The Lancet has just published its commissioned series on breastfeeding, vs the commercial formula industry: three papers, an editorial, and a comment.

Breastfeeding has proven health benefits for both mothers and babies in high-income and low-income settings alike. Yet, less than 50% of babies worldwide are breastfed according to WHO recommendations. For decades, the commercial milk formula industry has used underhand marketing strategies, designed to prey on parents’ fears and concerns, to turn the feeding of infants and young children into a multibillion-dollar business—generating revenues of about $55 billion each year.

Editorial: Unveiling the predatory tactics of the formula milk industry

For decades, the commercial milk formula (CMF) industry has used underhand marketing strategies, designed to prey on parents’ fears and concerns at a vulnerable time, to turn the feeding of young children into a multibillion-dollar business. The immense economic power accrued by CMF manufacturers is deployed politically to ensure the industry is under-regulated and services supporting breastfeeding are under-resourced.

Breastfeeding: crucially important, but increasingly challenged in a market-driven world. R Pérez-Escamilla,, et al.

In this Series paper, we examine how mother and baby attributes at the individual level interact with breastfeeding determinants at other levels, how these interactions drive breastfeeding outcomes, and what policies and interventions are necessary to achieve optimal breastfeeding.

Marketing of commercial milk formula: a system to capture parents, communities, science, and policy.  N Rollins et al.

We report how CMF sales are driven by multifaceted, well resourced marketing strategies that portray CMF products, with little or no supporting evidence, as solutions to common infant health and developmental challenges in ways that systematically undermine breastfeeding. Digital platforms substantially extend the reach and influence of marketing while circumventing the International Code of Marketing of Breast-milk Substitutes.

The political economy of infant and young child feeding: confronting corporate power, overcoming structural barriers, and accelerating progress.  P Baker, et al.

First, this paper highlights the power of the commercial milk formula (CMF) industry to commodify the feeding of infants and young children; influence policy at both national and international levels in ways that grow and sustain CMF markets; and externalise the social, environmental, and economic costs of CMF. Second, this paper examines how breastfeeding is undermined by economic policies and systems that ignore the value of care work by women, including breastfeeding, and by the inadequacy of maternity rights protection across the world, especially for poorer women. Third, this paper presents three reasons why health systems often do not provide adequate breastfeeding protection, promotion, and support.

Comment: Stemming commercial milk formula marketing: now is the time for radical transformation to build resilience for breastfeeding, by Tanya Doherty et al.

One of the striking messages of the Lancet Breastfeeding Series is that the consumption of commercial milk formula (CMF) by infants and young children has been normalised. More children are consuming CMF than ever before. Only 48% of the world’s infants and young children are breastfed as recommended, despite the huge body of evidence on the lifelong benefits of breastfeeding. This situation reflects the stranglehold the CMF industry has on governments, health professionals, academic institutions, and increasingly on caregivers and families through pervasive social media.

*******

For 30% off, go to www.ucpress.edu/9780520384156.  Use code 21W2240 at checkout.

The USDA is trying to improve nutrition standards for school meals.  I wish it the best of luck.

It is proposing over the next several years to:

• Limit added sugars in certain high-sugar products and, later, across the weekly menu;
• Allow flavored milk in certain circumstances and with reasonable limits on added sugars;
• Incrementally reduce weekly sodium limits over many school years; and
• Emphasize products that are primarily whole grain, with the option for occasional non-whole grain products.

This does not make it sound as if USDA is in much of a hurry.  Or that it is doing anything particularly radical.

Take the sugar proposals, for example.  Currently, the re are no limits on sugars in school meals, which means that any limits ought to be an improvement.  The USDA proposal sugar limits in two phases:

1. Product-based limits: Beginning in school year (SY) 2025-26, the rule proposes limits on products that are the leading sources of added sugars in school meals:
   1. Grain-based desserts (cereal bars, doughnuts, sweet rolls, toaster pastries, coffee cakes, and fruit turnovers) would be limited to no more than 2 ounce equivalents per week in school breakfast, consistent with the current limit for school lunch.
   2. Breakfast cereals would be limited to no more than 6 grams of added sugars per dry ounce. This would apply to CACFP [Child and Adult Care Food Program] as well, replacing the current total sugars limit.
   3. Yogurts would be limited to no more than 12 grams of added sugars per 6 ounces.
   4. Flavored milks would be limited to no more than 10 grams of added sugars per 8 fluid ounces for milk served with school lunch or breakfast. For flavored milk sold outside of the meal (as a competitive beverage for middle and high school students), the limit would be 15 grams of added sugars per 12 fluid ounces.
2. Overall weekly limit: Beginning in SY 2027-28, this rule proposes limiting added sugars to an average of less than 10% of calories per meal, for both school breakfasts and lunches. This weekly limit would be in addition to the product-based limits described above.

