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Response to Danone’s response to Globalization Monitor’s exposé of formula milk companies’ product development strategies and promotional practices in Hong Kong and mainland China

Re: Danone’s response to Globalization Monitor’s exposé of formula milk companies’ product development strategies and promotional practices in Hong Kong and mainland China”

We welcome Danone’s willingness to have a constructive dialogue with GM regarding its product development and promotional practices in Hong Kong. We note that Danone claims to be compliant with the public health recommendations made by the World Health Organization and dedicated to supporting breastfeeding in the first 1,000 days of infants’ lives. We also note that Danone proclaims science to be at the heart of the company’s commitment to infants and young children’s nutrition and health. We hope to see these commitments genuinely reflected in Danone’s business practices and that appropriate corrective actions regarding the issues our report and this message raise will be taken promptly.

We raised four issues in our initial correspondence with Danone:

Firstly, we asked Danone to explain the reasons behind developing Nutrilon Pronutra+ and Aptamil Pronutra+ and for charging a higher price for the latter (+17.0%), when they are nearly identical compositionally and nutritionally.

Danone was evasive in its reply, merely stating that it followed the relevant laws and standards governing the ingredients used in infant formula products, and that Nutrilon Pronutra+ and Aptamil Pronutra+’s recipes “reflect Danone’s research progress in the fields of nutrition, immunity and gastrointestinal health.”

Our allegation was not that Danone breached the standards which require certain ingredients to be included in infant formula products, but that it made little sense to create two products that have near-identical compositions and nutritional profiles (see p.14). We concluded that Danone was essentially repackaging the same product, and that this was a likely price discrimination tactic employed to maximise profit.

Danone tried to explain away the prices difference between Nutrilon Pronutra+ and Aptamil Pronutra+ with research costs, the quality of raw materials, manufacturing techniques and packaging. We emphasise that a price difference is premised on the fact that Danone produced two products, for which Danone failed to provide proper justification. We reiterate that Nutrilon Pronutra+ and Aptamil Pronutra+ both contain the same patented prebiotics combination of scGOS and lcFOS, which suggests that the price difference cannot be explained by research costs (see p.14). Nutrilon Pronutra+ and Aptamil Pronutra+ also have very similar packaging (see p.14). Finally, we note that Danone admits that commercial considerations affect their pricing strategies.

Secondly, we pointed out potentially significant conflict of interests in Danone’s product development, evident from the fact that Danone presents research and clinical studies conducted by their own employees as independent evidence corroborating the claims it uses to promote its formula products.

Danone’s response failed to address the core problem that presenting studies it conducted as independent evidence supporting their promotional claims misleads consumers and carers. In our report, we pointed out that Danone claimed there are more than 55 publications worldwide that prove their claim that scGOS:lcFOS (9:1) benefits baby health, but cited only three studies on its website, all conducted by researchers employed by Danone’s various research institutions (see p.16).

We acknowledge that, as Danone claimed, the studies it conducted are published on independent and peer-reviewed journals; however, we disagree that peer review committees and scientific panels always guarantee the quality and impartiality of published studies. We emphasise that industry funding in research means that the businesses paying to support the studies have a strong and inherent vested financial and commercial interest in the outcome of the research. Such worries are not unfounded or mere guesswork but supported by studies on the relationship between the presence of industry funding in biomedical, nutrition and health research and its quality, as well as studies on the relationship between the presence of industry funding and research outcomes.

Ioannidas and Trepanowski (2018) report that “industry funding of nutrition research predicts scientific findings favourable to sponsors’ interests with odds ratios greater than 3,” meaning it is three times more likely for industry-sponsored research (compared to non-industry-funded research) to produce conclusions in favour of sponsor’s products. Lesser et al. (2007) found that the correlation between funding source and conclusion to be statistically significant, and that the proportion of intervention studies with unfavourable conclusions was 0% for all industry funding versus 37% for no industry funding. The reach of the formula milk industry does not stop there. Van Tulleken (2018) observed industry influence in the development of cow’s milk allergy diagnosis guidelines that are vague and inaccurate, causing the overdiagnosis of such allergy by nearly 500% between 2006 and 2016, thus creating a huge market for formula makers to introduce “medicalised”, hypoallergenic formulas into the market.

