New Zealand Infant Formula Marketers Association

The New Zealand Infant Formula Marketers' Association (NZIFMA) represents the four companies marketing infant formula and follow-on formula in New Zealand: Wyeth NZ Limited, Nutricia Limited, H.J. Heinz Co (NZ) Ltd and Bayer New Zealand Ltd. Dairy Goat Co-operative (NZ) Ltd and Fonterra Group, although not marketing infant formulas in New Zealand are also NZIFMA members.

Marketing of infant formula in New Zealand is governed by the NZIFMA Code of Marketing Practice, which was formalised in 1997 in consultation with the Ministry of Health. The Code is based on the World Health Organization's International Code of Marketing Breast-milk Substitutes, and the Ministry of Health Publication: Guidelines for New Zealand Health Workers (June 1997 - ISBN 0-478-09487-6) which interprets the WHO Code in the New Zealand context.

NZIFMA works closely with the Ministry of Health and infant formula companies on all matters relating to code development and marketing compliance.

The Association welcomes this inquiry into Obesity and Type Two Diabetes in New Zealand. It provides an opportunity to focus attention on this important challenge facing the NZ community.

This submission will focus on addressing three key sections from the Terms of Reference:

1. To examine the causative factors likely to be driving increases in obesity and type two diabetes, including nutrition and physical activity.

2 To inquire into the effectiveness, particularly for children, of current obesity prevention approaches and interventions including primary prevention and screening, information provision, education, physical activity and voluntary steps taken by the food industry.

3. To consider what policy or legislative mechanisms, if any, should be used to give effect to any findings of the inquiry.

Recommendations:

NZIFMA believes that education plays an important role in empowering people to make informed choices about their health and wellbeing. NZIFMA strongly believes mothers who are not breastfeeding should have ready access to the information they need to optimise their infant’s nutrition, particularly around appropriate levels of feeding.

NZIFMA calls on the Committee to ensure that any public health campaign promoting the benefits of breast-feeding is complemented with a targeted campaign, advising mothers who formula-feed how to ensure they are feeding their baby in a safe and appropriate manner. In addition a campaign educating mothers and health workers of feeding practices to prevent overfeeding of an infant should be a priority.

We believe it is vital that campaigns promoting breastfeeding should also advise that babies would be placed at risk if mothers, who are no longer breastfeeding, provide other milks rather than infant formula or follow-on formula to their infants before they are 12 months old.

There have been many exciting developments in the field of infant nutrition, particularly with regard to the ongoing health benefits of the many bioactive substances found in milk.

In the 1960’s, manufacturers’ and researchers’ main interest was in concentrating on what infants needed for survival. What we now know is that early nutrition does matter in terms of long-term health effects. It is understood that early nutrition may have a permanent effect on growth and development of the infant. One opportunity is to alter the composition of infant formula and the other opportunity is to prevent over feeding during infancy through education.

Infant formula manufacturers have made changes to infant formulas based on new scientific evidence, for example extensive protein changes have been made. Infant formulas, particularly in the past, provided higher amounts of protein than that found in breast-milk for a number of reasons, which included poor standard of measures for protein and amino acids when compared with standards recognised today. This resulted in an over-estimation of protein intakes for the infant. Over the past 90 years infant formulas have changed from being most similar to cow’s milk, in regards to protein profile to whey dominant formulas that meet the average casein to whey ratio of human breast-milk. While international health authorities welcomed the introduction of whey dominant formulas, it was still recognized that the type and amount of whey and casein proteins found in cow’s milk and human breast milk were not the same.

Since that time manufacturers have made advancements in the type and the amount of protein. This has allowed manufacturers to lower the amount of protein, which has benefits for the infant, such as reduced renal solute load. However, innovations such as these are also expected to benefit infants who are formula-fed over the longer term, including their growth, cognition and bone health. Two thousand papers in the last 5 years have been published that demonstrate advances in the understanding of human milk. Infant formula manufacturers are committed to this research and will continue to apply this knowledge gained to infant formulas, to ensure that formula-fed infants receive the best possible start in life.

Recent research suggests that the highest priority in prevention of obesity later in life should be placed on the prevention of overfeeding during infancy. Overfeeding during infancy has been investigated in animals and humans and has shown to have an association with long-term negative health effects.^¹ Growth acceleration during infancy has been shown to have a 30% attributable risk to obesity later in life.^² A recent study investigating maternal control and infant weight gain has shown that when feeding is controlled by the infant there is less accelerated weight gain i.e. term infants had a tendency to grow along their growth curves^³ when compared with mothers who placed a high level of control over what the infant was being fed.

