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Despite increasing evidence about the value and importance of breastfeeding, less than half of the world's infants and young children (aged 0–36 months) are breastfed as recommended. This Series paper examines the social, political, and economic reasons for this problem. First, this paper highlights the power of the commercial milk formula (CMF) industry to commodify the feeding of infants and young children; influence policy at both national and international levels in ways that grow and sustain CMF markets; and externalise the social, environmental, and economic costs of CMF. Second, this paper examines how breastfeeding is undermined by economic policies and systems that ignore the value of care work by women, including breastfeeding, and by the inadequacy of maternity rights protection across the world, especially for poorer women. Third, this paper presents three reasons why health systems often do not provide adequate breastfeeding protection, promotion, and support. These reasons are the gendered and biomedical power systems that deny women-centred and culturally appropriate care; the economic and ideological factors that accept, and even encourage, commercial influence and conflicts of interest; and the fiscal and economic policies that leave governments with insufficient funds to adequately protect, promote, and support breastfeeding. We outline six sets of wide-ranging social, political, and economic reforms required to overcome these deeply embedded commercial and structural barriers to breastfeeding.

In this Series paper, we examine how mother and baby attributes at the individual level interact with breastfeeding determinants at other levels, how these interactions drive breastfeeding outcomes, and what policies and interventions are necessary to achieve optimal breastfeeding. About one in three neonates in low-income and middle-income countries receive prelacteal feeds, and only one in two neonates are put to the breast within the first hour of life. Prelacteal feeds are strongly associated with delayed initiation of breastfeeding. Self-reported insufficient milk continues to be one of the most common reasons for introducing commercial milk formula (CMF) and stopping breastfeeding. Parents and health professionals frequently misinterpret typical, unsettled baby behaviours as signs of milk insufficiency or inadequacy. In our market-driven world and in violation of the WHO International Code for Marketing of Breast-milk Substitutes, the CMF industry exploits concerns of parents about these behaviours with unfounded product claims and advertising messages. A synthesis of reviews between 2016 and 2021 and country-based case studies indicate that breastfeeding practices at a population level can be improved rapidly through multilevel and multicomponent interventions across the socioecological model and settings. Breastfeeding is not the sole responsibility of women and requires collective societal approaches that take gender inequities into consideration.

Background: A new index to determine body iron promises a simpler approach to monitoring iron deficiency (ID) prevalence. Objective: Our objective was to compare ID defined as body iron Design: We used measures of iron status and inflammation from 486 children aged 1-2 y, 848 children aged 3-5 y, and 3742 nonpregnant females aged 12-49 y from the National Health and Nutrition Examination Survey 2003-2006. Results: ID prevalences ([+ or -] SE) based on the body iron model in children (1-2 and 3-5 y) and in females (12-19 and 20-49 y) were 14.4 [+ or -] 1.9%, 3.7 [+ or -] 0.8%, 9.3 [+ or -] 1.0%, and 9.2 [+ or -] 1.6%, respectively. ID prevalences based on the ferritin model in children (3-5 y) and females (12-19 and 20-49 y) were 4.5 [+ or -] 0.9%, 15.6 [+ or -] 1.2%, and 15.7 [+ or -] 0.8%, respectively. The [kappa] statistics for agreement between the 2 models were 0.5-0.7. Among females (12-49 y) the positive predictive values of ID based on the body iron model and the ferritin model for identifying anemia were 43 [+ or -] 3% and 30 [+ or -] 2%, respectively, whereas negative predictive values did not differ. C-reactive protein was elevated in 28.8 [+ or -] 3.1% of females with ID by the ferritin model but not by the body iron model and in 0% of persons with ID by the body iron model but not by the ferritin model. Conclusions: The agreement between the 2 indexes was fair to good. Among females, the body iron model produced lower estimates of ID prevalence, better predicted anemia, and appeared to be less affected by inflammation than the ferritin model. Am J Clin Nutr 2009;89:1334-42.

