The Wasted Years
A Critique of Infant & Child Nutrition - POLICY, PRACTICE & POLITICS
Published on 25. March 2023
Book
Paperback/Softback
310 pages
978-1-909675-34-6 (ISBN)
Description
The development of policy and practice for infant and young-child feeding has a long and troubled history, with decades of conflict and a failure to deliver solutions to the target population - infants, children and their parents. The key divisions are between the World Health Organization (WHO), industry and breastfeeding interest groups. And more recently health professionals and parents have become caught in the crossfire.
How can the feeding of young children worldwide generate so much division and dysfunction, leading to acrimony, boycotts and legal actions? And how has this situation been allowed to persist for so many decades?
In 2020 the global mortality rate for children under five years of age was reported to be 4.9 million a year; 45% of those deaths were nutrition related. Around 149 million children under the age of five were suffering from the physical and cognitive effects of stunting. Another 49 million were affected by wasting.
Today, global breastfeeding rates are disappointing, the global pandemic of childhood obesity is still spreading, and more children are both overweight and malnourished - the so-called double burden of malnutrition.
With this backdrop, Professor Forsyth proposes that poor leadership and ineffective partnership-working are key factors in the failure to deliver effective policies and practices, and have contributed to preventable suffering in this vulnerable population. He takes a health-professional perspective to unpick the opposing philosophies and idealogies and reflects on the underlying policies, practices and politics. To prevent further dysfunctional behaviour and unnecessary suffering-he concludes-the wasted years must end, and a fresh start begin. This requires new thinking, new priorities and new people.
WHAT THE BOOK COVERS
* The roles of WHO, governments, health professionals, activist groups and parents
* Inappropriate marketing of breastmilk substitutes by the infant-formula industry
* Limitations of scientific evidence for underpining infant-feeding policy and practice
* Recognising there is more to infant feeding than just breastfeeding
* Controversies about introducing and continuing solid foods
* Policies that have to be sensitive to the global socioeconomic diversity of families
* The importance of family-friendly policies and issues of realism and idealism
* Misuse of the concept of 'conflict of interest'
* Failures in leadership and governance across all stakeholders
* The need for an independent review and transformational change
WHO THIS BOOK IS FOR
* Health policy-makers
* The infant-formula industry
* Breastfeeding groups and activists
* Parents, families and caregivers
* Health professionals including doctors, midwives, nurses and nutritionists
How can the feeding of young children worldwide generate so much division and dysfunction, leading to acrimony, boycotts and legal actions? And how has this situation been allowed to persist for so many decades?
In 2020 the global mortality rate for children under five years of age was reported to be 4.9 million a year; 45% of those deaths were nutrition related. Around 149 million children under the age of five were suffering from the physical and cognitive effects of stunting. Another 49 million were affected by wasting.
Today, global breastfeeding rates are disappointing, the global pandemic of childhood obesity is still spreading, and more children are both overweight and malnourished - the so-called double burden of malnutrition.
With this backdrop, Professor Forsyth proposes that poor leadership and ineffective partnership-working are key factors in the failure to deliver effective policies and practices, and have contributed to preventable suffering in this vulnerable population. He takes a health-professional perspective to unpick the opposing philosophies and idealogies and reflects on the underlying policies, practices and politics. To prevent further dysfunctional behaviour and unnecessary suffering-he concludes-the wasted years must end, and a fresh start begin. This requires new thinking, new priorities and new people.
WHAT THE BOOK COVERS
* The roles of WHO, governments, health professionals, activist groups and parents
* Inappropriate marketing of breastmilk substitutes by the infant-formula industry
* Limitations of scientific evidence for underpining infant-feeding policy and practice
* Recognising there is more to infant feeding than just breastfeeding
* Controversies about introducing and continuing solid foods
* Policies that have to be sensitive to the global socioeconomic diversity of families
* The importance of family-friendly policies and issues of realism and idealism
* Misuse of the concept of 'conflict of interest'
* Failures in leadership and governance across all stakeholders
* The need for an independent review and transformational change
WHO THIS BOOK IS FOR
* Health policy-makers
* The infant-formula industry
* Breastfeeding groups and activists
* Parents, families and caregivers
* Health professionals including doctors, midwives, nurses and nutritionists
More details
Language
English
Place of publication
Cove
United Kingdom
Target group
College/higher education
Professional and scholarly
Dimensions
Height: 258 mm
Width: 152 mm
Thickness: 12 mm
ISBN-13
978-1-909675-34-6 (9781909675346)
Copyright in bibliographic data and cover images is held by Nielsen Book Services Limited or by the publishers or by their respective licensors: all rights reserved.
Schweitzer Classification
Person
Professor Stewart Forsyth is Honorary Professor of Paediatrics, University of Dundee, and formerly Medical Director and Consultant Paediatrician, NHS Tayside, Scotland in the UK.