In today’s society where there is pressure to out perform in the areas of academia and sporting prowess, there is pressure felt by parents to ensure their child is growing faster than the norm. There is no doubt that during the first year of life mothers track closely their infant’s growth, along with their health worker. A lack of education regarding the use of growth charts by health workers and mothers and a poor understanding of infant feeding practices can result in a mother over-feeding the infant.

Therefore, there is an opportunity to affect long-term health through education of mothers and health workers of the importance of not over-feeding, by allowing infants to grow along their growth curves and prevent unnecessary accelerated growth. The release of new WHO growth charts may change the way we assess standard growth in infants and may provide the vehicle to address overfeeding during infancy with health workers.

NZIFMA will continue to work with the NZ Government and its agencies to ensure that best-practice nutrition is reflected in the composition of infant formula in NZ and in highlighting the opportunities to encourage optimal feeding practices for infants.

Diet and nutrition play a crucial role in preventing obesity and related conditions, such as type two diabetes. NZIFMA recognizes the importance of the stage between birth and childhood as a vital period of growth and development. We value the importance of making sure every child is given the best possible foundation in life.

Infant nutrition is certainly one significant part of an overall picture. Maternal nutrition while a baby is in utero, the subsequent introduction of solid foods, nutrition during childhood and nutrition in adulthood all affects the risk of various lifestyle diseases.

Obesity and type two diabetes are lifestyle diseases. Successful strategies should focus on good nutrition as a life long goal and main outcome. However, the causes of lifestyle diseases are multifactorial. Strategies to increase spontaneous exercise, including a reduction in sedentary activities in childhood (e.g. television watching) would be essential in reducing incidence amongst children.

Links between infant nutrition and obesity / type two diabetes:

NZIFMA believes that breastfeeding is the optimum method of infant feeding from birth and should be encouraged wherever possible. However, some mothers are unable to breastfeed, due to a variety of reasons, which can include illness, use of medication or where children are adopted or fostered. Where a child cannot be breastfed, infant formula and follow-on formula are the only suitable alternatives until the age of 12 months.

NZIFMA strongly believes that these mothers deserve to have access to high quality information to allow them to make informed choices about the types of formula they feed their baby, and to ensure they understand safe and appropriate methods of preparing and feeding formula, including how to avoid over-feeding.

Breast-milk is a complex substance, and like other kinds of milk, appears to have beneficial effects beyond simply providing energy and the protein “building blocks” of growth. However, the full range of these beneficial effects and their causes are not fully understood. Some studies have found that breastfeeding seems to have a small but consistent protective effect against obesity in children, but cannot explain why this is so.^⁴

Many of these studies have concluded that it is unclear whether this protective effect is due to confounding factors, and that further research is needed to explore the effect of confounding factors in more detail.^⁵^,^⁶

The problem of ‘confounding factors’ in breastfeeding studies is considerable. A confounding factor is a variable (e.g., maternal weight, maternal smoking), which is related to one or more of the variables defined in a study (e.g. breastfeeding). A confounding factor may falsely demonstrate an apparent association between the study variables where no real association between them exists. It can also mask an actual association. If confounding factors are not measured and considered, bias may result in the conclusion of the study.

What this means in practice is that in many communities, a mother’s decision to breast-feed is frequently linked to other factors, such as parental level of education, parental income, maternal smoking and maternal weight. These factors can interact and influence outcomes, and it can be difficult to account for the degree to which any one factor or combination of factors has resulted in an outcome, and indeed, if there is any causal link at all. This is particularly so when there is a long interval of time between the emergence of possible causal factors and the final effect, such as in the case of infant nutrition and obesity in later life.

There is less information about the link between breastfeeding and incidence of type two diabetes. One study found that breastfeeding in the first two months of life reduced the risk type two diabetes, however this study was carried out on a population with a high incidence of type two diabetes, the Pima Indians.^⁷ Information was collected on babies born between 1950 and 1978. It is unclear whether these findings hold true for other populations, or for babies born more recently who have been fed more modern types of formula with different compositions.

However, the link between obesity and the development of type two diabetes is well accepted, and for this reason, NZIFMA acknowledges the importance of preventing obesity as an important way of tackling the incidence of type two diabetes, and the host of other health problems related to obesity.

Any discussion of infant nutrition must recognize the importance of providing suitable foods as the infant is introduced to solids and is eventually weaned. It is generally recommended that solid foods be introduced from around 6 months onwards as a baby’s digestive system develops and they require more nutrients for growth.

Appropriately prepared and portioned fresh foods play an important role in this next stage of nutrition in a child’s life. These foods contribute to dietary habits that may last a lifetime. As a child’s diet develops to include solids the portion and type of food is important to ensure the child is able to not only achieve optimal nutrition intakes but also have an opportunity to regulate their own intakes to prevent over-feeding. Commercial products that are nutritionally balanced for children, in appropriate portion sizes, could make an important positive contribution to the nutrition of a child’s diet.