Background: Several investigators have concluded that the waist-to-height ratio is more strongly associated with cardiovascular disease risk factors than is the body mass index (BMI; in kg/[m.sup.2]). Objectives: We examined the relation of the BMI-for-age z score and waist-to-height ratio to risk factors (lipids, fasting insulin, and blood pressures). We also compared the abilities of these 2 indexes to identify children with adverse risk factors. Design: Children aged 5-17 y (n = 2498) in the Bogalusa Heart Study were evaluated. Results: As assessed by the ability of the 2 indexes to 1) account for the variability in each risk factor and 2) correctly identify children with adverse values, the predictive abilities of the BMI-for-age z score and waist-to-height ratio were similar. Waist-to-height ratio was slightly better (0.01-0.02 higher [R.sup.2] values, P < 0.05) in predicting concentrations of total-to-HDL cholesterol ratio and LDL cholesterol, but BMI was slightly better in identifying children with high systolic blood pressure (0.03 higher [R.sup.2], P < 0.05) in predicting measures of fasting insulin and systolic and diastolic blood pressures. On the basis of an overall index of the 6 risk factors, no difference was observed in the predictive abilities of BMI-for-age and waist-to-height ratio, with areas under the curves of 0.85 and 0.86 (P = 0.30) and multiple [R.sup.2] values of 0.320 and 0.318 (P = 0.79). This similarity likely results from the high intercorrelation ([R.sup.2] = 0.78) between the 2 indexes. Conclusions: BMI-for-age and waist-to-height ratio do not differ in their abilities to identify children with adverse risk factors. Although waist-to-height ratio may be preferred because of its simplicity, additional longitudinal data are needed to examine its relation to disease. KEY WORDS BMI, body mass index, waist, height, waist-to-height ratio, children, lipids, blood pressure, insulin

Background: Hemoglobin and erythrocyte protoporphyrin (EP) tests are commonly used to screen for iron deficiency. However, little research has been done to systematically evaluate the sensitivity and specificity of these 2 tests. Objective: The objective of this study was to evaluate the sensitivity and specificity of hemoglobin and EP measurements in predicting iron deficiency in preschool children and in women of childbearing age. Design: We examined data from the third National Health and Nutrition Examination Survey (n = 2613 children aged 1-5 y and n = 5175 nonpregnant women aged 15-49 y). Children or women with blood lead [greater than or equal to] 10 [micro]g/dL were excluded from this study. We used the receiver operating characteristic (ROC) curve to characterize the sensitivity and specificity of hemoglobin and EP measurements in screening for iron deficiency, defined as having abnormal values for [greater than or equal to] 2 of the following 3 indexes: mean cell volume, transferrin saturation, and serum ferritin. Results: The ROC performance of EP was consistently better than that of hemoglobin for detecting iron deficiency in preschool children. However, in nonpregnant women, we found no significant difference between EP and hemoglobin in ROC performance for detecting iron deficiency. We observed the same results when we stratified the analyses by sex and race of the children and by race of the women. Conclusions: For children aged 1-5 y, EP is a better screening tool for iron deficiency than is hemoglobin. However, for nonpregnant women, EP and hemoglobin have similar sensitivity and specificity for predicting iron deficiency. Am J Clin Nutr 2003;77:1229-33. KEY WORDS Iron deficiency, hemoglobin, erythrocyte protoporphyrin, zinc protoporphyrin, mean cell volume, transferrin saturation, serum ferritin, receiver operating characteristic curve, preschool children, women, iron deficiency anemia

