Violations of the Code in Argentina: analysis of promotions, advertising and labeling of commercial milk formula and complementary foods products

Breastfeeding has unique benefits for the child and the mother, and its decline may be one of the most significant mass phenomena in infant feeding. While there are several causes, standing out among them is the marketing practices of commercial milk formula (CMF) and commercial complementary foods (CCF). This descriptive cross-sectional study was conducted using qualitative and quantitative methodology, between August 2018 and August 2020. Regarding the promotion, advertising and labeling of CMF and CCF, none of the companies in Argentina at the time complied with the International Code of Marketing of Breast-milk Substitutes or the related laws in force in the country. The multiple forms of violation found emphasize the need to establish and strengthen monitoring and enforcement mechanisms to curb abuses by the CMF and CCF industry in Argentina, safeguarding the rights of mothers, families, and their newborns. Likewise, the Government must lead the political process and adapt its regulatory framework in terms of transparency and conflict of interest, as well as generate comprehensive and intersectoral public policies on the protection of breastfeeding.


INTRODUCTION
Despite its unique benefits and its exclusive recommendation up to 6 months of age, breastfeeding is in decline worldwide (Victora et al. 2016), probably one of the most important mass phenomena of change in infant feeding.Commercial milk formula (CMF) sales have increased to about US$55 billion annually, with more children receiving formula products than ever (Rollins et al. 2023).Its decline is influenced by several causes, including CMF marketing practices (Palmer 1993).While pro-breastfeeding policies and programs can help to mitigate the problem, they are unlikely to fully reverse the impact of marketing of CMF (Piwoz and Huffman 2015;Pérez-Escamilla et al. 2023;Baker et al. 2021).The transition for infants and young children to diets that are higher in CMF has accelerated in recent decades, alongside rapid growth of ultra-processed food markets (Baker et al. 2021;Neves et al. 2021;Baker et al. 2020;FAO 2019).This dietary change raises serious concerns for human and planetary health (Victora et al. 2016;Baker et al. 2021;Jelliffe 1972;Baker et al. 2023).
These clear violations and lack of accountability by CMF companies continue to knowingly and regularly defy the principles and recommendations of the Code (Rollins et al. 2023).
Advertising and promotion strategies are used for CMF that appeal to people's subjective and unconscious issues -such as the manipulation of knowledge and evidence related to breastfeeding and CMF (Rollins et al. 2023).WHO defines promotion as "marketing activities other than advertising, personal selling, and publicity that stimulate consumer purchases at point-of-sale" (WHO 2012).In-store promotion includes giveaways, samples and price reductions (as different from standard pricing) (UNICEF 2019).Material and economic support of different types of events, congresses and activities of scientific societies or medical professionals, create conflicts of interest (Rollins et al. 2023).
The International Code of Marketing of Breast-milk Substitutes (hereinafter referred to as the Code) represents the international policy framework to protect breastfeeding against inappropriate and unethical marketing practices from manufacturers and distributors of products under the scope of the Code.The Code was adopted in 1981 by the WHA, the World Health Assembly (WHO 1981).It is regularly updated through WHA resolutions, and those should be considered part of the Code (WHO 2017).Ensuring compliance with the Code is thus a major way of avoiding inap-propriate marketing of CMF and commercial complementary foods (CCF) and promoting breastfeeding.
The Code (again, together with subsequent relevant resolutions of the WHA), applies to all products that are marketed or represented as a suitable partial or total replacement of breastmilk, including any milk products marketed for feeding infants and young children up to 3 years of age, other foods and beverages marketed as suitable for feeding infants less than 6 months or for feeding in a bottle.The Code also applies to feeding bottles and teats, and complementary foods marketed for children up to 3 years of age.
The Code prohibits all forms of promotion of these products, including advertising and the distribution of free samples.Product labels should not promote nutritional or health benefits, nor include images that idealize CMF.In this sense, the internationally accepted definition of food labels is "any tag, brand, mark, pictorial or other descriptive matter, written, printed, stenciled, marked, embossed or impressed on, or attached to, a container of food" (FAO and WHO 2007).
The Ministry of Health of Argentina (2023) Fisheries and Food 2007).By including the Code in the Argentine Food Code, all articles have been incorporated into its text except articles 6 and 7 concerning institutions and health professionals, since this would exceed the scope of food regulations.However, these articles referring to the health system were included in the previous resolution from 1997 mentioned above, although such resolution has less legal status than a law.
Furthermore, in 2005, ANMAT signed a resolution that establishes the general norms for food advertising, stating that "Foods contemplated in the International Code of Marketing of Substitutes of breast milk of the WHO must comply with what is established therein" (ANMAT 2005).
In 2013, the Law 26.873 for the Promotion and Public Awareness of Breastfeeding, was approved, which mentions among other objectives "to disseminate the Code in accordance with the provisions of the Argentine Food Code and its complementary regulations" (Ministry of Health of Argentina 2013).This law was passed in 2015 (Ministry of Health of Argentina 2015), and states that the scope of the Code is up to 24 months of age of the child.
Despite this strong legal framework in support of the Code, there has been little research on implementation in practice.Thus, the objective of the present study was to detect violations of the Code regarding the promotion, advertising and labeling of CMF and CCF.