Sugary products will still be allowed.  And schools have 4-5 years to comply (by that time, today’s elementary school children will be in high school).

Why the pussy-footing?  The USDA must be expecting ferocious pushback, and for good reason.  Anything, no matter how small, that threatens sales of foods commonly sold in schools will incite fights to the death.

• The dairy industry is gearing up to complain about restrictions on chocolate milk, which accounts for substantial revenues.
• The industry-funded School Nutrition Association, which represents school food serrvice personnel, strongly opposes the proposals, deeming them “unachievable.”

This, of course, was  precisely the reaction to Obama Administration immprovements to school meals, most of which were implemented with little difficulty.  Even so, Congress yielded to lobbying pressure and caved in on rules about potatoes, ketchup (a vegetable!), and whole grains.

I will never understand why everyone isn’t behind healthier foods for kids, but I’m not trying to get them to eat junk food.

As for why school meals matter so much to kids’ health, see Healthy Eating Research: Rapid Health Impact Assessment on Changes to School Nutrition Standards to Align with 2020-2025 Dietary Guidelines for Americans.

• Download the full report here.
• Download the executive summary here.
• Read the Press Release.

As for the gory details of the USDA’s proposals, see:

• Details of the proposed standards
• Comparison Chart: Current Standards vs. Proposed Standards
• Infographic: Proposed Rule for School Meal Standards
• Infographic: Proposed Timeline for Implementation
• Infographic: The Road Ahead – Building Back Better with School Meals
• Media Toolkit

Care to say something about this? FNS encourages all interested parties to comment on the proposed school meal standards rule during the 60-day comment period that begins February 7, 2023.

*******

For 30% off, go to www.ucpress.edu/9780520384156.  Use code 21W2240 at checkout.

Last week I did a post on the FDA’s reorganization.   I should have made one other point: the long-standing inadequacy of FDA funding.  For decades, Congress has assigned tasks to the FDA but provided inadequate funding to do those tasks adequately (hence 1% of imported foods are inspected).  Congress also assigns the funding for specific purposes.

Yes, FDA ought to be doing more, but it is not up to the agency to decide how to deploy its funds.

One more point: For long-standing historical reasons, FDA funding comes from congressional Agriculture committees, even though it is an agency of the Public Health Service.  That is one reason why USDA’s food safety programs are funded at so much higher a level than FDA’s.

With that said, the FDA has come out with some recent initiatives of interest.

I.  Front-of-Package labels.  The FDA is proposing to research a front-of-package symbol: “an easy-to-understand, standardized system that is 1) mandatory, 2) nutrient-specific, 3) includes calories, and is 4) interpretive with respect to the levels of added sugars, sodium, and saturated fat per serving.”

It is doing this in response to a petition from the Center for Science in the Public Interest.

The comments that have come in so far are here.

It is examining the use of front-of-pack symbols in other countries.

It also plans to conduct research on consumer understanding of multiple designs.  Here are the prototype packages on which the designs will be tested.

None of these is likely to be as effective as the ones used in other countries.

Here is one of the better options, in my opinion.

To file comments, go here.  It’s important to do this because the Consumer Brand Association (formerly the Grocery Manufacturers Association) and other industry groups are unlikely to accept any labeling scheme that might discourage you from buying a product.

II.  Qualified health claim: cocoa flavanols.  The FDA has approved a qualified health claim for cocoa flavanols and reduced risk of cardiovascular disease.

This was in response to a petition from the Swiss chocolate company, Barry Callebaut.

Here’s what the FDA will allow.  Yes, this is absurd (look at what the FDA has to go through to get to this), but companies must think statements like this will sell their products.

• “Cocoa flavanols in high flavanol cocoa powder may reduce the risk of cardiovascular disease, although FDA has concluded that there is very limited scientific evidence for this claim.”
• “Cocoa flavanols in high flavanol cocoa powder may reduce the risk of cardiovascular disease. FDA has concluded that there is very limited scientific evidence for this claim.”
• “Very limited scientific evidence suggests that consuming cocoa flavanols in high flavanol cocoa powder, which contains at least 4% of naturally conserved cocoa flavanols, may reduce the risk of cardiovascular disease.”
• “Very limited scientific evidence suggests that consuming cocoa flavanols in high flavanol cocoa powder, which contains at least 4% of naturally conserved cocoa flavanols, may reduce the risk of cardiovascular disease. This product contains at least 4% of naturally conserved cocoa flavanols. See nutrition information for_____ and other nutrients.”

