Violations of the International Code of Marketing of Breast-milk Substitutes: a multi-country analysis.

The marketing of formula milk as a substitute for breast milk continues to be ubiquitous and multifaceted despite passage by the World Health Assembly of the International Code of Marketing of Breast-milk Substitutes (the Code) in 1981. In this paper, we summarized reports of the Code violations from eight studies using the WHO/UNICEF NetCode protocol. Among 3,124 pregnant women and mothers with young children, in eight countries, 64% reported exposure to promotion of products covered under the Code in the previous 6 months, primarily from advertisements seen outside of health facilities (62%). Nearly 20% of mothers with an infant < 6 months reported that a health care provider had advised them to feed their child food or drink other than breast milk, and 21% of providers reported contact with a representative of a formula company in the previous 6 months to distribute promotional materials, samples, or free supplies (range 2%-53%). Of the 389 retail stores and pharmacies surveyed, promotions were observed in 63% (range 0-100%), and of 1,206 labels and inserts of products reviewed, nearly half included health and/or nutrition claims (range 0-100%). A strong, though non-significant, linear relationship between the composite violations score and quality of Code legislation was found; countries with the lowest percentage of violations had the strongest Code legislation. In Latin America, over 50% of health care providers reported no knowledge of the Code, and 50% reported no knowledge of national legislation. Our study highlights three key facts: 1) the marketing of BMS is ubiquitous and multifaceted, 2) the high variability of promotion across countries generally reflects the comprehensiveness of Code legislation, and 3) health care providers have poor knowledge of the Code and national legislation.

Prevention of childhood obesity and food policies in Latin America: from research to practice.

BACKGROUND: Addressing childhood obesity in Latin America requires a package of multisectoral, evidence-based policies that enable environments conducive to healthy lifestyles. OBJECTIVE: Identify and examine key elements to translating research into effective obesity policies in Latin America. METHODS: We examined obesity prevention policies through case studies developed with an expert in the specific policy. Policies were selected based on their level of implementation, visibility and potential impact to reduce childhood obesity. They include: (i) excise taxes on sugar sweetened beverages and energy-dense foods; (ii) front-of-package food label legislation; (iii) trans fatty acids removal from processed foods; and (iv) Ciclovías recreativas or 'open streets'. Case studies were coded to identify components that explained successful implementation and sustainability using the Complex Adaptive Health Systems framework. RESULTS: The analysis identified key elements for effective and sustainable policy, including evidence justifying policy; evidence-based advocacy by civil society; political will; and legislation and skillful negotiations across government, academia, the private sector and civil society. Scientific evidence and evaluation played an important role in achieving tipping points for policies' launch and sustain effective implementation. CONCLUSIONS: Well-coordinated, intersectoral partnerships are needed to successfully implement evidence-based anti-obesity policies. Prospective policy research may be useful for advancing knowledge translation.

Nutrition status of children in Latin America.

The prevalence of overweight and obesity is rapidly increasing among Latin American children, posing challenges for current healthcare systems and increasing the risk for a wide range of diseases. To understand the factors contributing to childhood obesity in Latin America, this paper reviews the current nutrition status and physical activity situation, the disparities between and within countries and the potential challenges for ensuring adequate nutrition and physical activity. Across the region, children face a dual burden of undernutrition and excess weight. While efforts to address undernutrition have made marked improvements, childhood obesity is on the rise as a result of diets that favour energy-dense, nutrient-poor foods and the adoption of a sedentary lifestyle. Over the last decade, changes in socioeconomic conditions, urbanization, retail foods and public transportation have all contributed to childhood obesity in the region. Additional research and research capacity are needed to address this growing epidemic, particularly with respect to designing, implementing and evaluating the impact of evidence-based obesity prevention interventions.

Growth and complementary feeding in the Americas.

BACKGROUND AND AIMS: To describe growth patterns of young children in Latin America and the Caribbean, the types of nationally representative data available on complementary feeding practices and complementary feeding practices. METHODS AND RESULTS: Data on growth, timing of introduction of liquids and foods, and complementary feeding practices were abstracted from nationally representative surveys. The high prevalence of stunting relative to the low prevalence of underweight is striking, with the "average" child in the region, with the exception of the Haitian child, short and chubby. The focus of the demographic and health surveys continues to be on undernutrition with only one question, intake of sugary foods, related foods that may have consequences for adult health. The United States has more comprehensive information; Mexico has information on beverage consumption and Brazil on soft drink and biscuit or snack consumption. In 14 of 19 countries, fewer than half of infants are exclusively breastfed for the first 6 months of life, indicating an early introduction of liquids and complementary foods. Among the 5 countries with data on the intake of sugary foods, intake in the previous 24 h among children 6-23 months of age ranged from 14% to 79%. CONCLUSIONS: The absence of data to characterize complementary feeding diets as they relate to risk of overweight and chronic diseases in the Region of the Americas calls attention to the need to improve data collection frameworks and methods to address this important gap in knowledge.

The effectiveness of a hospital-based program to promote exclusive breast-feeding among low-income women in Brazil.