Background: Maternal obesity has been associated with poor lactation in animal models, but the results of related research in humans are inconclusive. Objective: We tested the hypothesis that women who are obese before pregnancy or who gain excessive weight during pregnancy are less likely to initiate and maintain breast-feeding than are their normal-weight counterparts. Design: We analyzed 124 151 mother-infant pairs from the Pediatric Nutrition Surveillance System and the Pregnancy Nutrition Surveillance System. Body mass index (BMI) before pregnancy and gestational weight gain were categorized according to guidelines from the Institute of Medicine. Multiple logistic regression was used to identify the association between maternal obesity and breast-feeding initiation (n = 51 329), and multiple linear regression was used to examine the effect of maternal obesity on breast-feeding duration among women who initiated breast-feeding (n = 13 234). Results: Regardless of gestational weight gain, obese women were less likely to initiate breast-feeding than were women with a normal BMI before pregnancy who also gained the recommended weight during pregnancy. Maternal BMI before pregnancy and gestational weight gain were each independently associated with duration of breast-feeding. Women who were obese before pregnancy breast-fed [approximately equal to] 2 wk less than did their normal-weight counterparts, and women who either failed to reach or exceeded the recommended gestational weight gain breast-fed [approximately equal to] 1 wk less than did those who gained the recommended gestational weight. Conclusions: Both obesity before pregnancy and inadequate weight gain during pregnancy have a negative effect on breastfeeding practice. Women who are obese before pregnancy or who gain inadequate weight during pregnancy need extra support for breast-feeding. KEY WORDS Maternal obesity, BMI before pregnancy, gestational weight gain, breast-feeding initiation, breast-feeding duration, Pediatric Nutrition Surveillance System, Pregnancy Nutrition Surveillance System

Background: Validation studies of height- and weight-based indexes of body fatness in children and adolescents have examined only small samples of school-age children. Objective: The objective was to validate the performance of age- and sex-specific body mass index (BMI) compared with the Rohrer index (RI) and weight-for-height in screening for both underweight and overweight in children aged 2-19 y. Design: Data from the third National Health and Nutrition Examination Survey (n = 11096) and a pooled data set from 3 studies that used dual-energy X-ray absorptiometry (n = 920) were examined. The receiver operating characteristic curve was used to characterize the sensitivity and specificity of these 3 indexes in classifying both underweight and overweight. Percentage body fat and total fat mass were determined by dual-energy X-ray absorptiometry. Subcutaneous fat was assessed on the basis of the average of triceps and subscapular skinfold thicknesses. Results: For children aged 2-19 y, BMI-for-age was significantly better than were weight-for-height and RI-for-age in detecting overweight when average skinfold thicknesses were used as the standard, but no differences were found in detecting underweight. When percentage body fat or total fat mass was used as the standard, BMI-for-age was significantly better than was RI-for-age in detecting overweight in children aged 3-19 y. No differences were found between BMI-for-age and weight-for-height in detecting overweight or underweight. Conclusion: For children and adolescents aged 2-19 y, the performance of BMI-for-age is better than that of RI-for-age in predicting underweight and overweight but is similar to that of weight-for-height. Am J Clin Nutr 2002;75:978-85. KEY WORDS Dual-energy X-ray absorptiometry, body mass index, Rohrer index, weight-for-height, skinfold, anthropometry, receiver operating characteristic curve, sensitivity, specificity, children

Objective: To better characterize childhood growth and further assess potential limitations of the current National Center for Health Statistics and World Health Organization international growth reference. Design: The LMS method was used for curve fitting to summarize the changes in height and weight distributions by 3 curves representing the skewness (L), median (M), and coefficient of variation (S). A series of polynomial regression procedures was applied to smooth the L, M, and S curves. Setting: Subset data from 18 states contributing clinic data to the Centers for Disease Control and Prevention Pediatric Nutrition Surveillance System were used for this research reference. Methods: We chose only those clinics in which the height and weight distributions of children closely matched with those of the first and second National Health and Nutrition Examination Surveys. Results: Unlike the current international growth reference, the new reference has no disjunction at 24 months of age because it is based on a single data source for children aged 0 to 59 months. The reference also better characterizes the growth for infants than the current international reference, a fact we demonstrated with data from the National Health and Nutrition Examination Surveys, Pediatric Nutrition Surveillance System 1995, and the Davis Area Research on Lactation, Infant Nutrition, and Growth studies. Conclusions: The current National Center for Health Statistics and World Health Organization international growth reference needs to be updated. The methods used in this study will be useful to evaluate other data sets and to evaluate future modifications of growth references. Arch Pediatr Adolesc Med. 1998;152:471-479, The reference standard used by the the World Health Organization and the National Center for Health Statistics needs to be updated for accuracy and relevance. In reviewing data from the Centers for Disease Control and Prevention Pediatric Nutrition Surveillance System, it was found that height and weight distributions have changed, especially at age 24 months, where the old standards are disjoined. The new reference data also is an improvement regarding growth for infants.

