Digital marketing of commercial breastmilk substitutes and baby foods: strategies, and recommendations for its regulation in Mexico

This study aimed to identify digital marketing strategies of BMS, specifically commercial milk formula and baby foods in Mexico, used by the industry to influence parents and caregivers about their infant and young children’s feeding habits and propose recommendations for its regulation.

The main digital strategies include sending electronic newsletters with advertisement of commercial milk formula and baby foods to parents via email, through which companies collect personal information, promoting online parent clubs, collaborating or hiring influencers in social media and engaging with health professionals to promote their products, which were also found by the WHO multi-country study [11].

Companies use unethical promotional strategies in digital media that can be segmented according to the targeted population or “personas”, which are fictional profiles that represent groups of similar people in a target audience, to reach people on a more personal level, through messages, offers and the right products at the right time. Using social media data to target mothers more precisely by milk formula companies has been reported by Hastings et al. [35], and is part of the ‘surveillance capitalism’ where raw personal data is monetized for hidden commercial purposes and used for conditioning people’s behavior [36], increasing the corporate power of BMS industry.

Also, we found that commercial milk formula and baby food companies sponsor conferences, webinars, and other child health and nutrition events to position as an infant feeding advisor and educator, and engage with health professionals to conduct online events where they recommend their products, leading caregivers to believe that BMS have scientific support, and that it provides the same benefits as breastmilk. During 2021, the main formula company in the country launched an educational program on parenting and nutrition in the first 1000 days of life [37], interfering with adequate infant feeding practices. Medical marketing has been documented in Philippines were BMS industry have sponsored pediatric, midwives and nutritionist associations [38], and also by the WHO multi-country study [12]. This collaboration cannot be conceptualized as impartial or objective, as companies would have us believe. The events are plagued by the brand’s logo and slogan, which represents an “endorsement” by association, one of the main strategies of the marketing industry [35]. From the testimonies we collected, conflict of interest generated by the industry is often unrecognized, or it does not seem to be perceived as a problem or as a lack of compliance with the Code. However, promoting and endorsing the consumption of BMS and baby foods interferes with respect to a primary public health interest such as breastfeeding and adequate complementary feeding practices, violating the right of every child to reach their full potential of healthy nutrition during their first years of life and women’s right to informed decision-making [22, 23].

A key finding is the diversity of positions on the regulation of digital marketing of milk formula and baby foods, since civil society organizations, health professionals and influencers point out the lack of regulation in digital media, while BMS companies mention that regulations in Mexico are sufficient. Although companies say they agree with the Code, actually they only respect what is effectively regulated and sanctioned at the local level, so accepting the Code at the international level does not commit them to comply with it. However, national regulations have shortcomings in terms of the promotion and commercialization of milk formula and baby foods and loopholes in the legislation allow companies to market their products even though they are violating the Code.

These results are similar to those found in other countries, where violations of international and national legislation regarding digital marketing of BMS are frequent and difficult to regulate by the authorities. Failure to comply with regulations are observed mainly through online baby clubs, articles with educational information and direct messages through WhatsApp and content on social media [11, 39, 40].

Company’s representants declared that they promote only baby foods and growing-up milk for children from 1 year of age, which they perceive to be outside the scope of the Code. Growing-up milks are increasingly being marketed and recommended by health professionals in Mexico, making women believe their children need these products [41]. Widening the range of milk formulas for older children have been documented as part of the strategies used by industry to face regulations they perceived as applying only to infant formula and expand their business [5, 38]. It is necessary to use information such as that presented in this study and in the WHO multi-country study to show violations of the Code, since other indexes such as the Access to Nutrition Initiative rate many companies well despite their non-compliance every year [21].

Health professionals and civil society organizations identified health and nutrition claims as a factor that contributes to the abuse of formulas for misdiagnosed conditions, so they proposed it be regulated and suggested a plain packaging. A study in the United States found that health and nutrition claims increase the chances that a child will be offered formula, since most caregivers believe in claims found in advertising and over one-half of them agreed that formula can be better than breastmilk [42]. This is consistent with the testimonials of parents in our study, who trust advertising and expect the nutrition claims they read on formula cans or see in a social media post about the product to be true. The WHO recommends plain packaging for commercial milk formula, prohibiting the use of images and text that suggest formulas are equivalent or superior to breastmilk, health or nutrition claims, as well as endorsement by health professionals or organizations [12], also recommended in Hong Kong [43] and suggested by some actors in South Africa [44].

