Baby Milk Action comments on the EC Green Paper “Promoting healthy diets and physical activity: a European dimension for the prevention of overweight, obesity and chronic diseases”.
Directorate-General Health and Consumer Protection
Unit C4 – Health Determinants
E-mail: SANCO-C4-NUTRITIONGREENPAPER@cec.eu.int Postal address: L-2920 Luxembourg
Date: 31st March 2006
Baby Milk Action welcomes the opportunity to comment on the important issues raised in the
European Commission‟s Green Paper and is pleased that the Commission is consdiering taking steps
to address problems related to nutrition. As a member of the global network, the International Baby
Food Action Network, we have worked for over 25 years to protect infant and young child health,
focussing mainly on the impact of marketing of foods for this sector. Together with IBFAN groups
in Germany, Luxembourg and the Netherlands, we have carried out a project, part-funded by the
European Commission, which looked at the growing phenomenon of commercially-funded
education materials. We are also members of the umbrella organisations Sustain, the Alliance for
better food and farming, the UK Food Group, the Children‟s Food Bill and the UK Baby Feeding
law Group. We therefore have an interest in many of the topics covered. Summary:
Firstly, in answer to the question on Section V: “Are there issues not addressed in the present Green Paper which need consideration when looking at the European dimension of the promotion
of diet, physical activity and health?
Yes. The Green Paper must give much greater prominence to the issue of infant and young child
feeding. Indeed, the lack of acknowledgement of the importance of breastfeeding, not only for the
prevention of obesity, but also in the prevention of specific diseases (diabetes, breast cancer),
contradicts the committments made by all EU member states, and European documents such as
"Protecting, promoting and supporting Breastfeeding in Europe: a blueprint for action" and
"Feeding and Nutrition of Infants and Young Children - guidelines for the WHO European
Region" (no. 87 of the European series of WHO Regional Publications) and the
"European Strategy for Child and Adolescent Health and Development"
(document EUR/05/5048378 of the WHO Regional Office for Europe).
Action to remove the obstacles to breastfeeding is long overdue in the European region.
Our main suggestions are summarised below:
? The Green Paper should give official endorsement in Europe that protection, promotion and
support of exclusive breastfeeding for 6 months followed by continued breastfeeding and
appropriate complementary feeding, is the best nutritional strategy for ensuring best possible
standard of health and development of infants and young children.
? All policies and practices of all EU-based organisations, European Commission, EU
Governments and commitments made in the EU Platform for Action, should be in line with
the Global Strategy on Infant and Young Child Feeding, (which includes the International
Code of Marketing of Breast-milk Substitutes and subsequent relevant World Health
Assembly Resolutions) the Blueprint for Action on the Promotion, Protection and support
Baby Milk Action Comment on EC Green Paper. March 2006 1
of breastfeeding, the Global Strategy on Diet, Physical Activity and Health and the
Convention of the Rights of the Child
? There should be recognition and implementation throughout the EU of the safeguards
contained in the above documents regarding the need to avoid potential conflicts of interest,
so ensuring that the food industry is not involved in the production of educational materials
intended for use in schools and health care systems.
? The EC should: ban the promotion of foods high in fat, salt and sugar to children; ensure that
the labelling of foods allows ingredients to be easily identified; allow no health or nutrition
claims on foods for infants, children or pregnant and nursing mothers.
? Incentives (tax rebates etc) should not be given for inappropriate products or practices.
? DG Research should provide 100% funding for research in the public interest and should
refrain from encouraging applicants to partner food companies in research projects.
? A Code of Practice on the marketing of foods to children should be drawn up which could
provide a basis for action and a common benchmark to which all stakeholders could work.
This Code could be translated into legislation at a later stage if the voluntary approach fails.
? The European Platform for Action should accept for publication on its website only
commitments that are relevant, evidence-based (proven to have a positive outcome and
affect on behaviour) and in line with public health and environmental regulations,
recommendations and Conventions to which the EU is signatory.
? The EC should ensure that trade considerations and the drive under Lisbon Agenda to make
Europe the most competitive economy, do not outweigh the EC‟s committment to protect
health, the environment and human rights.
? EC policies should raise standards of consumer protection globally, not lower them.
Why are these steps necessary?
