Marketing violations involving products that compete with breastfeeding in the vicinity of early childhood education centers and health centers: a cross-sectional study based on an audit of the retail food environment, Maceió, 2022–2023

Bastos, Emanuelle Cristina Lins; Vidal, Nicole Almeida Conde; Aragão, Luan dos Santos; Costa, Gabriel Marx Assunção; Silveira, Jonas Augusto Cardoso da

doi:10.1590/S2237-96222025v34e20240666.en

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ORIGINAL ARTICLE • Epidemiol. Serv. Saúde 34 • 2025 • https://doi.org/10.1590/S2237-96222025v34e20240666.en linkcopy

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10.1590/S2237-96222025v34e20240666.a

This document is related to:

10.1590/S2237-96222025v34e20240666.b

This document is related to:

10.1590/S2237-96222025v34e20240666.c

Marketing violations involving products that compete with breastfeeding in the vicinity of early childhood education centers and health centers: a cross-sectional study based on an audit of the retail food environment, Maceió, 2022–2023

Infracciones comerciales de productos competidores de la lactancia materna en los alrededores de centros de educación infantil y unidades de salud: estudio transversal basado en auditoría del ambiente alimentario minorista, Maceió, 2022-2023

Authorship SCIMAGO INSTITUTIONS RANKINGS

Abstract

Objective Evaluate violations of the Brazilian Code of Marketing of Infant and Toddler Food, Teats, Pacifiers, and Baby Bottles (NBCAL) in the retail food environment around health centers and early childhood education centers in Maceió.

Methods This cross-sectional study, conducted between April 2022 and March 2023, audited all food retail outlets selling products regulated by the Code in the vicinity of health centers and early childhood education centers. The results were expressed as frequencies.

Results Of the 1,176 food retail outlets audited, 8.8% showed violations. The violations were concentrated in pharmacies (65.0%) and supermarkets (26.2%). When examining these two types of establishments (n=601), it was observed that 41.6% of those affiliated with retail chains exhibited violations. The probability of violation in retail chains was 6.8 times higher (95% confidence interval: 4.5-10.2) than in independent establishments. The most frequent violations occurred in follow-up formulas for early childhood children (27.5%), infant and follow-up formulas for infants (22.0%), and dairy compound products (19.7%). The promotional strategy most associated with the violations was special display (74.7%).

Conclusion The retail food environment in Maceió revealed violations of the Code, with pharmacy chains and supermarkets posing the main threats to breastfeeding. Given the responsibilities of distributors and industry provided for in the legislation, this work reported abusive marketing practices that negatively impact the human right to adequate food and nutrition of children.

Keywords
Food Social Space; Breast Feeding; Breast-Milk Substitutes; International Code of Marketing of Breastmilk Substitutes; Observational Study

Monitoring variables
Violations due to prohibited marketing promotion	Presence of any marketing promotion strategy for infant formula, infant follow-up formula, nipples, pacifiers, bottles, and nipple shields
Violation due to marketing promotion with a non-compliant or missing Ministry of Health’s warning statement	Absence or non-compliance of the warning statement linked to the marketing promotion of follow-up infant formulas for early childhood children, milks and similar products, complementary foods, and dairy compound products “The Ministry of Health warns: this product should not be used for children under 6 (six) months of age, unless expressly indicated by a doctor or nutritionist. Breastfeeding prevents infections and allergies and is recommended until two (2) years of age or older.” “The Ministry of Health informs: After 6 (six) months of age, continue breastfeeding your child and offer new foods.”
Monitoring indicators
Proportion of food retail outlets with violations	(Number of food retail outlets with violations of the Code/number of food retail outlets regulated by the Code)x100
Proportion of food retail outlets affiliated with retail chains	(Number of food retail outlets affiliated with retail chains/number of food retail outlets regulated by the Code)x100
Proportion of food retail outlets affiliated with retail chains with violations	(Number of food retail outlets affiliated with retail chains with violations of the Code/number of food retail outlets affiliated with retail chains)x100

