health:

Logo, Breastfeeding Division, IRH; adapted and modified by CGBI

Oral Rehydration

Growthand Development

Immunization / disease prevention

Reduced Maternal Cancer and Improved

Health

Birth Spacing /Fertility Reduction

Reduced Child Cancer and Chronic Disease

Savings of Family Resources

Infant and Young Child Nutrition

CIYCFC Labbok, 2008

2020 Goal

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

1990 Innocenti Declaration“Four Pillars”

1. Government commitment2. Health System

-- Quality assurance=Ten Steps-- Education of health professionals

3. Control of formula marketing-- Media-- Health personnel-- WIC

4. Workplace-- Paid leave and breaks-- Co-located child care

5. Community support with

Demand Creation

CIYCFC Labbok, 2008

2020 Goal

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

20032005

2007

2007 non-WIC

2007 WIC

0

5

10

15

20

25

30

35

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

EBF6

EBF3

Exclusive breastfeeding lags among WIC participants…

Percent Exclusively Breastfeeding at 3 and 6 months

Last issue: African Americans – on average - are least likely to breastfeed or to exclusively breastfeed

ANDAfrican 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

Outline

1. Brief review of why breastfeeding is vital for our future in the US.

2. Research on the influence of commercial formula advertising on breastfeeding

3. Consideration of guilt and shame4. What can WIC do – what can I do – to make a

difference?

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 familyWe care about kidsWe care about the communityWe care about the environment”

And what, exactly, does all this have to do with

breastfeeding?

What is Promised?What is Exploited?

Which image is modern and youthful and sexy?

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

“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

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.

How Does This Commercial Advertising Affect Women and their Partners?

• Cumulative impact of long-term exposure to various formula marketing techniques over a lifetime

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

Study Designed to Increase Understanding of How Women Perceive Formula

Marketing4 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

CHARACTERISITIC n (%)RACE/ETHINICITYWhite 26 (76)Black 6 (18)Hispanic 0 (0)Asian / Pacific 2 (6)

American Indian 0 (0)EDUCATION< Bachelor’s 5 (15)Bachelor’s Degree 10 (29)Master’s Degree 16 (47)Prof. Degree 3 (9)

CHARACTERISTIC n (%)ANNUAL HH INCOME

< $40,000 7 (21)$40,001 - $99,999 18 (53)

> $100,000 9 (26) AGE (YEARS) 18-25 3 (9)26-35 19 (56)36-45 8 (24)Missing data 4 (12)

Population in Focus Groups

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

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.”

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.’”

?

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?”

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

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

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.”

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

CDC NIH Breastfeeding Data for Children Born 2000-2009

How advertising supports first supplementation

Perceptions from Exposure to Advertisements

• 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

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

The Case for Increasing UnbiasedPrenatal Infant Feeding Education

Feeding Decisions Often Made

During Pregnancy or earlier

WIC counseling for breastfeeding

Self-Efficacy to improves duration

BFHI Step 3

Reasons for First Time

Supplementation

Susceptibility to formula ads and

products confirmed by

research

CDC Guide to BF Interventions ABM Protocols

3, 14, 19 and others

Understanding baby’s cues/

language

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)

WIC CAN MAKE A

REAL DIFFERENCE

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

Outline1. Brief review of why breastfeeding is vital for

our future in the US.2. Research on the influence of commercial

formula advertising on breastfeeding3. Consideration of guilt and shame4. What can WIC do – what can I do – to make a

difference?

The Reality of External Pressures…

Comic used withCourtesy of Neil

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.

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 guilt

GUILT is a self-created set of feelings if our shame is not addressed

Maternal guilt is ubiquitous...

If breastfeeding is something ‘Good’ and, therefore, something that must be done, thenDo mothers alone bear the responsibility and, hence, the guilt?

Who should be bearing the burden of guilt?

From the Rights Perspective: • Family, community, and, in the bigger picture,

States partiesFrom the System Perspective:• Providers• Three aspects that influence clinician actions

and communications: – 1) science; – 2) personal experience; – 3) lack of professional experience

GUILTY!!

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

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.

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.

WE CAN CHANGE UNHEALTHY CONFORMITY

Societal guilt may have an important role to play – but as health/nutrition change agents, we have an essential

role to play

Outline1. 1Brief review of why breastfeeding is vital for our future in

the US.2. Research on the influence of commercial formula advertising

on breastfeeding3. Consideration of guilt and shame

4. What can WIC do – what can I do – to make a difference?

Perceived barriers to exclusive breastfeeding, and to utilization of expanded food package

1. WIC promotes breastfeeding but…2. Exclusive BF package not valued3. Hospitals/ doctors promote formula4. Benefits of EBF not understood5. “Supply-&-demand” not understood6. Formula: crucial reserve, no harm7. Work and school are key reasons8. Few moms express for comfort9. Pumping challenging10. Nursing in public is not accepted

Holmes A, Chin N, Kaczorowshi J, Howard C. A barrier to exclusive breastfeeding for WIC enrollees: limited use of exclusive breastfeeding food package for mothers.(Women, Infants, and Children) Breastfeeding Medicine.  March 2009, 4(1): p25(6). 

Things to think about….• Do you assume breastfeeding at all visits?• Prenatally - How might you counsel a mother or family in

light of the information presented today? List 3-5 key points you would make.

• First Postpartum contact – List 3 reasons a mother may be doubting breastfeeding during the first days and weeks, and consider what you might counsel

• Plan of Action – 1) Listen to yourself – is anything you are saying creating doubt concerning the superiority of breastfeeding and risks associated with formula feeding? 2) List those experiences, and consider what else you might have said.