Scientific evidence has consistently demonstrated that artificial feeding increases mortality rates, increases
rates for illnesses such as infectious diseases, chronic diseases and auto-immune diseases, offers less than
optimal development and growth, lowers cognitive and visual development. Although more work needs to
be done, epidemiological evidence - 17 of the 21 studies - strongly suggest that breastfeeding represents an
ideal window of opportunity for obesity prevention. Once a child becomes obese, it is quite likely that s/he
will remain obese as an adult. Breastmilk could also influence the development of a taste receptors profile
which fosters a preference for lower energy diets later on in life. To give just three examples:
The seven-year WHO Multicentre Growth Reference Study (MGRS) of 8,500 children in 6 ?
countries (Brazil, Ghana, India, Norway, Oman and the USA) is due to be published in April 2006
will show that babies exclusively breastfed for six months are healthier and leaner than artificially
Artificially fed infants consume 30,000 more calories than breastfed infants by 8 months of age. This ?
is equivalent to 120 chocolate bars - 4 a week! (Riordan and Aerbach Breastfeeding & Human
Lactation Jones and Bartlett 1999)
The USA Centre for Disease Control and Prevention (CDC) considers that there are only two ?
potential, cost-effective interventions that can be put into place immediately to deal with the
childhood obesity epidemic: decreased television viewing and breastfeeding promotion. (Dietz WH.
Breastfeeding may help prevent childhood overweight. JAMA. 2001; 285:2506)
The survey on breastfeeding rates in Europe done by the authors of the Blueprint for Action on
Breastfeeding in Europe (a project funded by the European Commission) has shown that Breastfeeding rates in Europe are generally lower than the World Health Organization (WHO) recommendations and the targets
set by national governments. Even in countries where a high proportion of mothers choose to breastfeed from
birth, numbers fall significantly in the first six months. The number of mothers exclusively breastfeeding at
six months is low throughout Europe.
Baby Milk Action Comment on EC Green Paper. March 2006 2
EU Member States, European Parliamentarians and the thousands of NGOs, have been calling for greater
protection of breastfeeding and infant health ever since the International Code of Marketing of Breastmilk Substitutes was first passed in 1981. 82 out of 192 Member States of WHO have policies recommending 6
months exclusive breastfeeding. This includes 12 countries in the european region: Azerbaijan, Belarus,
Bosnia, Bulgaria, Czech Republic France, Georgia, Germany, Luxembourg, Netherlands, Slovakia and the
The Resolution which adopted the Code in 1981 ( WHA 34.22 ) stated that:
“...the adoption of and adherence to the International Code...is a minimum requirement and only
one of several important actions required in order to protect health practices in respect of infant and
young child feeding... [WHA] urges all Member States to give full and unanimous support to
the ...International Code in its entirety as an expression of the collective will of the membership of
the World Health Organisation.”
Answers to other specific questions:
IV.3. 2 What are the concrete contributions which Community policies, if any, should make towards
the promotion of healthy diets and physical activity, and towards creating environments which make
healthy choices easy choices?
The enlargement of European Community has provided a long overdue and important opportunity to
ensure that European policies – TV without Frontiers, CAP, all policies relating to food, Reseach
and scientific advice, are assessed for their health consequences. As a first step the relevant policies
should be brought into conformity with the recommendations of the UN and specfically the World
Health Organisation, the world‟s highest health policy setting body. Parents and infants and young children in the European Union (and those in countries where EU
products are exported) have a right to independent information and to the protection from
commercial exploitation and the European Community has a responsibility to help Member States
fulfill the obligations contained in the UN recommendations, rather than placing obstacles in their
way as it is now doing.
? The EC should implement policies which will effectively remove the obstacles to breastfeeding
and ensure that decisions regarding infant and young child feeding are taken outside the
commercial arena. These actions can be more important than promotion campaigns, since it is
often impossible for public health bodies to compete with the volume of materials produced by
? The EC should also ensure implementation of evidence-based programmes such as the
WHO/UNICEF Baby Friendly Initiative throughout all European health care systems, educational
establishments and in the community.
