It’s possible that I shall make an ass of myself. But in that case one can always get out of it with a little dialectic. I have, of course, so worded my proposition as to be right either way (K.Marx, Letter to F.Engels on the Indian Mutiny)
Thursday, February 09, 2023
THIRD WORLD U$A
Dental service use falls, oral health worsens after people become eligible for Medicare
For nearly 1 in 20 adults, Medicare eligibility was associated with the loss of all their teeth
Half of all older adults in the U.S. lack dental insurance and, in 2018, nearly half of older adults received no dental care. A new study by investigators from Brigham and Women’s Hospital, a founding member of the Mass General Brigham healthcare system, examined changes in dental care and oral health after older adults become eligible for Medicare, the traditional version of which covers medical services, but not dental care. Among more than 97,000 people, the researchers found a dramatic drop in the percentage of people receiving restorative dental care and an almost 5 percentage point increase the number people who lost all their teeth after they turned 65 and became eligible for Medicare. Their results are published in Health Affairs.
“Older adults have the lowest rates of dental insurance in the U.S. and cost is a major barrier for many in seeking dental care,” said corresponding author Lisa Simon, MD, DMD, a resident in the Brigham’s Department of Medicine. “We know that Medicare, by covering medical services, improves health outcomes and reduces racial health inequities among older adults, but it has the exact opposite effect for dental care.”
With very limited exceptions, traditional Medicare does not cover dental services. Medicare Advantage plans can offer dental services, but the extent of coverage varies. Federal efforts to expand Medicare dental coverage have not passed and policy debates about dental benefits are ongoing.
Simon and colleagues analyzed national data from the Medical Expenditure Panel Surveys from 2010 to 2019, examining changes in dental insurance and oral health care immediately after respondents became eligible for Medicare. The surveys included community-dwelling adults ages 50 to 85.
The team found that both traditional Medicare and Medical Advantage beneficiaries experienced immediate and long-term reductions in dental services use after Medicare enrollment. While the total number of annual dental visits did not change, the number of visits for restorative procedures, such as fillings or crowns, decreased by 8.7 percent. Adults also experienced an increase in complete edentulism—loss of all teeth—which puts people at higher risk of poor nutrition, lower quality of life and progression of cognitive impairment.
“Loss of teeth can have a number of negative downstream effects,” said Simon. “It’s associated with many geriatric conditions, including frailty and cognitive function.”
The authors note that the survey data used did not allow them to follow participants over long periods and the changes detected could be confounded by other life changes at age 65, such as retirement or receipt of Social Security income. Using other forms of survey data could help investigators focus on at-risk populations, such as adults living in long-term care facilities, and could help to identify and compare what dental benefit Medicare Advantage programs offer.
“Without dental coverage for adults who are eligible Medicare, we are seeing a rise in loss of teeth after age 65 among nearly 1 in 20 adults, which represents millions of Americans,” said Simon. “Our findings capture the magnitude of the problem but also point to the opportunity to improve oral health care access and outcomes, should policy makers expand Medicare coverage to include dental services.”
Disclosures: Simon received funding for consulting work with the CareQuest Foundation and the PrimaryCare Collaborative in 2020 and 2021.
Funding: This research was supported by the National Institute on Aging, National Institutes of Health (NIH) (Grant No. K23 AG058806), the Office of the Director, NIH (NIH Director’s Early Independence Award, DP5-OD024564).
Paper cited: Simon L et al. “Dental Services Use: Medicare Beneficiaries Experience Immediate And Long-Term Reductions After Enrollment” Health Affairs DOI: 10.1377/hlthaff.2021.01899
New Zealand is one of only a few island nations that could continue to produce enough food to feed its population in a nuclear winter, researchers have found.
In a new study Professor Nick Wilson, from the University of Otago and independent researcher Dr Matt Boyd, from Adapt Research in New Zealand, say five island nations, including New Zealand, could be well placed to continue to produce food despite the reduced sunlight and cooler temperatures caused by soot in the atmosphere following a nuclear war in the Northern Hemisphere. Australia (an island continent), Iceland, Vanuatu and the Solomon Islands were also likely to have robust food self-sufficiency, even in an extreme nuclear winter.
Their research is published in the international journal Risk Analysis.
Professor Wilson says while New Zealand was likely to continue to be able to produce enough food, its production and distribution was still threatened by the country’s extreme dependence on imported commodities, such as refined fuel.
The researchers investigated the impact of abrupt sunlight reducing scenarios caused by nuclear war, super volcano eruptions or asteroid impacts on agricultural production globally. They applied published crop models under ‘nuclear winter’ conditions to 38 island nations, combining this with other methods to estimate the food calorie supply. They also assessed a range of resilience factors that might protect countries from the impacts of a nuclear winter.
