Documents Show Internal Clash Before U.S. Officials Pushed to Weaken Toddler Formula Rules

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Over the past decade, countries around the world have sought to limit the advertising of “toddler formula,” a powdered drink that often promises to improve children’s brains, immunity and eyesight.

Public health experts and advocates have backed the proposed restrictions, saying that the marketing of toddler milk can mislead parents about its health benefits and even convince some to choose formula over breastfeeding. The concerns echo those made about infant formula marketing, which many countries have banned for years.

Industry sales, however, have not only persisted but boomed — with the help of a powerful ally: the United States government. As ProPublica reported this week, federal trade agencies have worked in tandem with formula companies to fight restrictions on formula marketing in international forums while also pressuring individual countries to water down or strike their own laws.

While these battles typically play out behind the scenes, ProPublica obtained thousands of pages of government records that provide a rare window into one of the more consequential campaigns of recent years. It happened during the Obama administration in 2016, as member nations of the World Health Organization (known collectively as the World Health Assembly) considered a resolution encouraging limits on the marketing and promotion of foods aimed at infants and young children, including toddler formula.

Concerned that the measure would inspire new laws against formula marketing, the industry spent millions lobbying various U.S. agencies to intervene.

Documents obtained via a Freedom of Information Act request show a stark pattern: representatives of U.S. trade agencies aggressively sought to weaken the WHO resolution while officials from the health agencies scrambled to defend the measure. One Microsoft Word document cataloged dozens of comments and objections.

This visualization captures four of the divisions between the Office of the U.S. Trade Representative, which advises the president on trade, and federal health entities such as the Department of Health and Human Services and the Centers for Disease Control and Prevention.

The full document, including the tracked changes and comments depicted below, can be viewed here.

Arguing Over Science

A Debate Over Endorsement

Watering Down the Resolution

A Fight Over Guidance

Draft World Health Assembly Resolution 69.9
Paragraph 5

Recognizing that the inappropriate promotion of commercial foods for infants and young children can mislead parents and other caregivers about the nutrition and health-related qualities of these foods and about their age-appropriate and safe use, and that the promotion of such products for infants under 6 months of age has been associated with earlier cessation of exclusive breastfeeding;

Recognizing that the inappropriate promotion of commercial certain foods for infants and young children can undermine progress in optimal infant and you[ng] child feeding. can mislead parents and other caregivers about the nutrition and health-related qualities of these foods and about their age-appropriate and safe use, and that the promotion of such products for infants under 6 months of age has been associated with earlier cessation of exclusive breastfeeding;

Recognizing that the inappropriate promotion of commercial certain foods for infants and young children can undermine progress in optimal infant and you[ng] child feeding. can mislead parents and other caregivers about the nutrition and health-related qualities of these foods and about their age-appropriate and safe use, and that the promotion of such products for infants under 6 months of age has been associated with earlier cessation of exclusive breastfeeding;

Recognizing that the inappropriate promotion of commercial certain foods for infants and young children can undermine progress in optimal infant and you[ng] child feeding. can mislead parents and other caregivers about the nutrition and health-related qualities of these foods and about their age-appropriate and safe use, and that the promotion of such products for infants under 6 months of age has been associated with earlier cessation of exclusive breastfeeding;

Recognizing that the inappropriate promotion of commercial certain foods for infants and young children can undermine progress in optimal infant and you[ng] child feeding. can mislead parents and other caregivers about the nutrition and health-related qualities of these foods and about their age-appropriate and safe use, and that the promotion of such products for infants under 6 months of age has been associated with earlier cessation of exclusive breastfeeding;

The conflict began with squabbling over this introductory paragraph to the draft resolution that acknowledged that promotion of infant formulas can lead to decreased breastfeeding.

Jennifer Stradtman, from the U.S. trade representative’s office, suggested a “more positive” framing and inserted new language.

Then, Stradtman removed the language about breastfeeding, writing in a comment that there was no evidence that the promotion of formula had been associated with stopping breastfeeding early.

Jennifer Seymour from the CDC disputed Stradtman’s claims and commented that the language about breastfeeding should not be deleted.

A Health and Human Services official agreed with Seymour, arguing there was significant evidence to support the statement.

Draft World Health Assembly Resolution 69.9
Paragraph 10

The World Health Assembly ENDORSES / TAKES NOTE OF the technical guidance on ending the inappropriate promotion of foods for infants and young children;

The World Health Assembly ENDORSES / TAKES NOTE OF the technical guidance on ending the inappropriate promotion of foods for infants and young children;

The World Health Assembly ENDORSES / TAKES NOTE OF the technical guidance on ending the inappropriate promotion of foods for infants and young children while recognizing that milk products and certain complementary foods provide adequate nutrition;

The World Health Assembly ENDORSES / TAKES NOTE OF the technical guidance on ending the inappropriate promotion of foods for infants and young children while recognizing that milk products and certain complementary foods provide adequate nutrition;

Another paragraph in the draft resolution, which sought to show support for the content of the WHO’s guidance on formula, created controversy.