? The EC should ensure that all policies and practices of all EU-based organisations, European
Commission, EU Governments and commitments made in the EU Platform for Action, are in line
with the Global Strategy on Infant and Young Child Feeding, (which includes the International
Code of Marketing of Breast-milk Substitutes and subsequent relevant World Health Assembly
Resolutions) the Blueprint for Action on the Promotion, Protection and support of breastfeeding,
the Global Strategy on Diet, Physical Activity and Health and the Convention of the Rights of the
? The EC should ban the promotion of foods high in fat, salt and sugar to children; ensure that the
labelling of foods sold within the community and exported from it, allows ingredients to be easily
identified; allow no health or nutrition claims on foods for infants, children or pregnant and nursing
Baby Milk Action Comment on EC Green Paper. March 2006 3
? The EC should recommend as EU wide policy, the adoption of sound nutritional standards for
schools meals and the removal of sugary, fatty and salty foods from vending or other outlets in
? The EC should encourage Member States to support the provision of mother-to-mother support
? The EC should recommend that nutrition education materials are not provided by food companies.
? The EC should ensure that incentives (tax rebates etc) are not given for inappropriate products or
On which areas related to nutrition, physical activity, the development of tools for the analysis of
related disorders, and consumer behaviour is more research needed?
There is a need for more research into the impact of public private partnership and food-industry sponsored
education materials, specifically looking at children‟s understanding of what is and is not a healthy diet and
the impact of the materials on behaviour. There needs to be specific attention paid to the promotion of
reformulated and generic/non-branded products and whether their presentation as a healthy option increases
overall calorie consumption. For example, some sections of the food industry defend the promotion of
chocolate as an aid to concentration. What message does this convey to the child? It is important that such
research is funded by and carried out by those who are not involved in marketing foods.
For example, there is widespread promotion of breast milk substitutes in the UK but manufacturers
vigorously proclaim that the legislation is strict and that their promotion does not undermine breastfeeding
and or lead to confusion. But a Mori survey commissioned by UNICEF and National Childbirth Trust in
2005 found that 31% of mothers said that the adverts they had seen implied that infant formula is as good as
breastmilk. 17% of those who used follow-on milks said they started before their baby was three months old
– even though it is unsuitable for children of this age. A Department of Health survey in 2004 found that
over a third (34%) of women believed that infant formulas are very similar or the same as breast milk. A
large proportion of parents
Questions on Section IV.4
How can the availability and comparability of data on obesity be improved, in particular with a view
to determining the precise geographical and socio-economic distribution of this condition?
Ensure that sufficient research is available that has been 100% funded from independent sources. DG
Research should be encouraged to change its present strategy of encouraging applicants to find business
partners for research projects. The potential for bias is present in all research. However, it is reduced if
research is commissioned and funded by a disinterested party rather than one active in the market. IBFAN
has been advocating that research on infant and young child feeding which forms the basis for public health
policies is free from commercial influence and we have been calling for funding bodies to provide 100%
funding for research in this specific, and quite well-defined area. We believe that this would help guarantee
optimal levels of health protection and would improve public trust. (NB: 100%public funding for essential
research into infant feeding would not prohibit manufacturers from carrying out research to improve the
safety and composition of their products.)
There is also a moral imperative to avoid conflict of interest. The WHA resolution 58.32 (2005) urges
Member States "to ensure that financial support and other incentives for programmes and health
professionals working in infant and young child health do not create conflict of interest" and “to ensure
that research on infant and young-child feeding, which may forms the basis for public policies, always
contains a declaration relating to conflicts of interest and is subject to independent peer review”.
Baby Milk Action Comment on EC Green Paper. March 2006 4
Questions on Section V
Which kind of education is required in order to enable consumers to fully understand the information
given on food labels, and who should provide it?
Labelling: Manufacturers have a responsibility to ensure that the labelling of foods allows ingredients to be
easily identified and the product safely used. Clear nutrition labelling, the Traffic Light scheme proposed by
the UK Food Standards Agency and llabelling in line with the International Code, would contribute to this.
Health or nutrition claims are not an appropriate way to convey health messages and should
not be permitted. They appear most frequently on processed packaged foods and breast milk
substitutes – while the foods that are healthier: fresh fruits and vegetables and breastmilk – do not
carry claims. A misleading impression is inevitably portrayed. Health and nutrition claims are also
invariably backed by industry-funded research.