Dr Boyd says although some other nations would likely be able to produce enough food, other factors, such as the collapse of industry and social functioning placed their resilience in doubt.
Professor Wilson says the findings are consistent with a 1980s study on the impact of nuclear war on New Zealand, although the country’s resilience has declined since then as its dependence on imported diesel and digital infrastructure has grown.
“Islands such as New Zealand are often very dependent on imports of refined liquid fuel, may lack energy self-sufficiency and are susceptible to breakdowns and shortages of critical commodities. While New Zealand could divert a high proportion of its dairy exports to supply the local market, it lacks the ability to manufacture many replacement parts for farm and food processing machinery.”
Dr Boyd says the findings of the study reinforce the precarious position many countries would find themselves in during a global catastrophe.
“New Zealand has the potential to preserve an industrial society through this kind of catastrophe, but it is not ‘plug-and-play’. A decent amount of strategic planning needs to happen and across a long period of time, but this planning would have benefits in dealing with a wide range of extreme risks.”
Dr Boyd says the findings show there is a need to analyse nuclear winter and other abrupt sunlight reducing scenarios as part of a comprehensive national risk assessment.
“We are not aware of any plan for this kind of global catastrophe, including whether priorities for rationing have been considered.
“With the Government expected to release New Zealand’s first National Security Strategy this year it is important that the catastrophic risks associated with abrupt sunlight reducing scenarios do not slip through the cracks.”
ITHACA, N.Y. -- Wash your hands. Wear a high-quality mask. Keep 6 feet between you and others. Meet outside when possible.
For nearly three years, the public has been inundated with rules, regulations and suggestions from public health officials on the best way to stay safe amid the COVID-19 pandemic. But with so many rules, and little direction about which matter more, people have been left to guesswork, which may have cost lives.
Economist Ori Heffetz, associate professor in the Samuel Curtis Johnson Graduate School of Management, and a colleague conducted an experiment with nearly 700 people in three countries to gauge the public’s perception of relative risk factors.
Among the conclusions: Talking 14 minutes longer was thought to be as risky as standing a foot closer; being indoors was thought as risky as standing three feet closer outdoors; and removing a properly worn mask, by either party, was thought as risky as standing four to five feet closer.
Heffetz and Rabin wanted to investigate the idea of tradeoffs in the context of people making decisions regarding their health.
“We wondered whether doctors and health officials are too reticent to indicate the relative importance of different measures,” said Heffetz, who’s also a professor at the Hebrew University of Jerusalem, and a research associate at the National Bureau of Economic Research.
“Imagine someone talking to their dentist, where they ask if it’s more important to floss twice a day or brush more often,” he said. “And the dentist always tells them, ‘Do both.’ But we want to understand what’s a big deal, what’s not so big, how do they compare?”
Their goal in this work: Helping to transform messaging, regarding COVID and other health and nonhealth domains, to more closely resemble the way most people make decisions.
“Think about weight loss, and the tradeoffs people make,” Heffetz said. “Nobody says, ‘Don’t eat anything but leaves.’ They’ll say, ‘Have your cup of coffee without cream, you’ll save so many calories,’ or ‘Indulge, and then spend two hours at the gym.’ We have a metric – calories – and we can use it to price things. And then we make our decisions. We can make our tradeoffs.”
For their experiment, conducted during the spring and summer of 2021, Heffetz and Rabin showed 676 online respondents in the U.S., the United Kingdom and Israel 30 pairs of five-second videos of acquaintances meeting. Respondents were asked to judge, for one of the two people designated, which of the two scenarios in each pair was riskier.
From their responses, the researchers were able to estimate people’s perceptions of how risks changed by the features of the conversation. They used videos rather than verbal descriptions in order to let people judge each depiction on their own, without any prompting.
“We wanted to do something that looks to respondents as realistic as possible,” Heffetz said. “And then we don’t draw their attention to any specific thing, we just show them the scenario. And if they notice the mask, the distance between the subjects, the cough or the hug … we let them pick what they think is important and then see what emerges.”
Heffetz and Rabin wondered if the messaging from health officials could have benefitted from a more nuanced set of guidelines.
“We only saw the list of things – ‘Do all of these things,’” Heffetz said. “But which one is more important, and less important? It was hard to get an answer. That may have cost lives, because people may have made the wrong decisions.”
But like the dentist, Heffetz said, health officials don’t want to tell you that one behavior may be more important than another. In a perfect world, people do them all because they’re all important.