Stradtman, the trade official, removed the word “endorses,” commenting that the trade representative’s office does not support using positive language to describe the nations’ stance on the resolution.

Then, a trade official tacked on language in support of milk products.

In response, health officials questioned why the clause supporting milk products was necessary.

Draft World Health Assembly Resolution 69.9
Paragraphs 11-12

The World Health Assembly urges Member States to take all necessary measures to implement the guidance on ending the inappropriate promotion of foods for infants and young children, while taking into account existing legislation and policies, nutrition and feeding recommendations, and national and international trade obligations, as appropriate;

The World Health Assembly urges advises Member States to take all necessary measures to implement the guidance on ending the inappropriate promotion of foods for infants and young children, while taking into account existing legislation and policies, nutrition and feeding recommendations, and national and international trade obligations, as appropriate;

The World Health Assembly urges advises Member States to take all necessary measures to implement the guidance on ending the inappropriate promotion of foods for infants and young children, while taking into account existing legislation and policies, nutrition and feeding recommendations, and national and international trade obligations, as appropriate;

The World Health Assembly urges advises Member States to take all necessary measures to implement the guidance to consider a range of factors when determining how best to address inappropriate promotion in their national contexts, including national policies, impact assessments, laws, priorities, and nutrition and feeding recommendations, regional nutrition profiles or needs, and national and international trade obligations.

The World Health Assembly urges advises Member States to take all necessary measures to implement the guidance to consider a range of factors when determining how best to address inappropriate promotion in their national contexts, including national policies, impact assessments, laws, priorities, and nutrition and feeding recommendations, regional nutrition profiles or needs, and national and international trade obligations.

A paragraph in the draft resolution urging member states to implement the WHO’s guidance brought more debate.

First, Stradtman asked to soften the language

Then, the trade representative’s office proposed deleting the entire section, saying the language sounded too much like a directive instead of a recommendation.

Next, trade officials proposed an alternative sentence that encouraged member states to “consider a range of factors” instead of “take all necessary measures.”

The health agencies responded that the trade officials’ edits were undercutting the purpose of the resolution.

Draft World Health Assembly Resolution 69.9
Paragraph 20

The World Health Assembly calls upon manufacturers and distributors of foods for infants and young children to end all forms of inappropriate promotion by fully implementing the recommendations set forth in the guidance on ending the inappropriate promotion of foods for infants and young children, irrespective of whether the recommendations have been transposed into national legislation;

The World Health Assembly calls upon manufacturers and distributors of foods for infants and young children provide labeling, including the age range for which the product is suitable, based on relevant Codex standards and guidance. to end all forms of inappropriate promotion by fully implementing the recommendations set forth in the guidance on ending the inappropriate promotion of foods for infants and young children, irrespective of whether the recommendations have been transposed into national legislation;

The World Health Assembly calls upon manufacturers and distributors of foods for infants and young children provide labeling, including the age range for which the product is suitable, based on relevant Codex standards and guidance. to end all forms of inappropriate promotion by fully implementing the recommendations set forth in the guidance on ending the inappropriate promotion of foods for infants and young children, irrespective of whether the recommendations have been transposed into national legislation;

Another section of the draft proposal described what the World Health Assembly was ultimately asking formula companies to do.

Trade officials struck much of the section and replaced it with instructions only about product labeling.

Seymour from the CDC fervently opposed changes by the trade representative’s office.

Ultimately, the U.S. delegation and its allies persuaded the WHO nations to scrap “endorsing” the resolution, as trade officials had advocated. Instead, the body voted to “welcome” the guidance “with appreciation.”

“That has caused a lot of confusion,” said Laurence Grummer-Strawn, a WHO official who focuses on child feeding and former nutrition chief for the CDC. “What does that really mean?”

Some of the points the U.S. health agencies had fought hardest for were missing, too, including the well-documented link between formula promotion and the early cessation of breastfeeding.

U.S. trade officials soon took up the formula industry’s cause around the globe, including in Southeast Asia, where Thailand, Hong Kong and Indonesia all either watered down or put on hold new regulations after U.S. objections.

Neither Stradtman nor Michael Froman, who was the U.S. trade representative at the time, responded to requests for comment for this story.

A trade representative’s office spokesperson declined to comment on its actions around the WHO resolution. In a general statement, the spokesperson said that “with regard to infant formula, USTR, in conjunction with others in the interagency, work to uphold and advocate for policy and regulatory decisions that are based on science.”

A CDC spokesperson did not comment on the interagency debate, saying only that Seymour was invited to join as an expert on breastfeeding and infant nutrition.

The Department of Health and Human Services did not respond to questions for this story. But Jimmy Kolker, the assistant secretary who led the negotiations for the U.S. in Geneva, told Reuters at the time that he was content with the outcome.

“In any resolution,” he said, “there are trade-offs.”

Heather Vogell is a reporter at ProPublica.

Lucas Waldron is a graphics editor at ProPublica.

Additional design by Zisiga Mukulu.