Provision of appropriate education materials: The Green Paper itself highlights the need to ensure that consumers are not misled and that children are not exploited. However, nowhere in the Green Paper is there
recognition of how easily health and education establishments can become channels for commercial
propaganda which masquerades as „education.‟ Inappropriately funded materials and facilities can distort children and parents understanding of what is and is not a healthy diet and it is extremely difficult to monitor
the extent of their use. The presence of such materials can negatively influence the quality of health
education and distort the curriculum in favour of business interests. Health professionals, teachers and
educators must be free to address nutrition issues freely without censure. When education or health
establishments are encouraged to look to the food industry for the provision of core educational materials
and facilitries their independence is compromised and their task of providing unbiased and objective
education is made much more difficult.
In this context the Convention on the Rights of the Child (CRC) is important. The CRC recognises the right
of every child to health and education, and their rights to protection from exploitation. The CRC could be
used in the context of education and marketing to children to ensure that educational materials are not
provided by people who also have an interest in selling products to children.
Article 24 (1.e) of the CRC calls on States Parties : “To ensure that all segments of society, in particular
parents and children, are informed, have access to education and are supported in the use of basic
knowledge of child health and nutrition, the advantages of breastfeeding, hygiene and environmental
sanitation and the prevention of accidents”
Article 17 calls for: “the development of appropriate guidelines for the protection of the child from
information and material injurious to his or her well-being.”
Article 32: “States Parties recognize the right of the child to be protected from economic
exploitation and from performing any work that is likely to be hazardous or to interfere with the
child's education, or to be harmful to the child's health or physical, mental, spiritual, moral or social
Article 36 says: “States Parties shall protect the child against all other forms of exploitation
prejudicial to any aspects of the child's welfare.”
Baby Milk Action Comment on EC Green Paper. March 2006 5
Education on parenting skills: It is especially important that information on infant feeding and parenting
skills is independent. Breastfeeding instructions produced by breastmilk substitutes manufacturers are
connected to a high frequency of artificial feeding. This is because of the way the instructions are given and
because when breast-milk substitutes are compared with breastfeeding, equivalence is implied - even if it is anot stated. As mentioned above, according to a Department of health Survey in 2004, despite the claims
that commercial promotion is supportive of breastfeeding, over a third (34%) of women in the UK believe
that infant formulas are very similar or the same as breast milk.
The NHS paper, Breastfeeding for longer – what works? provides an overview of key findings from a series of systematic reviews of studies of interventions relevant to the continuation of breastfeeding, together with
recommendations for practice and policy. The report concluded that the provision of materials produced by
formula companies on infant feeding in early pregnancy was not effective in extending the duration of bbreastfeeding and should not be used without further evidence of effectiveness.
Concerns about the impact of business sponsorship of education materials on health and the need to have
been expressed by the Baby Feeding Law Group – the ad-hoc group of 15 health professional and lay organisations (including the Royal College of Midwives - Royal College of Nursing - Royal College of
Paediatrics and Child Health, Unicef’s UK Baby Friendly Initiative and the National Childbirth Trust.
Question on Section V: Are voluntary codes (“self-regulation”) an adequate tool for limiting the advertising and marketing of energy-dense and micronutrient-poor foods? What would be the
alternatives to be considered if self-regulation fails?
No. Voluntary Codes cannot be relied on as a solution for this problem. IBFAN‟s experience of monitoring the baby food industry over 25 years, and the International Case Studies, “Using International
Tools to stop Corporate Malpractice – does it work?” has shown that when controls are comprehensive and independently monitored and enforced breastfeeding rates are increasing (or the decline is being halted) and
that this feeds through to reduced morbidity and mortality. Controls based on the International Code and
Resolutions have now been introduced in nearly 90 countries with over 60 with what we would consider to
be strong laws. UNICEF estimates that globally since 1990, exclusive breastfeeding rates have increased by
15% and that the controls on marketing have contributed to this rise.
It is important that regulations are clear and precise and that enforcement bodies are provided with sufficient
resources to ensure implementation. The lack of clarity in the UK legislation on the marketing of infant
formula, for example, has been described by Food Standards Enforcement Officers to ”hinder[s] the
effectiveness of the enforcing bodies, to the detriment of mothers and infants.”