“I’m sure some people do them all, but most of us often have to make a decision between two imperfect bundles,” he said. “And we would really like to know which one the professionals consider is the better choice in this case.
“Our results may suggest a major health-risk public-communications failure in terms of how behaviors compare in relative risk,” Heffetz said. “We think this would be something that maybe policymakers would listen to.”
WASHINGTON—The Endocrine Society applauds President Biden’s call to rein in soaring insulin prices for those with private insurance and urges Congress to take immediate action.
Biden plans to highlight the need for insulin affordability during tonight’s State of the Union address. He will call on Congress to extend insulin price caps—“commonsense, life-saving protection”—to all Americans, according to an administration statement.
While Congress passed a provision to make insulin more affordable in the Inflation Reduction Act, the monthly $35 insulin price cap in the law applies only to people with Medicare. An attempt to extend the benefit to millions more with private insurance failed in August in the Senate by a mere three votes.
Limiting out-of-pocket insulin costs to $35 a month would be life-changing, particularly for the more than 1.8 million American children and adults with type 1 diabetes. Their bodies cannot produce the insulin needed to break down sugar and provide energy, so they depend on the medication to survive.
In 2021 alone, nearly one in five American adults with diabetes—about 1.3 million people—rationed their insulin to save money, according to a study. Rationing insulin causes people with diabetes to become sicker and, in some cases, even die.
“The Endocrine Society has championed measures to improve insulin access for years,” said Society President Ursula B. Kaiser, M.D. “As physicians and researchers, it is heartbreaking to see our patients struggle to afford the medication that keeps them alive.”
More than 7 million people nationwide rely on insulin to manage their diabetes. According to the U.S. Center for Disease Control and Prevention, 37.3 million people nationwide—about 11 percent of Americans—have diabetes.
While insulin was discovered more than 100 years ago, the price of insulin nearly tripled between 2002 and 2013, and the trend upward has continued over the past decade. This has created an unnecessary crisis in health care with many people with diabetes being forced to choose between insulin and other necessities.
The Society will continue to work with policymakers to ensure all people with diabetes who rely on insulin can benefit from lower out-of-pocket costs.
“Insulin affordability is a bipartisan issue,” Kaiser said. “Our patients cannot wait any longer for help.”
# # #
Endocrinologists are at the core of solving the most pressing health problems of our time, from diabetes and obesity to infertility, bone health, and hormone-related cancers. The Endocrine Society is the world’s oldest and largest organization of scientists devoted to hormone research and physicians who care for people with hormone-related conditions.
The Society has more than 18,000 members, including scientists, physicians, educators, nurses and students in 122 countries. To learn more about the Society and the field of endocrinology, visit our site at www.endocrine.org. Follow us on Twitter at @TheEndoSociety and @EndoMedia.
Loss of tropical biomass due to climate change could lead to increased carbon emissions
A decrease in tropical forest biomass stemming from changes in climate may lead to increased carbon emissions that could accelerate global warming, according to a new study co-authored by YSE postdoctoral associate Maria del Rosario Uribe and Paulo Brando,associate professor of ecosystem carbon capture.
Tropical ecosystems store over half of the world’s above-ground carbon in their biomass, which includes vines, trunks, and leaves. A decrease in biomass reduces the capacity of these ecosystems to capture and store carbon. The research team said the decrease likely stems from prolonged and intense dry periods in the forests from climate change.
“Wetter regions have much more biomass, or carbon, than drier regions. If wetter tropical areas shrink due to climate change, then you’re likely to lose the massive amount of carbon they store as well,” says Uribe, who led the study.
The research team used maps from satellites to study above-ground biomass in the tropics of South America, Africa, and Asia. To make predictions about the future, researchers leveraged historical data reaching back to 1950 to build empirical statistical and machine learning models. They found a strong relationship between above-ground biomass and spatial climate variability.
Due to the empirical relationship between above-ground biomass and climate, factors such as fire, drought, and interactions with the soil are implicit in the model, the researchers note.
The researchers found that if greenhouse gas emissions from human activity are higher, losses of stored carbon could nearly double by 2100.
Uribe says she is hoping this data will strengthen the case for current climate policy initiatives, such as the Paris Climate Agreement that seek to limit global warming to no higher than 1.5 degrees Celsius compared to pre-industrial levels and preserve tropical forests.
Brando notes that the findings can be looked at as “glass half full or a glass half empty.” The losses due to climate change are not massive but are concentrated in a key specific region of the Southeastern Amazon.
“The tropics hold a considerable amount of carbon, almost 20 years of global human emissions,” Brando says. “We show that tropical ecosystems can resist a lot of climatic change, but these ecosystems’ future will depend on how we protect these areas from deforestation, logging, and human-made fires.”
