The following section presents the results, organized into key themes. We did not find significant recent literature on this topic. Therefore, in many places we draw upon and present new empirical findings.
The rise of big formula and the material foundations of its power
In this section we describe the evolution of the baby food industry, and in doing so, describe the material assets and resources the corporations have accrued, as milk formula markets have expanded worldwide.
Today, Nestlé, Danone, Reckitt Benckiser Mead Johnson (RBMJ), Abbott Laboratories (Abbott), Friesland Campina (RFC) and Feihe are the global market leaders. Table 2 provides a breakdown of their assets and resources. Although pharmaceutical companies have historically dominated the industry, especially in the US and reflecting the unique nature of the product ‘on the dividing line between food and pharmaceuticals’ , Big Formula now spans the pharmaceutical, food manufacturing and consumer goods sectors. The top-five are extensively globalized. Nestlé, Danone, Abbott and RFC are present in > 100 country markets and RBMJ in 50, with affiliate or subsidiary firms in most. Nestlé has a near ubiquitous global presence. With the exception of Feihe, which operates in China alone, Big Formula are transnational corporations headquartered in Europe or the US. In 2016 all corporations, with the exception of Abbott, generated the majority of sales in emerging markets (Table 2).
None sell BMS exclusively, comprising between 10 and 33% of total sales. However, the category has been a major, and if not the main, source of new revenue growth. For example, in 2018 the Nestlé Nutrition and Health Science division was the second largest contributor to total global sales, but the most important for generating new sales growth . Big Formula also includes other transnationals such as Kraft Heinz (US) and Groupe Lactalis (France), and important regional players such as Hipp and Hero Group in Europe. National firms are leaders in several markets, for example, Vinamilk in Vietnam, Meiji and Morinaga in Japan, and Namyang in South Korea. China is home to several large home-grown corporations . Big Formula are major employers, with the largest-five employing ~ 580,000 people between them worldwide. For Nestlé, Danone and RBMJ, only a small fraction (< 10%) are in their home countries. Approximately one fifth of Danone’s workforce, and one tenth of RFC’s, are employed in the division that manufactures BMS.
Until the mid-nineteenth Century babies were breastfed, or due to the mother’s death in childbirth, for other medical reasons or by choice, they were often wet-nursed by another woman. In some contexts, wet-nursing was an organized and regulated profession. In others, it was a service provided by family members, by slaves for their masters, or by poor women for the rich [6, 70, 71]. Artificial feeding of animal milks or other liquid foods also occurred, however it often resulted in malnutrition and high infant-mortality, exacerbated by poor sanitation and food hygiene [71, 72]. It was in this context the German chemist Justus von Liebig patented the first milk formula in 1865, informed by studies on the chemical composition of cows and human milk. By 1869, Liebig’s food for infants was being sold in Europe and the US, made from cow’s milk, malt and wheat flour, and potassium bicarbonate, and available first in liquid and then in powdered form, and purchased mostly by the wealthy. New techniques and materials for manufacturing bottles and teats, helped to promote the normalisation of artificial feeding, and supported early market expansion. By 1883, at least 27 patented brands of infant food had become available, and the age-old profession of wet-nursing quickly declined [70, 71].
Henri Nestlé, the founder of the company bearing his name, pioneered many of the industry’s early marketing techniques, including ‘direct mail’ of brochures to new mothers, and a ‘medical strategy’ of engaging doctors, conducting clinical trials, advertising in medical journals, and product endorsement by prominent scientists and health professionals . Nestlé, and other companies like Britain’s Cow and Gate, were at the vanguard of the industry’s first-wave of globalization, expanding along European colonial pathways, and benefiting from their ‘first-mover advantage’ in many markets [74, 75]. By the 1920s, Nestlé was by far the market leader, with 80 factories operating worldwide, plus 300 sales offices, depots or agencies . By this time, most of today’s commercial milk formula brands had become available [27, 71]. This included specialised milks for certain medical conditions affecting a small proportion of infants, the first using soy-based protein for those allergic to cow’s milk . Milk formula markets steadily expanded throughout the mid-twentieth century, alongside more intensive marketing to health professionals, the medicalisation of pregnancy and birth (including the frequent separation of mother and infant in birthing clinics), and the widespread use of formula in hospitals. These developments coincided with a precipitous decline in breastfeeding in many countries, reaching historic lows in the 1960s-70s .
From then onwards, however, breastfeeding rates began to resurge in many of Big Formula’s markets. This along with declining birth rates following the post-World War II ‘baby boom’, resulted in stagnating sales, and in response, companies started to intensify their marketing practices in markets of the Global South [27, 52]. Marketing techniques used to promote and normalise formula-feeding, included mass-media advertising, large-scale distribution of free samples, and salespeople dressed as ‘mothercraft nurses’, to engage mothers directly in maternity wards and in their homes [27, 28]. These practices were soon associated with widespread ‘commerciogenic malnutrition’ and infant deaths [6, 28], which in-turn triggered worldwide civil public scrutiny, and events that would lead to the adoption of The Code in 1981. Despite these developments, market expansion continued apace. Between 1978 and 1983, total world sales nearly tripled, from ~US$1.5 billion to ~US$4 billion , mainly through exports to overseas markets, as Big Formula took advantage of subsidies for dry milk products in the US and Europe . In 1984, facing new marketing regulations promulgated by The Code, the industry began marketing more intensively a wider range of product categories for older infants and young children. The availability of follow-up (6–12 months) and toddler (13–36 months) formulas markedly increased [27, 79], and in many markets today these categories now represent a near-equal, or even greater, market share than infant formula .
The Code was, in some respects, a product of its time. The 1970s–80s was an era of accelerating globalization, with rapid growth in the number and size of transnational corporations, and their economic power relative to nation states [30, 51]. With this came vocal calls from civil society, many governments, and various UN agencies, for the internationalisation of corporate regulation, with The Code being one among ~ 30 such codes and guidelines proposed across the UN system at the time [30, 31]. Remarkable changes in the global political and economic system have occurred since then. In the 1980s, the rise of neoliberal economic and social policies led to market liberalization, privatization and growing preferences for market-based approaches to governance [81, 82]. A ‘corporate food regime’ emerged, as transnational food corporations, mostly through foreign direct investment, began to globalise with renewed vigour, seeking growth opportunities in the rapidly industrialising countries of the Global South [48, 83, 84]. The establishment of the World Trade Organization (WTO) in 1995, and then an explosion in free trade agreements, accelerated this process, allowing such corporations to integrate their ‘global value chains’, while imposing new rules on how governments regulated their markets [85,86,87].
The above developments fostered ripe conditions for the most recent and remarkable phase of Big Formula’s global expansion. As shown in Fig. 1, this is reflected in the massive expansion in worldwide milk formula production and trade flows. In 2005, only Ireland and Singapore were exporting >US$5million of milk formula for retail sale to China; by 2017 at least 16 countries were – most notably Australia, New Zealand, France, and the Netherlands. In 2005, total world sales were US$22.9 billion; by 2019 this figure had more than doubled to US$55.6 billion [37, 38]. The world sales volume per child (0–36 months), more than doubled from 3.5 to 7.4 kg over the same period. This growth occurred mostly in the industrialising and highly-populated middle-income countries of East and South East Asia, and to a lesser extent Eastern Europe & Central Asia, Middle East & North Africa, and Latin America. During this period, China became the world’s largest and most competitive market. In 2005, the US was the world’s largest market and China represented just 14.1% of global sales. By 2019, it represented 32.5%, 2.3-fold larger than the US and Western European markets combined .
Today Big Formula is ‘hyper-globalized’ , with extensive global sourcing and production networks. In 2018, for example, Nestlé had 443 factories operating across 80 countries, of which 40 were listed as the division that manufactures BMS . Abbott operated 27 production sites globally, of which 14 were listed under its Nutrition division . Market expansion has also been enabled by massive growth in the industries providing milk formula manufacturing inputs. Between 1961 and 2014, for example, production of dry milk powder grew from 491,000 to 3,444,000 t, initially from output in European countries, and then from countries in Australasia and Latin American with industrial dairying systems [89, 90]. Figure S1 shows the significant expansion in dry milk powder production and trade flows between 2005 and 2014. Markets for dry milk powder are dominated by a handful of ‘Big Dairy’ corporations, including for example, Fonterra (New Zealand), Dairy Farmers of America (US), and Groupe Lactalis (France). China’s formula boom was enabled by expanded dairy production and exports from New Zealand in particular, which expanded rapidly following the Free Trade Agreement signed between the two countries in 2008. New Zealand was the first country to sign such an agreement, and by 2012, dairy exports comprised 30% of the country’s total exports to China [91, 92]. In recent decades vegetable oil production, and especially palm oil as a common milk formula ingredient, has also significantly expanded [19, 93].
The rise of Big Formula’s material power is also reflected in high levels of market concentration nearly everywhere. Figure 2 shows the market shares of leading corporations in key country markets and worldwide. In 2018, 61.6% of world sales accrued to the six largest milk formula manufacturers listed in Table 2. The three largest – Nestlé, Danone and RBMJ – had a combined world market share of 42%. In 2010, the largest four had near equivalent sales, but since then Nestlé and Danone have further consolidated their market positions. These gains have occurred through organic sales growth, but also through sustained merger and acquisition activity, with the industry currently undergoing ‘terminal’ consolidation . Recent acquisitions have included Danone’s of Numico/Nutricia in 2007 for US$18 billion, Nestlé’s of Pfizer’s infant nutrition division in 2012 for US$11.9 billion, and Reckitt Benckiser’s of Mead Johnson Nutrition in 2017 for US$16.6 billion. The acquired firms were already products of various mergers and acquisitions, going back many decades . Regional and national markets are even more consolidated. As shown in Fig. 2, many are oligopolistic, for example in the US, Brazil, South Africa and Indonesia, where only a few corporations dominate. The exception is China, where Nestlé leads, but a diverse mix of transnational and domestic players compete . Consolidation can enhance Big Formula’s market power over suppliers, allowing the sourcing of manufacturing inputs at lower-cost. By capturing markets, companies can also exert greater control over prices, and what products are available to consumers.
Several transformations in Big Formula’s distribution networks, also explain the phenomenal global expansion of milk formula markets. First, the liberalization of trade in retail services has enabled the ‘supermarketization’ of developing countries since the late 1990s, which alongside pharmacies, is a key channel for reaching urban consumers with rising incomes [19, 24]. Second, the medicalization of pregnancy, birthing and infant care in many countries, has created new opportunities for the industry to market products through health-care providers (see health professional co-optation), just as new practices that undermine breastfeeding, such as birth by caesarean section, have increased markedly in many countries [37, 94]. Finally, growth in ‘grey-market’ trade by third parties has also contributed significantly to rapid market expansion [24, 37]. Sophisticated Daigou (grey channel) operations in Australia, New Zealand, the UK and Germany have involved shoppers purchasing well known branded products for export in suitcases or small shipments to China, to the extent that in 2014, Daigou sales were equivalent to half of what foreign companies were selling in the formal Chinese market .
The baby food industry’s global influence network
To protect their worldwide interests, and to foster favourable regulatory and knowledge environments for expansion across their diverse markets, Big Formula and the wider industry employs an extensive global network of trade associations and other corporate-funded influence organizations. Figure 3 shows this network and Table S1 the full list of names and abbreviations. The lines represent membership in these organizations, which span many regulatory issues and corporate functions, at international, regional and national levels; the size of the circles represents the number of organizations each corporation associates with. The respective corporations are typically members of organizations in countries where they have a major market presence. Hence Nestlé, as the most transnationalised (Table 2), is a member of the most organizations in the network followed by Danone, RBMJ, Abbott and RFC. Major ingredients suppliers, such as DSM and Fonterra, also feature prominently.
Core to the network are ‘infant nutrition’ trade associations (red), which focus on baby food issues specifically. The first such organizations were established in the 1970s in response to emerging public relations and regulatory threats, enabling Big Formula to execute their public relations strategies and lobby at ‘arms-length distance’, while minimising negative publicity. The International Council of Infant Food Industries (ICIFI) was established by eight companies in 1975, following highly publicised Nestlé litigation against student activists in Switzerland [27, 28]. As civil society groups began to strongly agitate for adoption of The Code, ICIFI enabled Nestlé to make ‘third party rebuttals of the activists’ case’ . However, because of this, ICIFI’s public reputation soon diminished, and it was replaced in 1984 by the International Association of Infant Food Manufacturers (IFM) [97, 98].
The IFM itself was disbanded in 2016 and today the International Special Dietary Industries (ISDI) is the industry’s peak international lobby group, with 20 member associations across six continents . Two of these associations are regional – Specialised Nutrition Europe and The Asia Pacific Infant and Young Child Nutrition Association. Some have authoritative names, akin to professional and non-commercial organizations – for example, the Infant and Pediatric Nutrition Association of the Philippines, the Infant and Young Child Nutrition Council (India), and the Infant Nutrition Council of Australia & New Zealand. Some provide extensive infant and young child feeding advice on their websites. Others have developed clinical standards and guidelines for infant care. For example, Abbott provided seed funding to establish the European Foundation for the Care of Newborn Infants (EFCNI), ‘to represent the interests of preterm and newborn infants and their families’ . Hence, these ‘front groups’ appear to be public-interest civil society organizations, but in fact represent corporate interests .
Figure 3 shows the influence network also includes trade associations and lobby groups concerned with many other corporate issues and regulatory affairs. In yellow, for example, is a network of advertising and branding associations, many of which are member organizations of the World Federation of Advertisers (WFA). The activities of these organizations are diverse, but mainly focus on protecting the intellectual property rights of corporate brands, promoting voluntary advertising codes, and lobbying against governments adopting mandatory marketing regulations. Other types also feature prominently in the network including general business associations like the US and European Chambers of Commerce, who seek to foster trade access and protect free enterprise (brown), food, beverage and grocery manufacturers associations (green), dairy groups like the International Dairy Federation (blue), and corporate-funded scientific institutes and communications platforms, for example the International Life Sciences Institute (ILSI) and the International Food Information Council (IFIC) (purple).
Contesting standards in multi-lateral policy-making arenas
The lobbying activities of many organizations in the above network, are coordinated across multiple policy fora and decision-making spaces simultaneously. At the international level, this includes three key organizations that develop policy and govern the regulation of foods for infants and young children, and hence influence industry sales worldwide: the World Health Organization (WHO), Codex Alimentarius Commission (CAC), and World Trade Organization (WTO).
Technical standards and norms established by the WHO, are crucial in guiding global infant and young child feeding (IYCF) policy actions. Table 3 provides notable examples of how Big Formula, and member states representing the industry, have lobbied to undermine the scope and strength of The Code, since it was first proposed in 1979. Article 19 of the WHO Constitution grants the World Health Assembly, as the world’s highest health policy-making body, the power to adopt (listed from strongest to weakest) conventions, regulations and recommendations. As an example, the Framework Convention on Tobacco Control (FCTC) was adopted by the World Health Assembly in 2003, as a legally binding treaty. The adoption of The Code as a recommendation, rather than a more binding regulation, was attributed largely to the opposition of the US and other large-dairy producing member states at the time . Since then, lobbying efforts have focused mainly on limiting the ‘regulatory scope’ of WHO technical guidance and subsequent WHA resolutions. This includes opposing the extension of the recommended duration of exclusive breastfeeding, and technical guidance concerning cross-promotion, and the designation of products for ages 6–36 months (i.e. follow-up and toddler milks) as BMS .
Big Formula and the baby food industry have also influenced standard-setting processes at CAC, the UN food standard-setting body jointly administered by WHO and FAO, with a dual mandate to protect public health and safety, and to facilitate international food standards harmonisation and trade [30, 105, 107]. Codex standards – including specific ‘commodity standards’ for infant and specialised formulas, and follow-up formula, and ‘general standards’ on labelling, additives and others that apply to all commodities within scope – are developed by committees comprising voting member states, with technical input from observers, including industry trade associations and civil society organizations [105, 107]. Table 3 details several examples of how dairy-producing member states, and industry trade associations – mainly ISDI and the International Dairy Federation – have contested these standards.
This lobbying works in the interests of Big Formula and the wider industry for two key reasons. First, CAC standards function as a minimum benchmark, or regulatory ‘floor’, for the development of national regulatory measures on product composition, safety and labelling, and therefore influence regulatory standards worldwide [30, 107]. Second, the CAC is explicitly referenced in the WTO’s Sanitary and Phytosanitary Measures Agreement (SPS), and meets the criteria for a standard-setting body in the Technical Barriers to Trade Agreement (TBT). Subsequently, countries implementing regulatory measures more stringent than Codex standards may be required to provide scientific justification in the WTO and other trade policy fora. Because of this, CAC standard-setting processes have become highly politicised, with strong industry participation and influence [30, 107].
In Fig. 4, we present new data on the affiliations of participants in the Codex Committee on Nutrition and Foods for Special Dietary Uses (CCNFSDU), mandated to develop the standards for infant and specialised formulas, and follow-up formula respectively. Between 2005 and 2019, industry not only comprised 70% of non-state observers participating in the CCNFSDU meetings, far out-numbering observers from civil society and inter-governmental organizations, but also 28% of member state delegations. In several instances industry representatives were the member state delegation in its entirety.
The influence of the baby food industry is also evident in the WTO, the inter-governmental organization for developing, maintaining and enforcing a global system of trade rules and agreements. As WHO and UNICEF recently reported, formal trade arbitration concerning national implementation of The Code (i.e. through a WTO dispute panel and settlement process) has yet to eventuate . However, we have shown how member states with large dairy-producing industries – especially the US, EU, Australia and New Zealand – frequently use WTO processes to challenge BMS-related regulations adopted by other member states [Russ K, Baker P, Byrd M, Kang M, Siregar RN, Zahid H, McCoy D: Understanding the global trade and public health regime complex: a case study on breastfeeding and commercial breastmilk substitutes. Forthcoming]. Between 1995 and 2019, 110 interventions occurred against WTO member states relating to actual or proposed BMS marketing, labelling or safety testing regulations (Table 3). Here the term ‘intervention’ refers to ‘questions or comments relating to restrictions or proposed restrictions in one member country, registered to a WTO committee or council, by a delegation from another country, or during a trade policy review’. In some instances, interventions occurred across several years, resulting in significant changes to the planned implementation of The Code by a member state. For example, between 2015 and 2018, when Thailand started revising its ‘Milk Code’, including extending the scope of products from the ages 0–12 to –36 months, it faced repeated interventions via the WTO Trade Policy Review process, and then in the TBT Committee. The National Assembly passed the final legislation, but without the proposed restrictions on the marketing of products for ages 12–36 months [Russ K, Baker P, Byrd M, Kang M, Siregar RN, Zahid H, McCoy D: Understanding the global trade and public health regime complex: a case study on breastfeeding and commercial breastmilk substitutes. Forthcoming].
Contesting standards in bi-lateral and national policy-making arenas
The baby food industry spend large sums on lobbying and political financing to influence government positions in the above international arenas, and to achieve favourable regulatory environments within countries. Several examples of this lobbying in national arenas, and also bilateral actions taken by governments against other governments on behalf of the industry, are listed in Table 4. Although Nestlé, Danone, RBMJ and Abbott all have corporate policies on lobbying, framed as ‘interactions with public authorities’, ‘advocacy’ or ‘political participation’ in Table 5 respectively, much of their lobbying is conducted by the aforementioned trade associations.
To illustrate this further, and to demonstrate links between lobbying actions in both the national and international arenas, we present US lobbying data. We have already shown how the US has had a disproportionate impact in opposing strong international standards on foods for infants and young children. This influence is understandable given that, between 2007 and 2018, the six US market-leading corporations together spent US$184.2 million in total, on lobbying the US Government . This lobbying was targeted mainly at the Senate, the House of Representatives, and at various times, the Food and Drug Administration, State Department, Office of the US Trade Representative (USTR), and Department of Agriculture (USDA). As Fig. 5 shows, four of these corporations declared lobbying expenditures as specifically related to BMS, totalling US$55.1 million (30% of total lobbying expenditure) or an average of US$5 million per year, with the number of lobbyist they employed fluctuating between 20 and 80 over the time period. Of this BMS-related expenditure, US$43.8 million (79.4%) was attributed to Abbott alone, and US10.1 million (18.4%) to Mead Johnson (all reported prior to its acquisition by Reckitt Benckiser in 2017) . Significant BMS-related lobbying expenditures were also reported by dairy trade associations, food and beverage trade associations, and the Infant Nutrition Council of America [Russ K, Baker P, Byrd M, Kang M, Siregar RN, Zahid H, McCoy D: Understanding the global trade and public health regime complex: a case study on breastfeeding and commercial breastmilk substitutes. Forthcoming].
Of Abbott’s expenditure on BMS-related lobbying, US$20.0 million (45.8%), was dedicated to trade-related concerns. For Mead Johnson, this figure was US$5.8 million (57.2%) . This lobbying was frequently targeted at the State Department and USTR, and to significant effect. As detailed in Table 4, this was reflected in actions taken by the US Government on behalf of the industry to oppose marketing regulations in Hong Kong, Thailand, Malaysia and Indonesia in the WTO, and/or through direct bilateral engagement with governments in national arenas [116, 119]. Lobbying targeted at the USDA was also significant, conceivably because this agency administers the nation’s Special Supplemental Programme for Women, Infants and Children (WIC). Through WIC, the government purchases more than half of all milk formula sold in the US market, and provides ‘nutrition services’ to ~ 1.9 million infants [23, 124, 125]. In 2014, Nestlé alone spent an estimated US$160,000 lobbying in relation to the WIC programme .
Political financing is the deployment of financial resources for political gain, in particular payments, gifts or promises, made to elected officials, political parties or government administrators. Big Formula’s corporate policies on political financing vary (Table 5). Danone and RBMJ do not allow it, Nestlé allows it with executive permission, and Abbott (US) allows it. We were unable to source a policy for RFC. However, none of those with policies appear to have prohibited political financing by third parties. Total political financing by the lead US corporations averaged ~US$2 million per year between 1990 and 1999, increasing to US$3 million per year between 2000 and 2012, and have averaged $1 million per year since then. More funds went to candidates for the House of Representatives than for the Senate or White House, and most recipients won their election. In the last 10 years, Abbott’s contributions have steadily grown and now dominate industry political contributions. Political financing also occurs at sub-national levels. Abbott for example, donated $US2.9 million between 2009 and 2019 to state-level candidates and political action committees .
Policy substitution & partnership
The power of Big Formula over first-food systems further resides in the adoption of voluntary self-regulation through corporate policies on responsible marketing, and the acceptance and legitimisation of these private regulatory initiatives by third parties. These policies are summarised in Table 5.
The first explicit promotion of self-regulation began in 1975, when ICIFI released a Code of Ethics as a public relations response to the severe public scrutiny Nestlé’s was receiving at the time. The IFM had an industry-wide self-regulatory code, the Rules of Responsible Conduct, until it was disbanded in 2016 . At the country-level, several self-regulatory or co-regulatory codes exist. For example, the Marketing in Australia of Infant Formulas: Manufacturers and Importers Agreement, administered by the Infant Nutrition Council Australia and New Zealand, a trade association representing Big Formula, functions as Australia’s ‘national response’ to The Code. However since 2016, there appears to be no global industry-wide policy. Instead, various policies are adopted across the corporations. Nestlé first adopted such a policy, the Nestlé Charter, in 1982 . Others followed only much later; Danone in 2011, Abbott in 2016, and RBMJ and RFC in 2017. However, these policies fall far short of compliance with The Code, ranging from 46 to 10%, as assessed by the Access to Nutrition Initiative in 2016–18 .
In their policies, all state they abide by The Code as implemented by national governments – i.e. as adopted into national laws and regulations – notwithstanding that, through their aforementioned trade associations, they lobby against those very laws and regulations in the first place. The Code applies to all countries, irrespective of their development status. Yet most corporate policies are bifurcated, with stricter standards for ‘higher-risk’ countries with high child malnutrition and mortality rates; the policies of Nestlé and RBMJ only apply to such countries. None apply to products for children beyond 12 months of age, nor address the issue of cross-promotion (see the later section on marketing strategies) . At the country-level, subsidiary and affiliate firms often fail to comply with both national regulations and corporate policies . Since 1991, IBFAN , and several others [39, 131, 132], have reported extensive Code violations across many countries. These reports are often reviewed and contested by the companies, who consider compliance with local laws and regulations, or their corporate policies only, and not with The Code itself .
Big Formula seeks to legitimise their corporate policies, and reinforce their image as socially responsible actors, through ostensibly independent third-party corporate accountability initiatives. Nestlé first initiated this strategy in 1982, when it established the Nestlé Infant Formula Audit Commission (NIFAC), to monitor compliance with its stated commitments in the Nestlé Charter. The over-arching objective was to end Nestlé’s long-running conflict with activists, co-opt more moderate groups, and thereby ‘divide and conquer’. It was to serve as ‘an instrument for damage control and containment’, by re-focusing media attention away from the activists case, and establishing ‘boundaries around the issues that activists might raise, and the manner in which they were addressed’ . Considered an important public relations victory, this contributed to some (although not all) civil society groups ending the Nestlé Boycott in 1984. However, NIFAC was soon considered ‘seriously inadequate’ , when continuing country-level violations were reported, and it was disbanded in 1991 . Today, all except Abbott detail internal auditing and compliance processes for their policies, although RFC does so vaguely. Nestlé and Danone also list third-party auditors, of which two are most apparent – the Access to Nutrition Initiative (ATNI), and the FTSE4Good Index as an ethical investment index of the UK company FTSE Russel.
Nestlé was the first to join the FTSE4Good Index in 2011, by meeting its ‘Breast Milk Substitutes Marketing Criteria’ (from hereon ‘Criteria’). In order to join, company policies must ‘align’ with The Code, and comply with national legislation and regulatory requirements. Danone followed in 2016, and then Mead Johnson in 2018, following its acquisition (and subsequent policy revisions) by the existing member Reckitt Benckiser . Other companies, however, have viewed the Criteria as unrealistic ‘because it limits their ability to market’ . The Criteria also falls well short of compliance with The Code. Initially launched in 2001, the Index excluded any company allegedly breaching The Code, and hence no companies were included. The Criteria were revised in 2003, although again no company met the entry requirements. In 2011, it was further revised, this time through a process managed by a small group of industry experts and academics, enabling Nestlé’s entry into the Index. The criteria deals with some issues outside the scope of The Code, for example, by requiring disclosures on corporate lobbying practices and internal compliance systems. However, the new criteria required ‘alignment’ and not compliance with The Code, and as ‘a start’ applied to ‘higher risk’ countries only, which reflected the design of Nestlé’s own policy .
Although, some corporations state their policies are not intended as interpretations nor replacements of The Code, Nestlé has represented the FTSE4Good BMS Criteria as an acceptable level of regulation. For instance, in 2017 the company stated ‘More than 35 years after its adoption, only 39 countries have implemented all the recommendations of the WHO Code. To rapidly accelerate progress, all countries that are yet to do so could pass regulations aligned with the minimum standards set by the [Criteria] …’ . However, this would fall far short of full implementation of The Code. Such policies, and third-party auditing reports, are also used directly in public communications to portray Big Formula as compliant. For instance, after ranking second place in the 2018 ATNI assessment, and despite scoring just 45%, a Nestlé press release claimed this reflected it’s ‘commitment to policies, practices and compliance’ with The Code . Earlier, in 2014, the Chairman of Nestlé was quoted as saying ‘We are the only infant formula producer which is part of FTSE4Good. We are being checked and controlled by FTSE4Good. They make their audits in different parts of the world and we have to prove that we are complying with the WHO Code and up to now we can prove that in everything we are’ , as quoted in .
Despite their violations of The Code, Big Formula’s ‘social license’ to operate under this self-regulatory regime, is further legitimised through partnerships with UN initiatives and agencies. For example, in 2002, Nestlé joined the UN’s Global Compact ‘without challenge’, as arguably the world’s largest self-regulatory initiative, that pledges corporations to abide by ten principles on labour standards, human rights and environmental sustainability [31, 44]. In 2019, Danone partnered with the Food and Agricultural Organization of the United Nations to promote nutrition, food safety and sustainable food systems .
Strategic corporate philanthropy
Another important example of Big Formula’s power is strategic corporate philanthropy, involving the establishment of tax-exempt corporate foundations, as outlined in Table 5, that fund a range of social and environmental initiatives. These further foster an image of corporate social responsibility, and serve directly as a form of promotion.
For example, the Abbott Fund, established in 1951, involves a range of partnerships and funding arrangements ‘to lead change and create new models for health care systems, improve nutrition and address other social needs’, including various child nutrition and micronutrient initiatives across several countries . Since 2012, the Danone Ecosystem Fund has supported the Srikandi Academy, a training institute in Indonesia, through its domestic brand Sari Husada in partnership with the local organization PKPU. By working with key health professional associations, this aims to develop a Ministry of Health endorsed first 1000 days curriculum and toolkits for ‘upskilling’ Indonesia midwives and health workers, with further business coaching, micro-credit and medical equipment made available for establishing practices in rural areas. Through this programme Sari Husada contacts 80,000 midwives each year. As of 2016, it had trained 228 ‘health care cadres’ to engage midwives and spread awareness to mothers, and had sensitised 47,893 people in rural areas to nutrition .
Corporate philanthropy also results in direct brand promotion through the donation of surplus products during emergencies, often to humanitarian relief organizations, and well in excess of actual need . In 2000, for example, Wyeth and Nestlé were quoted in a Wall Street Journal article as ready to donate tonnes of free formula for HIV-infected mothers in Sub-Saharan Africa, if asked to by UNICEF. The article framed UNICEF’s refusal to accept these donations as representing a ‘feud against the industry’ and as ‘killing millions of children’ . In 2017, in just one month, Mead Johnson donated enough milk formula for ~ 54,000 child feedings across three US states and territories affected by natural disasters .
The Covid-19 pandemic has also been utilised as a marketing opportunity, under the guise of corporate social responsibility. For example, in the Philippines since the beginning of the pandemic (January 2019 to July 2020), there were 291 reported violations of the countries ‘Milk Code’ legislation, compared with 70 in 2019. Of these violations, 235 (81%) were related to donations of BMS products . Covid-19 related marketing violations were reported in Canada, Italy, India, Pakistan, the Philippines and the UK . This included, for example, inferring products boost immunity, associating products with health authorities, offering counselling and support services to parents, and sponsoring health professional ‘educational’ events on Covid-19 and infant and young child feeding .
Co-opting health professionals
The co-option of healthcare professionals in the marketing of their products is a further representation of Big Formula’s power, despite strict provisions in The Code against such practices . A ‘comfortable symbiotic relationship’ between physicians and formula companies has long existed, ever since Henri Nestlé first pioneered the industry’s medicalised marketing techniques in the late nineteenth Century , and prescribing formula became a lucrative practice for both. Marketing to health professionals led to formula becoming widely available and used in hospitals throughout the mid-twentieth century in many countries, and both doctors and the public coming to perceive formula as convenient, safe and medically-endorsed, and as associated with modernity and ‘scientific motherhood’ [70,71,72].
Paediatricians, allergists, nurses, midwives, dietitians, lactation consultants and nutritionists, are among others, trusted sources of infant and young child feeding advice for parents. Medical endorsement bolsters Big Formula’s legitimacy with consumers and policy-makers, and serves as an important form of promotion in itself. A significant proportion of their sales workforce is dedicated to ‘securing the recommendation’. For example, Mead Johnson (now RBMJ) had a global salesforce of 1900 employees in 2010, of which 1350 (71%) were dedicated to health care settings, and the remaining 550 (29%) to pharmacy and supermarket retailers . Techniques used across the industry have included site visits to hospitals, sponsoring new clinical equipment and the design of newly constructed neonatal wards, providing free or low-cost samples for use in maternity discharge packs, providing branded gifts (e.g. lanyards, mugs and pens), paid advertising in journals, various ‘educational interfaces’, and sponsoring professional associations and emerging professional influencers [37, 146]. Some have acted illegally. For example, sales staff at Danone’s subsidiary Dumex, in China, were found to have bribed at least 116 people from across 85 hospitals and health groups, to promote products to parents of newborns .
Educational interfaces have included the sponsorship of scientific meetings (e.g. seminars, symposia and conferences), and direct provision of continuing education courses for health workers, delivered on-site and often with meals and refreshments , or through extensive online ‘e-learning’ platforms. For example, the latter includes the Nestlé Nutrition Institute, a not-for-profit organization providing 300,000 health professional members worldwide with access to 3000 articles, hundreds of videos, infographics and presentation slides, described as an ‘exclusive accredited e-learning and continuous medical education programs that provide practical guidance on the nutrition of infants and children’ [148, 149]. In some instances, they have partnered with training providers directly. For example, since 2017, Abbott partnered with teaching hospitals in China and Vietnam, to train > 6500 healthcare professionals, providing ‘a model for other hospital pediatric nutrition programs in the region’ .
Sponsoring professional associations is widely practiced. A 2019 survey of 114 paediatric association websites found 60% received financial support from BMS companies, ranging from 82% in the Americas to 38% in Africa. Only 16% had published conflict of interest policies, statements or guidelines . This study did not assess sponsorship of other professions, and therefore represents a fraction of total industry engagement. A prominent example, is Big Formula’s long historical relationship with the American Academy of Pediatrics (AAP). As of 2017, excluding payments for advertising and conference exhibits, the AAP was receiving US$3.3 million from four companies every year, accounting for ~ 3% of its annual budget . Big Formula leveraged this relationship through co-branding when, in 2013, US hospitals were reportedly distributing discharge packs of formula samples bearing the AAP logo, and copies of the AAP book on breastfeeding bearing a company brand. This arrangement has since been discontinued [121, 152].
Strategies have also been used to co-opt health professionals in the marketing of specialised formulas . Such formulas are for conditions affecting a small proportion of the infant population, including premature birth, diarrhoea, allergy treatment and prevention [42, 154]. Prescribing behaviours are shaped by research activities, clinical guideline development, medical education and public awareness – all activities Big Formula influences. Industry-driven over-diagnosis of cows-milk protein allergy (CMPA) in particular, has contributed to rapid sales growth in specialised formula sales. In the UK, for example, between 2006 and 2016 specialised formula prescriptions for infants with CMPA increased 500% from 105,029 to 600,000, a rate greatly exceeding any credible change in actual prevalence. This reflected a ~ 700% increase in expenditure by the National Health Service on these products from £8.1 million to >£60 million . The baby food industry, or its marketing consultants, funded the development of at least three clinical guidelines on CMPA, with 81% of all guideline authors reporting a conflict of interest. Furthermore, recommendations made to manage the symptoms as CMA, were found to lack supporting conclusive evidence .
Big Formula also works with health professionals to redefine the adaptive food selection behaviours of young children as deviant and abnormal, as conditions that can be eliminated through the use of their products. For example, by collaborating with psychologists, dietitians, and physicians, Abbott, created a new definition for a condition termed ‘feeding difficulties’ . To establish a standard for helping paediatricians accurately identify and manage children with this newly created condition, Abbott funded researchers developed the IMFeD (Identification and Management of Feeding Difficulties for Children) tool in 2011 . Marketing was then employed to fuel awareness of ‘picky eating’ amongst consumers, and to associate this syndrome with poor cognitive and social outcomes for children, thereby appealing to parental anxieties. Advertisements and advice for health professionals focused on prescribing enriched formula milk to children to prevent this ‘state’ .
Capturing the science and knowledge environments
Another key representation of Big Formula’s power over first-foods systems, is scientific capture [158, 159]. To legitimise their products and to support their engagement with health professionals, policy-makers and consumers, Big Formula has acquired vast scientific research capabilities, coordinated through corporate nutrition research divisions, philanthropic foundations and external partners (Table 6). Nestlé, for example, has ‘the world’s largest private nutrition research capability’ with ‘nutritional expertise in every market’ . The Nestlé Nutrition Institute, is not only a ‘continuing education platform’ for health professionals, but also the ‘world’s largest private food and nutrition research organization’, employing ~ 5000 staff across 30 facilities worldwide, and generating ~ 200 peer-reviewed research articles every year .
The research generated (and funded) by these platforms promotes a biomedical and nutrient-centric interpretation of infant and young child nutrition, typically focusing on the ‘fortification’ of baby foods (e.g. micronutrient fortified infant cereals), the ‘reformulation’ of products to enhance their nutrient profile (e.g. reduced lactose formulas), or the development of novel product ingredients that ‘functionalise’ their products (e.g. human-milk oligosaccharides) [49, 162]. Such research enables Big Formula to exercise discursive power, and institutionalise certain beliefs and practices in several ways. First, to drive sales by actively portraying their products ‘as close as possible to breastmilk’, and to amplify this message through actual or implied claims about the health and developmental benefits of their products, to both health professionals and consumers (see marketing strategies) [163,164,165]. Second, it shapes wider public perceptions about infant and young child nutrition, by rendering milk formulas as safe, nutritionally adequate and scientific, thereby detracting from the wider health implications of their products [49, 163, 166]. Third, by framing these efforts as part of corporate social responsibility initiatives, this science further legitimises their image as responsible corporate actors and desirable policy partners .
Scientific capture also extends into population-level nutrition surveillance research. This not only serves to inform product development across Big Formula’s diverse markets, but also to engage with policy-makers, and through partnerships, with various professional associations, universities and research institutes. For example, RFC has partnered in the South East Asia Nutrition Survey, involving 16,744 children across Malaysia, Indonesia, Thailand and Vietnam, resulting ‘in a better understanding of the diet, health, dietary needs and general dietary patterns of children in Southeast Asia’. Furthermore, the ‘ … findings of the survey have helped local governments and policy makers to develop and implement a scientifically grounded nutrition policy for children in Southeast Asia’ . The purpose of Nestlé’s Feeding Infants and Toddlers Study (FITS) and Kids Nutrition and Health Study (KIDS) is ‘to explore eating patterns, nutrient intakes and food sources of nutrients among infants and children in different countries around the world’. These have involved ‘large-scale cross-sectional surveys’ in Brazil, China, Nigeria, UAE and the US, and studies using national survey data in Australia, China, Mexico, the Philippines and Russia. Since 2002, these studies have collectively generated ~ 90 articles with ~ 100 collaborators [168, 169].
Big Formula also coordinates with other corporate actors, to generate and promote favourable research and knowledge environments. For example, Abbott, RBMJ and Danone, along with various transnational food corporations, are members of the International Life Sciences Institute (ILSI), a corporate-funded organization founded in 1978 by a Coca-Cola Scientific and Regulatory Affairs executive, with the aim of promoting ‘global partnerships for a healthier world’ . Nestlé withdrew its membership in 2020 (this followed the withdrawal of Mars in 2018, citing concerns with ILSI’s ‘advocacy-led studies’) . Despite its claim of being a neutral scientific organization, ILSI members promote industry positions informing health policy responses across many countries and nutrition issues [171,172,173]. Through its Washington D.C. headquarters, and eighteen branches, its member activities are coordinated across all regions under a ‘One-ILSI’ strategy . As an example, in 2008–2009 members established the South East Asia Region’s Technical Committee and Expert Panel on Maternal, Infant and Young Child Nutrition. During this period ‘in collaboration with seven regional health and research agencies, a total of six Expert Consultations, 11 Seminars and Workshops [were] held in the region with 13 scientific papers published in peer-reviewed journals’. Demonstrating its reach and influence, ‘About 1,000 nutrition, public health and pediatric professionals from government agencies, health and research institutions, NGOs and the private sector attended the meetings’ .
As they accumulate greater resources, Big Formula can employ world-leading advertising, branding and public relations agencies, to implement more intensive and sophisticated forms of marketing . The term ‘marketing’ includes a set of corporate strategies – the so-called ‘marketing mix’ – including product design, pricing, advertising and promotion, retail placement and public relations strategies, among others. Such marketing effectively undermines breastfeeding; exposure is associated with reduced initiation, exclusivity and duration in all country contexts [13,14,15]. Within countries, marketing exposure appears to ‘cascade’, concentrating initially in first-tier cities with higher income consumers, before becoming more prominent in peri-urban areas, lower-tier cities and towns, as has occurred in China .
Big Formula are among the world’s most recognised and valuable brands, and largest advertising spenders. Nestlé, for example, is among the world’s most recognised household names, with its brand valued at $US12.6 billion in 2019, ranked 50th among global brands. The company spent an estimated US$9.9 billion on ‘consumer facing’ advertising in 2016, the third highest spender worldwide . Although we could not source data on Big Formula’s marketing expenditures specifically, we used a conservative estimate of ~ 3–10% of sales , to estimate a global spend of between US$1.68–5.56 billion in 2019. These figures far outweigh any expenditure on breastfeeding promotion by governments, international organizations and global health donors . Some national marketing data are available, and indicate a significant increase in expenditure on milk formulas for older infants and young children, relative to infant formula. For example, in 2015, three companies Nestlé, Abbott and Mead Johnson spent US$9.75 million on advertising infant formula in the US market, and US$16.83 million advertising toddler milk .
Big Formula contract agencies to develop and execute their strategies. The globalization and consolidation of the advertising sector since the 1980s has been well described. A small number of ‘global communications groups’ based in the US, Europe and Japan, control most of the world market through networks of subsidiary agencies. These have typically followed their corporate clients into new markets, hence globalizing alongside them, and providing coordinated services across diverse markets [28, 86]. This sector features significantly in Big Formula’s global influence network (Fig. 3). The entry of a corporation into a new market can change the intensity and forms of marketing by the industry as a whole. For example, prior to the mid-1980s, the three largest US manufacturers practiced a voluntary ban on advertising in agreement with the American Academy of Pediatrics (AAP), and as pharmaceutical companies, they could rely upon their extensive sales networks to health care providers. With no such network in place, Nestlé decided to ignore this agreement when it entered the market in 1985, and began direct-to-consumer advertising in 1988 . In 1993, it filed a lawsuit against the US companies and the AAP, claiming the advertising ban was a barrier to trade in violation of US competition law .
The first key pillar of Big Formula’s marketing strategy is health professional co-optation, which we have already described (see co-opting health professionals). Direct-to-consumer advertising is the second pillar. Traditional advertising channels include parenting magazines, television and in-store retail displays [40, 146]. As digital technologies expand worldwide, parents and especially mothers, are increasingly engaged through social media platforms, parenting forums, mobile apps, e-commerce sites, reward programmes and sponsored parenting blogs [146, 164, 177, 178]. Celebrities and other influencers are employed to promote products on social media, and to host events on- and offline [178, 179]. Health professionals and other experts host question and answer sessions and webinars on infant feeding and other lifestyle topics on social media [179, 180]. Advertisements often contain links to clubs, carelines and promotion lines, where women are encouraged to engage with industry representatives and health professionals in a one- to-one conversation .
‘Big Data’ analytics platforms enable sophisticated forms of market segmentation and targeting, as personal data can be collected and then used to generate tailored, and even personalised, advertisements to parents differentiated by, for example, income, parenting stage and lifestyle [19, 41, 42, 182]. Messages often portray milk formula as a symbol of modernity, as equivalent with or superior to breast milk, and formula-feeding as extensively practised, and as a desirable lifestyle choice [41, 146, 183]. Appeals are made to the emotional and psychological aspects of parenting (e.g. ‘when mothers milk fails’ and ‘freedom from judgement’), tensions between formula-feeding and breastfeeding parents (e.g. Abbott’s The Sisterhood of Motherhood campaign), and parental aspirations (e.g. child learning ability, paternal bonding, and minimising parent-child conflict) [41, 183].
The third key pillar of Big Formula’s market strategy, is product innovation. In a process of market segmentation, the creation of entirely new product categories is used to not only to generate new sales growth, but also to circumvent marketing regulation. By the late 1970s, 200 infant formula products and 50 brands were reportedly available across 100 countries . However, prior to The Code infant formula was the main product category, promoted ‘from birth’ without upper-age limit. From 1984 onwards, just as governments were beginning to implement The Code, the marketing of follow-up formulas and toddler-milks markedly intensified, and soon became widely available. This was described by one industry report as the renaming of products ‘primarily to avoid regulation and restrictions on advertising’ applying to the first 6 months only . By using nearly identical branding and labelling across their entire product range, Big Formula have ‘cross-promoted’ their products, including infant formula in countries where legislation prohibits this [42, 165, 166, 184]. This strategy of cross-promotion also extends from ‘womb-to-tomb’, through branded milk formula products for all life-stages, including infants and young children, but also for pregnant and lactating mothers, older children and adolescents, and the elderly (i.e. grandparents) who are also often involved in making feeding decisions .
Finally, Big Formula’s aforementioned scientific capabilities are also used to support ‘nutritional positioning’, a marketing technique involving the development of products with novel ingredients and implied or direct health claims, often on premium or specialised products that sell for markedly higher prices [42, 163,164,165]. Ingredients once found only in specialised formulas have been increasingly added to nearly all products. Many claims have no publically available evidence, or only poor-quality evidence, to support them [185, 186]. The evidence that does exist, often cites studies directly sponsored by Big Formula . Claims made on product labels include inter alia those relating to brain, eye and immune system development, reduced allergies, and to specific outcomes linked with normal infant behaviours, including sleeplessness, fussiness and regurgitation [188, 189]. These claims are supported by the addition of functional ingredients claimed to mimic breastmilk (e.g. human-milk oligosaccharides, essential fatty acids, and probiotics), or reformulated ingredients (e.g. reduced lactose) [186, 188].
When combined, these techniques powerfully influence social norms and beliefs about what feeding practices are considered normal, acceptable and socially desirable [42, 146]. For example, one recent US survey found 52% of caregivers agreed with the statement that infant formula can be better for babies’ digestion and brain development than breastmilk; 62% that it can provide nutrition not present in breastmilk .