Association of Food and Nonalcoholic Beverage Marketing With Children and Adolescents' Eating Behaviors and Health: A Systematic Review and Meta-analysis

Contemporary digital marketing techniques used in unhealthy food campaigns targeting young people

The digital marketing of unhealthy foods and non-alcoholic beverages has a detrimental impact on children's eating behaviours, leading to adverse diet-related health outcomes. To inform the development of evidence-based strategies to protect children online, this study aimed to describe contemporary digital marketing techniques and industry reported impacts from unhealthy food and beverage marketing campaigns aimed at young people aged 3-17. We conducted a qualitative conceptual content analysis of 111 industry reports detailing the nature and impact of unhealthy food and beverage marketing campaigns from around the world that directly or indirectly targeted children through digital channels. We categorised and narratively describe how food and beverage companies are using digital marketing techniques, across four conceptual groups: (i) leveraging data and technology to optimise marketing, (ii) profiling and segmenting audiences, (iii) targeting and personalisation, and (iv) generating participation and engagement. Industry reported impacts on young people as a result of campaigns included i) increased exposure to, and engagement with, unhealthy food marketing, ii) purchases and consumption of unhealthy foods and beverages iii) formation of emotional brand connections and enhanced future marketing through data collection. Our findings support and extend existing literature revealing how multinational food and beverage companies are using advanced digital marketing techniques, including artificial intelligence and new technologies, to shape children's food behaviours and influence their diets worldwide. Policy actions are needed to protect children from the sophisticated digital marketing techniques used by the food and beverage industry.

What Are the Roots of the Nation's Poor Health and Widening Health Inequalities? Rethinking Economic Growth for a Fairer and Healthier Future

Health inequalities are differences in health between groups in society. Despite them being preventable they persist on a grand scale. At the beginning of 2024, the Institute of Health Equity revealed in their report titled: Health Inequalities, Lives Cut Short, that health inequalities caused 1 million early deaths in England over the past decade. While the number of studies on the prevalence of health inequalities in the UK has burgeoned, limited emphasis has been given to exploring the factors contributing to these (widening) health inequalities. In this commentary article I will describe how the Government's relentless pursuit of economic growth and their failure to implement the necessary regulatory policies to mitigate against the insecurity and health effects neoliberal free market capitalism (referred to as capitalism herein) causes in pursuit of innovation, productivity and growth (economic dynamism) is one key driver underpinning this social injustice. I contend that if the priority really is to tackle health inequalities and ensure health for all then there is an imperative need to move beyond regulation alone to mitigate the worst effects of capitalist production; the goal of the economy has to change to fully restore the balance between economic growth and public health.

How Children's Experiences and Perceptions of Their School Food Environment Influence Their Food-Related Decisions In-School in Urban Ghana

School food environments play an important role in shaping children's food-related decisions, including where and what foods to acquire and consume on a school day. In Ghana, evidence indicates that food environments in and around schools may limit healthy food acquisition and consumption behaviour. This study aimed to understand how children's experiences and perceptions of their school food environment influence food acquisition and consumption decisions. Data from 18 focus group discussions with children (n = 157; aged 10-17 years) attending Public Basic Schools in the Greater Accra Region of Ghana were analysed, guided by the African urban food environment framework for creating healthy nutrition policies and interventions. Children's food decisions in school were found to be influenced by experiences and perceptions at multiple food environment levels: macro, physical and social levels in combination with individual-level factors. At the macro level, exposure to food advertisements on television emerged as an influence on food-related decisions. At the physical level, experiences and perceptions of environmental sanitation, food vendor hygiene practices, affordability, and food quality were consistently reported to influence decisions. Social-level experiences including influence from friends/peers, family (mostly caregivers/parents) and social qualities of food vendors also shaped food-related decisions. Caregiver/parental dietary advice was often linked to healthier acquisition and consumption decisions by children in school. The findings highlight the need for actions that work in synergy across multiple levels of the school food environment to create conditions that support children to acquire and consume healthier diets.

The marketing of commercial foods for infants and toddlers in Australian supermarket catalogues

Commercial foods for infants and young children are prominent on supermarket shelves in Australia, with parents commonly believing they are a healthy choice, yet evidence shows many commercial foods are nutrient-poor. The aim of this study was to examine the nature and extent of promotions for commercial infant and toddler foods in Australian supermarket catalogues. Digital catalogues from four leading Australian supermarket chains were collected and content analysed over 12 weeks from August to October 2023 (n = 60 catalogues with 2206 pages). Using a coding guide, one researcher coded all advertised products to identify commercial infant and toddler foods and recorded the labelled age range, product category, packaging type, and associated promotions for each product. A total of 121 commercial infant and toddler food products were identified across 49 catalogue pages (3.5% of all pages examined). The most advertised categories of commercial infant and toddler foods were fruit purees (40%), snacks (27%), and confectionary (12%); 74% of advertised commercial foods were labelled for infants under 12 months; 26% were labelled for toddlers 12-36 months of age; and 50% of products were packaged in pouches. Techniques used to promote commercial infant and toddler foods included price (95%) and health-related messaging (20%). Foods promoted for infants and young children in Australian supermarket catalogues are misaligned with the recommendations within Australia's Infant Feeding Guidelines. There is an urgent need to reduce the promotion of packaged commercial infant and toddler foods in supermarket catalogues to better support and promote healthy diets for young children.

The impact of brand advertising on children's food preferences and behavioural intentions: an experimental study

OBJECTIVE

Despite strong evidence linking exposure to food and beverage marketing with poor diet quality and negative health impacts in children, the effect of brand marketing (i.e. marketing featuring branded content, but no food products) is uncertain. This study evaluated the impact of brand marketing v. product-based advertising on children's food preferences and behavioural intentions.

DESIGN

An online survey was administered to participants randomised to one of four ad conditions; familiar product (i.e. from popular Canadian brands); familiar brand (i.e. no food product, Canadian brand); unfamiliar product (i.e. foreign products); and unfamiliar brand ad (i.e. foreign brand). Participants viewed three ads displaying features of that condition and answered three 5-point Likert-scale questions related to the study outcomes: food preference, purchase intent and pester power. The average of all outcomes determined the total impact. An ANOVA with Bonferroni post hoc tests evaluated differences in impact between conditions.

SETTING

Canada participants: n 1341 Canadian children (9-12 years).

RESULTS

Familiar product ads had a higher total impact on children (mean score 3·57) compared with familiar brand ads (2·88), unfamiliar brand ads (3·24) or unfamiliar product ads (3·09; P < 0·001 for all pairwise comparisons). Total impact was lower for familiar brand ads than for unfamiliar brand ads or unfamiliar product ads (P < 0·001 for all pairwise comparisons). The impact of an unfamiliar brand and product did not differ (P = 0·53).

CONCLUSIONS

Results suggest that familiar product ads seem to have a stronger impact on children's food preferences and behavioural intentions than familiar brand ads, unfamiliar brand ads and unfamiliar product ads.

Immersive Virtual Reality Dietitian Improves Portion Control Self-Efficacy and Portion Size Estimation Accuracy

OBJECTIVE

To compare the impact of a nutrition education program delivered in person and within an immersive virtual reality (iVR) nutrition education experience application called immersive virtual alimentation and nutrition (IVAN). To compare IVAN with its updated version, IVAN 2, and develop a portion size estimation task for use within iVR.

DESIGN

Two randomized controlled experiments.

SETTING

Laboratory.

PARTICIPANTS

Ninety-two adults (aged 29 ± 14) years) enrolled. In experiment 1, 25 adults were randomized to in-person and 20 to the IVAN condition. In experiment 2, 25 adults were randomized to IVAN 1, and 22 adults were randomized to IVAN 2 conditions.

INTERVENTION

Nutrition education materials delivered in person by IVAN 1 and IVAN 2.

MAIN OUTCOME MEASURES

Changes in portion control self-efficacy and portion-size overestimation.

ANALYSIS

Linear mixed-effects models and t tests.

RESULTS

In experiment 1, the portion size self-efficacy improved for both conditions (B = 2.40; SE = 0.61; P <0.001) with no difference between conditions. In experiment 2, the portion size self-efficacy improved for both conditions (B = 1.23; SE = 0.55; P = 0.03), as did the portion-size overestimation value (B = -21.51; SE = 4.97; P <0.001), with no difference between conditions.

CONCLUSIONS AND IMPLICATIONS

Portion-size education material shows similar efficacy delivered through IVAN and in person. The efficacy of IVAN 2 was higher than IVAN 1. Portion size estimation tasks within iVR may be useful for the assessment of participants' ability to estimate portion sizes.

What influences Indian primary school children's food behaviors? - Perceptions of children, mothers and teachers

BACKGROUND

Development of healthy food behaviors in childhood is significant for optimum growth and development of children as well as future health. However, many Indian children display unhealthy dietary habits including poor intakes of fruits and vegetables and excessive consumption of calorie-dense, nutrient-poor foods and sugar-sweetened beverages. Therefore, the factors that influence their daily diet need to be explored for developing future interventions and policies. In this light, the present inquiry was designed to examine the various influences on the food behaviors of Indian primary school children.