He graduated in medicine from the University of Glasgow in 1973, and after junior training posts in medicine, surgery and obstetrics and paediatrics, pursued a career in medical paediatrics specializing in neonatal intensive care in Edinburgh and Dundee and was appointed consultant paediatrician in 1983 with responsibility for the Neonatal Service in Dundee, Tayside.
Subsequently he was appointed to Clinical Director roles and latterly was the Medical Director for the University Teaching Hospitals.
His Scotland-wide roles included Specialist Advisor on Medical Paediatrics to the Chief Medical Officer, Vice-Chair of the Scottish Governments Child Health Support Group, Chair of National Review of Neonatal Services in Scotland, and Deputy Convenor of Children in Scotland the largest children's charity in Scotland. More recently he has been Chair of the Early Nutrition and Later Health Task Force at the International Life Sciences Institute in Brussels. In 2012 he received the OBE award from HRH The Queen for contribution to children's health in Scotland.
He has had a longstanding research interest in infant and young-child nutrition and was the paediatric lead for the Dundee Infant Feeding Study which he initiated with his colleague Professor Peter Howie, Professor of Obstetrics and Gynaecology in 1986, and the results of the study were published in the British Medical Journal in 1990, 1993 and 1998. The study was one of the most comprehensive prospective assessments of the health benefits of breastfeeding during childhood in a developed country, and the published papers are still regularly referenced today. His most recent research has been related to the role of long chain polyunsaturated fatty acids in health and wellbeing in early life.
Professor Forsyth was commissioned to undertake advisory and health service reviews for the Scottish Government and also the UK Government, he is a past member of the Scottish Infant Feeding Advisory Group that was chaired by the Chief Nurse for Scotland, and in the past he has been a regular contributor to infant-feeding organizations including the Annual Conference of the Baby Friendly Initiative.
He is also Board Chairman of a Counselling organization based in Dundee and a founding member and former Chair of an organization called Parent-to-Parent which provides support for families with children with special needs.
He graduated in medicine from the University of Glasgow in 1973, and after junior training posts in medicine, surgery and obstetrics and paediatrics, pursued a career in medical paediatrics specializing in neonatal intensive care in Edinburgh and Dundee and was appointed consultant paediatrician in 1983 with responsibility for the Neonatal Service in Dundee, Tayside.
Subsequently he was appointed to Clinical Director roles and latterly was the Medical Director for the University Teaching Hospitals.
His Scotland-wide roles included Specialist Advisor on Medical Paediatrics to the Chief Medical Officer, Vice-Chair of the Scottish Governments Child Health Support Group, Chair of National Review of Neonatal Services in Scotland, and Deputy Convenor of Children in Scotland the largest children's charity in Scotland. More recently he has been Chair of the Early Nutrition and Later Health Task Force at the International Life Sciences Institute in Brussels. In 2012 he received the OBE award from HRH The Queen for contribution to children's health in Scotland.
He has had a longstanding research interest in infant and young-child nutrition and was the paediatric lead for the Dundee Infant Feeding Study which he initiated with his colleague Professor Peter Howie, Professor of Obstetrics and Gynaecology in 1986, and the results of the study were published in the British Medical Journal in 1990, 1993 and 1998. The study was one of the most comprehensive prospective assessments of the health benefits of breastfeeding during childhood in a developed country, and the published papers are still regularly referenced today. His most recent research has been related to the role of long chain polyunsaturated fatty acids in health and wellbeing in early life.
Professor Forsyth was commissioned to undertake advisory and health service reviews for the Scottish Government and also the UK Government, he is a past member of the Scottish Infant Feeding Advisory Group that was chaired by the Chief Nurse for Scotland, and in the past he has been a regular contributor to infant-feeding organizations including the Annual Conference of the Baby Friendly Initiative.
He is also Board Chairman of a Counselling organization based in Dundee and a founding member and former Chair of an organization called Parent-to-Parent which provides support for families with children with special needs.