Some thoughts…• Formula samples in the home do decrease duration, therefore:

– Encourage avoidance of accepting samples or keeping them in the house

– Counsel on alternative problem-solving approaches

• You know many women have been convinced to view formula as a “solution”, therefore …

– Emphasize the common experiences: discuss the common “bumps in the road” at different infant ages – days 1-7, days 10-14, wks 2-6, wks 10-12.

– Offer/discuss solutions to problems is through support/resources – offer ways of getting help

YOU are the one who will make optimal breastfeeding a reality.

Thank you!

Questions?(Please address any remaining questions to rlee@nwica.org)

Basic Bibliography• Jensen E, Labbok M. Unintended consequences of the WIC formula rebate program on infant feeding outcomes: Will the new food packages be enough? Submitted for publication• Evans K, Labbok M, Abrahams S. WIC and Breastfeeding SupportServices: Does the mix of services offered vary with race and ethnicity? Submitted for publication • Centers for Disease Control. National Immunization SurveyBreastfeeding Data www.cdc.gov/breastfeeding/data/• Holmes A,Chin N,et al. A Barrier to Exclusive Breastfeeding for WIC Enrollees: Limited Use of Exclusive Breastfeeding Food Package for Mothers. Breastfeeding Medicine 2009 Mar;4(1): 25-30.• USG Accountability Office. Some Strategies Used to Market InfantFormula May Discourage Breastfeeding; State Contracts Should Better Protect Against Use of WIC Name. 2006; i-40.•United States Government Accountability Office. FNS Could TakeAdditional Steps to Contain WIC Infant Formula Costs. 2006; i-38.•Maternal Request for In-hospital Supplementation of Healthy Breastfed Infants among Low-income Women. Katie DaMota, Jennifer Bañuelos, Jennifer Goldbronn, Luz Elvia Vera-Beccera and M. Jane Heinig. J Hum Lact 2012 28: 476

Select Resources by TopicTopic: Infant Formula – Pervasive and Expensive• Parry K et al

• U. S. Government Accountability Office. Report to Congressional Addressees: Breastfeeding. Washington, DC, 2006.

• Kaplan D.L. and Graff K.M. Marketing Breastfeeding – Reversing Corporate Influence on Infant Feeding Practices. J Urban Health. 2008 July; 85(4):486-504

• Kent G. WIC’s Promotion of Infant Formula in the United States. Int Breastfeed J. 2006 Apr 20; 1(1):8.

• Fentiman L.C. Marketing Mothers’ Milk: The Commodification of Breastfeeding and the New Markets for Breast Milk and Infant Formula. Nevada Law Journal. 2010; 10 (1): Article 3.

Select Resources by TopicTopic: Social Media• 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.

• ILCA Blog: The International Code: Is it still relevant in an information age? By Norma EscobarPart 1: http://lactationmatters.org/2013/03/12/the-international-code-part-1/Part 2: http://lactationmatters.org/2013/03/14/the-international-code-is-it-still-relevant-in-an-information-age-part-2/

Select Resources by TopicTopic: Exposure to Infant Formula Marketing • Bergevin Cynthia Dougherty Y, Kramer MS. Do infant formula samples shorten the duration of

breast-feeding? Lancet. 1983;321(8334):1148-51.• Caulfield LE, Gross SM, Bentley ME, Bronner Y, Kessler L, Jensen J, et al. WIC-based

interventions to promote breastfeeding among African-American women in Baltimore: effects on breastfeeding initiation and continuation. J Hum Lact. 1998;14(1):15-22.

• Dungy CI, Christensen-Szalanski J, Losch M, Russell D. Effect of discharge samples on duration of breast-feeding. Pediatrics. 1992;90(2):233-7.

• Eastham CA. Differential effect of formula discharge packs on breastfeeding by maternal race/ethnicity. APHA 133rd annual meeting and exposition. Philadelphia. 2005.

• Rosenberg KD, Eastham CA, Kasehagen LJ, Sandoval AP. Marketing infant formula through hospitals: the impact of commercial hospital discharge packs on breastfeeding. Am J Public Health. 2008;98(2):290-5.

• Donnelly A, Snowden HM, Renfrew MJ, Woolridge MW. Commercial hospital discharge packs for breastfeeding women. Cochrane database of systematic reviews (Online). 2000(2):CD002075.

• Parry, K; Taylor, E; Labbok, M. Understanding Women’s Perceptions of Infant Formula Advertising. Birth 40:2 June 2013

Select Resources by TopicTopic: Prenatal Breastfeeding Education Research and Related• Lumbiganon P, Martis R, Laopaiboon M, Festin MR, Ho JJ, Hakimi M. Antenatal breastfeeding education for

increasing breastfeeding duration. Cochrane Database of Systemic Reviews. 2012. Issue 9. Prenatal BF education appear to increase BF duration, however, no specific antenatal BF Education can be recommended due to methodological limitations.

• Dyson L, McCormick FM, Renfrew MJ. Interventions for promoting the initiation of breastfeeding. Cochrane Database of Systemic Reviews. 2005. Issue 2. Subgroup analysis showed that one-on-one, needs-based, informal repeat BF Ed sessions and generic, formal antenatal education sessions (less so) are effective in terms of an increase in BF rates among women on low incomes regardless of ethnicity and feeding intention.

• Cauto de Oliviera, MI, Camacho, LAB, Tedstone, AE. Journal of Human Lactation. 2001;17:326-343. Group prenatal education was effective in increasing BF duration in 6/8 studies analyzed.

• US Preventative Services Taskforce Report on Breastfeeding Interventions:– http://www.uspreventiveservicestaskforce.org/uspstf08/breastfeeding/brfeedsyn.pdf

• CDC Guide to Breastfeeding Interventions:– http://www.cdc.gov/breastfeeding/pdf/breastfeeding_interventions.pdf