Objective: To explore on-package formula messaging with reference to legislation and government issued guidance in Great Britain (GB). Design: Formula products were identified, pictures of all sides of packs collated, and on-package text and images were coded. Compliance with both GB legislation and guidance issued by the Department of Health and Social Care (DHSC) was assessed. Setting: All formula packs available for sale over the counter in GB between April and October 2020. Participants: Formula packs (n71) including infant formula, follow-on formula, growing-up formula and specialist formula were identified, coded and analysed. Results: In total, 41% of formula packs included nutrition claims and 18% included health claims that may be considered non-permitted according to DHSC guidance. Additionally, 72% of products showed images considered ‘non-permitted’. BMS legislation states infant and follow-on formula packs should be clearly distinguishable but does not provide criteria to assess similarity. Based on DHSC guidance, 72% of infant and follow-on formula packs were categorised as showing a high degree of similarity. Marketing practices not covered by current legislation were widespread, such as 94% of infant formula packs including advertisements for follow-on formula or growing-up formula. Conclusions: Text and images considered non-permitted according to DHSC guidance for implementing Breast Milk Substitute (BMS) legislation were widespread on formula products available in GB. As terms such as 'similarity’ are not defined in BMS legislation it was unclear if breaches had occurred. Findings support the WHO call for loopholes in domestic legislation to be closed as a matter of urgency.

Self-completed 24 h dietary recalls (24-HRs) are increasingly used for research and national dietary surveillance. It is unclear how difficulties with self-completion affect response rates and sample characteristics. This study identified factors associated with being unable to self-complete an online 24-HR but willing to do so with an interviewer. Baseline 24-HRs from the ASCOT Trial were analysed (n = 1224). Adults who had been diagnosed with cancer in the past seven years and completed treatment, were invited to self-complete 24-HRs online using myfood24®. Non-completers were offered an interviewer-administered 24-HR. One third of participants willing to provide dietary data, were unable to self-complete a 24-HR. This was associated with being older, non-white and not educated to degree level. Compared to interviewer-administered 24-HRs, self-completed 24-HRs included 25% fewer items and reported lower intakes of energy, fat, saturated fat and sugar. This study highlights how collection of dietary data via online self-completed 24-HRs, without the provision of an alternative method, contributes to sampling bias. As dietary surveys are used for service and policy planning it is essential to widen inclusion. Optimisation of 24-HR tools might increase usability but interviewer-administered 24-HRs may be the only suitable option for some individuals.

ObjectiveTo understand how mothers use commercial milk formula (CMF) labels to inform their feeding choices and explore mothers’ understanding of differences between CMF products.DesignQualitative study with recruitment via social media. Online semistructured interviews, including a product mapping exercise and thematic analysis.ParticipantsMothers (n=25) using CMF for children <3 years living in Great Britain (GB).ResultsMothers were drawn to brands they recognised from years of exposure to CMF advertising. CMF products were assumed to vary according to brand and stage, but participants found on-pack information did not explain how. This added to anxiety about choosing ‘the best one’ and mothers would have liked guidance from healthcare professionals (HCPs). Wide availability of CMF for older infants and children, and on-pack messaging suggesting progression from one product to the next, led many to believe these products were necessary. There was confusion over the appropriate use of specialist products. While mothers rarely mentioned on-pack health and nutrition claims, they were attracted to the overall appearance of packs and messaging relating to science, research and nature. References to breast milk and a logo perceived to represent a breastfeeding mother were taken as indicators of closer similarity to breast milk.ConclusionsCMF legislation in GB should be updated to restrict brand advertising and the use of on-pack text and images that mothers perceive as indicating products have a closer similarity to breast milk. Greater input from HCPs was desired by new mothers and would support them to make more informed choices about CMF.

Birth to age 2 is a critical period for establishing lifelong healthy eating habits. The composition, labelling and marketing of formula is governed by Regulation (EU) No 609/2013 and delegated acts, which the UK adopted in 2021 (1) . These permit promotion of follow-on formula (FOF, suitable from 6 months) but not infant formula (IF, suitable from birth) or formula labelled as food for special medical purposes (FSMP, suitable for the dietary management of specific conditions e.g. colic). Furthermore, they state that packaging (text, images and colours) of FOF and formula labelled as FSMP should be designed to avoid confusion with IF. Similarity between products promotes brand identity but could result in inappropriate infant feeding. The present study aimed to assess similarities between the packaging of IF, FOF and formula labelled as FSMP.A scoping review of formula available over the counter in mainland GB between April and October 2020 was undertaken. Images of the front, sides and back of formula products were compiled in a database. Prominent visual aspects of packaging were coded and classified. Five features were examined, based on those previously identified in Department of Health and Social Care (DHSC) guidelines as likely to cause confusion (2) . Products received one score point for each feature that was the same (colour of packaging, size and position of logo, image used, position of image, position of text describing product) giving a maximum similarity score of 5. The higher the similarity score, the more challenging the formula products within a brand range are to distinguish from each other.In total 71 formula products were identified, and 302 images were coded and examined. This included 18 FOFs, which were compared to 18 same brand IFs. We also analysed 6 formulas labelled as FSMP, that were compared to 6 same brand IFs. A similarity score ≥4 out of 5 was found for 72% of FOFs and 29% of formulas labelled as FSMP. In addition, 94% of IF packs included on-package advertisements for FOF and one quarter (5/18) included nutrition and health claims within advertisements, which are promotional tools and not permitted on IF in order to protect breastfeeding.FOF and formula labelled as FSMP are sold in packaging which appears similar to IF. These risks infants being given inappropriate formula by mistake. The health and nutrition claims displayed on FOFs may also have a health halo effect on IFs which are not permitted to include such claims. These findings highlight the need for future legislation and guidelines to include clear instructions to ensure packaging for different types of formula is clearly distinguishable and will feed into a qualitative study of formula choices.

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