When the Convention on International Trade in Endangered Species of Wild Fauna and Flora, or CITES, allowed a one-off chance for China to bid on a 108-ton stockpile of ivory amassed from natural African elephant deaths and culling in 2008, many conservationists around the world assumed Chinese public sentiment toward ivory would become more favorable. But new YSE-led research published in Conservation Biology, whichemploys machine learning techniques to analyze public opinion, reveals that the exact opposite happened.
“After CITES authorized the sale of ivory, our analysis shows that the macro-public opinion in China became more negative toward ivory,” says Yufang Gao ’14 MESc, a PhD student in conservation science and environmental anthropology. “Chinese mass media coverage of ivory became more framed as anti-ivory, with news stories more focused on ivory smuggling and the government’s efforts to tightly control the ivory trade.”
The International Union for the Conservation of Nature has listed the African forest elephant as critically endangered, the savanna elephant as threatened, and the Asian elephant as endangered. Where once there were 10 million wild elephants in Africa, there are now only about 400,000 left on the continent. The Asian elephant population has declined 50% in the last three generations to about 50,000 and they are now at a high risk of extinction.
Gao has been dedicated to studying the elephant ivory trade for more than a decade. For this study, he teamed up with Yuntian Liu, a statistician at the Yale Center for Outcomes Research & Evaluation, and a team of international researchers to review Chinese media coverage of the elephant ivory between 2000 and 2021.
Using a machine learning technique known as latent Dirichlet allocation topic modeling, the researchers studied how media stories framed ivory in 6,394 pieces of coverage, looking for evidence of how wildlife policies impacted public opinion in China.
“LDA topic modeling [helps us identify and define] recurring topics. In this case, topics refer to collections of words that commonly appeared together throughout news stories on ivory, such as smuggling, customs, seized, Africa, endangered, and animal,’” Liu says.
The team was particularly interested in the impact of the 2008 decision by CITES —a 173-nation coalition that monitors international plant and animal trade — allowing the sale of African ivory stockpiles to China and a 2016 ban on domestic ivory trade announced by the Chinese government (a move by China to deter elephant poaching in Africa for illegal ivory trade).
Gao and Liu looked for clues on how these policies influenced Chinese public opinion on ivory arts and culture, elephant conservation, and ivory-related crimes. Their discovery that the CITES-approved sale of ivory negatively influenced public opinion on ivory was not the only surprising finding.
Many conservationists hypothesized that the 2016 domestic ivory ban would lead to more negative public opinions in China about ivory. But after the ban, media framing shows that macro-public opinion throughout China became more positive about elephant ivory.
Gao says the ban may have drawn more attention to the perceived value of ivory in art and culture, making ivory seem more desirable.
The research is important because it underscores the need for conservationists to take a more nuanced approach to understanding the relationship between mass media reports, policies, and public opinion, Gao notes.
“By monitoring mass media framing of wildlife and conservation issues, we might be able to sooner identify emerging problems or threats toward wildlife or the environment,” he says.
He recommends that conservation organizations work more closely with the media to share information and elevate the importance of wildlife conservation in mainstream public dialogue.
“Conservation is a social process that involves many different stakeholders, including the media industry, governments, general public, researchers, and more,” he says. “Topic modeling is a powerful tool for uncovering shifts in media framing, dynamics of the interplay between different perspectives, and gauging how policies are actually changing public opinions.”
Parents: It might be time to rethink your family’s video-gaming rules.
New research findings challenge the fears parents have been hearing for years that children who spend hour after hour playing video games, or choose games of certain genres, would manifest unhealthy results in their cognitive ability.
“Our studies turned up no such links, regardless of how long the children played and what types of games they chose,” said Jie Zhang, associate professor of curriculum and instruction at the University of Houston College of Education and a member of the research team. The work is published in the Journal of Media Psychology.
In reaching the conclusions, researchers examined the video gaming habits of 160 diverse urban public-school preteen students (70% from lower income households), which represents an age group less studied in previous research. Participating students reported playing video games an average of 2.5 hours daily, with the group’s heaviest gamers putting in as much as 4.5 hours each day.
The team looked for association between the students’ video game play and their performance on the standardized Cognitive Ability Test 7, known as CogAT, which evaluates verbal, quantitative and nonverbal/spatial skills. CogAT was chosen as a standard measure, in contrast to the teacher-reported grades or self-reported learning assessments that previous research projects have relied on.
“Overall, neither duration of play nor choice of video game genres had significant correlations with the CogAT measures. That result shows no direct linkage between video game playing and cognitive performance, despite what had been assumed,” said May Jadalla, professor in the School of Teaching and Learning at Illinois State University and the study’s principal investigator.