The double burden of malnutrition (DBM), defined as the simultaneous manifestation of both undernutrition and overweight and obesity, affects most low-income and middle-income countries (LMICs). This Series paper describes the dynamics of the DBM in LMICs and how it differs by socioeconomic level. This Series paper shows that the DBM has increased in the poorest LMICs, mainly due to overweight and obesity increases. Indonesia is the largest country with a severe DBM, but many other Asian and sub-Saharan African countries also face this problem. We also discuss that overweight increases are mainly due to very rapid changes in the food system, particularly the availability of cheap ultra-processed food and beverages in LMICs, and major reductions in physical activity at work, transportation, home, and even leisure due to introductions of activity-saving technologies. Understanding that the lowest income LMICs face severe levels of the DBM and that the major direct cause is rapid increases in overweight allows identifying selected crucial drivers and possible options for addressing the DBM at all levels.

Objective: To describe the prevalence of and risk factors associated with regular water supplementation of neonates. Design: Evaluation of data from the Food and Drug Administration's Infant Feeding Practices Study, a panel study of US women of fairly high socioeconomic status who were followed up from late pregnancy through their infants' first year of life. The sample was drawn from a nationally distributed consumer mail panel. Each mother was asked whether she gave her neonate water at least 3 times per week. Participants: A total of 1677 mothers of infants who were neonates in April through November 1993. Main Outcome Measures: Percentages of mothers who gave their neonates water at least 3 times a week, considering infant feeding status, mother's education, and family income. Results: About one fourth (24.7%) of the mothers reported giving their neonates water at least 3 times per week. Stratification by feeding practices and socioeconomic factors revealed that 41.6% of mothers who formula-fed their neonates, 47.4% of mothers with less than a high school education, and 35.4% of mothers with an annual family income less than $22 500 gave their neonates water at least 3 times per week. Conclusions: Water supplementation of neonates was a prevalent practice in this cohort of women. Feeding practices, maternal education, and family income were all significant risk factors associated with this behavior. Arch Pediatr Adolesc Med. 1997;151:830-832, Many mothers give water to their new babies, despite recommendations against it. Infants, particularly in the first month of life, get sufficient water from formula or breast milk, and additional water can be dangerous. Researchers reviewed surveys of 1,677 mothers of neonates. About 25% of women gave their babies water at least three times per week. Mothers who fed formula, those with less than a high school education, and those from low-income families were more likely to give supplemental water.

Abstract Because social and cultural norms are associated with women's breastfeeding behaviors, it is important to understand public opinions toward breastfeeding in the United States. Using data from the Healthstyles [...]