? A Code of Practice on the marketing of foods to children should be drawn up taking the
International Code of Marketing of Breastmilk Substitutes as its model. This could provide a
basis for action and a common benchmark which all stakeholders could work to. This Code
should be translated into legislation.
How can effectiveness in self-regulation be defined, implemented and monitored?
Self-regulation is always difficult to monitor because companies work to their own codes of practice and
these can vary over time and from country to country and sometimes from shop to shop. There is no
common benchmark on which to judge effectiveness of these measures. Voluntary codes drawn up by
companies are also usually narrow and entirely dependent on industry's goodwill. If companies choose not
to behave, very little can be done.
a Results and policy implications of the cross-national investigation: rethinking infant nutrition policies under changing socio-
economic conditions. Marchione TJ and Helsing E. Project report, Acta Paediatrica Scandinavica 1984;Suppl 314. b Howard et al., 2000
Baby Milk Action Comment on EC Green Paper. March 2006 6
IBFAN‟s experience of monitoring the baby food industry over the last 25 years has shown the value of
having a level playing field for all companies and a common international benchmark, which in the case of
infant feeding is the International Code of Marketing of Breastmilk Substitutes and the 11 subsequent WHA Resolutions. With a very few exceptions – and despite vigorous claims to the contrary – companies continue to market products in violation of the Code wherever it is not effectively implemented in legislation. c
Companies also invariably challenge the validity of independent monitoring – any monitoring carried out without their participation – so it is important that monitoring bodies are established which can command
the confidence of the public.
The international benchmark enables monitors to be trained using the same protocol all over the world.
Training is provided by IBFAN‟s International Code Documentation Centre (ICDC) under the auspices of
national governments and/or UNICEF field offices. The monitoring reports which are produced are an
essential tool which governments use to help improve controls and ensure that they keep pace with
Whatever strategy is used – self-regulation or legislation - it is essential that Member States are encouraged
to set up monitoring bodies that are entirely independent. While all companies and NGOs have a
responsibility to monitor their own practices, it is essential that there is in addition an independent
monitoring procedure. It is important also to define the word „independent‟. Simply hiring a firm to carry
out an audit for you is not the same as being monitored by an entirely independent body. The EU should
either find funds to carry out this task, or encourage Member States to do this at national level.
Which measures should be taken towards ensuring that the credulity and lacking media literacy of
vulnerable consumers are not exploited by advertising, marketing and promotion activities?
See comments above regarding education materials.
There seems to be no evidence that providing primary school children with industry-funded media literacy
programmes such as Media Smart, have any positive impact on children‟s behaviour with regard to the
consumption of inappropriate foods. We believe that such schemes are another – albeit very sophisticated - form of marketing which has the potential to exploit children.
It is an undeniable fact that corporations have a legal duty to maximise profits for their shareholders. Any
investment – in education or anything else – must show a return, in either the short or long term. Teaching
materials and media literacy schemes such as Media Smart present an even more complex problem than
brand promotions. Their educational content is difficult to evaluate and through them the boundaries between
advertising, marketing and independent information become blurred. Such schemes allow companies –
many of which will be marketing products irresponsibly - to gain the trust of children and teachers, to
rewrite history and to reposition themselves in society as providers of healthy food.
In 1998 Baby Milk Action conducted a survey of head teachers in the UK for the development of our
education pack, Seeing through the Spin, Public relations in the Global Economy. (www.babymilkaction.org/spin) This pack, which was funded by the European Commission, aims to develop
students‟ critical faculties, and to provide them with the tools they need deconstruct the many subtle PR messages they receive. From our research it seems that teachers have no formal way (other than their own
judgment) of assessing material which was sent to them – much of it unrequested.
If the EC does not consider it feasible to ban the food industry from providing nutrition or health education
materials in schools or media-literacy schemes, it should ensure that it does nothing to promote the notion
that such schemes are endorsed. This Green Paper should explicitly acknowledge that there is an inherent
conflict of interest which cannot be surmounted.
c IBFAN‟s Breaking the Rules, Stretching the Rules 2004 www.ibfan.org/site2005/Pages/article.php?art_id=302&iui=1
Baby Milk Action Comment on EC Green Paper. March 2006 7
Question V.2 What contributions can public-private partnerships make toward consumer
In IBFAN‟s experience, public-private partnerships involving food or other industries, especially those marketing products to or for children, carry very many risks which are rarely acknowledged by those dinvolved in the partnerships. They should be avoided unless absolutely necessary and in any case strictly managed to avoid conflicts of interest and ensure transparency. As a safeguard, any provision of public
services (school or education facilities etc) should not be bound by rules of commercial confidentiality. See
also comments on education above.