But the study revealed another side of the issue, too. Certain types of games described as helping children build healthy cognitive skills also presented no measurable effects, in spite of the games’ marketing messages.
“The current study found results that are consistent with previous research showing that types of gameplay that seem to augment cognitive functions in young adults don’t have the same impact in much younger children,” said C. Shawn Green, professor in the Department of Psychology at the University of Wisconsin-Madison.
Does this mean the world can play on? Maybe, the research suggests. But the experts also caution that gaming time took the heaviest players’ away from other, more productive activities – homework, to be specific – in a process psychologists call displacement. But even in those cases, the differences were slight between those participants and their peers’ CogAT measures of cognitive abilities.
“The study results show parents probably don’t have to worry so much about cognitive setbacks among video game-loving children, up to fifth grade. Reasonable amounts of video gaming should be OK, which will be delightful news for the kids. Just keep an eye out for obsessive behavior,” said Zhang. “When it comes to video games, finding common ground between parents and young kids is tricky enough. At least now we understand that finding balance in childhood development is the key, and there’s no need for us to over-worry about video gaming.”
The study was funded by the National Science Foundation.
Gay men discriminate against feminine gay men, new psychology study finds
University of Sydney psychology study finds both gay men and heterosexual men prefer masculine over feminine gay men for a high-status role, suggesting feminine gay men may face implicit discrimination in the workplace
Psychology study finds both gay men and heterosexual men prefer masculine over feminine gay men for a high-status role, suggesting feminine gay men may face implicit discrimination in the workplace
Key findings
Gay men and heterosexual men prefer masculine-presenting gay men for high-status roles
Masculine presentation was enough to elicit preferential treatment, regardless of qualifications
Gay men are complicit in prejudice against more feminine-presenting gay men
Both gay men and heterosexual men prefer masculine-presenting men for high-status roles, according to a new study from the University of Sydney, leaving more feminine-presenting gay men disadvantaged and facing internal bias, prejudice and potential discrimination in the workplace, including in hiring practices and promotion opportunities.
The research published in the prestigious peer-reviewed journal Sex Roles is believed to be the first experimental study to demonstrate status costs for gay men who present with more feminine than masculine qualities across workplace hierarchies. It also demonstrates implicit bias among gay men as a community.
Ben Gerrard is a researcher in gender and sexuality in the School of Psychology at the University of Sydney. He defines feminine-presenting traits as more feminine, as traditionally understood/defined vocal quality, body language and posture.
Mr Gerrard says the finding that gay men prefer a more “straight-acting” gay man for high-status roles is disappointing and potentially creating a gay glass ceiling in workplaces.
“Gay men are potentially blocking each other from positions of power and leadership due to this implicit bias,” he said. “Men are still expected to conform to more traditional masculine styles of leadership and if they fail to sufficiently project masculine traits they are at risk of status penalites. This is an example of internalised homophobia among the gay community and it impacts opportunities for these gay men.”
Mr Gerrard said while gay men appear to enjoy increasing equality and representation in Western cultures, they are still disadvantaged in pursuing high-status opportunities, compared to heterosexual men. “The findings point to the need for advocacy and training to counter apparent bias against feminine-presenting gay men in a range of professional contexts and populations,” he said.
Testing internal biases against sexuality and gender traits
The researcher created a mock TV commercial casting brief for a campaign promoting tourism in Sydney. The mock campaign aimed to sell Sydney overseas and the casting called for an actor who could be viewed as a leader or someone who would be admired by the audience.
The researcher, (himself a professional actor) created videos of six shortlisted ‘candidates’ using professional actors, all gay men in real-life, who acted the same script in both a feminine-gay and masculine-gay manner (manipulating their voice, mannerisms, and posture but otherwise everything else was kept identical).
A survey of 256 gay and heterosexual men were invited to watch the videos and to look for an actor who could be seen as a “leader” who could represent Australia. They viewed the feminine or masculine version of a particular actor, and placed casting preferences for the role. The researcher found that bothgay men and heterosexual men preferred the more masculine-gay male actor for the advert (discriminating against the feminine-gay actor).
Heterosexual men higher in homonegativity and gay men higher in misogyny both showed a stronger preference for the masculine-gay actor over the feminine-gay actor. These findings hold important implications for implicit bias and hiring practices.
Need for greater acceptance
More work is required to challenge the prevailing association between masculinity and high status, Mr Gerrard says, especially in light of contemporary leadership theories, which suggest traits, traditionally perceived as ‘feminine’, such as warmth, can be more effective in managing modern workplaces.
