Three weeks ago, a House of Lords committee published a report about obesity, diet and the role of the food industry with the polemical title ‘Recipe for health: a plan to fix our broken food system’. In its section on infant feeding, it made the fundamental error that formula feeding causes obesity and that promoting breastfeeding is needed to prevent childhood obesity.
The committee, it turned out, had only heard about infant feeding from witnesses from anti-industry and breastfeeding promotion organisations, who all gave the same line and were not interrogated by the committee. The evidence they provided to support their claims was not scrutinised, and had it been, different conclusions should have been reached.
So, just over two weeks after the publication of the report, we wrote to the committee to explain their mistakes around infant feeding. This was their dispiriting reply:
‘Thanks for your email and the attached letter to Baroness Walmsley. The Committee has now concluded its work and so has formally ceased to exist, which means that it is not possible for the Committee to revisit its position on the issues set out in the report, or on the evidence it received in good faith. However, the Chair is very grateful to you for taking the time to write with your concerns and for drawing them to her attention.’
We are not political commentators, but as citizens whose lives may be affected by the work done in these parliamentary groups and committees, it seems to us problematic to say the least that they can make highly politicised recommendations that potentially affect our lives and then vanish again, facing no scrutiny or accountability.
We publish here what we wrote to the committee so it is on record. Should any of the members wish to talk to us about this matter, we remain open to discussion! We are not going anywhere or vanishing any time soon.
Dear Baroness Walmsley,
Re: Misleading advice about infant feeding
Congratulations on the publication of the report ‘Recipe for health: a plan to fix our broken food system’. We agree that obesity is a significant concern that needs to be addressed. However, we are concerned that the committee has received biased and misleading advice on the matter of infant feeding.
First, the committee was advised that, at a population level, babies who are breastfed are significantly less likely to become obese (paragraph 374). This association is true, but there is no evidence that it is causal. Women in more disadvantaged groups are both more likely to bottle feed and to have obese children. This has led some to jump to the conclusion that formula milk causes obesity. To the best of our knowledge, only one randomised trial looked at the impact of breastfeeding promotion on obesity rates. This trial found that participants who received breastfeeding promotion were more likely to breastfeed and their children were more likely to be overweight or obese in adolescence (Martin et al., 2017).
Second, the committee was advised that infant formula companies give women ‘messages that make [them] doubt [their] self-efficacy to breastfeed’ (paragraph 382), and that the UK ‘should update domestic law in line with the International Code of Marketing of Breastmilk Substitutes to end the inappropriate promotion of formula milks’ (paragraph 384). However, there is no evidence that the limited marketing allowed of follow-on milk and other products by formula companies impacts parents’ early infant feeding decisions or women’s self-efficacy to breastfeed. The last Infant Feeding Survey from 2010 found that the top three reasons women gave for stopping breastfeeding were difficulties with latching the baby on, low milk supply and pain (McAndrew et al., 2012).
Third, the committee was informed of high rates of gastroenteritis in infants in Blackpool due to poor bottle-feeding practices such as ‘feeding with a propped-up bottle and re-heating bottles’ (paragraph 375). We would urge the committee to interrogate this evidence, as we suspect it is again a case of confounding by socioeconomic status. While there is good quality evidence that suggests that babies who are formula fed are more likely to have gastrointestinal infections when compared to babies who are breastfed, the difference in risk is minimal (in one good quality study, 9% versus 13%) (Kramer et al., 2001)[1], and certainly not large enough to explain ‘three times the national rate of young babies visiting A&E departments with gastroenteritis’ (Appendix 6, paragraph 45).
Fourth, the committee was told that breastfeeding is inherently responsive feeding and that breastfed babies ‘follow their own satiety cues’ (Corrected Oral Evidence: Food Diet and Obesity 07/03/2024, Q53), implying that breastfed babies cannot be overfed. This is not consistent with research that demonstrates rapid infant weight gain can occur in babies who are breastfed, as well as babies who are formula fed, and that there is a strong genetic component to weight that is not related to feeding method (Johnson et al., 2011, 2014). We are also concerned that the implication behind the statement ‘You cannot force a baby to breastfeed’ represents a stigmatising view of families who formula feed as force-feeding their babies and causing obesity. The prevalence of such attitudes undermines parents’ trust in public health services.