METHODS

Informed by the socio-ecological framework, this study used an exploratory qualitative research approach to conduct semi-structured interviews with 22 primary school children, 19 mothers, and 18 teachers residing in Varanasi, India. For children, the interviews were preceded by a drawing session where the interviewees were asked to draw their preferred and non-preferred food and beverage items. Interviews were carried out in English or Hindi and digitally recorded. Interviews were conducted until data saturation was achieved. Digital recordings were transcribed verbatim and translated to English (where necessary) for the purpose of thematic analysis. The transcripts were coded both deductively and inductively using the NVivo software program.

RESULTS

Individual level influences included taste and nutritional knowledge. At the interpersonal level, the family food environment and peers emerged as key determinants. The physical environment also played a pivotal role in determining food behaviors, with the school food environment and food availability in the marketplace being significant. Lastly, at the societal level, television and internet advertisements were frequently cited as important determinants of children's food behavior.

CONCLUSIONS

The collective insights from the three stakeholder groups have the potential to inform public health nutrition policies and interventions targeting the different socio-ecological factors to encourage healthy eating in Indian primary school children.

Rewriting the Narrative: Advancing Justice and Equity in the U.S. Food System

The concept of 'food justice' recognizes the systemic injustices embedded in the U.S. food system and the urgent need for transformative policies to ensure equitable access to affordable, nutritious, and culturally relevant food. Limited access to these foods drives food insecurity and increases the prevalence of diet-related diseases in low-income and minority communities. Dominant narratives that individualize hunger and food insecurity often blame the individual and overlook the underlying structural factors that sustain these issues. These narratives have considerable influence. They shape public opinion and can also guide policy decisions. This commentary explores the goals of the food justice movement in the U.S., describes how the food and racial justice movements intersect, and examines the role of commercial marketing and public policy in shaping the food justice discourse. We also reflect on the efforts that should be made to reframe these dominant narratives and facilitate meaningful change in the food environment.

Fatty infiltration predicts retear and functional impairment following rotator cuff repair: systematic review and meta-analysis

INTRODUCTION

Fatty infiltration (FI) in rotator cuff (RC) is detected in many patients with complete RC tears. But there remains controversy on the prognostic effects of FI in RC tears, especially for patients with moderate and severe FI. This study aims to systematically review the relationship between the severity of preoperative FI and risk of retear, and the association between preoperative FI and functional outcomes.

MATERIALS AND METHODS

We searched PubMed, Embase and Web of Science for studies on association between preoperative FI and retear or functional outcomes following complete RC repair. FI was assessed using Goutallier classification and global fatty degeneration index (GFDI). Meta-analysis was performed to determine odds ratios (ORs) for retear among patients with mild (grade 0-1), moderate (grade 2) and severe (grade 3-4) FI in RC tears. We delivered qualitative synthesis on association between FI and functional outcomes.

RESULTS

Eighteen studies with 1997 patients were included in the systematic review and ten studies were included in the meta-analysis. Patients with GFDI ≤ 1 had lower retear odds (OR = 0.08, 95%CI 0.02-0.29, p < 0.01). Moderate FI in supraspinatus muscle (SSP) was associated with higher retear odds compared with mild FI (OR = 1.95, 95%CI 1.09-3.48, p = 0.02) and severe FI was associated with more retear compared with moderate FI (OR = 3.37, 95%CI 1.08-10.53, p = 0.04). Similar effects were observed in FI in infraspinatus muscle (ISP) (moderate vs. mild: OR = 2.22, 95%CI 1.07-4.62, p = 0.03; severe vs. moderate: OR = 2.06, 95%CI 1.02-4.16, p = 0.04). The severity of FI in subscapularis muscle and teres minor muscle was not observed to be associated with the retear rates. In functional outcomes, lower grade of FI in GFDI was associated with better prognosis. FI in single muscles failed to present prognostic effects on functional outcomes.

CONCLUSIONS

The severity of FI in SSP and ISP showed effects on retear following complete RC repair. The GFDI was a compatible predictor for risk of anatomic and functional impairment.

Advertisements of ultra-processed products outside food outlets: field evidence from Montevideo, Uruguay

OBJECTIVES

To evaluate the prevalence of advertisements for ultra-processed products outside food outlets in Montevideo (Uruguay) and explore the patterns of these advertisements across areas with different socio-economic statuses (SES).

DESIGN

Cross-sectional field survey of advertisements of ultra-processed products outside food outlets. The percentage of outlets featuring any type of advertisement of ultra-processed products on the exterior part of the outlets was calculated, at the aggregate level and separately by type of outlet and type of product. Comparisons were made considering the SES of the tract where outlets were located.

SETTING

106 census tracts in Montevideo, differing in geographical location and SES.

PARTICIPANTS

Outlets selling foods and beverages, located within the selected census tracts.

RESULTS

30·7 % of the 1217 food outlets identified in the field survey featured some type of exterior advertisement of ultra-processed products. Sweetened beverages (specifically soda) were the most frequently advertised ultra-processed product category, followed by ice cream. After adjusting for the type of outlet, medium SES tracts exhibited the highest prevalence of ultra-processed product advertisements outside food outlets (36·0 %). Differences in the prevalence of advertisements of specific categories with SES were also found, which may reflect variations in the types and characteristics of food outlets.

CONCLUSIONS

Results from this work suggest the frequent presence of exterior advertisements of ultra-processed products and highlight the need to develop effective policies to reduce their use as part of a comprehensive set of strategies to discourage the consumption of ultra-processed products.

A scoping review of children's and parents' attitudes to and awareness of digital food marketing

Digital food marketing (DFM) of unhealthy foods and beverages (high in saturated fats, sugar and salt) to children and young people influences brand recall, recognition, purchase intentions and attitudes, and increases consumption of unhealthy foods and beverages. Understanding children's and parents' awareness of, and attitudes toward, such marketing is crucial for developing health-promoting advocacy and policy solutions. This registered systematic scoping review synthesized literature on children's, young people's and parents' attitudes and awareness of DFM. A structured search of Medline, PsycInfo, Academic Search Complete (Ebscohost), Scopus and CINAHL was conducted. Inclusion criteria were peer-reviewed studies focused on children (<18 years), young people (<24 years) or parents, published after 2000, examining attitudes or awareness of online marketing of food or non-alcoholic beverages. Data were extracted and charted in Excel. Forty studies were included for synthesis. Studies of children/young people (n = 31) show varying levels of awareness regarding DFM on social media and other digital media. While some understand social media marketing tactics, others struggle to recognize ads. Preferences lean towards influencer marketing and 'native' advertising styles. There is limited evidence on parents' views (n = 9 studies), but these suggest low parental awareness of digital marketing tactics targeting children, and unclear opinions on regulation. Overall, the findings suggest a need for a versatile, trans-disciplinary research and advocacy agenda to capture the complex and rapidly evolving digital marketing landscape, enhance critical digital literacies (including power inequalities) for both children and parents, increase knowledge-sharing and advocacy, and develop regulatory policies.

Unhealthy food advertising on social media: policy lessons from the Australian Ad Observatory

The World Health Organization and public health experts are calling for urgent restrictions on the online marketing of unhealthy food. The harmful effects of exposure to advertising for 'unhealthy foods', including discretionary foods high in fat, salt or sugar, particularly for children, has prompted a proposed policy action in Australia to prohibit all online unhealthy food marketing. We used a novel data donation infrastructure, the Australian Ad Observatory, to create a dataset of 1703 ads promoting top-selling unhealthy food brands that had been placed by 141 different advertisers on 367 individual Australians' Facebook feeds. We used this dataset to identify any targeting of unhealthy food ads towards young people (18-24), investigate harmful marketing practices by four of the top advertisers (KFC, McDonald's, Cadbury and 7-Eleven); and demonstrate how online advertising may be made observable and accountable. We find indications that young people (18-24), especially young men, are being targeted by unhealthy food, especially fast food, ads. We also find that unhealthy food brands use potentially harmful marketing strategies to appeal to children, young people, parents and the broader community, including cartoon characters, and associations with popular sports and greenwashing. The policy implications of our findings are that a broad prohibition on all forms of unhealthy food advertising online is desirable to protect not only children but also young people and the broader community. Such a prohibition will go one step towards addressing the commercial and digital determinants of health caused by harmful industries' use of online automated advertising.

Does outdoor advertising correlate with retail food purchases made by adolescents? A cross-sectional study in Canada

Food marketing plays a substantial role in shaping adolescent diets, having wide-ranging ramifications for health behaviours and outcomes throughout the life course. Yet, there remains a dearth of research about how outdoor advertising as a specific channel of food marketing affects purchasing behaviours. We examine self-reported purchases made at retail food outlets by adolescents as it relates to the availability of outdoor food and beverage advertising around each participant's home, school, and along the journey to and from school. We also consider the impacts of sociodemographics and consumption attitudes on purchasing, as compared to the geographic availability of outdoor advertising. Data are drawn from a survey completed by 545 adolescents in 2018 across four secondary schools in the Middlesex-London region of Ontario, Canada. The availability of outdoor advertising in the home and school environment is marginally correlated with self-reported purchases made at fast food, table-based, grocery, and variety retail outlets. However, consumption attitudes, cultural background, and gender are significantly correlated with purchases, with substantially larger effect sizes. The overall results were consistent between estimating the availability of outdoor advertising in the immediate area surrounding the home and along the journey to and from school. There is considerable health promotion policy interest in regulating outdoor advertising around child-serving locations. However, scarce health promotion resources would be better allocated to educational programming that addresses the substantial role of consumption attitudes in affecting adolescent purchasing behaviour, as compared to the considerably weaker impact of outdoor food advertising observed in our analysis.

