Breastfeeding: Some Strategies Used to Market Infant Formula May Discourage Breastfeeding; State Contracts Should Better Protect Against Misuse of WIC Name (08-FEB-06, GAO-06-282). Millions of U.S. mothers and infants each year forgo the health benefits of breastfeeding and rely on infant formula. Infants who are breastfed are less likely to develop infectious diseases and chronic health problems, such as diabetes and asthma, while breastfeeding mothers are less likely to develop certain types of cancer. Recognizing the health benefits of breastfeeding for infants and mothers, the U.S. Department of Health and Human Services' Healthy People 2010 campaign has recommended that more U.S. infants be breastfed and that babies be breastfed for longer periods of time. According to the U.S. Department of Agriculture (USDA), the U.S. would save a minimum of $3.6 billion in health care costs and indirect costs, such as parents' lost wages, if breastfeeding increased to meet these Healthy People goals. Breastfeeding rates are particularly low among infants who participate in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC). WIC is administered by the USDA's Food and Nutrition Service (FNS) in cooperation with state and local agencies. The program provides free food and infant formula to improve the health and nutritional well-being of low-income women, infants, and young children. Nearly half of infants born in the U.S. receive benefits through WIC. Although formula manufacturers agree that breastfeeding is best, they market infant formula as an alternative for mothers who do not exclusively breastfeed. A congressional committee asked us to review the potential impact of infant formula marketing on breastfeeding rates, especially for infants in the WIC program. We answered the following questions: 1) What are the estimated breastfeeding rates for infants in the general population and for infants on WIC, and how do these rates compare to recommended breastfeeding rates? 2) How is infant formula marketed to women in general and to women on WIC in particular? 3) What is known about the impact of infant formula marketing on the breastfeeding rates of women in the general population and women on WIC? -------------------------Indexing Terms------------------------- REPORTNUM: GAO-06-282 ACCNO: A46497 TITLE: Breastfeeding: Some Strategies Used to Market Infant Formula May Discourage Breastfeeding; State Contracts Should Better Protect Against Misuse of WIC Name DATE: 02/08/2006 SUBJECT: Child nutrition Children Food programs for children Health statistics Infants Marketing Parents Statistical data Surveys Women Breast feeding Infant formula HHS Healthy People 2010 Initiative Special Supplemental Nutrition Program for Women, Infants and Children ****************************************************************** ** This file contains an ASCII representation of the text of a ** ** GAO Product. ** ** ** ** No attempt has been made to display graphic images, although ** ** figure captions are reproduced. Tables are included, but ** ** may not resemble those in the printed version. ** ** ** ** Please see the PDF (Portable Document Format) file, when ** ** available, for a complete electronic file of the printed ** ** document's contents. ** ** ** ****************************************************************** GAO-06-282 * Studies of Infant Formula Discharge Packs Included in Our Re * Study of Prenatal Infant Formula Advertising Included in Our * GAO's Mission * Obtaining Copies of GAO Reports and Testimony * Order by Mail or Phone * To Report Fraud, Waste, and Abuse in Federal Programs * Congressional Relations * Public Affairs GAO February 2006 BREASTFEEDING Some Strategies Used to Market Infant Formula May Discourage Breastfeeding; State Contracts Should Better Protect against Misuse of WIC Name GAO-06-282 Contents Letter 1 Appendix I Briefing Slides 6 Appendix II Advertising Data 36 Appendix III Literature Review 37 Appendix IV Studies in Literature Review 39 Abbreviations CDC Centers for Disease Control and Prevention FNS Food and Nutrition Service NIS National Immunization Survey USDA United States Department of Agriculture WIC Special Supplemental Nutrition Program for Women, Infants, and Children This is a work of the U.S. government and is not subject to copyright protection in the United States. It may be reproduced and distributed in its entirety without further permission from GAO. However, because this work may contain copyrighted images or other material, permission from the copyright holder may be necessary if you wish to reproduce this material separately. United States Government Accountability Office Washington, DC 20548 February 8, 2006 The Honorable Robert Bennett Chairman The Honorable Herb Kohl Ranking Minority Member Subcommittee on Agriculture, Rural Development, and Related Agencies Committee on Appropriations United States Senate The Honorable Henry Bonilla Chairman The Honorable Rosa L. DeLauro Ranking Minority Member Subcommittee on Agriculture, Rural Development, Food and Drug Administration, and Related Agencies Committee on Appropriations United States House of Representatives The Honorable Tom Harkin Ranking Minority Member Committee on Agriculture, Nutrition, and Forestry United States Senate Millions of U.S. mothers and infants each year forgo the health benefits of breastfeeding and rely on infant formula. Infants who are breastfed are less likely to develop infectious diseases and chronic health problems, such as diabetes and asthma, while breastfeeding mothers are less likely to develop certain types of cancer. Recognizing the health benefits of breastfeeding for infants and mothers, the U.S. Department of Health and Human Services' Healthy People 2010 campaign has recommended that more U.S. infants be breastfed and that babies be breastfed for longer periods of time. According to the U.S. Department of Agriculture (USDA), the U.S. would save a minimum of $3.6 billion in health care costs and indirect costs, such as parents' lost wages, if breastfeeding increased to meet these Healthy People goals. Breastfeeding rates are particularly low among infants who participate in the Special Supplemental Nutrition Program for Women, Infants and Children (WIC). WIC is administered by the USDA's Food and Nutrition Service (FNS) in cooperation with state and local agencies. The program provides free food and infant formula to improve the health and nutritional well-being of low-income women, infants, and young children. Nearly half of infants born in the U.S. receive benefits through WIC. Although formula manufacturers agree that breastfeeding is best, they market infant formula as an alternative for mothers who do not exclusively breastfeed. A congressional committee asked us to review the potential impact of infant formula marketing on breastfeeding rates, especially for infants in the WIC program. 1 We answered the following questions: 1) What are the estimated breastfeeding rates for infants in the general population and for infants on WIC, and how do these rates compare to recommended breastfeeding rates? 2) How is infant formula marketed to women in general and to women on WIC in particular? 3) What is known about the impact of infant formula marketing on the breastfeeding rates of women in the general population and women on WIC? On December 14, 2005, we briefed interested congressional staff on the results of our analysis. This report formally conveys information provided during that briefing. In summary, we reported the following findings: o WIC and non-WIC breastfeeding rates fell short of most national goals, but rates were substantially lower for WIC infants. o Infant formula marketing targets non-WIC mothers and also reaches WIC mothers. Some of these marketing efforts use the trademarked WIC acronym in promotional materials. Although FNS requires states to restrict this practice in their WIC contracts, most states do not. o A majority of studies we reviewed that examine giving free formula samples to mothers at hospital discharge found lower breastfeeding rates among both WIC and non-WIC mothers. However, little is known about the impact of most types of marketing. In order to better protect the WIC acronym and logo from being inappropriately used in infant formula advertisements, we are recommending that the Secretary of Agriculture educate all states about The Senate Committee on Appropriations asked in the 2005 Agriculture, Rural Development, Food and Drug Administration, and Related Agencies appropriations report (Senate Report 108-340) that we conduct this study. Page 2 GAO-06-282 Breastfeeding FNS' policy restricting the use of the WIC acronym and logo and ensure that all state formula contracts include provisions restricting the use of these trademarks in infant formula advertisements. We used the following methodologies to develop our findings. To identify breastfeeding rates, we analyzed 2004 data from the Centers for Disease Control and Prevention's (CDC) National Immunization Survey (NIS) and compared the breastfeeding rates of WIC and non-WIC infants to the Healthy People 2010 breastfeeding goals. We also interviewed officials regarding survey methodology, and we determined that the survey and analysis were sufficiently reliable for the purposes of this briefing. To examine how infant formula is marketed to women in general and women on WIC, we analyzed data from market research company TNS Media Intelligence on television, radio, print, and outdoor infant formula advertisements between 1999 and 2004. To assess the reliability of the data, we talked with company representatives about data quality control procedures and reviewed relevant documentation. We determined the data were sufficiently reliable for the purposes of this briefing. To supplement the data, we surveyed state WIC directors and conducted interviews with women on WIC and with officials from infant formula companies and the National WIC Association. We also corresponded with FNS and reviewed state infant formula contracts, FNS policies, and infant formula advertisements. To assess the impact of infant formula marketing on breastfeeding rates of non-WIC and WIC participants, we reviewed U.S. studies published between January 1980 and July 2005 on the impact of infant formula marketing on breastfeeding rates. We examined each study's research methodology, including its sampling frame and analytic techniques, to determine whether the results should be included in our findings. Only two of the studies we reviewed included mostly WIC participants, and these studies had small samples. For additional information on our study review, please see appendixes III and IV. We conducted our work from June 2005 to November 2005 in accordance with generally accepted government auditing standards. This study focused on the marketing of infant formula and its impact on breastfeeding rates. We did not assess the impact of other factors that may affect breastfeeding rates, such as cultural factors and whether women work outside of the home, because this was beyond the scope of our work. In addition, available data did not allow us to assess whether there is a causal relationship between trends in infant formula marketing and historical breastfeeding rates in the U.S. We provided a draft of this report to officials of the U.S. Department of Agriculture for review and comment and incorporated their comments where appropriate. On January 6, 2006, the officials provided us with oral comments. They stated they agreed with our recommendation that the Secretary of Agriculture educate all states about FNS' policy restricting the use of the WIC acronym and logo and ensure that all state formula contracts include provisions restricting the use of these trademarks in infant formula advertisements. The officials noted that it may be necessary to include language in the state contracts allowing for fair use of the WIC name and acronym, as allowed by federal trademark law. They also explained that such use may serve a helpful purpose by informing health care providers and WIC participants of the infant formulas and medical foods that are available through WIC. We noted that our recommendation language was sufficiently broad to allow USDA to include language it considers appropriate in protecting the WIC trademark, including allowances for fair use. Officials also noted that the report did not consider the impact of employment factors on breastfeeding rates and that such factors may be particularly important for WIC participants, many of whom are employed outside the home. We agreed and explained that assessing the importance of such factors was beyond the scope of this report. We are sending copies of this report to relevant congressional committees and other interested parties and will make copies available to others upon request. In addition, this report will be available at no charge on GAO's Web site at www.gao.gov. If you or your staff have any questions about this report, please contact me at (415) 904-2272 or [email protected]. Contact points for our Offices of Congressional Relations and Public Affairs may be found on the last page of this report. Patrick di Battista (Assistant Director), Melissa Emrey-Arras (Co-Analyst-in-Charge), Marissa Jones (Co-Analyst-in-Charge), Rachael Chamberlin, Vivian Horn, Jim Lager, Jean McSween, Karen O'Conor, Dan Schwimer, and Jay Smale also made significant contributions to this report. David D. Bellis Director, Education, Workforce, and Income Security Issues Appendix II: Advertising Data To understand how infant formula is advertised through the mass media in the U.S., GAO purchased and analyzed data from TNS Media Intelligence on infant formula advertising between 1999 and 2004 in major U.S. markets. These data identified infant formula advertisements in the following media outlets: Television o network TV, o spot TV, o cable TV, and * syndicated TV * Print o magazines, o Hispanic magazines, o business to business publications, o national newspapers, * Hispanic newspapers, and o other newspapers * Radio o national spot radio (Data was only available on radio advertising expenditures, not the number of ads aired.) TNS Media Intelligence also searched for infant formula advertisements on outdoor signs but did not find any during this time period. To assess the reliability of the data, we talked with company representatives about data quality control procedures and reviewed relevant documentation. We determined the data were sufficiently reliable for the purposes of estimating trends in marketing by formula companies. Appendix III: Literature Review To identify research that evaluates the impact of infant formula marketing on breastfeeding rates among the general population and WIC participants in particular, we searched relevant databases from January 1980 through July 2005 using Dialog, including Agricola, Biosis, and CAB. We also consulted with USDA, the Centers for Disease Control and Prevention, the National WIC Association, infant formula companies, and other experts in the field. In addition, we identified studies through citations in previously identified studies, as well as through online journals and search engines. In order to focus on evaluation of the impact of infant formula marketing, we identified studies that met the following criteria: o The document is an original research study or an analysis of research data evaluating the impact of infant formula marketing on breastfeeding rates among U.S. women in general or WIC participants specifically. o The document has been published in a refereed medium (for example, a journal article, book or book chapter, or USDA-issued report). o The document's publication date is 1980 or later. o All of the research described in the document was conducted in the United States. o The document is in English. Some studies were excluded because the research was not conducted in the United States or because they did not otherwise meet our criteria. For example, we excluded one study of the impact of hospital discharge packs on breastfeeding rates because the study had been conducted in Canada. We identified 17 studies meeting our review criteria, and we conducted detailed reviews of each study's research methodology, including its research design, sampling frame, selection of measures, data quality, limitations, and analytic techniques. 