What is Codex, and Why is it Important?

You’re a lactation professional working with families to help solve breastfeeding/chestfeeding problems. Why should you care about something called the Codex Alimentarius Commission?

Your focus may be to help families reach their breastfeeding/chestfeeding goals. Think about some of the things that get in the way of that – poor information and advice from other health professionals and from families and friends, physiological challenges, and most certainly easy availability and heavy promotion of breastmilk substitutes. When breastmilk substitutes need to be used, you want to be sure that they meet basic standards, and that they are not labeled and marketed in such a way as to further discourage breastfeeding. That’s where international food standards come in, and the Codex Alimentarius Commission (Codex) is the global body that sets those standards.

The Food and Agriculture Organization of the United Nations (FAO) and the World Health Organization (WHO) are the parent bodies of the Codex Alimentarius Commission. The members of Codex are member countries, with 188 member countries plus the European Union. Non-governmental organizations (NGOs) can apply for observer status with Codex and participate in meetings, offering expert opinion and information. ILCA is officially recognized as an observer for Codex, and has been participating and contributing to these meetings for 16 years; Maryse Arendt has been the primary spokesperson for ILCA at these meetings, and Lisa Mandell, ILCA’s Global Advocacy Adviser, joined her this year.

Codex has more than 15 different committees that work in specific areas. The one that sets standards for infant formulas, follow up formulas, and growing up milks is the Codex Committee on Nutrition and Foods for Special Dietary Uses (CCNFSDU). This committee usually meets once a year. The committee did not meet in 2020 due to the pandemic; they met this year virtually, and ILCA was there to represent you and your concerns on this important world stage.

The work of Codex and its committees is long-term and follows a complex process. It is often influenced more by trade issues than public health, frequently involves controversies and compromises, and eventually results in food standards that are adopted by the member countries. This year’s virtual meeting of CCNFSDU occurred during the last week of November 2021, and we are excited to report on some positive decisions made at this meeting.

Three standards are currently being developed by CCNFSDU:

— a revision of the standard for follow up formula (FUF) for older infants (defined as 6-12 months)

— a standard for growing up milk (GUM), identified by Codex as drink or product for young children with added nutrients, or drink for young children (defined as 12-36 months)

— a standard for ready-to-use therapeutic foods (RUTF), which are provided to children 6-59 months with severe acute malnutrition

In the community of lactation care providers and breastfeeding supporters, many of us are frustrated just by the existence of FUFs and GUMs. These products were developed by industry as a way to get around the International Code of Marketing of Breastmilk Substitutes (the Code). Regular infant formula is adequate for the first year, with no need for a special formula for 6-12 months; and growing up milks are highly-processed food products that are not needed at all; both FUF and GUM are considered breastmilk substitutes by WHO.

However, these products exist, and as such it is important to set standards for them. One of the biggest issues for ILCA and others concerned about protecting breastfeeding was about sweet taste of the product and  whether flavourings could be included in FUF and GUM. The concern about use of sweet taste and flavourings is that these products replace the liquid part of a diet and are considered breastmilk substitutes; allowing flavourings could cause infants and children to develop a preference for sweet taste, which could have a negative impact on food choices and lifelong health; it could also cause infants and children, and their caregivers, to prefer these products and increase their use. ILCA strongly supported not allowing flavourings in either product. Country delegations have the first chance to comment on any issue, and all countries who spoke supported no flavourings in FUF. At least 13 country delegations spoke for no flavourings in either FUF or GUM, and 7 countries supported allowing flavourings for GUM, stating that it was not a breastmilk substitute (BMS), that these older children (12-36 months) are already exposed to a wide variety of other foods and flavors; and that flavourings should not impact sweet taste. The Chair concluded that no flavourings would be allowed in FUF. Much more discussion occurred, with more countries stating either their support or disagreement with allowing flavourings in GUM. Delegates from WHO and UNICEF stated clearly that these products for children aged 12-36 months are breastmilk substitutes, and are considered not necessary in the diet; they opposed allowing flavourings. The Chair suggested a compromise solution for GUM, allowing flavourings but adding a footnote that national and/or regional authorities may restrict or prohibit the use of the listed flavourings.

WIN: No flavourings allowed in FUF 

Partial WIN: Flavourings allowed in GUM, but countries may restrict or prohibit use of flavourings.

Another big concern of ILCA and others at this meeting was the definition to be used for “growing up milk,” for ages 12-36 months. The previous meeting ended with the following definition: “Drink/product for young children with added nutrients or Drink for young children means a product manufactured for use as a liquid part of the diversified diet of young children [which may contribute to the nutritional needs of young children].” In considerable discussion on whether these products should be defined as breastmilk substitutes, a compromise was to include the following footnote: “In some countries these products are regulated as breast-milk substitutes.” This was despite WHO guidance, adopted by the World Health Assembly (WHA), that all FUF and GUM should be considered breastmilk substitutes.  The text in brackets above was left to be discussed at this meeting. The arguments against including this text are that it does not need to be included; and that the World Health Assembly has agreed that these products are unnecessary and including this text suggests that these products can play an important role in the diets of young children, which they do not. Considerable discussion among countries and observers, including some objections to including “with added nutrients” in the name options, resulted in a decision to delete the bracketed text. Additional discussion over the name options led to a decision to offer four name possibilities from which countries can choose one: drink for young children with added nutrients, product for young children with added nutrients, drink for young children, or product for young children.

WIN: Definition of GUM will NOT include the phrase “which may contribute to the nutritional needs of young children”

Another important agenda item at this meeting was finalizing the preamble for Ready-to-use Therapeutic Foods (RUTF), for children aged 6-59 months suffering severe acute malnutrition (SAM). The preamble to a standard sets the stage for what the standard covers. Thanks to the suggestion of a representative from UNICEF, and with the support of country delegations, ILCA, and other observers, it was agreed to add to the preamble the following clause, identifying that interventions for SAM should occur: “within an appropriately designed programme that promotes continuation of breastfeeding, appropriate transition to nutritious family food and psycho-social support for recovery.” Additionally, the adopted preamble concludes that use of RUTF “does not preclude other dietary options including the use of locally based foods. RUTF is not for general retail sale.”

WIN: Preamble for RUTF will stress the importance of programmes to support continued breastfeeding. Additionally, RUTF is not for general retail sale and thus cannot be promoted.

The CCNFSDU meeting covered many other topics (composition of FUF and GUM, nutrient reference values for children, and much more). The next meeting of CCNFSDU (tentatively planned for early 2023) will include finalizing the preambles for FUF and GUM, which we hope will clearly reference the Code. This is important work that ultimately serves to protect consumers. For our population of families with infants and young children, the contributions of ILCA representatives, along with the important voices of other observer organizations and many country delegations, will help to protect and support breastfeeding, and infant and child health.

For more information on Codex and other Codex committees, see:

Arendt, M. (2021). Advocacy at Work During the Codex Committee on Food Labelling Meeting. Journal of Human Lactation, 089033442110570. https://doi.org/10.1177/08903344211057083

Arendt, M. (2018). Codex Alimentarius: What Has It To Do With Me? Journal of Human Lactation, 089033441879465. https://doi.org/10.1177/0890334418794658

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