III.  GRAS panels.  The FDA has issued final guidance on best practices for panels deciding which ingredients can be Generally Recognized as Safe.

This lays out the guidelines for

• Identifying GRAS panel members who have appropriate and balanced expertise.
• Steps to reduce the risk of bias, or the appearance of bias, that may affect the credibility of the GRAS panel’s report, including assessing potential GRAS panel members for conflict of interest and the appearance of conflict of interest.
• Limiting the data and information provided to a GRAS panel to publicly available information.

A lot of this is headache-inducing.  FDA rulemaking takes forever.  Can’t wait to see how all this turns out.

*******

For 30% off, go to www.ucpress.edu/9780520384156.  Use code 21W2240 at checkout.

And don’t miss Food Corps‘ gift of Veggie Valentine cards.  Here’s an example:

*******

For 30% off, go to www.ucpress.edu/9780520384156.  Use code 21W2240 at checkout.

Astaxanthin is the dye used by growers of farmed salmon to give the fish a pink color.  They do this by matching the desired amount of the dye to this SalmoFan template.

Astaxanthin, claim its makers, is an antioxidant and, therefore, good for you.

First the public relations: Screen shot: Astaxanthin reduces work-induced visual stress in people aged over 40 – BGG trial: Astaxanthin supplementation has been found to reduce visual display terminal (VDT) work-induced visual stress in people aged over 40, according to a new Japan trial sponsored by supplier BGG Japan. Read more

As for the actual research:

The study: Effects of diet containing astaxanthin on visual function in healthy individuals: a randomized, double-blind, placebo-controlled, parallel study.  Takahiro Sekikawa, Yuki Kizawa, Yanmei Li, Naoki Miura. J Clin Biochem Nutr.  https://doi.org/10.3164/jcbn.22-65.

Results:  In participants aged ≥40 years, corrected visual acuity of the dominant eye after visual display terminal work at 6 weeks after intake demonstrated a higher protective effect of astaxanthin in the astaxanthin group vs the control group (p<0.05). In participants aged <40 years, no significant difference was seen between the astaxanthin and control groups. Moreover, no significant difference was found in functional visual acuity and pupil constriction rate between the astaxanthin and control groups [my emphasis].

Conclusion: These results suggest astaxanthin reduces oxidative stress caused by visual display terminal work. Age-related reduction in ciliary muscle strength is likely the main detractor of visual acuity. Correspondingly, astaxanthin reduced visual display terminal work-induced visual stress in the middleaged and elderly.

Conflict of interest: This trial was sponsored by BGG Japan Co., Ltd., which provided all costs for the implementation of the trial. TS and YK are employees of BGG Japan Co., Ltd. YL is an employee of Beijing Gingko-Group Biological Technology Co., Ltd., which belongs to the same company group as BGG Japan Co., Ltd. NM received funding from BGG Japan Co., Ltd. to provide medical services to the trial participants.

Comment: BGG makes astaxanthin products.  This is a company-sponsored study conducted by researchers employed or paid by the company.  It is an excellent example of interpretation bias—putting a positive spin on results that are marginally significant in some groups but not others, or null.

*******

For 30% off, go to www.ucpress.edu/9780520384156.  Use code 21W2240 at checkout.

Oh no!  US Snack Index reveals consumers’ fear of running out of snacks during the Super Bowl

This has to be a commentary on where we are as a food nation.

This survey of Super Bowl fans found that a whopping 49% “would rather see their team lose than have to sit through the game without snacks.”

OK.  The survey was conducted by Frito-Lay, a not exactly disinterested observer, but still.

It makes clear that the Super Bowl is only peripherally about sports.  It is about eating junk food.

You don’t believe me?  Try:

• Super Bowl foods better than a touchdown
• 7% of all chicken wings are consumed during the Super Bowl: 1.42 billion
• So are 300 million gallons of beer, 28 million pounds of chips
• 139.4 million pounds of avocados, 3.8 Million Pounds of popcorn

As for Super Bowl food politics, try getting your head around the danger Mexican truckers face bringing avocados North for your guacamole.

Enjoy the game!

*******

For 30% off, go to www.ucpress.edu/9780520384156.  Use code 21W2240 at checkout.

Thanks to Lisa Young for this:

The average price of a dozen eggs goes up and up.   It now averages $4.25 a dozen, and that’s for the cheapest kinds.

