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Now it is universally accepted and known that breastfeeding gives children the best start in life. But the good fight to protect breastfeeding never ends

Everybody, from legislators and academics, to professionals and parents, knows now that in all normal circumstances 'breast is best'. More than that: breastfeeding and breastmilk is crucial protection for the child and also for the mother. This is no longer a matter for any serious debate. But we may sometimes forget that what is now known for sure, and not publicly contested by the baby formula manufacturers, was contested not so long ago.

An essential element in the change of attitude has been and remains the accumulation of evidence on the physical, mental, emotional and social benefits of breastfeeding. But of itself, scientific knowledge does not change a climate of opinion. One of the two additional essential factors has been and remains the courageous position of the World Health Organization, ever since the period in the 1970s and 1980s when Halfdan Mahler was WHO director-general. The other factor also has been and remains the phenomenal achievement of the global networks of public health activists who work with the World Alliance for Breastfeeding Action, the International Baby Food Action Network, and other alliances. They are resolutely supported by scientists who are independent from the baby formula industry, which is – as readers of this journal know – a very big business indeed.

Breastfeeding has many aspects. As well as the benefits mentioned above, it reminds us that we should take care before jumping to the conclusion that chemical analogues are equivalent or even superior to natural food. This is one of the lessons we need to learn, looking back to the days not so long ago, when baby formula was believed even by independent scientists to be as good as or even superior to breastmilk.

Go forth and fortify

Thus, are we really sure that 'enriched' and 'fortified' ultra-processed products that tick the micronutrient requirement boxes are as good for us, as are combinations of foods in which these vitamins and minerals are naturally present? This is now a big issue. In the US, the Academy of Nutrition and Dietetics, the American Society for Nutrition (ASN) the Institute of Food Technologists, and the International Food Information Council (the last of which represents the interests of big business) have teamed up.

The position of their 'Food and Nutrition Solutions Joint Task Force', just now published in The Journal of Nutrition (1) is that when food and products are categorised according to their degree of processing, as groups they are more or less equally nourishing. Thus: 'The processing level was a minor determinant of individual foods' nutrient contribution to the diet and, therefore, should not be a primary factor when selecting a balanced diet'.

In other words, don't distinguish between fresh and minimally processed foods, and processed and ultra-processed products. Generally speaking, they are all OK. (Or not OK, but the Joint Task Force paper does not dwell on that, despite obesity in the US now being a public health catastrophe). Its conclusion is: 'A food's nutrient composition and the frequency and amount eaten, rather than level of processing, should be stressed as the most important considerations for the selection of a healthy diet'. In other words: 'Don't pig out and you will be fine'.

Given that so many ultra-processed products are formulated to be ultra-palatable, it would be rather wonderful if the Joint Task Force findings stood up; but they fall down. Here is why. First, the paper stresses the importance of dietary cholesterol as a 'food component to reduce or limit'. Commonly consumed fresh or minimally animal foods like meat and eggs are high in cholesterol, whereas the industrial ingredients of most ultra-processed products are of plant origin and therefore contain no cholesterol. True. However, the paper shows that consumption of cholesterol in the US, at an average of 278 milligrams a day, has now dropped to below the usual recommended ceiling. Even more striking, another paper from the same stable states: 'Dietary cholesterol is now known to be only a modest contributor to blood cholesterol' (2).

By contrast, the paper has little to say about added sugars or salt, and does not mention the toxic trans fats (still present in the US food supply). It also does not mention energy density, despite energy-dense 'fast' and other processed products, and sugared drinks, being probable causes of over-consumption and thus weight gain and obesity (3-5).

Cholesterol aside, the main basis for the Task Force's audacious conclusion is product 'enrichment' and 'fortification' with synthetic micronutrients. With reference to an earlier Journal of Nutrition paper also from the same stable (6), the paper says 'A recent analysis of usual nutrient intake in the US found that enrichment and/or fortification dramatically improved intakes of several key nutrients, including folate, iron, and vitamins A, B1, and D'. An author of all three papers, Victor Fulgoni, is well placed to know this. Now an independent consultant, he previously was vice-president (nutrition) at Kellogg headquarters in Battle Creek, Michigan. He may well know how many thousands of tonnes of vitamins and minerals are added to the US food supply every year to all sorts of processed food and drink products. The discussion goes on to say: 'Nutrient deficiency is prevented for many Americans because of the contributions of processed foods'.

Are the synthetic micronutrients added to processed products as nourishing as those naturally contained in fresh and minimally processed foods? Perhaps they can be, but it is a big jump to assume that they typically are. But there is a much bigger issue here. The position of the Joint Task Force seems to be as follows. Processed and ultra-processed products are generally low in cholesterol. More important, no matter how energy-dense, fatty, sugary or salty they are, many contain substantial amounts of micronutrients in synthetic form. In other words, products can be basically made from degraded industrial ingredients, but as long as they also contain equivalents of low-dose vitamin and mineral pills, they can be advertised with health claims, and are just as good for you as fresh food. (Or just as bad, but the general tone of the papers referred to here is upbeat).

There is a link here, between infant and young child nutrition, and that of weaned and older children and adults. Formula manufacturers are now asked not to promote their products as equivalent or superior to breastmilk. But the manufacturers of ultra-processed products, including those promoted aggressively for and to children, are not inhibited. Nor ever will they be, as long as policies to control and prevent obesity and chronic diseases continue to be shaped by 'public-private partnerships' in which the transnational corporations that manufacture energy-dense fatty, sugary or salty ultra-processed products are lead players.