Children's Cereal Purchases by U.S. Households: Associations With Child Versus Adult TV Ad Exposure

INTRODUCTION

Research is needed to demonstrate the impact of child-directed advertising on household purchases of nutrient-poor children's foods to support mandatory government regulations. This study examines the relationship between total TV advertising to children versus adults and U.S. household purchases of high-sugar children's cereals. Posthoc analyses examine potential differential marginal effects of advertising on households experiencing health disparities.

METHODS

Longitudinal NielsenIQ U.S. Consumer Panel Data (2009-2017) provided monthly volume (oz) of ready-to-eat cereal purchases by households with children (<12 years) (N=76,926). Nielsen gross ratings point data measured monthly TV advertising to children (6-11 years) and adults (18-49 years) (2008-2017). A 2-part Cragg hurdle model assessed associations between child versus adult advertising for children's cereal brands (n=9) and subsequent household cereal purchases, including differences by household sociodemographic characteristics. Data were collected in 2021 and analyzed in 2023.

RESULTS

Advertising to children, but not adults, was positively related to household purchases of children's cereals (p<0.01) across all sample households. Lower price (p<0.05) and greater household size (p<0.01) also predicted higher purchases. Marginal effects of advertising to children were higher for Black versus non-Black households (p<0.01), and positively related to purchases by middle/high-income (p<0.01) but not low-income households. Advertising to adults only predicted greater children's cereal purchases by low-income households (p<0.01).

CONCLUSIONS

Advertising children's cereals directly to children may increase household purchases and children's consumption of these high-sugar products. Child-directed advertising may also disproportionately influence purchases by Black households. This study supports further restrictions on advertising of nutrient-poor foods directly to children.

How TikTok Influencers Disclose Food and Beverage Brand Partnerships: Descriptive Study

BACKGROUND

Food and beverage marketing is an important influence on the health and diets of adolescents. Food and beverage companies spend billions of dollars annually on advertisements to promote their products and are increasingly focusing on social media influencers. Influencer product endorsements blur the line between entertainment and marketing.

OBJECTIVE

This study aimed to quantify how often TikTok influencers promote products from food and beverage brands and document the range of ways they disclose brand relationships in their content.

METHODS

We collected up to 100 videos posted on or before July 1, 2022, from each of the top 100 influencers on TikTok in the United States and recorded information about the influencer (eg, number of followers) and video (eg, number of views and likes). For each video that contained food or beverage products, we identified the main product featured. A team of research assistants then coded each video for how the product was featured (ie, in the video, audio, or caption) and, for branded products, whether the video was accompanied by any disclosures of brand relationships. Average pairwise percentage agreement among coders was 92%, and average pairwise Cohen κ was 0.82.

RESULTS

Among the 8871 videos from 97 influencers that made up the final analytical sample, we identified 1360 videos (15.3%) that featured at least one food or beverage product. These 1360 videos were viewed >9 million times and received >1 million likes each. Nearly half (n=648, 47.6%) of the videos featured a branded product. Most videos featuring a branded product did not contain a brand relationship disclosure (n=449, 69.3%). Among videos that disclosed a brand relationship, influencers used 10 different types of disclosures. Tagging a brand in the video's caption was the most common disclosure method (n=182, 28.1%). Six types of caption hashtags were used to disclose brand relationships, including #[brandname] (n=63, 9.7%) and #ad (n=30, 4.6%). Only 1 video (0.2%) made use of TikTok's official disclosure label and only 1 video (0.2%) verbally mentioned a contractual agreement with a brand.

CONCLUSIONS

Among the food and beverage videos with disclosures we identified, the most frequently used mechanism-tagging the brand-did not clearly differentiate between sponsored content and the influencer trying to attract a brand or followers who may like that brand. Social media users, particularly adolescents, need clearer, more robust disclosures from influencers to protect against the undue influence of food marketing. These findings may also inform calls for the Children's Food and Beverage Advertising Initiative-the largest self-regulatory pledge to reduce unhealthy food marketing-to include older adolescents, who are heavily targeted by food and beverage companies on social media.

A novel Adolescent Health Behavior Checklist

Purpose

Adolescents are experiencing rising rates of obesity, insufficient exercise, and sleep disorders. To provide a scientific basis for policymakers to develop targeted and evidence-based health behavior education and policies, this study employed structural equation modeling to design the Adolescent Health Behavior Checklist (AHBC).

Methods

We designed a draft 6-dimensional AHBC, which includes the dimensions of exercise, diet, personal responsibility, sleep, interpersonal relationships, and stress management. Each item is rated on a 5-point Likert scale, with higher scores indicating healthier behavior. Through exploratory factor analysis (EFA) and confirmatory factor analysis (CFA), we optimized the construct validity of the AHBC.

Results

The optimal factor structure was first determined using EFA with 177 middle school students participating in the process. EFA suggested a hierarchical, 6-factor AHBC with good internal consistency (global Cronbach's alpha = 0.96). Using an independent sample of 349 middle school students, CFA confirmed the construct validity of the AHBC. The final model demonstrated a good fit: SRMR = 0.058, CFI = 0.990. Five out of six latent variables had factor loadings higher than 0.7, and 81% of the item-level factor loadings exceeded 0.7. Additionally, all latent variables had McDonald's omega values higher than 0.7, indicating acceptable convergent validity. Finally, factor correlations showed that the AHBC has good discriminant validity.

Conclusions

The AHBC is a 31-item checklist that assesses adolescents' all-around health behaviors, using a score of four as the benchmark value. The shortcomings of the current checklist are discussed, along with future theoretical and practical directions for improvement.

The impact of the social media industry as a commercial determinant of health on the digital food environment for children and adolescents: a scoping review

INTRODUCTION

There is emerging evidence that the social media industry contributes to adverse health outcomes by shaping the digital food environment for children and adolescents (aged 0-18). The aim of this scoping review was to determine the extent of research on how the social media industry, including the broader online landscape, influences the digital food environment and affects child and adolescent health.

METHODS

A scoping review was conducted in the electronic databases of PubMed, Scopus and PsycINFO, along with forward and reverse citation searching for peer-reviewed articles published in English between 2000 and May 2023. A qualitative descriptive synthesis of the included articles was performed to identify trends, themes and research gaps in the current literature.

RESULTS

The review identified 36 articles for inclusion. Most research was conducted in high-income countries and publications have increased since 2021. The review found most children and adolescents are exposed to food advertisements on social media and most advertised food is ultra-processed. Heightened by a lack of social media advertising awareness, digital food marketing influences children and youth's consumption and food behaviour. Voluntary children's food marketing regulations are ineffective for the online environment. Countering unhealthy food marketing will require media literacy and government regulation.

CONCLUSION

The social media industry may act as a commercial determinant of health to shape the digital food environment as an extension of the obesogenic environment. Further research should explore approaches to monitor unhealthy food marketing practices and understand social media's role in the digital food environment.

The relationship between perceptions toward advertising and consumption of energy-dense nutrient-poor foods among adults in the United States: results from a national survey

Introduction

Much of the research on the effects of food advertising has been focused on children and adolescents; however, adults may also be influenced. Prior research has also shown that exposure to food advertisements have impacted the consumption behaviors of adults. The purpose of this study is to explore (1) the differences in perceptions toward and trust in food advertisements between racial/ethnic population subgroups; and (2) the associations between perceptions toward food advertising and the consumption of energy-dense, nutrient poor (EDNP) foods among adults using data from a national data set (n = 1,535).

Methods

Data from the National Cancer Institute's Family Life, Activity, Sun, Health, and Eating (FLASHE) survey were utilized in this secondary data analysis study. We conducted one-way ANOVAs to evaluate demographic subgroup differences within advertising trust and perceptions, and utilized bivariate and multivariable linear regression models to examine associations between (1) the perceptions toward and trust in food advertisements between racial/ethnic population subgroups; and (2) the associations between perceptions toward food advertising and the consumption of EDNP foods, while controlling for sociodemographic factors.

Results

Results show significant differences between racial/ethnic groups on advertising perceptions (F = 8.59, p < 0.0001). Planned contrasts show that there was a statistically significant and meaningful difference (p = 0.04) between Non-Hispanic Blacks (mean = 2.85) and Non-Hispanic Whites (mean = 2.52) for trust in food advertising. Regression analyses show that as positive perceptions toward food advertising increase among adults, there is an increase in daily frequency of consumption of EDNP foods and drinks (𝛽 = 0.15, p < 0.0001). This pattern was similar for trust in food advertising (𝛽 = 0.13, p < 0.0001).

Discussion

Given that previous studies have shown that ethnic minority groups, particularly Non-Hispanic Blacks, are more likely to be exposed to unhealthy food advertisements across various types of media, such as TV, billboards, and in grocery stores, it is possible that Non-Hispanic Black adults have greater trust in food advertising because of the increased environmental exposure to advertising through various channels of communication. Numerous studies have demonstrated that exposure to food advertisements is linked to consumption of the foods found in those advertisements. Our results provide some initial empirical support for the cognitive mechanisms of how exposure to food advertising may contribute to consumption. Developing advertising literacy interventions to inoculate against the cognitive impacts of food advertising may be a viable strategy to limiting consumption of EDNP foods.