BACKGROUND: Hemochromatosis reportedly affects 3 to 8 persons per 1,000 and is associated with an elevated risk of morbidity and mortality. We sought to ascertain its prevalence in a community and to assess the association between phenotype and genotype. METHODS: All health maintenance organization employees were invited to participate in hemochromatosis screening using a repeated elevation of the transferrin saturation test as the case definition ([is greater than or equal to] 50% in women and [is greater than or equal to] 60% in men with no other cause). Iron overload from hemochromatosis was defined as serum ferritin concentration [is greater than or equal to] 95th percentile and mobilizable iron [is greater than or equal to] 99th percentile for age and sex, or hepatic iron index [is greater than or equal to] 1.9. The HFE gene was analyzed for mutations. RESULTS: Participation among employees was 28% (1,653 of 6,000); 83% were women. The prevalence of hemochromatosis was 8 per 1,000 (13 of 1,653), and the prevalence of iron overload from hemochromatosis was 4 per 1,000 (5 of 1,653). Compared with those who had no HFE mutation, the relative risk (RR) for hemochromatosis was greatest for C282Y homozygotes (RR = 147), compound heterozygotes (RR = 19), and H63D homozygotes (RR = 9). Overall, 38% of participants had at least one HFE mutation. Screening based on an initial elevated transferrin saturation test had the best sensitivity, whereas DNA testing offered the best specificity and predictive value positive for iron overload disease. CONCLUSIONS: In this population, we found a greater than expected prevalence of hemochromatosis and demonstrated a clear association with the HFE genotype. Promotion of screening is complicated by controversies in case definition and the large number of persons who will be detected before they have clinically significant iron loading, in whom the risk of clinical disease is unknown. Larger screening studies in more diverse populations are necessary to characterize the burden of disease and to follow those at risk (based on HFE or iron status measures) to establish the natural history of hemochromatosis. Am J Med. 1999;107:30-37. [C] 1999 by Excerpta Medica, Inc.

ABSTRACTCare immediately following birth affects breastfeeding outcomes. This analysis compared improvement in maternity care practices from 2011 to 2013 among hospitals participating in a quality improvement collaborative, Best Fed Beginnings (BFB), to hospitals that applied but were not selected (non–Best Fed Beginnings [non-BFB]), and other hospitals, using Centers of Disease Control and Prevention’s Maternity Practices in Infant Nutrition and Care (mPINC) survey data to calculate total and subscores for 7 care domains. Analysis of covariance compared change in scores from 2011 to 2013 among BFB, non-BFB, and other hospitals. BFB hospitals had twice the increase in mPINC score compared to non-BFB and a 3-fold increase compared to other hospitals. Learning collaborative participation may have accelerated progress in hospitals implementing breastfeeding-supportive maternity care.

OBJECTIVE To better understand the mechanisms behind breastfeeding and childhood obesity, we assessed the association of weight gain with the mode of milk delivery aside from the type of milk given to infants. DESIGN A longitudinal study of infants followed up from birth to age 1 year. Multilevel analyses were conducted to estimate infant weight gain by type of milk and feeding mode. SETTING Pregnant women were recruited from a consumer mail panel throughout the United States between May 2005 and June 2007. PARTICIPANTS One thousand eight hundred ninety nine infants with at least 3 weight measurements reported during the first year. MAIN EXPOSURES Six mutually exclusive feeding categories and proportions of milk feedings given as breastmilk or by bottle. MAIN OUTCOME MEASURES Weight measurements reported on 3-, 5-, 7-, and 12-month surveys. RESULTS Compared with infants fed at the breast, infants fed only by bottle gained 71 or 89 g more per month when fed nonhuman milk only (P &lt; .001) or human milk only (P = .02), respectively. Weight gain was negatively associated with proportion of breastmilk feedings, but it was positively associated with proportion of bottle-feedings among those who received mostly breastmilk. Among infants fed only breastmilk, monthly weight gain increased from 729 g when few feedings were by bottle to 780 g when most feedings were by bottle. CONCLUSIONS Infant weight gain might be associated not only with type of milk consumed but also with mode of milk delivery. Regardless of milk type in the bottle, bottle-feeding might be distinct from feeding at the breast in its effect on infants' weight gain.