Content
Introduction 1
About the Author 3
Abbreviations and acronyms used in this book 4
Boxes, figures and tables in this book 7
1 Three institutions 9
The World Health Organization (WHO) 9
WHO and the UN 10
WHO and Codex Alimentarius 11
Performance of the three institutions 12
2 Three policies 15
The Code 16
The Innocenti Declaration 19
WHO Global Strategy for Infant and Young Child Feeding 20
3 Why has the Code been associated with decades of conflict? 27
The Code - is it time for a new perspective? 31
4 Why have breastfeeding policies failed to engage with populations? 39
Exclusive breastfeeding 40
Interface between exclusive breastfeeding and the introduction of
complementary foods 42
Breastfeeding for two years or beyond 44
Personalized breastmilk and depersonalized infant-feeding policies 46
Breastmilk and the newborn gastrointestinal tract 49
Suboptimal lactation 50
Emotional and psychological consequences of ceasing breastfeeding 52
Personalized care and support for parents 55
5 Why has complementary feeding been neglected? 61
Complementary-feeding strategy 62
Exclusive breastfeeding and the complementary feeding interface 68
An integrated approach to infant and young-child feeding is essential 69
Complementary feeding and malnutrition 70
6 Is non-compliance prevalent across all stakeholders? 77
Evidence of lack of commitment to the Code by governments 78
Evidence of failure of compliance by health services 79
Evidence of failure to govern the Code 82
Non-compliance issues for families 83
A way forward 84
7 When is a breastmilk substitute no longer a breastmilk substitute? 91
What is the policy status of this new interpretation of breastmilk substitutes? 92
Is WHO's interpretation of breastmilk substitutes plausible? 94
What is the objective of WHO's new interpretation of 'breastmilk substitutes'? 98
The impact on parents 99
8 How critical is the duration of continued breastfeeding for child health? 109
Evidence or opinion? 109
Establishing evidence on breastfeeding and child health 111
More on the Belarus PROBIT study 116
Breastfeeding in the second year of life 121
Alignment of research and advocacy 122
9 The journey from scientific research to clinical practice 129
Intervention studies 130
Docosahexaenoic acid (DHA) 131
Cochrane reviews (meta-analyses) 132
Data from randomized clinical trials (RCTs) 133
Appraisal of evidence and the process of making policy 133
What is the best evidence for public health policy-makers? 134
Pragmatism when applying research to practice 134
10 Family-friendly policies-less idealism and more realism 137
Philosophical divisions 137
Public engagement 138
Economic status 141
Misleading information 143
The importance of choosing the right language 147
Advising on policy 149
Equality, caring and respect 150
Interface with health professionals 152
11 The relationship of breastfeeding to maternal health 157
Breastfeeding, menstruation and infertility 157
Breastfeeding, obesity, cardiovascular disease and diabetes 158
More findings from the PROBIT study 162
Breastfeeding and cancer 163
Breastfeeding, cancer and docosahexaenoic acid (DHA) 166
12 Interest groups, advocates and activists 171
Special interest, advocates and activists 171
The Global Breastfeeding Collective 173
WHO and activism 175
How could this be managed differently? 179
13 Dysfunctional partnership-working 183
WHO and industry 184
Industry and governance 186
WHO working with health professionals 189
A Strategic Advisory Group (SAG) on infant and young-child feeding 192
14 Product regulation and monitoring 195
Evaluation of changes in formula composition 196
DHA and infant formulas 196
Regulatory systems for marketing, promotion, labelling and packaging 199
Transformational change 203
15 Stakeholder conflict of interest and independent regulation 217
Self-interest 218
Conflict of interest 219
Collaborative infant-feeding research 219
Sponsorship of educational meetings 220
Conflict of interest or interest in conflict? 223
The interface between policy-makers, paediatricians and industry 228
Is there a way forward? 231
Should WHO disentangle itself from conflict of interest? 233
16 An independent review of infant-feeding policy-making is long overdue 241
Roles and responsibilities of WHO, WHA and governments 241
Roles and responsibilities of policy-makers, health professionals and industry 243
Parent-friendly policies 244
Integrated approach to infant and young-child diet 245
Policy integration 245
Independent regulatory authorities 246
The way forward 247
17 A memorandum of understanding between WHO and Nestle 251
What should Nestle and WHO bring to the table? 251
18 A framework for change management 259
Global and national policy-making 259
Infant feeding and morbidity and mortality 259
Breastmilk and infant formula 260
Complementary feeding 260
Inequality 260
The importance of food 261
Parental involvement 261
Health benefits of breastfeeding for infants 261
Infant-feeding policy 262
Conflict of interest 262
Interest groups, advocates and activists 263
Partnership-working 263
Governance 263
Critical success factors 264
19 Seven steps to transformational change 265
A strategic framework to balance global and national responsibilities 265
A global and national code of practice for infant and young-child feeding 265
A global regulatory framework for regulation of infant formula 266
A research framework that supports research in academic and industry 266
A governance framework to set standards for all stakeholders 267
A parental involvement framework 267
A memorandum of understanding (MoU) between WHO and Nestle 267
20 Final reflections 269
21 On the 40th Anniversary of the adoption of the Code 279
Epilogue 283
References 284
Useful links 299