Seeing is believing: How front-of-pack food imagery shapes parents' perceptions of child-oriented snack foods

Child-oriented snack foods often display front-of-pack images suggesting they are natural or wholesome, yet many of these products are ultra-processed and nutrient poor. This study investigated parent's perceptions in response to common forms of front-of-pack food imagery on child-orientated snacks. An online experiment comprising four between-subjects food image conditions (no image; food photo; food cartoon; cartoon of children gardening) and two within-subjects snack type conditions (fruit; vegetable) was conducted with N = 800 Australian adult parents/guardians of children aged 4-10 years. Participants viewed packaged snacks then rated them on visual appeal, perceived healthfulness, suitability for their child, and purchase intentions. For each outcome, 4 (between-subjects) x 2 (within-subjects) mixed ANOVAs were performed, with significant main effects explored using post-hoc pairwise t-tests with Bonferroni adjustment. The extent to which perception metrics predicted purchase intention within each condition was examined using multiple regression analyses. Participants perceived snacks displaying food photographs as healthier compared to all other conditions. When children's snacks displayed food photos, participants perceived the snack as more suitable for their child and showed stronger intentions to purchase the product than when cartoon children were displayed. Participants preferred fruit over vegetable snacks across all metrics, particularly when the picture was photorealistic. Visual appeal was the only perception metric that consistently predicted purchase intention across conditions. Findings provide clear evidence that parent's perceptions and purchase intentions towards children's snack foods are enhanced by pictures displayed on the packaging. Policy to regulate food packaging should require that foods depicted on the packaging accurately reflect product ingredients, particularly where whole foods are represented, and the actual ingredients are highly processed and no longer provide the nutrition of whole foods.

Children's digital privacy on fast-food and dine-in restaurant mobile applications

Children are targeted by unhealthy food marketing on digital media, influencing their food preferences, intakes and non-communicable disease risk. Restaurant mobile applications are powerful platforms for collecting users' data and are popular among children. This study aimed to provide insight into the privacy policies of top dine-in and fast-food mobile apps in Canada and data collected on child users. Privacy policies of the top 30 fast-food and dine-in restaurants in Canada were reviewed. A convenience sample of 11 English-speaking Canadian residents aged 9-12 years with fast-food apps on their mobile phones were recruited to use ≥1 fast-food restaurant mobile app(s). Children used the app(s) for 5-10 minutes and placed food orders. Parents submitted a Data Access Request (DAR) on their child's behalf to the food company. Descriptive analysis and a flexible deductive approach to content analysis evaluated data collected through DARs. Overall, 26 privacy policies were analyzed. The intended age of app users was indicated by 12 (46%) food companies, 10 (39%) of which specified it as ≥13 years. No company had a compulsory age verification process. Twenty-four (92%) companies disclosed the data collected on app users: 23 (89%) did not distinguish between information pertaining to children or adults, and 21 (81%) described a protocol for action if they inadvertently collected data on children. Twenty-four DARs were sent to companies; 11 (45.8%) of which were fulfilled by companies, and 4 (16.7%) resulted in the receipt of children's data. All responding food companies were found to collect sociodemographic information on child participants (e.g., name, email). Some collected other information, such as order details and available promotional offers. This study demonstrates current fast-food and dine-in restaurant privacy policies are insufficient and provides insight into data collected on children via fast-food apps. Policies must be strengthened to ensure children's privacy and protection online.

Beyond the screen: Exploring the dynamics of social media influencers, digital food marketing, and gendered influences on adolescent diets

Adolescent obesity remains a public health concern, exacerbated by unhealthy food marketing, particularly on digital platforms. Social media influencers are increasingly utilized in digital marketing, yet their impact remains understudied. This research explores the frequency of posts containing food products/brands, the most promoted food categories, the healthfulness of featured products, and the types of marketing techniques used by social media influencers popular with male and female adolescents. By analyzing these factors, the study aims to provide a deeper understanding of how social media influencer marketing might contribute to dietary choices and health outcomes among adolescents, from a gender perspective, shedding light on an important yet underexplored aspect of food marketing. A content analysis was conducted on posts made between June 1, 2021, and May 31, 2022, that were posted by the top three social media influencers popular with males and female adolescents (13-17) on Instagram, TikTok, and YouTube (N = 1373). Descriptive statistics were used to calculate frequencies for posts containing food products/brands, promoted food categories, product healthfulness, and marketing techniques. Health Canada's Nutrient Profile Model was used to classify products as either healthy or less healthy based on their content in sugar, sodium, and saturated fats. Influencers popular with males featured 1 food product/brand for every 2.5 posts, compared to 1 for every 6.1 posts for influencers popular with females. Water (27% of posts) was the primary food category for influencers popular with females, while restaurants (24% of posts) dominated for males. Influencers popular with males more commonly posted less healthy food products (89% vs 54%). Marketing techniques varied: influencers popular with females used songs or music (53% vs 26%), other influencers (26% vs 11%), appeals to fun or coolness (26% vs 13%), viral marketing (29% vs 19%), and appeals to beauty (11% vs 0%) more commonly. Influencers popular with males more commonly used calls-to-action (27% vs 6%) and price promotions (8% vs 1%). Social media influencers play a role in shaping adolescents' dietary preferences and behaviors. Understanding gender-specific dynamics is essential for developing targeted interventions, policies, and educational initiatives aimed at promoting healthier food choices among adolescents. Policy efforts should focus on regulating unhealthy food marketing, addressing gender-specific targeting, and fostering a healthy social media environment for adolescents to support healthier dietary patterns.

Latinx and White Adolescents' Preferences for Latinx-Targeted Celebrity and Noncelebrity Food Advertisements: Experimental Survey Study

BACKGROUND

Exposure to food advertisements is a major driver of childhood obesity, and food companies disproportionately target Latinx youth with their least healthy products. This study assessed the effects of food and beverage advertisements featuring Latinx celebrities versus Latinx noncelebrities on Latinx and White adolescents.

OBJECTIVE

This web-based within-subjects study aims to assess the effects of food and beverage advertisements featuring Latinx celebrities versus Latinx noncelebrities on Latinx and White adolescents' preferences for the advertisements and featured products.

METHODS

Participants (N=903) were selected from a volunteer sample of adolescents, aged 13-17 years, who self-identified as Latinx or White, had daily internet access, and could read and write in English. They participated in a web-based Qualtrics study where each participant viewed 8 advertisements for novel foods and beverages, including 4 advertisements that featured Latinx celebrities and the same 4 advertisements that featured Latinx noncelebrities (matched on all other attributes), in addition to 2 neutral advertisements (featuring bland, nontargeted products and did not feature people). Primary outcomes were participants' ratings of 4 advertisements for food and beverage brands featuring a Latinx celebrity and the same 4 advertisements featuring a Latinx noncelebrity. Multilevel linear regression models compared the effects of celebrities and differences between Latinx and White participants on attitudes (advertisement likeability; positive affect; and brand perceptions) and behavioral intentions (consumption; social media engagement-"liking;" following; commenting; tagging a friend).

RESULTS

Latinx (n=436; 48.3%) and White (n=467; 51.7%) participants rated advertisements featuring Latinx celebrities more positively than advertisements featuring noncelebrities on attitude measures except negative affect (Ps≤.002), whereas only negative affect differed between Latinx and White participants. Two of the 5 behavioral intention measures differed by celebrity advertisement status (P=.02; P<.001). Additionally, the interaction between celebrity and participant ethnicity was significant for 4 behavioral intentions; Latinx, but not White, participants reported higher willingness to consume the product (P<.001), follow brands (P<.001), and tag friends (P<.001). While White and Latinx adolescents both reported higher likelihoods of "liking" advertisements on social media endorsed by Latinx celebrities versus noncelebrities, the effect was significantly larger among Latinx adolescents (P<.01).

CONCLUSIONS

This study demonstrates the power of Latinx celebrities in appealing to both Latinx and White adolescents but may be particularly persuasive in shaping behavioral intentions among Latinx adolescents. These findings suggest an urgent need to reduce celebrity endorsements in ethnically targeted advertisements that promote unhealthy food products to communities disproportionately affected by obesity and diabetes. The food industry limits food advertising to children ages 12 years and younger, but industry self-regulatory efforts and policies should expand to include adolescents and address disproportionate marketing of unhealthy food to Latinx youth and celebrity endorsements of unhealthy products.

Additives in foods marketed to children in Uruguay, an emerging Latin American country

Foods are frequently marketed to children through the inclusion of a wide range of elements on the packages. Several studies conducted in different countries around the globe have shown that products marketed to children are usually high in sugar and other nutrients associated with non-communicable diseases. The present exploratory cross-sectional study aimed at providing additional evidence on the composition of products marketed to children by analysing the disclosure of additives in such products. Data were collected at nine supermarkets in two Uruguayan cities between August and October 2021. All packaged products available in each supermarket were surveyed using a cell phone app, except for culinary ingredients. All the information from the labels was extracted. Products marketed to children were identified based on the presence of indicators of child-directed marketing on the package. The disclosure of additives was analysed based on the information available in the ingredient list. The prevalence of food additive disclosure was calculated. Of the 7,343 products included in the database, 573 (7.8%) were classified as marketed to children. Candies and cookies were the categories with the largest number of products marketed to children. The great majority of the products marketed to children disclosed at least one food additive (93.5%). These products tended to more frequently notify colourings, antioxidants, acidity regulators, raising agents, stabilisers, humectants, anticaking agents, and glazing agents compared to products not marketed to children. These findings underscore the need to expand the current scope of regulations on marketing targeted at children beyond nutrients to include additives potentially linked to adverse health effects, such as artificial colourings.