ABSTRACTIntroduction:The Women, Infants, and Children (WIC) branch of the Hawaii Department of Health encourages and assists mothers in breastfeeding. A study was done to determine whether an electric breast pump (vs. a manual pump) would increase breastfeeding duration in those returning to work or school full-time.Materials and Methods:During 20022003, a randomized trial was conducted among 280 women, with the duration of breastfeeding analyzed in 229 of these women. Descriptive analyses and a multivariate logistic regression analysis assessed factors associated with breastfeeding at 6 months. Unadjusted and adjusted survival analyses were performed to estimate the duration of breastfeeding.Results:In all, 76.8 of women using the manual breast pump and 72.3 of those using the electric breast pump breastfed for at least 6 months. This difference did not reach statistical significance. In the survival analysis adjusted for pump assignment, maternal age, race/ethnicity, marital status, and parity, women with at least some college education breastfed for a 38 shorter time than women with a high school or lower education.Conclusions:Our findings suggest that the manual breast pump may work as well as the electric breast pump when breastfeeding is encouraged and supported among women returning to work or school full-time. Particular attention should be given to examining reasons why women with greater education breastfed for a shorter duration. Further research is needed to validate these results to better inform breastfeeding women returning to work or school.

Attempts to understand determinants of anemia and iron deficiency have led researchers to examine the role of Helicobacter pyloriinfection. The current study assessed determinants of anemia and iron deficiency, including H. pylori, in Alaska Native children.

PurposeTo determine the prevalence of alcohol consumption among breastfeeding and non-breastfeeding women at 3 months postpartum.MethodsWe analyzed the most recent data available, which were from the 1993–1994 Food and Drug Administration Infant Feeding Practices Study I, a longitudinal panel study of infant–mother pairs. Self-reported data on alcohol consumption were analyzed for 772 breastfeeding women and 776 non-breastfeeding women age ≥14 years.ResultsAt 3 months postpartum, 36 of breastfeeding women and 40 of non-breastfeeding women consumed alcohol (p 0.09). In multinomial regression models adjusted for age, race, education, income, marital status, region, smoking, and alcohol consumption before and during pregnancy, breastfeeding women were significantly less likely than non-breastfeeding women to consume two drinks per week (p< 0.01), or equal to or more than three drinks per week (p< 0.01), but equally likely to consume one drink (p 0.23).ConclusionsA substantial percentage of breastfeeding women consumed alcohol. Their infants may or may not have been exposed, as some women may have used alcohol avoidance strategies. Nationally representative data are needed on alcohol consumption and infant feeding practices among breastfeeding women.

Purpose: Examine the penetrance (defined by high transferrin saturation [TS]) of C282Y and H63D in the U.S. population.Methods: 5171 participants from the Third National Health and Nutrition Examination Survey, 1992 to 1994.Results: 77.1% (95% confidence interval [CI], 2.3, 95.1) of men and 51.9% (95% CI, 0, 84.2) of women with C282Y homozygosity had high TS. The associations of H63D homozygosity with high TS were stronger in people aged 50 years or older than in younger persons. Among Mexican-Americans, simple H63D heterozygosity was associated with high TS.Conclusions: The associations between HFE genotype and high TS may vary by sex, age, and ethnic group.

Purpose: Examine the penetrance (defined by high transferrin saturation [TS]) of C282Yand H63Din the U.S. population.

To describe public perceptions on breastfeeding constraints, the authors studied the responses of 2369 US adults who participated in the Healthstyles 2000 national mail survey (response rate = 75%). Among them, 2351 answered at least 1 of the 12 breastfeeding items. Public perceptions were positive for 8 of the 12 items. Among the other 4, however, almost half of US adults (45%) agreed that a breastfeeding mother has to give up too many lifestyle habits, 31% thought that babies ought to be fed cereal or baby food by age 3 months, 31% said that 1-yearolds should not be breastfed, and 27% considered breastfeeding in public embarrassing. The results revealed more negative perceptions among non-whites, people under 30 or above 65 years, and those who had low income and less education. To promote and support breastfeeding in society as a whole, these messages need to be considered in planning and implementing breastfeeding interventions.