The New York Times explains

• Inflation
• The war in Ukraine
• Higher feed costs
• Higher energy costs (those hens have to be kept warm)
• Avian flu (44 million hens died or were killed)
• Higher-than-normal demand

It could get worse.  Avian flu infects animals as well as birds and could infect us.

How’s that for a cheery thought.

Small egg farms, anyone?

Or chickens as art, per National Geographic?

********

For 30% off, go to www.ucpress.edu/9780520384156.  Use code 21W2240 at checkout.

So many readers have asked me to comment on the American Academy of Pediatrics’ Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity that I thought I ought to say something about it.

The guideline report is so long and detailed that I cannot imagine anyone actually reading it.  I started with the introduction, which summarizes basic facts.

• 14.4 million children and adolescents are affected by obesity.
• Obesity is a chronic disease with potentially serious health consequences
• Childhood obesity is strongly affected by social determinants of health (poor education, poverty, racism, exposure to toxins, etc)
• Childhood obesity is stigmatized in ways that fail to acknowledge social determinants.

What got press attention—and the attention of readers of this blog—is the AAP’s endorsement of drug and bariatric surgical treatment of obese children.

I cut right to the chase and looked at Appendix I, which gives the AAP’s algorithm for deciding on treatment options.  

The report’s major conclusions expand on this chart (the report does not define KAS, but I think it means Knowledge, Attitudes, and Skills):

KAS 9.  Pediatricians and other PHCPs should treat overweight (BMI ≥ 85th percentile to <95th percentile) and obesity (BMI ≥ 95th percentile) in children and adolescents, following the principles of the medical home and the chronic care model, using a family-centered and nonstigmatizing approach that acknowledges obesity’s biologic, social, and structural drivers.

KAS 10.  Pediatricians and other PHCPs should use motivational interviewing (MI) to engage patients and families in treating overweight (BMI ≥ 85th percentile to <95th percentile) and obesity (BMI ≥ 95th percentile).

KAS 11.  Pediatricians and other PHCPs should provide or refer children 6 y and older (Grade B) and may provide or refer children 2 through 5 y of age (Grade C) with overweight (BMI ≥ 85th percentile to <95th percentile) and obesity (BMI ≥ 95th percentile) to intensive health behavior and lifestyle treatment. Health behavior and lifestyle treatment is more effective with greater contact hours; the most effective treatment includes 26 or more hours of face-to-face, family-based, multicomponent treatment over a 3- to 12-mo period.

KAS 12.  Pediatricians and other PHCPs should offer adolescents 12 y and older with obesity (BMI ≥ 95th percentile) weight loss pharmacotherapy, according to medication indications, risks, and benefits, as an adjunct to health behavior and lifestyle treatment.

KAS 13.  Pediatricians and other PHCPs should offer referral for adolescents 13 y and older with severe obesity (BMI ≥ 120% of the 95th percentile for age and sex) for evaluation for metabolic and bariatric surgery to local or regional comprehensive multidisciplinary pediatric metabolic and bariatric surgery centers.

What is not in this guideline is anything that addresses the social determinants of childhood obesity.  What we have here is a focus on treating the symptoms, but getting nowhere near the cause.

It is difficult for someone like me who is not affected by those determinants to even imagine how drugs and surgery could be thought even remotely acceptable for children, even those over the age of 12, but I am not treating these kids.

Providers who do treat obese children tell me they are relieved to be able to offer options that might help kids achieve healthier weights.

As I see it, these should be absolute last resorts if used at all. And this is without even getting into issues of cost or our dysfunctional health care system.

In public health terms, drugs and surgery are “downstream” solutions to a problem that began way upstream with all those societal determinants.

If ever we needed upstream approaches, chldhood obesity is a prime example.

Upstream means policy changes that make healthy eating more appealing, accessible, and affordable  That’s what pediatricians need to be calling for.

This AAP report deliberately separates treatment from prevention.  It promises a discussion of prevention in a subsequent report.  I hope it is as hard hitting as any AAP report has ever been.

If childhood obesity teaches us anything, it is that our society needs to change in ways that are healthier for our children.

Additional supporting documents

• Executive Summary: Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity
• Appraisal of Clinical Care Practices for Child Obesity Treatment. Part I: Interventions
• Appraisal of Clinical Care Practices for Child Obesity Treatment. Part II: Comorbidities

Thanks to all the people who wrote me about this.  Much appreciated.

*******

For 30% off, go to www.ucpress.edu/9780520384156.  Use code 21W2240 at checkout.