Opinions were divided on front-of-package warning labeling for commercial milk formulas and baby foods, which are not included in the current labeling regulation in Mexico [30]. While the companies and marketing agencies were against it, parents positively valued the possible implementation of this public policy, since it would be useful to them when choosing the foods that they will offer their children. Formulas contain excess sugars [45], and many baby foods contain added sugars and salt, as well as unhealthy fats [46] that increase the long-term risk of poor metabolic health and chronic diseases [47], so it is crucial to define a nutrient profile for a warning labeling and end the inappropriate promotion of these products [25].

Recommendations for strengthening Mexican regulations to end the inappropriate promotion of commercial BMS and baby foods

Recommended regulations are summarized in Table 3 and were developed by the research team after interpreting the results, and considering the Code’s provisions, subsequent resolutions and recommendations by the WHO.

Table 3 Digital marketing strategies of commercial breastmilk substitutes and baby foods and recommendations for strengthening regulations in Mexico

The promotion and commercialization of BMS and baby foods must be regulated, monitored and sanctioned in case of non-compliance, with the aim of protecting the health of children [29]. These penalties must be significant compared to the sales of their products. For this, updated legal instruments are required. They should include the different strategies used in digital media and be aligned with the Code and recommendations from international organizations such as WHO and UNICEF. In this sense, sponsorship, publicity, and advertising promotion of BMS should be prohibited in all media, as well as images, nutrition and health claims, and the endorsement or organizations and health professionals.

There should be no contact, including digital media, between BMS and baby food companies and pregnant women, mothers, fathers and caregivers of infant and young children. Also, companies should not be allowed to sponsor health professionals or events related to nutrition and infant feeding, nor develop and disseminate educational material related to breastfeeding, nutrition and infant health in any media.

It is important to implement codes of ethics, such as the NutriCOI [48] developed by many actors in Mexico and international organizations which seeks to encourage professionals and other sectors related to the problem of malnutrition to conduct themselves in an ethical, transparent and professional way in the face of a potential conflict of interest with the industry and thereby ensure the protection of children’s health and nutrition.

It is essential to limit the interference of the industry in areas such as the academic training of health professionals, as well as in the implementation of educational programs for parents and caregivers of infant and young children which interferes with the decision to breastfeed and with adequate infant feeding practices.

Strengths and limitations

We recognize that a limitation of this study is that some actors were not considered, so it is desirable to complement this perspective with the voice of other actors involved, such as managers, health students, directors of regulatory agencies and policymakers. However, one of the strengths is that we included industry representatives, marketing agencies and influencers who are key actors in the digital marketing ecosystem, often left out in other studies due to the challenge of identifying and contacting them, and agreeing to participate.

We opted to use the semi-structured interview to give priority to the speeches of the participants and focus on main aspects of digital marketing of BMS and baby foods, at the expense of other elements that could provide understanding of marketing of these products, for example in other media. Since digital marketing is constantly changing and new strategies are rapidly implemented, these may not have been explored in this study in addition to those documented in this article. Although face-to-face interviews would have provided greater inputs to contrast qualitative information, perhaps many key actors would not have participated, hence virtual interviews helped us identify the important practices used in digital marketing.

On the other hand, one of the main strengths of the study is being a pioneer in adapting the first phase of the CLICK monitoring framework to assess parents and other key actors experience and awareness of digital marketing strategies of BMS and baby foods. In addition, we incorporated different voices involved in digital marketing including key actors who market, advertise and prescribe the product to the final consumer, thus providing evidence for public policy and the regulatory instruments that urgently need renewal.

The Mexican case can serve as an example to other countries in the Latin American region to evidence the strategies that companies use in digital media, probable very similar, to persuade mothers and fathers to buy their products and the actions that need to be made to regulate the inappropriate promotion of BMS and baby foods.

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