The Healthy People 2010objective to increase US national breastfeeding rates uses data from the Ross Laboratories Mothers Survey for monitoring. Because of scientific and political problems related to the use of these data, the Centers for Disease Control and Prevention (CDC) recently held a meeting on surveillance systems for monitoring breastfeeding behaviors in the United States. Participants identified and discussed 12 surveillance systems that collect or could collect breastfeeding data. None of the existing systems met the participants' definition of an ideal system, although each was seen as providing additional insight into breastfeeding behaviors. Key recommendations are to (1) justify the need for additional resources to build a comprehensive national system; (2) add questions on breastfeeding incidence, duration, and exclusivity to the National Immunization Survey; (3) ensure that breastfeeding questions on national surveys are consistent; and (4) encourage state use of the breastfeeding module of the CDC's Pregnancy Risk Assessment Monitoring System.

Both breastfeeding initiation and duration increased in Peru during 1977-86. Although one would have expected that the average incidence and duration of breastfeeding would have declined as a result of changes in population characteristics, the potential for an overall decline was more than overcome by changes in behavior. A net increase in initiation and duration is shown for all subgroups of interest. The largest absolute increases are documented for children who, in 1977, were the least likely to be breastfed and who were breastfed for the shortest durations.

Retrospective demographic surveys typically collect substantial information about child health. This information is often collected for all children born during a specified period. For women with several young children, the interview can become quite long. To shorten the interview, some surveys have asked child health questions only for the last child born. However, data on the last birth may be biased because last children have a younger age distribution and have longer subsequent birth intervals than does the average child. In this paper, we propose an alternative approach to collecting child health data - that child health questions be asked only for a child chosen randomly from among the respondent's children younger than age five. This alternative has the advantage of keeping the interview shorter but does not lead to biased information.

Objective:This study evaluates the effectiveness of a peer counseling program at increasing breastfeeding by participants in the Mississippi Special Supplemental Nutrition Program for Women, Infants and Children (WIC). Methods:Data from the 1989–1993 Pediatric Nutrition Surveillance System were analyzed to compare breastfeeding rates in clinics with and without peer counseling programs. A questionnaire completed by program staff to describe the program in greater detail helped identify characteristics associated with greater success. Results:The incidence of breastfeeding rose from 12.3% to 19.9% in those clinics with peer counseling programs, but only from 9.2% to 10.7% in clinics without a program. Clinics that started a program earlier showed greater changes in breastfeeding incidence. However, the presence of lactation specialists or consultants in the clinic appeared to be more important than the presence of less-trained peer counselors. Peer counselors who spent more than 45 minutes per participant were more effective than those spending less time. Conclusions:The peer counseling program significantly increased the incidence of breastfeeding, particularly in clinics with lactation specialists and consultants. Success can be enhanced by ensuring that peer counselors spend a great deal of time with the participants.

Although the prevalence of smoking has decreased since 1980 among active duty military personnel, it remains higher than among the adult civilian population; among military veterans, the prevalence of smoking has not been well described. The objectives of this study were to describe patterns of cigarette smoking behaviors among United States veterans and nonveterans and to examine the association between military veteran status and cigarette smoking. We analyzed data from a cross-sectional survey from a national probability sample of the civilian, noninstitutionalized adult population (National Health Interview Survey supplements). We estimated the prevalence of ever, current, and former smoking, as well as crude and adjusted odds ratios (AORs) of each outcome measure among veterans and nonveterans, by gender. The prevalence of ever smoking was 74.2% (±0.7%) among veterans and 48.4% (±0.5%) among nonveterans; current smoking prevalence was 33.9% (±1.0%) among veterans and 27.7% (±0.5%) among nonveterans. Among those who had not initiated smoking before the age of 18 years, veterans were more likely than nonveterans to report ever smoking (AOR = 1.8 for men and 1.9 for women) and current smoking (AOR = 1.9 for both men and women). After statistical adjustment, no difference was seen in cessation behavior. We concluded that the prevalence of ever and current smoking was higher among U.S. military veterans. The association was the strongest among veterans who had not initiated smoking before the age of 18 years. These findings are consistent with the hypothesis that military service is a risk factor for cigarette smoking, and they support the military’s current prevention and cessation efforts.