Learning to live well

Countries and places where we can best find out how to prevent obesity and chronic diseases include those where such conditions have remained rare

Now to come to this month's special commentary; this updates and republishes one of the first contributions to World Nutrition. It is by Harriet Kuhnlein, for many years director of the Center for Indigenous Peoples' Nutrition and Environment at McGill University, Montréal, Canada. Celebrating the good news contained in the commentary in this editorial, may give a false impression. Given the choice, practically everybody would prefer to live as no doubt all readers of WN do, with substantial incomes, free from food insecurity, with the prospect of relatively safe and long lives and access to medical care, and able to travel and to enjoy the products of science and technology, including the genuine variety of delicious and healthy foods and drinks that can be found in supermarkets.

True. But isn't it strange, that almost all research on obesity, diabetes, heart disease and other disabling and deadly conditions, is carried out in countries and on behalf of populations whose disease patterns have gone haywire, where such conditions are common or epidemic. It stands to reason that a substantial amount of work should be done in territories where chronic diseases are still uncommon or rare. Such populations may be food-insecure, with relatively short average life expectancy; but reliable observers like Denis Burkitt and Hugh Trowell in East Africa, and their colleagues in other parts of the world, confirmed that a few generations ago, old people in many non-industrialised countries and regions rarely suffered from such conditions (7).

More work is also needed in parts of the world where food systems and therefore patterns of diet are changing fast. There is a touching example of this in the picture on the left (above), taken by Association member Lois Englberger, who died last year. In the Pacific Island of Pohnpei, where she worked, clinical vitamin A deficiency had become fairly common. The reason was that the people had forgotten the special value of the orange Karet variety of banana, native to the island, which is an intensely rich source of carotenoids. The picture above was reproduced on one of a series of postage stamps celebrating native foods.

What does all this tell us about our place in this world? There is a warm and hopeful message in all the very many strange stories of the ascendancy of the type of civilisation in which almost all of us live now. It is that in some ways we are strong, rich, wise and fortunate, and that in other ways we are weak, poor, foolish and wretched, and that it is not quite yet too late for us to learn.

For there remain populations in many parts of the world who in different ways, according to history, choice and circumstance, have largely kept what we have mostly lost. They have made a better job of preserving the world than we have. They often may well have a much better idea of what is good for them, including their food systems and diets, than we do. They also may have a better idea of what is good for us than we do. We have much to learn from them. More good news here is that leaders within the UN Food and Agriculture Organization, which this month celebrates World Food Day, are now determined to promote food and nutrition in all its social, cultural, environmental as well as biological aspects.

Examples of populations and communities who remain healthy, or have learned once again to live well, surely should encourage us as we tread the steep stony path towards prevention and control of obesity and chronic non-communicable diseases.

A lesson to learn

Meanwhile though, when will UN agencies and national governments realise and act on the fact that the transnational manufacturers of energy-dense fatty, sugary or salty ultra-processed products and sugared drinks, cannot be part of any public health solution? That they, just as surely as cigarette manufacturers and the alcohol trade – and the baby formula industry – are causes of public health problems? One answer, is that the networks almost all of volunteer activist women, did change the minds of UN agencies, national governments, and citizens, on the big issue of breastfeeding and infant formula. It can be done. Let this be a lesson and an inspiration.

References

1. Eicher-Miller H, Fulgoni V III, Keast D. Contributions of processed foods to dietary intake in the US from 2003-2008: a report of the Food and Nutrition Sciences Solutions Joint Task Force of the Academy of Nutrition and Dietetics, American Society for Nutrition, Institute of Food Technologists, and International Food Information Council. Journal of Nutrition, published on-line 18 September 2012. Doi:10.3945/jn.112.164442
2. Dwyer J, Fulgoni V III, Clemens R, Schmidt D, Freedman M. Is 'processed' a four-letter word? The role of processed foods in achieving dietary guidelines and nutrient recommendations. Advances in Nutrition 2012, 3, 536-548. doi: 10.3945/an.111.000901.
3. Prentice A, Jebb S. Fast foods, energy density and obesity: a possible mechanistic link. Obesity Reviews 2003, 4, 4, 187-194.
4. World Cancer Research Fund/ American Institute for Cancer Research. Determinants of weight gain, overweight, and obesity. [Chapter 8]. In: Food, Nutrition, Physical Activity and the Prevention of Cancer: A Global Perspective. Washington DC: AICR, 2007.
5. Marchione M. Studies more firmly tie sugary drinks to obesity. Yahoo! Finance from Associated Press, 21 September 2012. http://finance. yahoo.com/news/studies-more-firmly-tie-sugary-drinks-obesity-201251759.html
6. Fulgoni V III, Keast D, Bailey R, Dwyer J. Foods, fortificants and supplements: where do Americans get their nutrients? Journal of Nutrition 2011; 141, 1847-1854.
7. Trowell H, Burkitt D. Western Diseases. Their Emergence and Prevention. London: Edward Arnold, 1981.
8. McLuhan TC. Native North America. [Chapter VI] The Way of the Earth. Encounters with Nature in Ancient and Contemporary Thought. New York: Simon and Schuster, 1994.