“We operate in teams-based workplaces now where effective leadership qualities – warmth, empathy and good communication – are all considered feminine traits, and a more feminine-presenting gay man might be an ideal candidate for a leadership role,” Mr Gerrard said. “And yet we still value traditional masculinity at a senior leadership level as a measure of the capacity to lead, because traditional feminine traits are considered too soft or not authoritative enough.”
“This homophobic bias is putting pressure on feminine-presenting gay men to conform so they might be passable as a heterosexual man,” Mr Gerrard said. “What we need is an increase in authentic representation of empowered feminine-presenting gay men - especially in the media: in order to counter misinformed biases regarding their ability to lead. There needs to be education and awareness within the community and in recruitment processes - around the potential to be unconsciously influenced by these unfair biases.”
IMAGE: HUMAN INFANTS AND YOUNG CHILDREN ARE MOST LIKELY TO SURVIVE, GROW AND DEVELOP TO THEIR FULL POTENTIAL WHEN BREASTFED. DESPITE SCIENTIFIC EVIDENCE MORE INFANTS ARE FED FORMULA MILKS TODAY THAN EVER BEFORE.view more
CREDIT: CREDIT: THE LANCET
Peer-reviewed / Literature review, opinion / People
Fewer than half of infants globally are breastfed as recommended by WHO [1], with formula milk sales on the rise despite formula feeding failing to offer the same nutrition, health and development benefits as breastfeeding.
The Lancet 2023 Series on Breastfeeding argues that formula milk companies exploit parent’s emotions and manipulate scientific information to generate sales at the expense of the health and rights of families, women, and children.
The Series highlights the economic and political power of the dominant formula milk companies and the public policy failures which mean millions of women are prevented from breastfeeding as recommended.
The authors stress that breastfeeding is a collective responsibility of society and call for more effective promotion, support and protection for breastfeeding, including a much better trained healthcare workforce and an international legal treaty to end exploitative formula milk marketing and prohibit political lobbying.
Formula milk marketing tactics are exploitative, and regulations need to be urgently strengthened and properly implemented according to a new three paper Series publish in The Lancet. Experts call for an international legal treaty to end irresponsible formula milk marketing and political lobbying, accompanied by more effective breastfeeding support worldwide.
Series co-author, Professor Nigel Rollins, WHO, says “The sale of commercial milk formula is a multi-billion-dollar industry which uses political lobbying alongside a sophisticated and highly effective marketing playbook to turn the care and concern of parents and caregivers into a business opportunity. It is time for this to end. Women should be empowered to make choices about infant feeding which are informed by accurate information free from industry influence.”
He continues, “Our Series finds society, politics, and economics all contribute to why fewer than half of infants globally are breastfed as recommended [1]. Breastfeeding should be considered society’s collective responsibility, not the sole concern of women. We need to see wide-ranging actions across different areas of society to better support mothers to breastfeed for as long as they want.” [2]
“Babies are most likely to survive and grow to their full potential when breastfed. [3] Breastfeeding promotes brain development, protects infants against malnutrition, infectious diseases, and death, while also reducing risks of obesity and chronic diseases in later life. Yet, globally, many women who wish to breastfeed face multiple barriers, including insufficient parental leave and lack of support in healthcare systems and at the workplace, in the context of exploitative marketing tactics of the commercial milk formula industry”, says Series co-author Professor Rafael Pérez-Escamilla, Yale University School of Public Health, US. [2]
In a novel analysis, the Series describes how profits made by the formula milk industry benefit companies located in high-income countries while the social, economic and environmental harms are widely distributed and most harmful in low and middle income countries.
An exploitative marketing playbook
Triggered by The Baby Killer investigative report into Nestle’s marketing of formula milk in the Global South in the 1970s, the World Health Assembly developed the voluntary International Code of Marketing of Breast-milk Substitutes and subsequent resolutions (the Code) in 1981 [4]. However, the powerful influence of the milk formula industry and the marketing of their products in violation of the Code continues, with sales from commercial formula milk having rapidly increased over the past twenty years and now at more than $55 billion a year.
The Series outlines the exploitative tactics used by formula milk companies to sell their products, including taking advantage of parents’ worries about their child’s health and development. One common reason women introduce formula milk is interpretating unsettled baby behaviour, especially disrupted sleep and persistent crying, as a sign that breast milk is insufficient. [5,6] However, sleep patterns of babies are not the same as for adults and unsettled baby behaviours are common. When mothers are appropriately supported, concerns can be addressed successfully without the use of formula milk.