METHODS
In accordance with practice suggested in a recent series of relevant article in the Lancet, this paper uses the term CMF instead of "breastmilk substitute" to highlight the artificial and ultra-processed nature of these products, underlining the irreplaceable status of breastmilk (Rollins et al. 2023).The terms breastfeeding and woman are used as generic terms, although it is recognized that not all breastfeeding individuals identify themselves as women (Pérez-Escamilla et al. 2023).
This was a descriptive, semi-longitudinal study conducted using qualitative and quantitative methodology.It was descriptive because it detailed Code violations regarding the promotion, advertising and labeling of CMF and CCF intended for consumption by children under 24 months of age, and in a sense semi-longitudinal because the identical variables were studied over a given period of time.It was also correlational, since, in addition to analyzing each variable, the interrelationship between some of them was considered to discover and reveal these relationships.The methodology was qualitative, as the technique of content analysis of promotions, advertisements, and labels of CMF and CCF was applied, and quantitative, because the data collected were tabulated in a database and analyzed according to the number, frequency, and percentage of occurrence of non-compliance with the Code.

DELIMITATION OF THE STUDY AND DATA COLLECTION
Regarding the promotion and advertising of CMF and CCF, compliance with the Code and the law in force in Argentina was monitored on the websites of the companies and websites of discounts (Hotsale and Cybermonday), in the most popular digital newspapers and magazines in the country ("Oh lala", "La Nación" and "Infobae"), in the online reports of congresses for pediatricians, and in the most commonly used social networks in Argentina (Instagram and Facebook), in the period between August 2018 and August 2020.Likewise, this analysis was carried out in supermarkets and pharmacies in the Autonomous City of Buenos Aires (CABA), both in the online purchase option and in several personal visits.
Regarding the labeling, during a visit to at least one from each of the major chains of supermarkets (12) and pharmacies (13) in CABA, all 37 available CMF and CCF products labeled for and to children younger than 2 years old, were photographed to analyze the information contained on the labels and identify possible non-compliance.
Information was collected through structured observation, and it was documented through photographic capture (in person) and computer screen capture (virtual).The collected information was transferred to an Excel spreadsheet, and it was analyzed using three different forms for each aspect examined and adapted from the NetCode protocol for Violations of the Code in Argentina: analysis of promotions, advertising and labeling of commercial milk formula and...

RESULTS
At the time of the study, it was observed that there were six companies producing and selling CMF and CCF (Nutricia Bagó, Nestlé, Mead Johnson, Roemmers, SanCor and La Serenísima), and most of them own more than one brand.(These production and marketing companies are the ones surveyed at the time of the investigation, although there may have been subsequent mergers and/or acquisitions of these companies by other corporations.)PROMOTIONS 220 promotions of CMF and CCF were found on websites, social networks (Instagram and Facebook), congresses, supermarkets, and pharmacies in CABA. Figure 1 shows the number of promotions of CMF and CCF for each company at each point of sale.Most promotions were carried out in pharmacies and supermarkets.
The photographs in Figure 2 exemplify the violations mentioned before.ADVERTISING Figure 3 summarizes the number of advertisements of CMF and CCF found per company.In total, 3 advertisements were found on Facebook, 6 on newspaper and magazine websites and 5 on YouTube.
The photographs in Figure 4 exemplify the violations mentioned before.