Type of business	Regulated food retail outlets n (%)	Food retail outlets with violations n (%)	Food retail outlets affiliated with retail chains n (%)	Food retail outlets affiliated with reta il chains with violations n (%)
Butcher shops, fish markets, and meat-packing plants	32 (2.7)	1 (3.1)	-	-
Candy retail store	9 (0.7)	1 (11.1)	6 (66.7)	1 (16.7)
Market stall or street market stalls	3 (0.2)	-	-	-
Grocery stores	379 (32.2)	3 (0.8)	3 (0.8)	-
Bakeries	114 (9.6)	3 (2.6)	4 (3.5)	-
Greengrocers or produce markets	13 (1.1)	-	1 (7.7)	-
Markets or supermarkets	244 (20.7)	27 (11.0)	47 (19.3)	16 (34.0)
Department stores	17 (1.4)	-	3 (17.6)	-
Pharmacies	357 (30.3)	67 (18.8)	114 (31.9)	51 (44.7)
Children’s product stores	6 (0.5)	0	1 (16.6)	-
Department stores	2 (0.1)	1 (50.0)	2 (100.0)	1 (50.0)
Total	1,176 (100.0)	103 (8.8)	181 (15.3)	69 (38.1)

	Violations by product groups regulated by the Code
	Infant formula and follow-up formulas for infants n (%)	Teats, pacifiers, bottles and nipple shields n (%)	Infant formula for early childhood children n (%)	Milks and similar products n (%)	Dairy compound products n (%)	Complementary foods n (%)	Total n (%)
Establishments^a	289 (9.0)	319 (3.5)	210 (21.0)	856 (1.3)	523 (10.3)	669 (2.7)	1,176
Type of violation^b
Prohibited marketing promotion	59 (22.0)	34 (12.6)	-	-	-	-	269 (100.0)
Marketing promotion with a non-compliant or missing warning statement from the Ministry of Health	-	-	74 (27.5)	27 (10.0)	53 (19.7)	22 (8.2)	269 (100.0)
Marketing promotion strategy^c
Price promotion	20 (15.0)	3 (2.3)	58 (43.6)	7 (5.2)	38 (28.5)	7 (5.3)	133
Special display	40 (19.9)	36 (17.9)	52 (25.9)	13 (6.4)	40 (19.9)	20 (10.0)	201
Distribution of informational material	-	-	3 (75.0)	1 (25.0)	-	-	4
Progressive discount	6 (10.3)	1 (1.7)	30 (51.7)	-	21 (36.2)	-	58
Gifts/ prize draws	1 (16.7)	-	3 (50.0)	2 (33.3)	-	-	6

Manufacturers	Product groups regulated by the Code						Total n (%)
Manufacturers	Infant formula and follow-up formula for infants n (%)	Teats, pacifiers, bottles and nipple shields n (%)	Infant formula for early childhood children n (%)	Milks and similar products n (%)	Dairy compound products n (%)	Complementary foods n (%)	Total n (%)
Nestlé	46 (78.0)	-	65 (87.8)	20 (74.1)	34 (64.1)	20 (90.9)	185 (78.7)
Danone	13 (22.0)	-	9 (12.2)	-	19 (35.9)	-	41 (17.4)
Itambé	-	-	-	5 (18.5)	-	-	5 (2.1)
Camponesa	-	-	-	1 (3.7)	-	-	1 (0.4)
Betânia	-	-	-	1 (3.7)	-	-	1 (0.4)
Maizena	-	-	-	-	-	2 (9.1)	2 (0.9)
Total	59 (100.0)	-	74 (100.0)	27 (100.0)	53 (100.0)	22 (100.0)	235 (100.0)
Lolly	-	14 (41.2)	-	-	-	-	14 (41.2)
Lillo	-	7 (20.6)	-	-	-	-	7 (20.6)
Neopan	-	4 (11.8)	-	-	-	-	4 (11.8)
Kuka	-	3 (8.8)	-	-	-	-	3 (8.8)
Mam	-	2 (5.9)	-	-	-	-	2 (5.9)
Philips	-	1 (2.9)	-	-	-	-	1 (2.9)
Fiona	-	1 (2.9)	-	-	-	-	1 (2.9)
Nuk	-	1 (2.9)	-	-	-	-	1 (2.9)
Needs	-	1 (2.9)	-	-	-	-	1 (2.9)
Total		34 (100.0)					34 (100.0)

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Secretaria de Vigilância em Saúde e Ambiente - Ministério da Saúde do Brasil SRTVN Quadra 701, Via W5 Norte, Lote D, Edifício P0700, CEP: 70719-040, +55 (61) 3315-3464 - Brasília - DF - Brazil
E-mail: revista.saude@saude.gov.br

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[fnte3] ^aThe n represents the number of establishments that marketed a given product group, and the % indicates the proportion of establishments with violations. ; ^bInformation accounted for considering the occurrence of violations at the establishment level; ^cInformation accounted for considering the occurrence of violations by product. The sum of percentages may exceed 100.0% as a single product could present violations across multiple dimensions of the Code.