Balancing the right to health and commercial speech: the approach of Argentina's Supreme Court

Noncommunicable diseases (NCDs) cause significant human and economic costs globally. Each year, 17 million people die from an NCD before age 70. The burden of NCDs is associated with socioenvironmental, cultural factors and social behavior, including modifiable risk factors like tobacco use, unhealthy diets, physical inactivity and alcohol consumption. NCDs can be prevented if healthy environments are guaranteed by the promotion of effective public policies that control the behavior of the tobacco, food and alcohol industries. The regulation of marketing strategies of unhealthy products, and even its ban, has been demonstrated as an effective measure to protect the right to health and promote human rights. However, companies that produce and commercialize these ultra-processed food products argue that protecting measures restricting marketing violate their constitutional right to freedom of speech, among others. Regarding tobacco product marketing activities, the Supreme Court of Justice of Argentina has ruled that it is afforded less constitutional protection than political speech and could be restricted to protect public health and human rights. This article examines the tobacco marketing case and, using an analytical framework argues that the proportionality test used by the Supreme Court could indeed be applied to ultra-processed food products. It is concluded that a complete ban on ultra-processed food product marketing would be constitutionally valid.

Feasibility and Preliminary Efficacy of Co-Designed and Co-Created Healthy Lifestyle Social Media Intervention Programme the Daily Health Coach for Young Women: A Pilot Randomised Controlled Trial

BACKGROUND

Young women spend 50 min daily on social media (SM); thus, SM platforms are promising for health interventions. This study tested the feasibility and preliminary efficacy of the co-designed SM intervention the Daily Health Coach (DHC). The DHC is a 3-month healthy lifestyles intervention programme, targeting eating, physical activity, and social wellbeing behaviours in women aged 18-24, via the dissemination of health and nutrition content on social media platform Instagram.

METHODS

The programme was tested using an assessor-blinded, two-arm pilot randomised controlled trial with 46 participants over 12 weeks. Engagement was assessed via SM metrics; acceptability via post-programme questionnaires; and feasibility included retention, randomisation, recruitment, and data collection. Secondary outcomes-dietary quality, physical activity, social influence, disordered eating behaviours, body image, and digital health literacy-were assessed using validated surveys. Analyses included t-tests, chi-squared tests, and linear mixed models. The treatment effects were estimated by testing mean score differences from baseline to 3 months for intention-to-treat populations.

RESULTS

The DHC scored 83.6% for programme satisfaction. Over time, a significant decrease in body image disturbance was observed (p = 0.013). A significant group-by-time interaction for digital health literacy (p = 0.002) indicated increased ability to discern evidence-based nutrition information (p = 0.006). The waitlist control group showed increased social influence compared to the intervention group (p = 0.034). No other significant changes were observed.

CONCLUSION

The DHC is a feasible and acceptable method for disseminating nutrition information. Larger studies are needed to determine efficacy.

Urban environment and children's health: An umbrella review of exposure response functions for health impact assessment

BACKGROUND

Urban settlements have become the main living environment. Understanding the impact of urban exposures on human health has therefore become a growing area of research. Up-to-date knowledge about the influence of urban exposures on pregnant women's and children's health is especially relevant, as they are particularly vulnerable to certain external influences.

AIM

This review aims to provide a synthesis of systematic reviews with meta-analyses reporting on an association between the urban environmental risk factors and health outcomes in pregnancy, infants, children and adolescents.

METHODS

We conducted an umbrella review, methodically analysing systematic reviews with meta-analyses, published between January 2016 and December 2022 in PubMed or Scopus. Adhering to the PRISMA checklist, we searched for free text using Medical Subject Headings (MeSH) terms related to air pollution, noise pollution, temperature, green space exposure, built and food environment, health outcomes, children (aged 0-18 years), pregnancy and systematic reviews with meta-analyses. We extracted key characteristics of each included study and assessed the quality of the included studies via the R-AMSTAR 2 tool.

RESULTS

Twenty-four studies met our inclusion criteria and identified 104 associations including 15 exposures and 60 health outcomes. The most frequently studied associations were related to air pollutants, followed by the built and food environment and noise. Birth outcomes (including low birth weight, pre-term birth or stillbirth) were the most commonly affected health outcomes, followed by respiratory outcomes such as asthma or respiratory infections. A total of 45 exposure-response function were reported to be statistically significant, including 10 exposures and 23 health effects.

CONCLUSION

This umbrella review provides an overview of the evidence and availability of exposure response functions between selected urban exposures and child health outcomes. This helps to identify research gaps and to build the basis for health impact assessment.

Characterising the extent and nature of digital food and beverage marketing in Singapore: a descriptive study

OBJECTIVE

To characterise the nature of digital food and beverage advertising in Singapore.

SETTING

Food and beverage advertisements within twenty clicks on the top twelve non-food websites and all posts on the Facebook and Instagram pages of fifteen major food companies in Singapore were sampled from 1 January to 30 June 2018.

DESIGN

Advertised foods were classified as being core (healthier), non-core or mixed dishes (e.g. burger) using the WHO nutrient profile model and national guidelines. Marketing techniques were assessed using published coding frameworks.

PARTICIPANTS

NA.

RESULTS

Advertisements (n 117) on the twelve non-food websites were largely presented as editorial content. Food companies posted twice weekly on average on social media sites (n 1261), with eatery chains posting most frequently and generating the largest amount of likes and shares. Key marketing techniques emphasised non-health attributes, for example, hedonic or convenience attributes (85 % of advertisements). Only a minority of foods and beverages advertised were core foods (non-food website: 16·2 %; social media: 13·5 %).

CONCLUSIONS

Top food and beverage companies in Singapore actively use social media as a platform for promotion with a complex array of marketing techniques. A vast majority of these posts were unhealthy highlighting an urgent need to consider regulating digital food and beverage advertising in Singapore.

Extent and Nature of Television Food and Nonalcoholic Beverage Marketing in 9 Asian Countries: Cross-Sectional Study Using a Harmonized Approach

BACKGROUND

Rising childhood obesity rates in Asia are adding risk for the future adult burden of obesity and noncommunicable diseases. Weak policies across most Asian countries enable unrestricted marketing of obesogenic foods and beverages to children. Television is the common medium for food marketing to reach this audience.

OBJECTIVE

This study aimed to assess the extent and nature of television food and nonalcoholic beverage marketing in 9 Asian countries (Bangladesh, China, India, Malaysia, Mongolia, Nepal, the Philippines, Sri Lanka, and Vietnam) with capacity building support from the International Network for Food and Obesity/Non-Communicable Disease Research, Monitoring and Action Support, who enabled harmonization of data collection method and content analyses.

METHODS

Advertised foods were categorized as permitted or not permitted based on the nutrient profile models established by the World Health Organization regional offices for South-East Asia (SEARO) and the World Health Organization regional offices for Western Pacific (WPRO). Overall rates of food advertisements (advertisements per hour per channel) and persuasive strategy use were analyzed along with comparisons between children's peak viewing time (PVT) and non-PVT.

RESULTS

Cross-country comparisons, irrespective of country income level, indicated that not permitted food advertising dominated children's popular television channels, especially during PVT with rates as per WPRO or SEARO criteria ranging from 2.40/2.29 (Malaysia) to 9.70/9.41 advertisements per hour per channel (the Philippines). Persuasive strategy rates were also comparatively higher during PVT. Sugar-sweetened beverages, sugar-containing solid foods, and high salt- and fat-containing snacks and fast foods were frequently advertised. Evaluation of the application of WPRO and SEARO nutrient profile models identified inconsistencies due to regional taste and cuisine variations across Asia.

CONCLUSIONS

This study clearly showed that unhealthy food marketing through popular children's television channels is widely occurring in Asia and is a clear breach of child rights. Evidence outcomes will benefit advocacy toward stronger policy regulations to control unhealthy food marketing and strengthen strategies to promote a healthier food environment for Asia's children.

The relationship between youth's exposure to unhealthy digital food marketing and their dietary intake in Canada

There is limited evidence on how exposure to digital marketing of unhealthy foods affects youth's dietary behaviours. This study therefore aimed to examine the association between youth's self-reported digital food marketing exposure and dietary intakes, and explore predictors of frequent unhealthy food consumption. A survey was conducted among 1075 youth in Canada (aged 10-17 years) in April 2023. Proportional odds models examined associations between frequency of exposure to digital marketing of unhealthy foods and frequency of consumption of those foods, adjusted for sociodemographic characteristics and digital device usage. Compared with participants reporting no exposure to digital fast-food marketing in the past week, those exposed ≥4 times per week were more likely to consume fast food more frequently. Youth exposed to digital marketing of sugary drinks and salty/savoury snacks ≥1 time(s) in the previous week were more likely to consume these foods on a greater number of days, compared with those reporting no exposure to this marketing in the past week. Reporting exposure to digital marketing of desserts/sweet treats every day or more than once a day was associated with more frequent consumption of desserts/sweet treats. Province of residence (Ontario/Quebec) and total daily time spent online predicted more frequent consumption of fast food, sugary drinks, salty/savoury snacks, and desserts/sweet treats. Overall, more frequent self-reported exposure to digital marketing of unhealthy foods is associated with more frequent consumption of these foods by Canadian youth. Regulations are needed to help protect youth from digital food marketing, which may help reduce their unhealthy food consumption.