“The formula milk industry uses poor science to suggest, with little supporting evidence, that their products are solutions to common infant health and developmental challenges. Adverts claim specialised formulas alleviate fussiness, help with colic, prolong night-time sleep, and even encourage superior intelligence. Labels use words like ‘brain’, ‘neuro’ and ‘IQ’ with images highlighting early development, but studies show no benefit of these product ingredients on academic performance or long-term cognition. This marketing technique violates the 1981 Code, which says labels should not idealise the use of formula, and exploits poor science to create an untrue story to sell more product,” says Professor Linda Richter, Wits University, South Africa. [2] (For artwork illustrative of formula packaging see figure 3 and 4 in paper 2 of the Series. For a direct link to the images, please see notes to editors).
The Series explains how formula milk marketing exploits the lack of support for breastfeeding by governments and society to use gender politics to sell its products. The authors describe how the formula milk industry frames breastfeeding advocacy as a moralistic judgment that is anti-feminist and damaging to women, while presenting milk formula as a convenient and empowering solution for working mothers.
In recent years, digital communications have greatly increased the reach of marketing in ways that blur the difference between advertising and the provision of nutrition and care advice. The Series highlights examples of digital marketing such as industry-paid influencers sharing the difficulties of breastfeeding as preludes to formula milk marketing, and industry sponsored parenting apps with 24/7 chat services that enable product placement, offer free samples or deals, and promote online sales. The authors argue there is very little regulation of the formula milk industry online and there are regular violations of the Code.
A new review, conducted for the Series, of 153 studies details how marketing practices in violation of the Code have continued in nearly 100 countries and in every region of the world since its adoption more than forty years ago [7]. The Series says voluntary uptake of the Code is not enough and calls for an international legal treaty on the commercial marketing of food products for babies to protect the health and wellbeing of mothers and families.
The formula milk lobby
The Series also draws attention to the power of the milk formula industry to influence national political decisions and interfere with international and national regulatory processes. The formula industry has established a network of trade associations and front groups that lobby against the Code and other breastfeeding protection measures. For example, in 2012, South Africa passed new national legislation to implement The Code into law, however, this took nine years with many setbacks resulting from industry lobbying. Formula milk manufacturers formed a new lobby group, the Infant Feeding Association, which applied pressure for amendments to the regulations.
This outsourcing of lobbying allows the corporations themselves to project an image of benevolence and corporate social responsibility, suggesting that they can adequately self-regulate through corporate policies on responsible marketing. However, their self-regulation falls far short of compliance to the Code.
As well as influencing political organisations, the authors argue formula milk companies also draw on the credibility of science by sponsoring professional organisations, publishing sponsored articles in scientific journals, and inviting leaders in public health onto advisory boards and committees, leading to unacceptable conflicts of interest within public health.
“The voluntary Code is not working – formula milk companies chose to disregard the guidance and lobby at every opportunity to weaken regulation. We need a stricter international legal treaty on the marketing of milk formula which is incorporated into law across the world. The treaty must protect policymaking from industry influence, with obligations for senior public officials to divulge meetings with lobbyists and requirements for scientific organisations to disclose funding sources and members of expert advisory groups. This would regulate the commercial milk formula industry while not restricting the sale of the products to those who need or want them. More generally, the global and public health community must also be much more critical about public-private partnerships that enable or tolerate conflicts of interest” says Professor David McCoy. [2]
Society-wide changes needed
In addition to ending the marketing tactics and industry influence of formula milk companies, broader actions across workplaces, healthcare, governments, and communities are needed to more effectively support women who want to breastfeed.
Half a billion working women globally are not entitled to adequate maternity protection. A systematic review of studies found women with a minimum of three months maternity leave, paid or unpaid, were at least 50% more likely to continue breastfeeding compared to women returning to work within three months of giving birth [8]. The authors call for governments and workplaces to recognise the value of breastfeeding and care work, by actions such as extending paid maternity leave duration to align with the six month WHO recommended duration of exclusive breastfeeding.
Women also face a lack of breastfeeding promotion, protection and support within healthcare systems due to limited public budgets, skilled support by health workers, influence from milk formula industry and an absence of care that is culturally appropriate and led by the needs of women. Authors argue that breastfeeding outcomes improve when health systems actively empower women and enable experienced peers to support women during pregnancy, childbirth and onwards. Healthcare providers should offer skilled counselling before and after birth to all mothers to enable them to address unsettled baby behaviours whilst continuing to breastfeed if they wish to do so.