COMMERCIAL MILK FORMULA
All CMF labels were -in different ways -non-compliant with the Code (Table 1).
Nutrilon (Nutricia Bagó) and La Serenísima Baby (La Serenísima) mention in the "Important notice" box that "when breastfeeding is not possible or is insufficient, the pediatrician is the best person to advise on the type of food to give".This message may discourage breastfeeding.
The image in Figure 5 exemplifies the non-compliance with the Code and the law in force in the country by the CMF "Enfabebe" (Mead Johnson and SanCor), mentioning on the front of the package that "its formula boosts mental development, helps strengthen the immune system, favors digestion", among other things, making unsubstantiated health claims.The objective of such claims and this type of terminology is to add authority and create the false impression that there is a strong body of scientific evidence in support of the claims, with little effort made to establish the strength of evidence itself (Rollins et al. 2023;Baker et al. 2021).
5 of 9 CMF packages contained images that go beyond the illustration of the preparation method or product identification, such as illustrations of toys, animated characters, and mascots.These were: Vital (Nutricia Bagó), Enfabebe (Mead Johnson and SanCor), La Serenísima Baby (La Serenísima), Sancorbebebe (SanCor) and Nutribaby (Roemmers).
Another strategy that was found in all the CMF was cross-promotion.WHO defines cross-promotion as "a consumer sales promotion technique in which the manufacturer attempts to sell the consumer new or other products Violations of the Code in Argentina: analysis of promotions, advertising and labeling of commercial milk formula and... related to a product the consumer already uses or which the marketer has available" (WHO 2010).WHO has pointed out that "this can include packaging, branding and labelling of a product to closely resemble that of another (brand extension)" (WHO 2016a).WHA resolution 69.9 explicitly states that follow-on formula for infants up to 36 months of age are substitutes for breastmilk (WHO 2016b).These follow-on formulas are unsuitable for feeding infants under 6 months of age but are promoted with labels that resemble those of infant formula.This situation leads to confusion, inappropriate use and can discourage exclusive breastfeeding in the first six months of life.Two concrete examples of cross-promotion can be seen in Figure 6.

COMMERCIAL COMPLEMENTARY FOODS
All CCF labels examined were non-compliant with the Code and Argentinian law (Table 2).

DISCUSSION
This research established that the companies Nutricia Bagó, Nestlé, Roemmers, La Serenísima, Mead Johnson and SanCor, related to the commercialization of CMF and complementary foods, do not comply with the Code and the law in force in Argentina.This situation of non-compliance is likely one cause of the low prevalence of exclusive breastfeeding in the country.
CMF marketing is a multi-faceted, sophisticated, wellresourced and powerful influencing system that generates demand and sales of products at the expense of the health and rights of families, women and children (Rollins et al. 2023).
Internationally, despite obvious conflicts of interest, CMF industry observers are permitted to actively participate in meetings of the Codex Alimentarius standard-setting process, which provides access to national policy makers and compromises the setting of standards for CMFs (Rollins et al. 2023;Russ et al. 2021;Boatwright et al. 2021).Perhaps due to political pressure from those who demand market freedoms without limits, in our study in Argentina we found an indecisive State, failing to monitor and implement the Code or even its own laws regarding the promotion and protection of optimal infant feeding practices.
While the present study provides information regarding on Code violations in the promotion, advertising and label-Violations of the Code in Argentina: analysis of promotions, advertising and labeling of commercial milk formula and... ing of CMF and CCF in Argentina, it is limited in that it is only a snapshot of reality.Nevertheless, we believe it to be reliable and lacking in selection bias for the time period covered.

CONCLUSIONS
The present study indicates a need to strengthen the political will and the capacity of the relevant Argentinian authorities to monitor compliance with the Code and to establish mechanisms for monitoring and enforcement of current regulations, to curb abuses by the CMF and CCF industry, and to safeguard the rights of mothers and their Violations of the Code in Argentina: analysis of promotions, advertising and labeling of commercial milk formula and...  newborns to adequate information on feeding methods so that they can make truly informed decisions in this regard.Violations of the Code in Argentina: analysis of promotions, advertising and labeling of commercial milk formula and...

Figure 1 .
Figure 1.Distribution of promotions of CMF and CCF in each point of sale and by company

Figure 2 .
Figure 2. Examples of promotions detected that violate the Code and the law in force in Argentina.

Figure 3 .
Figure 3. Distribution of advertisements of CMF and CCF by company and by product

Figure 5 .
Figure 5. Example of the label of the CMF EnfaBebé 1 that violate the Code and the law in force in Argentina.

Figure 6 .
Figure 6.Examples of the labels of the CMFs Nutrilon (Nutricia Bagó) and Nan (Nestle) that violate the Code and the law in force in Argentina.

Table 2 . Non-compliance with the Code on labels of CCFs
Violations of the Code in Argentina: analysis of promotions, advertising and labeling of commercial milk formula and...