In considering the role for nutrition in obesity and type two diabetes prevention, we urge the Committee to recognize the importance of appropriate food choices throughout infancy and childhood, to ensure infants and young children receive the best possible nutrition for growth and development, and recognise that good nutrition early is essential in establishing good dietary habits for life.

Infant formula manufacturers are committed to the best possible nutrition in those infants who are not breastfed. Under the guidance of expert nutritionists and paediatric advice, the composition of infant formulas has evolved as research has uncovered new ways to improve infant formula, often by ensuring that it more closely resembles the composition of breastmilk.

There have been some misinformed reports that "infant formulas are full of sugar" and hence contribute to obesity. This statement is incorrect. All of the standard cow’s milk based infant formulas contain lactose, the same sugar found in breast milk, at the same concentration as breast milk.

Lactose exists almost nowhere else in nature, and aids the absorption of calcium and other nutrients. Researchers believe that breastmilk also contains lactose because one of its components, galactose, is used in making certain complex sugars in the brain and other tissues, although we know that babies can make galactose themselves from glucose. Soymilk formulas do not contain lactose although the sugar level is the same.

Lactose is present in breastmilk at higher levels than in cow's milk, and is also considered a very important source of readily available calories for the baby. Lactose is therefore added to formula to ensure that it is more similar to the composition of breastmilk, because research indicates this is better for babies. This is fundamentally different to “adding sugar” to a product to sweeten it or to increase the energy content with “empty calories.”

NZIFMA will continue to work closely with health authorities to ensure that best practice in infant nutrition is reflected in the composition of formulas.

Being able to accurately chart an infant’s growth against the standard is a very important tool for paediatricians and health workers to assess whether an infant is growing correctly or may be at risk of underweight or overweight. Moreover the implementation of health charts and the perceptions mothers gain from their use may have implications on child health. This provides an opportunity for further education for mothers and health workers.

The World Health Organization (WHO) published new infant growth charts on April 2006. These charts are based on a range of samples of exclusively breast-fed infants from different countries. The previous infant growth charts were based on data from several samples of formula fed children from a single country. Both sets of growth charts suffer from a number of technical and biological drawbacks. However, there is now a difference between the two sets of internationally recognised growth charts in regards to average and recommended growth rates. These differences cause us to reflect upon the current usage and implementation of infant growth charts, and highlights the need for education amongst health workers and parents to ensure that the purpose and limitations of growth charts are understood by both mother and health worker. Education will ensure that growth chart information is not incorrectly applied and so prevent inappropriate accelerated infant growth through over-feeding.

Conclusion:

Addressing and prevention the incidence of obesity and type two diabetes in New Zealand is a vital issue for our community. Strategies that target diet and nutrition will play an important role in achieving a goal of reducing the incidence of obesity and type two diabetes.

NZIFMA supports the following strategies in the area of infant nutrition to address this issue:

NZIFMA thanks the Committee for the opportunity to present this submission for consideration. If there are any queries in relation to this submission please contact:

1 Singhal A. Early Nutrition and long-term cardiovascular health. Nutrition Reviews. 2004. 64;S44-9.

2 Stettler N, Stallings VA, Troxel AB, Zhoa J, Schinnar R, Nelson SE, Ziegler EE, Strom BL. Weight Gain in the First Week of Life and Overweight in Adulthood: A Cohort Study of European American Subjects Fed Infant Formula. Circulation. 2005. 111;1897-1903.

3 Farrow C, Blissett J. Does Maternal Control During Feeding Moderate Early Infant Weight gain? Pediatrics. 2006. 118;1898-1903.

4 Arenz S, Rucker R, Koletzko B and von Kries R. Breast-feeding and childhood obesity – a systematic review. International Journal of Obesity. 2004; 28:1247-1256

5 Owen C, Martin R, Whincup P, Smith G, Cook D. Effect of infant feeding on the Risk of Obesity Across the Life Course: A Quantitative Review of Published Evidence. Pediatrics. 2005; 115:1367-1377

6 Quigley MA. Duration of Breastfeeding and Risk of Overweight: A Meta-Analysis. American Journal of Epidemiology. 2006 163(9):870-872.

7 Pettit D, Forman M, Hanson R, Knowler W, Bennett P Breastfeeding and incidence of non-insulin dependent diabetes mellitus in Pima Indians. The Lancet. 1997; 350:166-168

Introduction:

Recommendations:

Links between infant nutrition and obesity / type two diabetes:

Conclusion: