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Misperceptions and misuse of Bear Brand coffee creamer as infant food: national cross sectional survey of consumers and paediatricians in Laos

BMJ 2008; 337 doi: (Published 09 September 2008) Cite this as: BMJ 2008;337:a1379

Rapid Response:

Nestlé’s Violations of the International Code on the Marketing of Breast milk Substitutes

We are very concerned about the misunderstanding of the International Code on the Marketing of Breast milk Substitutes (ICMBMS) by Roland Stieger representing Nestle (Thai) Ltd. (1-2) The example of the coffee creamer is only the tip of the iceberg. The obvious and ongoing International Code Violations include: The marketing of formula and non-formula products with the logo of a baby bear held in the breast-feeding position (ICMBMS Article 5): Sweetened condensed milk (45% sugar, 20% skimmed milk powder & palm oil) with the Bear Brand logo was still on sale in Vientiane, September 2008. In neighboring Thailand, an aggressive advertising campaign began in 2007 with the Bear Brand logo on sweetened condensed milk, milk products and formula products. Advertising on the sky train in Bangkok of Bear Brand products is easily recognized, September 2008. (3) In 2004, large billboards marketing formula products and "follow-up formulas" (which fall within the scope of code, ICMBMS Article 2) with the Bear Brand logo appeared in Vientiane, the capital city, and in Pakse. (ICMBMS Article 5) (1,4).

The Lao pediatricians appealed to the Ministry of Health to end this campaign (Figure 1). (5)

Figure 1

Nestle representatives in Vientiane hospitals give gifts, trips and other incentives to Lao doctors and nurses (ICMBMS Article 7). This violation is particularly serious in a country where health care workers have very low salaries.

A twisted violation of the code is the use of a baby bear, as pictures of infants are not allowed to appear on formula products (ICMBMS Article 9). Our research shows that the pictogram of the bottle with an X does not mitigate the appeal of the Bear Brand label.(6) Roland Stieger, Nestle representative, states
that the pictogram was introduced in 2002.(2) However, in 2006, infants with severe malnutrition were being fed coffee creamer without the pictogram. This bottle with X did not appear in Vientiane markets until 2007. Our research was the first to explore the public’s (mis)understanding of the pictogram.

Regarding Nestlé’s strict compliance with local laws, local laws and regulations in Lao are developing. Authorities were not aware of the seriousness of the problem. Why does Nestle prey on the poorest and least developed countries, where breast-feeding is the best intervention to save infants lives? (6)

We are deeply concerned that nearly one half of Lao children in rural areas are stunted.(8) The lowest exclusive breast-feeding rates in the region occur in Thailand, Myanmar, Vietnam and Laos. How much of this results from the marketing of breast milk substitutes and unchecked violations of the International Code? Shantha Boleman, UNICEF’s East Asia and Pacific Regional office in a statement about malnourished Asian children states, “The advertising of formula is having a huge impact in South-east Asia, because it is a growing market for the companies”.(9)

Nestle says they are very concerned that mothers in poor countries feed infants inappropriate breast milk substitutes and are taking “ongoing steps to stop the inappropriate use”. (2) Our question is how long and how many children will suffer and die before Nestle complies with the true purpose of the International Code, which is to promote breast feeding, the number one intervention to save infants lives.(7) Would it take so much time to change a similar logo that would strictly not be allowed in Switzerland or other informed countries?

We thank the P8 Masters’ students of the Institut de la Francophonie pour la Médecine Tropicale (Agence Universitaire de la Francophonie), Drs P Chanthavilay, PN Newton, JP René, V Amstutz, G Slesak, J Krahn, K Surinder, M Anderson, C Chu. We thank M DeBlaise and Bryan Watt, P Lévy and D Benoit. We thank the Lao paediatricians and the staff of Health Frontier, Vientiane.

1 The International Code of Marketing of Breast Milk Substitutes,

2 Stiegler R. Nestlé’s works to ensure appropriate use of milk products. BMJ 2008

3 Bear Brand protection joins hands.

4 World Health Assembly. World Health Assembly resolution 39.2

5 ABC Online. Lily Yan Laos parents mistakenly feeding infants coffee creamer.

6 Barennes H, Andriatahina T, Latthaphasavang V, Anderson M, Srour L. Misperceptions and misuse of Bear Brand coffee creamer as infant food: national cross sectional survey of consumers and paediatricians in Laos. BMJ 2008; 337; a1379.

7 Jones G, Steketee RW, Black RE, Bhutta Z A, Morris Saul S, Bellagio Child Survival Study Group; How many child deaths can we prevent this year? Child Survival II. Lancet 2003; 362.

8 WFP Laos. Comprehensive Food Security and Vulnerability Analysis for rural Lao PDR. 2006.

9 Marwaan Macan-Marker. Children Under Five Straggling. Global Geopolitics; Inter Press Service, five-straggling/

Competing interests:
None declared

Competing interests: No competing interests

05 January 2009
Hubert Barennes
Training and Reasearch Coordinator
Leila M Srour
Vientiane Laos