The impact of exposure to sugary drink marketing on youth brand preference and recall: a cross-sectional and multi-country analysis

BACKGROUND

Consumption of sugary drinks (SD) among children and adolescents is a prevalent public health issue both within Canada and worldwide. This problem is exacerbated by the powerful marketing of such beverages to youth, which is known to influence a wide range of dietary behaviours.

METHODS

A cross-sectional, secondary analysis of the International Food Policy Survey Youth Wave 2019 was conducted to assess the relationship between self-reported exposure to SD marketing within the past 30 days or SD brand advertisements and brand preference and brand recall among youth aged 10-17 from Australia, Canada, Chile, Mexico, the United Kingdom, and the United States. Ordinal, multinomial, and binary logistic regression were used as appropriate to examine these associations.

RESULTS

Youth brand preference and recall was positively associated with self-reported exposure to general and brand-specific SD marketing across all countries. No statistical interaction was observed between youth age and SD marketing overall or within countries. Soft drinks, sports drinks, and fruit juice brands were most commonly recalled by all youth.

CONCLUSION

Similar results were observed among children and adolescents within all countries. Global marketing policies should consider older children and adolescents to adequately protect and support child health.

Facilitators and barriers to healthful eating among adolescents in high-income countries: A mixed-methods systematic review

Adolescent obesity continues to be a public health challenge with poor quality diets contributing to its etiology. As part of the process to plan health promotion and policy interventions, understanding adolescents perceived facilitators and barriers to healthful eating is important. An integrative convergent mixed-methods systematic review was used to synthesize qualitative and quantitative evidence from studies among adolescents aged 10-19 years in high-income countries. Medline, Embase, PsycInfo, and Scopus were searched for peer-reviewed articles published between 2010 and 2023 and exploring adolescents' perspectives on healthful eating and contemporary contextual factors. Transformed quantitative data were integrated with qualitative data. Text was coded into subthemes and themes using an inductive approach. Key facilitators included health and physical appearance; motivation; taste; nutrition knowledge, awareness, and skills; nutrition education access; availability and accessibility of healthful foods; family; and social influences and digital media. Key barriers included taste and cravings for unhealthful foods; mood; lack of motivation, awareness, knowledge, and skills; high availability and low cost of unhealthful foods; peers and social influences; ineffective school policies; high density of fast-food outlets; unhealthful food advertising; digital influences; and time constraints. Social, behavioral, digital, and food environmental factors should be considered from an adolescent perspective in the design of education, health promotion, and policy interventions.

Virtual Reality-Based Food and Beverage Marketing: Potential Implications for Young People of Color, Knowledge Gaps, and Future Research Directions

Unlabelled

Exposure to unhealthy food and beverage marketing is a major contributor to excessive weight gain among young people and it may disproportionately affect Black and Latinx communities. Appropriate and comprehensive regulations on food and beverage companies are essential, particularly as companies expand their reach and leverage the latest technologies to create marketing experiences using immersive virtual reality (VR). Although immersive VR technology is in its infancy, the potential effects of immersive VR food and beverage marketing on consumption, coupled with the history of racially targeted marketing by food and beverage corporations toward Black and Latinx communities, and the heightened burden of diet-related illnesses in Black and Latinx communities underscore a critical need to investigate immersive VR marketing targeting young people of color. This viewpoint will provide a brief description of VR food and beverage marketing as the newest food and beverage marketing frontier, highlight key concerns and knowledge gaps, and underscore future directions in research.

Children's self-reported exposure to sugary beverage advertisements and association with intake across six countries before and during the COVID-19 pandemic: a repeat cross-sectional study

BACKGROUND

Children's exposure to sugary beverage advertising may have changed during the COVID-19 pandemic due to shifts in media habits, which could subsequently have influenced intake. This study aimed to examine: 1) children's frequency and setting of exposure to advertisements of sugary beverages in six countries before and during the COVID-19 pandemic; 2) the association between exposure to sugary beverage advertisements and intake.

METHODS

Children aged 10-17 years (n = 28,908) in Australia, Canada, Chile, Mexico, the United Kingdom (UK) and the United States (US) completed online surveys in 2019, 2020 and 2021 as part of the International Food Policy Study using a repeat cross-sectional study design. Respondents self-reported frequency and setting of exposure to sugary beverage advertisements, location of school classes (in-person/online, 2020-2021 only), screen time, and sugary beverage intake. Adjusted weighted logistic and negative binomial regression models stratified by country examined associations between year and reported sugary beverage advertising exposure, and associations between sugary beverage advertising exposure and intake. Differences in reported advertising exposure between students taking online or in-person school classes were explored.

RESULTS

Self-reported exposure to advertisements for sugary beverages at least weekly was relatively stable across years within countries, with differences in settings of exposure. Exposure to sugary beverage advertisements increased on digital media independently of screen time from 2019 to 2021 in Australia, Canada, the UK and US, with a concomitant decrease in exposure in retail settings in all countries except the UK. In Australia and the UK, children attending all classes online were more likely to report at least weekly (vs less than once a week) exposure to sugary beverage advertisements, and children attending all classes online were more likely to report exposure to advertisements on digital media and in other settings (e.g., billboard, magazines) compared to children attending in-person classes in Australia, Canada and the UK. Exposure to sugary beverage advertisements at least weekly (IRR = 1.12,99%CI:1.09-1.15) and in each of the settings was associated with sugary beverage intake.

CONCLUSIONS

Exposure to digital advertisements for sugary beverages increased from 2019 to 2021 in most countries, and exposure was associated with sugary beverage intake. Reducing children's exposure to advertising of less healthy foods, including on digital media, may reduce sugary beverage intake.

Associations between exposure to advertising of foods high in fats, salt and sugar and purchase of energy and nutrients: a cross-sectional study

OBJECTIVE

To assess associations between self-reported advertising exposure to foods high in fats, salt and sugar and household purchases of energy, nutrients and specific product categories.

DESIGN

A cross-sectional design was used. Advertising exposure data were gathered using a questionnaire administered to the main shopper of each household, and purchase data from supermarkets and other stores for these households were accessed for a 4-week period during February 2019.

SETTING

Households in London and the North of England.

PARTICIPANTS

Representative households (N 1289) from the Kantar Fast Moving Consumer Goods Panel. Main shoppers were predominantly female (71 %), with a mean age of 54 years (±13).

RESULTS

Linear regression models identified that exposure to foods high in fats, salt and sugar advertising through traditional mediums (including broadcast and print), but not digital, transport, recreational or functional mediums, was associated with greater purchases of energy (9779 kcal; 95 % CI 3515, 16 043), protein (416 g; 95 % CI 161, 671), carbohydrate (1164 g; 95 % CI 368, 1886) and sugar (514 g; 95 % CI 187, 841). Generalised linear models showed that individuals who reported exposure to sugary drink advertising were more likely to purchase sugary drinks (1·16; 95 % CI 2·94, 4·99) but did not purchase more energy or nutrients from sugary drinks. There was no evidence of associations between exposure to advertising for sugary cereals or sweet snacks and purchases from these categories.

CONCLUSIONS

There was a strong influence of traditional advertising and sugar-sweetened beverage advertising on household food and drink purchases, thus supporting the need for advertising restrictions across traditional formats and for sugary drinks specifically.

Food choice, embodied knowledge and circumscribed agency: factors influencing adolescent girls' and boys' dietary practices in three states in northern Nigeria

OBJECTIVE

The objective of this study was to explore adolescent dietary practices, related norms and acceptable communication platforms in northern Nigeria to inform future nutrition project design.

DESIGN

This was a qualitative formative research study. We used purposive sampling and conducted thirty focus group discussions with male and female adolescents aged 10-14 and 15-19 years (n 180) and six with adult influencers (n 36). We also administered a 24-h dietary recall with the adolescents using the Diet Quality Questionnaire.

SETTING

The study was conducted in urban and rural areas in three states in northern Nigeria.

RESULTS

Adolescents reported consuming six nutritious food groups the previous day on average. However, there was a wide disparity and only half consumed all five recommended food groups. Adolescents' food choices were influenced by perceptions of the functional and physical benefits of nutritious foods and preferences for satisfying foods. Diverse foods were available in the food environment, but affordability constrained access to nutritious foods. Limited access to income and gender norms constrained adolescent agency over food choice. Girls, particularly those who were pregnant, had less agency related to food than boys. Adolescents thought that peers should be reached through group discussions, radio and phones, among other communication platforms.

CONCLUSIONS

Adolescents consumed relatively diverse diets. Adolescent food choice was influenced by their embodied experience and knowledge related to nutrition and taste, home food environment and circumscribed agency. Opportunities exist to support healthy diets for adolescents by strengthening adolescents' embodied knowledge, food environments and social support.