We believe that this misleading advice is a result of the widely held belief that exclusive breastfeeding is significantly superior to formula milk. However, even a rapid look at the evidence quickly dispels this myth (see for example Oster, 2019, or Ritchie, 2023a, b). Most studies that explore the impact of breastfeeding are observational, meaning they cannot properly account for confounders (like socioeconomic status, but also unknown confounders). There is, in fact, no high-quality evidence that demonstrates that efforts to increase rates of exclusive breastfeeding improve health outcomes in a high-income context like the UK (Fair et al., 2021). Yet, the widespread belief in the superiority of breastfeeding, together with historical poor practices by the formula industry, has led to a strong anti-industry sentiment, in turn resulting in a lack of objectivity and poor-quality advice.
We are a group of parents whose newborn babies were insufficiently fed in the early days of life following professional advice to exclusively breastfeed and to avoid infant formula. Some of our babies were readmitted to hospital because of this. We and our children have personally suffered because of the same poor-quality advice that your committee received. We urge you to seek further advice on the topic of infant feeding and reconsider your conclusions in this area.
References
Fair, F. J., Morrison, A., Soltani, H., 2021. The impact of Baby Friendly Initiative accreditation: An overview of systematic reviews. Maternal & Child Nutrition, 17(4), e13216. https://doi.org/10.1111/mcn.13216.
Johnson, L., Llewellyn, C.H., van Jaarsveld, C.H.M., et al. 2011. Genetic and environmental influences on infant growth: prospective analysis of the Gemini twin birth cohort. PLoS One. 2011;6 (5):e19918. https://doi.org/10.1371/journal.pone.0019918.
Johnson, L., van Jaarsveld, C.H.M., Llewellyn, C.H., et al. 2014. Associations between infant feeding and the size, tempo and velocity of infant weight gain: SITAR analysis of the Gemini twin birth cohort. Int J Obes (Lond). 2014 Jul; 38 (7):980-7. https://doi.org/10.1038/ijo.2014.61.
Kramer, M.S., Chalmers, B., Hodnett, E.D., et al., 2001. Promotion of Breastfeeding Intervention Trial (PROBIT): A randomized trial in the Republic of Belarus. JAMA; 285 (4):413–420. https://doi.org/10.1001/jama.285.4.413.
McAndrew, F., Thompson, J., Fellows, L., et al., 2012. Infant Feeding Survey 2010. Health and Social Care Information Centre. Available from: https://sp.ukdataservice.ac.uk/doc/7281/mrdoc/pdf/7281_ifs-uk-2010_report.pdf, Accessed date: 8 June 2022
Martin, R.M., Kramer, M.S., Patel, R., Rifas-Shiman S.L., et al., 2017. Effects of promoting long-term, exclusive breastfeeding on adolescent adiposity, blood pressure, and growth trajectories: a secondary analysis of a randomized clinical trial. JAMA Pediatr. Jul 3; 171(7): e170698. https://doi.org/10.1001/jamapediatrics.2017.0698.
Oster, E., 2019. Is breast really best? I looked at all the data to find out. The Guardian. Available from: https://www.theguardian.com/lifeandstyle/2019/jun/20/is-breast-really-best-i-looked-at-all-the-data-to-find-out. Accessed date 3 November 2024
Ritchie, S., 2023a. Does breastfeeding make kids smarter? I don’t know and you don’t either. i News. Available from: https://inews.co.uk/news/does-breastfeeding-make-kids-smarter-i-dont-know-and-you-dont-either-2273681?srsltid=AfmBOorYo8CIkn1CMM-G3D1IaceFFmT8WnMkTyeCJ1X_CsbKm3VR4umv. Accessed date 3 November 2024
Ritchie, S., 2023b. We restrict baby formula and shame mothers for using it for no good scientific reason. i News. Available from: https://inews.co.uk/news/baby-formula-restrict-shame-mothers-no-reason-2368250. Accessed date 3 November 2024
[1] It is worth noting that this study was conducted in Belarus in the 1990s and the figures in the UK today are likely to be substantially lower.