OBJECTIVES: This study examined the effectiveness of a hospital program to promote exclusive breast-feeding in Santos, Brazil. METHODS: In a prospective design, women who delivered at a hospital with an active breast-feeding promotion program (n = 236) were compared with women who delivered at a nearby control hospital (n = 206). RESULTS: The two groups had similar demographic characteristics and previous breast-feeding histories. Exposure to breast-feeding activities, assessed by maternal recall prior to discharge, was universally high at the program hospital and universally low at the control hospital. Multivariate survival analysis showed that exclusive breast-feeding lasted 53 days longer among women who delivered at the program hospital. CONCLUSIONS: Hospital-based breast-feeding promotion programs may be effective in extending the duration of exclusive breast-feeding.

Age-specific responsiveness of weight and length to nutritional supplementation.

Evaluation of the responsiveness of weight and length to supplementary feeding shows that the two periods of greatest response coincide with weaning (ages 3-6 mo) and peak incidence and duration of diarrheal disease (ages 9-12 mo). Analyses were done for seven consecutive nonoverlapping intervals comparing children randomly assigned to receive supplemental feeding from birth to age 36 mo or to serve as control subjects. Absolute responsiveness was greatest between ages 3-6 mo; supplemented infants grew 0.61 cm more and gained 162 g more than did unsupplemented infants (p less than 0.005). Relative to rates of growth, responsiveness was greatest between ages 9 and 12 mo (the period of peak diarrheal prevalence), followed by ages 3-6 mo (the period of weaning). Responsiveness to supplementation is thus directly related to age-dependent risk patterns for malnutrition. Targeting supplementation programs to coincide with periods of high nutritional risk should maximize their effectiveness in reducing malnutrition, though caution should be exercised to avoid disruption of breast-feeding.

[Interaction of dietary intake and diarrheal disease in child growth]. / Interacción de la ingesta dietética y la enfermedad diarreica en el crecimiento de los niños.

There is evidence in the literature of the negative effects of diarrheal disease, and of the positive effects caused by food supplementation in postnatal growth. The present study analyzes the nature of the relationship between the effects of diarrheal disease and food supplementation on the growth of children of a rural area of Guatemala. The data analyzed were collected in a longitudinal study on food supplementation carried out by INCAP during the period comprised between 1969 and 1977. An important negative effect of diarrheal disease on growth was found on children three to 36 months of age with low dietary intake. Nevertheless, it was found that the negative effect of diarrheal disease on growth was lower in children whose dietary intake had important increments. In contrast, as compared with a study carried out in Colombia, where the supplementary feeding effect was restricted to groups with higher incidence of diarrhea, the supplementation effect on growth of Guatemalan children was found to be present at all levels of prevalence of diarrheal diseases. This article discusses the possible causes of the different results found in the Colombian study, as compared with those derived from the present study.

Nutritional supplementation: effects on child stunting because of diarrhea.

Research has shown that the positive effect of nutritional supplementation on child growth in malnourished populations is small relative to the large negative effect of diarrheal disease. To test the hypothesis that the effects of supplementation and diarrhea are synergistic in that supplementation modifies the negative effect of diarrhea on linear growth, length and diarrheal morbidity were compared at 36 mo of age for two cohorts of Colombian children: supplemented from birth and unsupplemented. Among unsupplemented children diarrhea was negatively associated with length. Among supplemented children diarrhea had no effect on length and differed from that of unsupplemented children. Thus, supplementation completely offset the negative effect of diarrheal disease on length. Targeting supplementation programs to the critical period of high diarrheal prevalence among infants and young children should increase the effectiveness of such programs in preventing growth retardation associated with diarrhea.

PIP: To test the hypothesis that supplementation modifies the negative effect of diarrhea on linear growth, body length and diarrheal morbidity were compared at 36 months of age for 2 cohorts of Columbian children: those receiving supplements from birth and those not receiving supplements. The sample was a subset from a longitudinal study that took place in Bogota, Columbia, between 1973 and 1980 and consisted of 456 families randomly assigned to 6 experimental groups. There were 148 children in the unsupplemented group. The 140 children from the supplemented group received supplements from the 6th month of pregnancy until they were 36 months old. The supplementary feeding included 30 g of protein daily, and 7.5 mg or 15 mg of ferrous sulphate daily as well as vitamin A every 6 months. Supplemented children had a mean 16 episodes of diarrhea, compared with a mean of 18 episodes of the unsupplemented cohort, and they spent a total of 73 days ill, compared with 83 days ill for unsupplemented children. Linear regression analysis showed that the slopes for unsupplemented children were significantly different from 0 (p 0.001). Each day with diarrhea was associated with a reduction of about 0.03 cm in attained length at age 36 months. In contrast, for supplemented children diarrhea had no effect on attained length at age 36 months. 2-way analysis of variance showed that the difference between supplemented and unsupplemented children in attained length in the lowest quartile of diarrhea was small, but the difference in the highest quartile was almost 5 cm. Cumulative growth patterns of children in the high quartile of diarrheal disease revealed that the difference between unsupplemented children was a median of 13 cm, thus supplementation made up nearly 40% of the deficit, compared with the reference standard (5 cm/13 cm). Targeting supplementation programs to the critical period of high diarrheal prevalence among infants and young children should help prevent growth retardation associated with diarrhea.