Navigating the online food environment: policy pathways for promoting food access, transparency, and healthy food choices online

The internet is drastically changing how U.S. consumers shop for groceries, order food from restaurants, and interact with food marketing. There is an urgent need for new policies to help ensure that the internet is a force for good when it comes to food access, transparency, and nutrition. This article outlines actions that federal agencies-like the U.S. Department of Agriculture (USDA), U.S. Food and Drug Administration (FDA), and Federal Trade Commission (FTC)-and state and local governments can take to improve the online food environment. We recommend policies in three settings: online grocery retail, online restaurant ordering, and marketing on social media and other online platforms. For example, USDA could finalize regulations increasing access to online WIC and remove barriers to accessing online SNAP by requiring large retailers to waive online delivery and service fees for SNAP purchases. FDA could improve access to nutrition information by issuing guidance describing what product information should be available at the online point of selection. FTC could give better guidance on appropriate tactics when marketing to children and collect better data on how companies are marketing food to children online. Finally, state governments could pass laws like New York's recently introduced Predatory Marketing Prevention Act to address false and misleading advertising of unhealthy foods aimed at children and other vulnerable groups.

Assessment of foods for infants and toddlers in Australia against the World Health Organization's Nutrient and Promotion Profile Model for food products for infants and young children

OBJECTIVE

Global public health agencies have recommended stronger regulation of food marketing to protect children's diets. This study assessed commercial foods for infants and toddlers available in Australian supermarkets for compliance with the World Health Organization (WHO) Regional Office for Europe's Nutrient and Promotion Profile Model: supporting appropriate promotion of food products for infants and young children 6-36 months in the WHO European Region (NPPM).

DESIGN

Dietitians assessed a sample of commercial foods for infants and toddlers against the composition, labelling and promotion requirements of the NPPM.

SETTING

Australia.

PARTICIPANTS

Commercial foods for infants and toddlers (n 45) available in two major Australian supermarkets, purposely sampled across product categories and brands.

RESULTS

Fewer than one quarter (23 %) of the assessed products met all nutrient content requirements of the NPPM. No products met all of the labelling or promotional requirements. All products included at least one promotional marketing claim that was not permitted under the NPPM.

CONCLUSIONS

The NPPM is useful to assess and monitor the nutritional composition and prevalence of marketing claims on commercial foods for infants and toddlers. Findings of noncompliance with the NPPM recommendations indicate an urgent need for stronger government regulation of the composition, labelling and marketing of commercial foods for infants and toddlers in Australia.

My feed is what I eat? A qualitative study on adolescents' awareness and appreciation of food marketing on social media

BACKGROUND

Adolescents spend much of their time online and hence are exposed to a lot of non-core (energy-dense, nutrient-poor) social media food marketing (SMFM). This may influence their dietary choices and health. This present study aimed to investigate adolescents' perceptions towards SMFM; that is, their recognition and appreciation of SMFM.

METHODS

Semi-structured one-on-one interviews were conducted with Dutch adolescents aged 13-16 years (n = 16), on Skype. Examples of food promotions on Instagram, Snapchat, TikTok and YouTube were discussed with adolescents.

RESULTS

Adolescents' reasons for recognising and appreciating or liking SMFM were often related to the level of product integration. Factors that determined participants' recognition of SMFM included product focus (e.g., brand or product prominence), sponsorship disclosure, type of content (paid, influencer and peer-generated content) and promotional strategy (e.g., discounts, promotional texts, layout). Participants' appreciation of SMFM was determined by the format of a post (image, video, text, pop-up), trustworthiness of the source (brand, celebrity, friend/peer), type of product promoted (core, non-core) and appearance or layout of a post (e.g., professionalism, appeal).

CONCLUSIONS

The present study contributes to the ongoing debate on how to increase adolescents' resilience to commercial messages that promote non-core foods. Adolescents mostly enjoy watching non-core video content from peers or influencers and do not perceive this as food marketing. It is recommended that future studies investigate the effects of earned social media marketing formats (i.e., unpaid peer and influencer endorsements) promoting non-core foods on adolescents' dietary intake, and how they can be made more critical towards such types of SMFM.

Characterising Parent-Appeal Marketing on Foods for Children: A Scoping Review

PURPOSE OF REVIEW

This scoping review examines current evidence on parent-appeal marketing on the front-of-pack of food products for children and the impacts on parents' perceptions, intentions, and behaviours.

RECENT FINDINGS

Thirteen relevant studies were identified. Marketing features on packages of foods for children that appealed to parents include health claims, nutrition claims, non-nutrient claims such as 'natural', healthy-looking product images, images of healthy ingredients, and celebrity endorsements. At the same time, parents were wary of front-of-pack marketing and find it confusing, deceptive, and misleading. Child-appeal marketing features such as cartoon characters and bright colours gave parents the perception that products were unhealthy. Overall, this scoping review offers important insights into the types of front-of-pack marketing that appeal to parents and offers an inventory of parent-appeal marketing features. These findings support the design and implementation of policies that aim to reduce commercial influences on children's diets through stronger regulation of marketing of foods for children.

Unhealthy Food and Beverage Marketing to Children in the Digital Age: Global Research and Policy Challenges and Priorities

Food and nonalcoholic beverage marketing is implicated in poor diet and obesity in children. The rapid growth and proliferation of digital marketing has resulted in dramatic changes to advertising practices and children's exposure. The constantly evolving and data-driven nature of digital food marketing presents substantial challenges for researchers seeking to quantify the impact on children and for policymakers tasked with designing and implementing restrictive policies. We outline the latest evidence on children's experience of the contemporary digital food marketing ecosystem, conceptual frameworks guiding digital food marketing research, the impact of digital food marketing on dietary outcomes, and the methods used to determine impact, and we consider the key research and policy challenges and priorities for the field. Recent methodological and policy developments represent opportunities to apply novel and innovative solutions to address this complex issue, which could drive meaningful improvements in children's dietary health.

Creation and validation of a NOVA scored picture set to evaluate ultra-processed foods

There has been a rapid shift in the modern food environment towards increased processing in foods consumed in the United States (US) and globally. The NOVA system (not an acronym) for classifying food on degree of processing currently has the most empirical support. Consumption of foods in the NOVA 4 category, ultra-processed foods (UPF), is a risk factor for a host of poor health outcomes including heart disease, stroke, and cancer. Despite these poor health outcomes, UPF make up 58% of calories consumed in the US. Methodologies for assessing the reinforcing and rewarding properties of these foods are necessary tools. The Becker-DeGroot-Marschak auction paradigm (BDM) is a well validated tool for measuring value and is amenable to neuromonitoring environments. To allow for the testing of hypotheses based on level of food processing, we present a picture set of 14 UPF and 14 minimally-processed foods (MPF) matched on visual properties, food characteristics (fat, carbohydrate, cost, etc.), and rated perceptual properties. Further, we report our scoring of these foods using the NOVA classification system and provide additional data from credentialed nutrition professionals and on inter-rater reliability using NOVA, a critique of the system. Finally, we provide all pictures, data, and code used to create this picture set as a tool for researchers.

Development of a questionnaire for assessing the impact of children's food marketing exposure on diet-related outcomes

Introduction

The Government of Thailand has drafted legislation to protect children from the harmful impact of unhealthy food (including beverages) marketing. Local evidence on Thai children's exposure to, and the impact of, this marketing is necessary to, first, support the adoption of this Law and, second, to contribute to assessing policy implementation and effectiveness. This study aimed to develop and validate a questionnaire for examining Thai children's exposure to unhealthy food marketing and its impact on diet-related outcomes.

Materials and methods

To design the questionnaire, we first conceptualised the range of impacts of unhealthy food marketing on children's diet-related outcomes based on published frameworks. These outcomes related to food brand loyalty, preference, purchase and consumption. We conducted a literature review to gather related questions used in earlier surveys to assess these outcomes. Using these questions, we assessed content validity with five experts. Face validity and reliability were assessed for 32 children. Validity was assessed using Content Validity Index (CVI) and Kappa statistics. Reliability was assessed using Cronbach's alpha and intraclass correlation coefficients (ICC).

Results

We identified 15 survey questions that had been used to assess the outcomes of interest. The CVI of all questions was 1.0, indicating perfect agreement with each question's relevance by the experts. Most questions were perceived to be easy to read and comprehend, suggesting face validity. Cronbach's alpha and ICC of all questions were both 0.75, demonstrating internal consistency across responses to questions about, separately, brand loyalty, preferences, purchase and consumption.

Conclusion

The final 15-item questionnaire provides a valid and reliable survey instrument for measuring the impact of unhealthy food marketing on children's diet-related outcomes. This instrument will be useful for gathering local evidence on the need for policy reform to protect children from unhealthy food marketing in Thailand. The instrument also provides a cost-effective approach for generating evidence in other jurisdictions to propel policy actions. This is a pilot study and the validity and reliability needs further testing after a larger-scale roll-out.

The rise and fall of the Queensland Government policy to restrict unhealthy food and alcohol advertising on publicly owned assets

OBJECTIVE

To examine the strategies employed by opponents of the Queensland Government's policy to restrict unhealthy food and alcohol advertising on publicly owned assets and identify which of the opposing arguments appeared to influence the policy outcomes.