Index 302
About the Author 3
Abbreviations and acronyms used in this book 4
Boxes, figures and tables in this book 7
1 Three institutions 9
The World Health Organization (WHO) 9
WHO and the UN 10
WHO and Codex Alimentarius 11
Performance of the three institutions 12
2 Three policies 15
The Code 16
The Innocenti Declaration 19
WHO Global Strategy for Infant and Young Child Feeding 20
3 Why has the Code been associated with decades of conflict? 27
The Code - is it time for a new perspective? 31
4 Why have breastfeeding policies failed to engage with populations? 39
Exclusive breastfeeding 40
Interface between exclusive breastfeeding and the introduction of
complementary foods 42
Breastfeeding for two years or beyond 44
Personalized breastmilk and depersonalized infant-feeding policies 46
Breastmilk and the newborn gastrointestinal tract 49
Suboptimal lactation 50
Emotional and psychological consequences of ceasing breastfeeding 52
Personalized care and support for parents 55
5 Why has complementary feeding been neglected? 61
Complementary-feeding strategy 62
Exclusive breastfeeding and the complementary feeding interface 68
An integrated approach to infant and young-child feeding is essential 69
Complementary feeding and malnutrition 70
6 Is non-compliance prevalent across all stakeholders? 77
Evidence of lack of commitment to the Code by governments 78
Evidence of failure of compliance by health services 79
Evidence of failure to govern the Code 82
Non-compliance issues for families 83
A way forward 84
7 When is a breastmilk substitute no longer a breastmilk substitute? 91
What is the policy status of this new interpretation of breastmilk substitutes? 92
Is WHO's interpretation of breastmilk substitutes plausible? 94
What is the objective of WHO's new interpretation of 'breastmilk substitutes'? 98
The impact on parents 99
8 How critical is the duration of continued breastfeeding for child health? 109
Evidence or opinion? 109
Establishing evidence on breastfeeding and child health 111
More on the Belarus PROBIT study 116
Breastfeeding in the second year of life 121
Alignment of research and advocacy 122
9 The journey from scientific research to clinical practice 129
Intervention studies 130
Docosahexaenoic acid (DHA) 131
Cochrane reviews (meta-analyses) 132
Data from randomized clinical trials (RCTs) 133
Appraisal of evidence and the process of making policy 133
What is the best evidence for public health policy-makers? 134
Pragmatism when applying research to practice 134
10 Family-friendly policies-less idealism and more realism 137
Philosophical divisions 137
Public engagement 138
Economic status 141
Misleading information 143
The importance of choosing the right language 147
Advising on policy 149
Equality, caring and respect 150
Interface with health professionals 152
11 The relationship of breastfeeding to maternal health 157
Breastfeeding, menstruation and infertility 157
Breastfeeding, obesity, cardiovascular disease and diabetes 158
More findings from the PROBIT study 162
Breastfeeding and cancer 163
Breastfeeding, cancer and docosahexaenoic acid (DHA) 166
12 Interest groups, advocates and activists 171
Special interest, advocates and activists 171
The Global Breastfeeding Collective 173
WHO and activism 175
How could this be managed differently? 179
13 Dysfunctional partnership-working 183
WHO and industry 184
Industry and governance 186
WHO working with health professionals 189
A Strategic Advisory Group (SAG) on infant and young-child feeding 192
14 Product regulation and monitoring 195
Evaluation of changes in formula composition 196
DHA and infant formulas 196
Regulatory systems for marketing, promotion, labelling and packaging 199
Transformational change 203
15 Stakeholder conflict of interest and independent regulation 217
Self-interest 218
Conflict of interest 219
Collaborative infant-feeding research 219
Sponsorship of educational meetings 220
Conflict of interest or interest in conflict? 223
The interface between policy-makers, paediatricians and industry 228
Is there a way forward? 231
Should WHO disentangle itself from conflict of interest? 233
16 An independent review of infant-feeding policy-making is long overdue 241
Roles and responsibilities of WHO, WHA and governments 241
Roles and responsibilities of policy-makers, health professionals and industry 243
Parent-friendly policies 244
Integrated approach to infant and young-child diet 245
Policy integration 245
Independent regulatory authorities 246
The way forward 247
17 A memorandum of understanding between WHO and Nestle 251
What should Nestle and WHO bring to the table? 251
18 A framework for change management 259
Global and national policy-making 259
Infant feeding and morbidity and mortality 259
Breastmilk and infant formula 260
Complementary feeding 260
Inequality 260
The importance of food 261
Parental involvement 261
Health benefits of breastfeeding for infants 261
Infant-feeding policy 262
Conflict of interest 262
Interest groups, advocates and activists 263
Partnership-working 263
Governance 263
Critical success factors 264
19 Seven steps to transformational change 265
A strategic framework to balance global and national responsibilities 265
A global and national code of practice for infant and young-child feeding 265
A global regulatory framework for regulation of infant formula 266
A research framework that supports research in academic and industry 266
A governance framework to set standards for all stakeholders 267
A parental involvement framework 267
A memorandum of understanding (MoU) between WHO and Nestle 267
20 Final reflections 269
21 On the 40th Anniversary of the adoption of the Code 279
Epilogue 283
References 284
Useful links 299
Index 302