Question V.4 How can employers succeed in offering healthy choices at workplace canteens,
and in improving the nutritional value of canteen meals?
In addition to ensuring that fresh fruits and vegetables are provided and junk foods kept to the very minimum,
employers must ensure that adequate provisions, including nursing breaks are provided for employees and
that all practices at the very minimum meet the requirements of the ILO Convention 183 on Maternity
Protection at the Workplace.
Restaurants, cafes and all public places should ensure that breastfeeding is encouraged and that nursing
mothers are made welcome.
Question on V10.2
Under which conditions should the Community engage in exchanging experience and identifying best
practice between the EU and non-EU countries? If so, through which means?
The impact that EU policies have globally must not be forgotten. The EC should ensure that trade
considerations and the drive under Lisbon Agenda to make Europe the most competitive economy,
do not outweigh the EC‟s committment to protect health, the environment and human rights. In all
its relations with non-EC countries the EC should seek to raise standards of consumer protection
globally, not lower them.
As stated by Commissioner Kyprianou, when referring to the Lisbon agenda to make Europe the
world‟s most competitive economy: “Everybody agrees Europe needs to create jobs, boost productivity, increase labour participation. What is sometimes overlooked is that these measures
require a population in good health. I am pleased that Healthy Life Years are integrated into the Lisbon agenda. But health will only be a concrete part of Lisbon if Member States themselves einclude health measures in their action plans to fulfil those goals.”
As long as EU policies to protect breastfeeding fail to meet the minimum requirements of the UN
and lag far behind other countires, an imbalance is created and as a consequence, rather than raising
international standards of protection in fora such as the World Health Assembly and Codex, the EU
has been responsible for lowering them. The imbalance also affects the technical assistance which
is provided by the EU to non-EU and assession countries. The new proposals for the recast
Directive on Infant Formula, compound this problem by opening the door to marketing practices and
strategies which undoubtedly undermine breastfeeding. This cannot continue.
d Richter. J, Public-Private Partnerships and International Health policy Making, How can public interests be
safeguarded? Ministry of Foreign Affairs of Finland, DPIU www.gaspp.org/publications e European Health Forum Gastein - Session: European Health and partnership challenges. The widening health divide in
Europe. Partnerships between the state and its citizens, health reforms and patients safety Gastein, 7 October 2005
Baby Milk Action Comment on EC Green Paper. March 2006 8
It must not be forgotten that for developing countries breastfeeding and appropriate complementary
feeding are a matter of life and death: they help fulfil the Millennium Development Goals and have fthe potential to reduce under-5 mortality by 19%.
The importance of breastfeeding is recognised in the new World Bank Nutrition Strategy, Repositioning Nutrition as central to Development – a Strategy for Large Scale Action, which specifically cites the need for protection of breastfeeding as a policy intervention. “Breastfeeding promotion and appropriate
complementary feeding for children are a central part of growth promotion programs listed as a short route
to improving nutrition in table 3.1. But they deserve special mention, both because adequate breastfeeding
and complementary feeding could prevent more than twice as many deaths of children under age five as any
other intervention9and because there are ways to improve these interventions besides growth promotion
programs. An important policy intervention is enforcing the International Code on the Marketing of Breast
Milk Substitutes, which prevents inappropriate promotion and marketing of commercial infant formula
products. A second way to improve breastfeeding is through the Baby-Friendly Hospital Initiative, which
applies a 10-step process to improve practices in the labor and delivery wards of hospitals. The tenth step,
focusing on follow-up at the community level, has been among the most challenging to implement. A third
intervention, peer-to-peer counseling on breastfeeding (such as through La Leche League), has been used
throughout the world to extend breastfeeding support to communities.”
f Jones G et al. (2003) How many child deaths can we prevent this year? The Lancet, no 362, 65-71.
Risks of formula feeding A brief annotated bibliography INFACT Canada, updated May 2004
Baby Milk Action Comment on EC Green Paper. March 2006 9