These studies demonstrate that industry-funded research is likely to be biased. Given that the Codex Alimentarius Commission stipulates that health claims can only be used if the relationship of the nutrient in question to health is currently recognised by generally accepted scientific review, we are well within reason to doubt both the proclaimed credibility of Danone’s research and the company’s promotional strategies.

Thirdly, we questioned Danone’s use of hydrolysed protein in its formula products and decision to promote those products as helpful for the prevention of allergies, despite abundant evidence to the contrary.

We find it ironic that Danone claimed to want to have an open dialogue regarding the scientific evidence behind its formula products, given that it failed to address the findings in the systematic reviews and meta-analyses we cited in the report. These studies concluded that the evidence supporting the claim that hydrolysed formula reduces the risk of allergic or autoimmune diseases are inconclusive, inconsistent, of low-quality, and rife with methodological issues (see p.18).

Instead of directly and constructively engaging with the studies we provided, Danone cited five other studies which it claimed to “recommend infants who are at risk of developing cow’s milk protein allergy as their families have a history of allergies to use formula with partially hydrolysed protein.” We looked at these studies and discovered that Danone had distorted their findings to defend it’s the way it developed its products’ recipes.

Muraro et al. (2014) found that hypoallergenic formula can prevent food allergy in high-risk infants for the first four months of their lives. According to this finding, it makes little sense to develop “medicalised”, hypoallergenic formulas for infants beyond four months old; however, Danone’s Aptamil Prosyneo and Aptamil ProExpert have three and two stages respectively, going up to three-year-old children. Vandenplas et al. (2016) explicitly wrote in their systematic review that “only limited data could be found on the efficacy and safety of pHF (partially hydrolysed formula) in healthy term infants,” and that “with respect to long-term outcomes, particularly referring to immune, metabolic and hormonal effects, data are, however, non-existent.” They were only able to conclude that hydrolysed proteins are safe and suggested that long-term follow-up efficacy studies are required before a recommendation of this type of formula can be made. Vandenplas et al. (2014) found that only one of eight studies supporting the use of partially hydrolysed protein in formula milk were qualified for publication, which is indicative of the poor quality of the research conducted on the subject. Greer et al. (2008) found the evidence that “the onset of atopic disease may be delayed or prevented by the use of hydrolysed formulas compared with formula made with intact cow milk protein” was modest, and if these benefits exist, they are confined to the first six months of infants’ lives. Boyce et al. (2010) is a guideline for the diagnosis and management of food allergy, which does not provide proof of the efficacy of hydrolysed formula itself. Also, as previously stated, allergy diagnosis guidelines have not been immune to industry influence and interests either, meaning that the provisions in such guidelines should be taken with a pinch of salt.

Finally, we argued that Danone is cross-promoting its infant formula products through a commercial that idealises formula feeding.

Danone denied that its commercial idealised feeding children with its formula products, or that it insinuated that its products are superior or equivalent to breastmilk.

We note that the International Code of Marketing of Breast-milk Substitutes states that “informational and educational materials, whether written, audio, or visual, dealing with the feeding of infants and intended to reach pregnant women and mothers of infants and young children […] should not use any pictures or text which may idealize the use of breast-milk substitutes.”

This statement does not specify what exactly constitutes the idealisation of the use of BMS, and it is precisely this ambiguity that allows Danone to deny any wrongdoing even though its Aptamil commercial palpably “connects the Aptamil brand, a ‘letting-go’ style of parenting and the child’s future success, stoking parents’ sentiments and utilising their desire for the best for their children to promote its products” (see p.34). We believe this vagueness and ambiguity is something that the WHO and policymakers need to address in order to effectively rein in the inappropriate promotion of BMS.

We urge Danone to address these issues promptly and appropriately.

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