AbstractThe 1984 Surgeon General's Workshop on Breastfeeding delineated six priority areas for action to protect, promote, and support breastfeeding. In this article, we examine trends in breastfeeding behaviors and recall key events and actions that shaped these behaviors over the past 25 years. We examine progress in breastfeeding support through workplaces, public education, professional education, health system changes, support services, and research. Rates of initiation of breastfeeding more than doubled from a nadir of only 26.5% in 1970 to 61.9% in 1982. Initiation fell to 51.5% in 1990, but has risen almost monotonically since then to 74.2% in 2005. Trends in breastfeeding at 6 months have paralleled initiation trends. Black-white disparities have narrowed for breastfeeding initiation but not for continuation to 6 months. Considerable progress in breastfeeding support has been seen over the past 25 years, with more employers allowing women time and space to express milk at work, more states enacting legislation to ensure that accommodations are made for employed women and protect the right to breastfeed in public, more opportunities for physician education on breastfeeding, expansion of professional lactation services, and substantial increases in the amount of research on breastfeeding. However, only 21.4% of babies are breastfed for a year, and only 11.9% exclusively breastfeed for 6 months. Only 2% of babies are born in facilities that meet international standards of care, and 74% of employers do not offer lactation rooms or accommodations for breastfeeding. Thus, in spite of considerable progress, significant gaps remain in protecting, promoting, and supporting breastfeeding.

Background Extended breastfeeding is known to benefit the health of children in developing countries and despite widespread expectations of a decline in breastfeeding In these countries, it has been demonstrated that the incidence and duration of breastfeeding are in fact increasing in many countries. Methods In this paper, trends In breastfeeding duration are examined in 15 developing countries, using data from two comparable surveys for each country, the World Fertility Survey (conducted in the late 1970s) and the Demographic and Health Survey (conducted in the late 1980s). Multivariate regression models are used to examine differentials in breast-feeding behaviour across population subgroups in these countries for each time period, and these differentials are used to determine the extent to which the observed trends are due to changes in population characterstics and to what extent behaviour has changed within population subgroups. Results Results show that changes in the characteristics of the population have almost universally pushed breast-feeding durations In a downward direction. On the other hand, trends within population subgroups have been positive in all but two of the 15 countries examined. Conclusions Changes in population characteristics can be expected to continue for most developing countries, exerting a downward pressure on breastfeeding. Policies that promote breastfeeding are needed to counter these changes, especially in the most vulnerable population subgroups.

On September 10, I had the pleasure of interviewing my friend and colleague David Lawson Clark, the legal advisor for infant and young child nutrition and expert on the International Code of Marketing of Breast-milk Substitutes at UNICEF. A native of Scotland, David began his career as an attorney with the Scottish Development Agency and subsequently worked for the United Nations Interregional Crime and Justice Research Institute in Rome, Italy. Since 1995, David has assisted more than 60 countries in drafting legislation to implement the International Code of Marketing of Breastmilk Substitutes and has been instrumental in bringing a human rights-based approach to the protection, promotion, and support of breastfeeding. He has contributed to the development of international policy guidelines in the area of HIV and infant feeding and infant feeding in emergencies, and has provided guidance on issues around international trade agreements and intellectual property rights. David has written and contributed to many articles and publications on health and nutrition policy, developed courses and training materials on the implementation of the International Code and maternity protection, and has facilitated numerous workshops on the issue. (LGS refers to Dr. Laurence Grummer-Strawn and DC are the verbatim responses of David Clark).