1 We excluded 5 studies due to methodological limitations and retained 12 for analysis (listed in appendix IV). 1 The studies used different measures of breastfeeding, such as one week or one month, and defined exclusive breastfeeding in different ways, ranging from consumption of nothing but breast milk to consumption of no other milk or formula. Page 37 GAO-06-282 Breastfeeding Eleven of the remaining 12 studies examined the impact on breastfeeding of giving new mothers free infant formula samples in hospital discharge packages. 2 Only 2 of these studies included mostly WIC participants. One study examined the impact on breastfeeding of formula samples distributed to pregnant women in doctors' offices. Some studies compared receipt of formula discharge packs to receipt of no packs, while others compared them to receipt of breastfeeding promotion packs or other infant supply packs. Two of the studies were supported by infant formula companies. Appendix IV: Studies in Literature Review Studies of Infant Formula Discharge Packs Included in Our Review Bliss, Mary Campbell, Joy Wilkie, Curt Acredolo, Susan Berman, and Kathleen Phillips Tebb. "The Effect of Discharge Pack Formula and Breast Pumps on Breastfeeding Duration and Choice of Infant Feeding Method." Birth 24:2 (June 1997): 90-97. (This study was supported by infant formula manufacturer Mead Johnson.) Caulfield, Laura E., Susan M. Gross, Margaret E. Bentley, Yvonne Bronner, Lisa Kessler, Joan Jensen, Benita Weathers and David M. Paige. "WIC-Based Interventions to Promote Breastfeeding Among African-American Women in Baltimore: Effects on Breastfeeding Initiation and Continuation." Journal of Human Lactation 14:1 (1998): 15-22. (Study focused exclusively on WIC participants.) Dungy, Claibourne I., Mary E. Losch, Daniel Russell, Paul Romitti, and Lois B. Dusdieker. "Hospital Infant Formula Discharge Packages: Do They Affect the Duration of Breast-feeding?" Archives of Pediatrics & Adolescent Medicine 151 (July 1997): 724-729. Evans, Cynthia J., Nancy B. Lyons, and Marcia G. Killien. "The Effect of Infant Formula Samples on Breastfeeding Practice." Journal of Obstetric, Gynecologic, and Neonatal Nursing (September/October 1986): 401-405. Feinstein, Joel M., Jay E. Berkelhamer, Mary Ellen Gruszka, Cynthia A. Wong, and Ann E. Carey. "Factors Related to Early Termination of Breastfeeding in an Urban Population." Pediatrics 78:2 (August 1986): 210-215. Frank, Deborah A., Stephen J. Wirtz, James R. Sorenson, and Timothy Heeren. "Commercial Discharge Packs and Breast-Feeding Counseling: Effects on Infant-Feeding Practices in a Randomized Trial." Pediatrics 80:6 (December 1987): 845-854. Neifert, Marianne, Jane Gray, Nancy Gary, and Bonnie Camp. "Effect of Two Types of Hospital Feeding Gift Packs on Duration of Breast-feeding Among Adolescent Mothers." Journal of Adolescent Health Care 9:5 (1988): 411-413. Ryan, Alan S., Jeffrey L. Wysong, Gilbert A. Martinez, and Stephen D. Simon. "Duration of Breast-feeding Patterns Established in the Hospital." Clinical Pediatrics 29:2 (February 1990): 99-107. (This study was conducted by infant formula manufacturer Ross Laboratories.) Romero-Gwynn, Eunice. "Breast-feeding Pattern Among Indochinese Immigrants in Northern California." American Journal of Diseases of Children 143 (July 1989): 804-808. (Study included mostly WIC participants.) Snell, B.J., Marie Krantz, Rebecca Keeton, Karen Delgado, and Carol Peckham. "The Association of Formula Samples Given at Hospital Discharge with the Early Duration of Breastfeeding." Journal of Human Lactation 8:2 (1992): 67-72. Wright, Anne, Sydney Rice, and Susan Wells. "Changing Hospital Practices to Increase the Duration of Breastfeeding." Pediatrics 97:5 (May 1996): 669-675. Howard, Cynthia, Fred Howard, Ruth Lawrence, Elena Andresen, Elisabeth DeBlieck, and Michael Weitzman. "Office Prenatal Formula Infant Formula Advertising and Its Effect on Breast-Feeding Patterns." Obstetrics & Gynecology 95:2 (February 2000). Advertising Included in Our Review (130489) GAO's Mission The Government Accountability Office, the audit, evaluation and investigative arm of Congress, exists to support Congress in meeting its constitutional responsibilities and to help improve the performance and accountability of the federal government for the American people. GAO examines the use of public funds; evaluates federal programs and policies; and provides analyses, recommendations, and other assistance to help Congress make informed oversight, policy, and funding decisions. 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