METHODS

Retrospective qualitative policy analysis case study informed by the Policy Dystopia Model of corporate political activity. We used qualitative content analysis to examine data from stakeholder submissions to the 'Advertising content on Queensland Government advertising spaces' policies (v1 and 2), and Minister for Health's diaries.

RESULTS

Stakeholders from the food, beverage, alcohol and advertising industries and several not-for-profit health organisations opposed the policy. Industry actors used discursive strategies, coalition management (including co-option of not-for-profit health organisations), information management and direct involvement with policy makers to communicate their arguments against the policy. The second version of the policy was weaker regarding scope and key policy provisions, reflecting the arguments of industry actors.

CONCLUSIONS

Influence from industries with a clear conflict of interest should be minimised throughout policy development to ensure public health is prioritised over corporate gain.

IMPLICATIONS FOR PUBLIC HEALTH

Our findings can support other jurisdictions to prepare for industry opposition when designing policies to restrict unhealthy food and alcohol marketing.

Covert marketing of quick-service restaurants via news media in Australia: A content analysis

OBJECTIVE

To determine the extent and nature of news media coverage generated from press releases made by top-selling quick-service restaurants in Australia.

METHODS

We conducted a content analysis of press releases made between July 2021 and June 2022 by the five largest quick-service restaurant brands in Australia by brand share, including coding their main subject. We then conducted a content analysis of news media coverage related to the press releases, including coding its slant towards the brand.

RESULTS

Among 52 press releases, new food products (27% of press releases; all unhealthy foods) and corporate social responsibility activities (25%) were the most promoted subjects. For 62% of press releases, at least one news media item was identified. Among the 86 identified news media items, most related to press releases promoting new food products (45% of news media items) or corporate social responsibility activities (21%). News media items overwhelmingly had a slant favourable to the relevant brand (93%).

CONCLUSIONS

Press releases by top-selling quick-service restaurant brands in Australia commonly generate news media coverage that promotes such brands and their predominantly unhealthy products.

IMPLICATIONS FOR PUBLIC HEALTH

Policies restricting unhealthy food marketing should consider brand-generated news media coverage.

What Is the Nutritional Quality of Pre-Packed Foods Marketed to Children in Food Stores? A Survey in Switzerland

Food marketing targeting children influences their choices and dietary habits, and mainly promotes food high in fat, sugar, and salt as well as ultra-processed food. The aim of this study was to assess the nutritional quality of food and beverages marketed to children over the age of 3 and available on the Swiss market. Products with at least one marketing technique targeting children on the packaging were selected from five food store chains. Three criteria to assess nutritional quality were used: (1) nutritional composition (using the Nutri-Score), (2) degree of processing (NOVA classification), and (3) compliance with the World Health Organization (WHO) Nutrient Profile Model (NPM). A total of 735 products were found and analyzed. The most common marketing techniques used were childish names/fonts (46.9%), special characters (39.6%), and children's drawings (31.3%). Most products had a Nutri-Score of D or E (58.0%) and were ultra-processed (91.8%). Only 10.2% of products displayed the Nutri-Score. The least processed products generally had a better Nutri-Score (p < 0.001). Most products (92.8%) did not meet the criteria of the WHO NPM. Products that met the WHO NPM criteria, organic products, and products with a nutritional claim generally had a better Nutri-Score and were less processed (ps < 0.05). Pre-packaged foods and beverages marketed to children in the Swiss market were mostly of poor nutritional quality. Public health measures should be adopted to improve the nutritional quality of foods marketed to children in Switzerland and restrict the marketing of unhealthy foods to children.

Development and testing of two tools to assess point-of-sale food and beverage marketing to children in restaurants

OBJECTIVE

To describe the development and testing of two assessment tools designed to assess exterior (including drive-thru) and interior food and beverage marketing in restaurants with a focus on marketing to children and teens.

DESIGN

A scoping review on restaurant marketing to children was undertaken, followed by expert and government consultations to produce a draft assessment tool. The draft tool was mounted online and further refined into two separate tools: the Canadian Marketing Assessment Tool for Restaurants (CMAT-R) and the CMAT-Photo Coding Tool (CMAT-PCT). The tools were tested to assess inter-rater reliability using Cohen's Kappa and per cent agreement for dichotomous variables, and intra-class correlation coefficients (ICCs) for continuous or rank-order variables.

SETTING

Waterloo, Ontario, Canada.

PARTICIPANTS

Restaurants of all types were assessed using the CMAT-R (n 57), and thirty randomly selected photos were coded using the CMAT-PCT.

RESULTS

The CMAT-R collected data on general promotions and restaurant features, drive-thru features, the children's menu and the dollar/value menu. The CMAT-PCT collected data on advertisement features, features considered appealing to children and teens, and characters. The inter-rater reliability of the CMAT-R tool was strong (mean per cent agreement was 92·4 %, mean Cohen's κ = 0·82 for all dichotomous variables and mean ICC = 0·961 for continuous/count variables). The mean per cent agreement for the CMAT-PCT across items was 97·3 %, and mean Cohen's κ across items was 0·91, indicating very strong inter-rater reliability.

CONCLUSIONS

The tools assess restaurant food and beverage marketing. Both showed high inter-rater reliability and can be adapted to better suit other contexts.

More than a Nuisance: Implications of Food Marketing for Public Health Efforts to Curb Childhood Obesity

Fifteen years ago, public health experts urged industry, governments, and advocates to take action to dramatically improve the unhealthy food-marketing environment surrounding children in order to address the global childhood obesity crisis. Since then, research has confirmed that food marketing to children has far-reaching negative effects on their diets and health, takes advantage of adolescent vulnerabilities, and contributes to health disparities. In addition, digital marketing has profoundly changed young people's engagement with brands. Moreover, reliance on industry self-regulation as a solution has proven ineffective. Government-led policies have been more successful, but they remain limited in scope and challenging to adopt and implement. New approaches are necessary to increase public and policy maker awareness that food marketing is more than a nuisance, that it threatens the long-term health of children and adolescents worldwide, and that meaningful governmental action is urgently required to curtail industry's negative impact on young people's well-being.

Associations between everyday exposure to food marketing and hunger and food craving in adults: An ecological momentary assessment study

Food marketing in television and digital media negatively affects appetitive sensations and eating behaviour in children, but effects are less well understood for outdoor food advertising and adults. This research used Ecological Momentary Assessment (EMA) to explore associations between exposures to food advertising in various contexts (television, digital, outdoors) and adults' hunger and craving for highly advertised food categories. Over one week, participants provided ratings of cravings for types of food (fast food, soft drinks, snacks/confectionery, other) and hunger on a smartphone app up to six times per day when they saw a food advertisement (reactive assessment) and at random intervals (random assessment). Fifty-four participants (70.4 % female; 21.24 ± 3.84 years) provided 1223 assessments (24.7 % reactive, 75.3 % random). Data were analysed in R using multilevel multivariable linear regression models. Participants reported feeling hungrier (X2(1) = 5.85, p = .016, ΔAIC = 3.9) and having stronger cravings (X2(1) = 20.64, p < .001, ΔAIC = 318.6) after seeing food advertisements vs. random assessments. This was driven by greater hunger following television advertising exposure vs. random assessments (β = 1.58, SE = 0.61, p = .010, 95 %CIs 0.38 to 2.78), food advertising via digital devices or outdoors was not associated with hunger. Participants experienced stronger craving after seeing a food advertisement on television (β = 0.52, SE = 0.19, p = .006, 95 %CIs 0.15 to 0.89), outdoors (β = 0.39, SE = 0.12, p < .001, 95 % CIs 0.16 to 0.62) and in digital media (β = 0.36, SE = 0.14, p = .012, 95 % CIs 0.08 to 0.64), vs. random assessments. Cravings were (largely) specific to the advertised food category. EMA can be effective for assessing food marketing associations in adults. The current study provides evidence that food marketing is associated with hunger and craving in adults, which may, with replication, have implications for public health policy.

Perception and Impact of Food and Beverage Marketing on Children's Eating Behaviors and Associated Health Issues

BACKGROUND AND OBJECTIVE

Children are more susceptible to food and beverage marketing than adults, but little is known about the specific effects of marketing through the media most used by children. This study aims to discover variables that can help inform childhood obesity prevention strategies. Our findings indicate an association between food advertisements and children's consumption, evidencing a need for the concerned authorities to create strict guidelines that consider the nutritional value of advertised foods. This study aims to study the attitudes and practices of children related to their preference for unhealthy meals due to food marketing and their association with childhood obesity.

METHODOLOGY

A cross-sectional study of randomly selected guardians of children who were screened for obesity. A structured questionnaire was given to the children's parents.

RESULTS

The study found that most of the participants' children prefer fast food (291, 78.0%), eat healthy meals (287, 76.9%), and eat fruits and vegetables every day (198, 53.1%). Furthermore, most participants (340, 91.2%) indicated that they were aware of unhealthy diets, and 105 (28.2%) said their children were overweight. Most participants (326, 87.4%) also indicated that watching television (TV) was associated with eating high-calorie foods.

CONCLUSIONS

There is strong evidence that children exposed to food marketing develop attitudes about and choose unlimited healthy food and unhealthy foods, which negatively impacts their health. It is recommended that future research employs a wide range of methodologies to study contemporaneous marketing strategies.