Sonia Hernández-Cordero, Universidad Iberoamericana, Mexico City says, “We are seeing improvements in some countries. A case study which we commissioned for the Series found that, despite lacking federally mandated paid maternity leave, the US continues to recognise an increasing number of Baby-Friendly [9] hospitals each year, and the National Supplemental Nutrition Program for Women, Infants and Children (WIC), which reaches half of annual births in the US, is increasingly providing breastfeeding counselling as it continues to support more women to choose breastfeeding.” [2]
“Many governments fail to protect mothers and children from unethical marketing practices because of the economic and political power of trans-national companies. The extreme power of corporations relative to public-interest bodies must be re-balanced. Anti-trust legislation and the ending of corporate tax abuse would help reverse the favouring of private financial interests at the expense of the rights of mothers and infants”, says Professor David McCoy, United Nations University. [2]
“Advice that breastfeeding is best for their babies' health is no use if women are not supported to understand and manage unsettled baby behaviours, or if mothers without maternity leave or pay are forced to go back to work out of financial necessity”, says Dr Julie Smith, Australian National University. [2]
A large expansion in health professional training on breastfeeding, as well as statutory paid maternity leave and other protections are vital. This requires changing the way society views breastfeeding as the sole responsibility of individual women and putting the onus across all levels of society,” says Professor Rafael Pérez-Escamilla, Yale School of Public Health. [2]
A linked Editorial published in The Lancet says, “Some women choose not to breastfeed, or are unable to. Perceived pressure, or inability, to breastfeed—especially if it is at odds with a mother’s wishes—can have a detrimental effect on mental health, and systems should be in place to fully support all mothers in their choices. Women and families make decisions about infant feeding based on the information they receive, and a criticism of the CMF industry’s predatory marketing practices should not be interpreted as a criticism of women. All information that families receive on infant feeding must be accurate and independent of industry influence to ensure informed decision making.”
NOTES TO EDITORS
The Global Series launch is on Wednesday 8th February at 12:30 – 14:00 UK time. It will be livestreamed here. This Series received funding from BMGF for the research but not to authors for their time or writing. For a full list of researchers see the three papers.
[1] UNICEF. Global database 2021. Available from: https://data.unicef.org/topic/nutrition/breastfeeding/ [2] Quote direct from author and cannot be found in the text of the Article. [3] Victora CG, Bahl R, Barros AJ, et al. Breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. The Lancet 2016; 387(10017): 475-90. [4] https://www.who.int/publications/i/item/9241541601 [5] Vilar-Compte M, Pérez-Escamilla R, Orta-Aleman D, Cruz-Villalba V, Segura-Pérez S, Nyhan K, Richter LM. Impact of baby behaviour on caregiver's infant feeding decisions during the first 6 months of life: A systematic review. Matern Child Nutr. 2022 May;18 Suppl 3(Suppl 3):e13345. doi: 10.1111/mcn.13345. [6] Segura-Pérez S, Richter L, Rhodes EC, Hromi-Fiedler A, Vilar-Compte M, Adnew M, Nyhan K, Pérez-Escamilla R. Risk factors for self-reported insufficient milk during the first 6 months of life: A systematic review. Matern Child Nutr. 2022 May;18 Suppl 3(Suppl 3):e13353. doi: 10.1111/mcn.13353. [7] Becker GE, Zambrano P, Ching C, et al. Global evidence of persistent violations of the International Code of Marketing of Breast-milk Substitutes: A systematic scoping review. Maternal & child nutrition 2022; 18(S3): e13335. [8] Navarro-Rosenblatt D, Garmendia ML. Maternity Leave and Its Impact on Breastfeeding: A Review of the Literature. Breastfeed Med 2018; 13(9): 589-97. [9] https://www.unicef.org.uk/babyfriendly/
Paper 1: NR received grants from the Bill & Melinda Gates Foundation during the conduct of this study. All other authors declare no competing interests. Paper 2: PB reports receiving funds from WHO to undertake research on the political economy of infant and young child feeding, which included research on CMF marketing. PB also reports funding from the Australian Research Council, UNICEF, The World Bank, and WHO to undertake research, prepare policy reviews, write reports, or attend meetings, outside the submitted work. GK was employed by M&C Saatchi World Services, which was commissioned by UNICEF and WHO to design and implement a multicountry study examining the scope and influence of CMF marketing. GH and DM report receiving funds from WHO to undertake qualitative and secondary research on the political economy of breastfeeding and other research describing the nature of CMF marketing. KR reports receiving a research grant from Alive & Thrive and FHI360 that supported earlier research that is now cited in this Series paper. Paper 3: PB and DM report funding from the WHO Department of Maternal, Newborn, Child and Adolescent Health and Ageing for conducting reviews and specific analyses in preparation of this paper. All other authors declare no competing interests. The findings reported in this manuscript reflect the viewpoints and findings of the authors only, and do not necessarily represent those of the study funder.
