Exposure to unhealthy product advertising: Spatial proximity analysis to schools and socio-economic inequalities in daily exposure measured using Scottish Children's individual-level GPS data

Differences in children's exposure to television advertising of unhealthy foods and beverages in Spain by socio-economic level

BACKGROUND

The influence of food advertising on food preferences and consumption could also contribute to the socio-economic inequalities among Spanish children in terms of eating habits and childhood obesity. Although the main food advertising channel targeted at children in Spain is television, available studies estimate exposure indirectly by combining content data with audience data. The aim of this study was therefore to describe the frequency of exposure to television advertising of unhealthy foods and drinks, measured directly, among Spanish children and adolescents, and analyse its socio-economic inequalities.

METHODS

Observational study of television advertising impacts in a sample of 1590 children aged 4 to 16 years drawn from a consumer panel representative of the Spanish population in this age group, over the course of a full week of broadcasting in February 2022. The sample was obtained through stratified random sampling by Autonomous Region, with quotas being set by reference to socio-demographic variables. Exposure was measured with an audiometer, and the nutrient content of the food and drink advertised was analysed using the nutrient profile of the WHO Regional Office for Europe. We used the Chi-squared test to analyse possible differences in advertising coverage by socio-economic level.

RESULTS

The participants saw a weekly mean of 82.4 food and drink commercials, 67.4 of which were for unhealthy products (81.8%), mostly outside the child-protection time slot. On average, low-social class participants received 94.4% more impacts from unhealthy food and drink advertising than did high-class participants (99.9 vs. 51.4 respectively). The mean advertising coverage of unhealthy foods and drinks was 71.6% higher in low-class than in high-class participants (10.9% vs. 18.7%; p = 0.01).

CONCLUSION

Spanish children and adolescents received an average of 10 impacts per day from television spots for unhealthy foods and drinks. The exposure of low-class children is double that of high-class children, a finding compatible with the high prevalence of childhood obesity in Spain and the related socio-economic inequalities. To protect Spanish minors from the harmful effects of food advertising and reduce the related social health inequalities would require the implementation of a 24:00 watershed for unhealthy food advertising on television.

Urban school neighbourhoods dominated by unhealthy food retailers and advertisements in Greater Tunis: a geospatial study in the midst of the nutrition transition

OBJECTIVE

Food environments are a major determinant of children's nutritional status. Scarce evidence on food environments exists in low- and middle-income countries (LMIC). This study aims to fill this gap by documenting the obesogenicity of food environments around schools in Greater Tunis, Tunisia - an LMIC of the Middle East and North Africa region with an ongoing nutrition transition and increasing rates of childhood obesity.

DESIGN

In this cross-sectional study, we assessed built food environments around fifty primary schools. Ground-truthing was performed to collect geographic coordinates and pictures of food retailers and food advertisement sets within an 800-m road network buffer of each school. Retailers and advertisement sets were categorised as healthy or unhealthy according to a NOVA-based classification. Associations between school characteristics and retailers or advertisement sets were explored using multinomial regression models.

SETTING

Greater Tunis, Tunisia.

PARTICIPANTS

Random sample of fifty (thirty-five public and fifteen private) primary schools.

RESULTS

Overall, 3621 food retailers and 2098 advertisement sets were mapped. About two-thirds of retailers and advertisement sets were labelled as unhealthy. Most retailers were traditional corner stores (22 %) and only 6 % were fruit and vegetable markets. The prevailing food group promoted was carbonated and sugar-sweetened beverages (22 %). The proportion of unhealthy retailers was significantly higher in the richest v. poorest areas.

CONCLUSIONS

School neighbourhood food environments included predominantly unhealthy retailers and advertisements. Mapping of LMIC food environments is crucial to document the impact of the nutrition transition on children's nutritional status. This will inform policies and interventions to curb the emergent childhood obesity epidemic.

Advertisement of unhealthy commodities in Bristol and South Gloucestershire and rationale for a new advertisement policy

BACKGROUND

Bristol City Council introduced a new advertisement policy in 2021/2022 which included prohibiting the advertising of unhealthy food and drink (HFSS), alcohol, gambling and payday loans across council-owned advertising spaces. This mixed methods study is part of the BEAR study, and aimed to explore the rationale and the barriers and facilitators to implementing the policy, and describe the perceived advertising environment prior to implementation.

METHODS

Semi-structured interviews were carried out with seven stakeholders involved in the design and implementation of the advertising policy. A stakeholder topic guide was developed before interviews took place to help standardise the lines of inquiry between interviewees. A resident survey was developed to collect socio-demographic data and, for the purpose of this study, information regarding observations of advertising for HFSS products, alcohol and gambling.

RESULTS

Fifty-eight percent of respondents residing in Bristol and South Gloucestershire reported seeing advertisements for unhealthy commodities in the week prior to completing the survey. This was highest for HFSS products (40%). 16% of residents reported seeing HFSS product advertisements specifically appealing to children. For HFSS products in particular, younger people were more likely to report seeing adverts than older people, as were those who were from more deprived areas. An advertisement policy that restricts the advertisement of such unhealthy commodities, and in particular for HFSS products, has the potential to reduce health inequalities. This rationale directly influenced the development of the advertisement policy in Bristol. Implementation of the policy benefitted from an existing supportive environment following the 'health in all policies' initiative and a focus on reducing health inequalities across the city.

CONCLUSIONS

Unhealthy product advertisements, particularly for unhealthy food and drinks, were observed more by younger people and those living in more deprived areas. Policies that specifically restrict such advertisements, therefore, have the potential to reduce health inequalities, as was the hope when this policy was developed. Future evaluation of the policy will provide evidence of any public health impact.

The Founder: Dispositional Greed, Showbiz, and the Commercial Determinants of Health

Marketing unhealthy products by multinational corporations has caused considerable harm to individual health, collective wellbeing, and environmental sustainability. This is a growing threat to all societies and a significant contributor to the rising global burden of non-communicable diseases and early mortality. While there is growing consideration of the commercial determinants of health, this is largely focused on the methods by which unhealthy products are marketed and disseminated, including efforts to manipulate policy. Little attention has been paid to the underlying psychological traits and worldviews that are driving corporate greed. Here, we consider the role of "dispositional greed" in the commercial determinants of health with a focus on the historical attitudes and culture in the ultra-processed food industry-exemplified by "The Founder" of the McDonald's franchise. We argue that greed and associated psychological constructs, such as social dominance orientation and collective narcissism, permeate the commercial determinants of health at a collective level. This includes how a culture of greed within organizations, and individual dispositional greed, can magnify and cluster at scale, perpetuated by social dominance orientation. We also consider the ways in which "showbiz" marketing specifically targets marginalized populations and vulnerable groups, including children-in ways that are justified, or even celebrated despite clear links to non-communicable diseases and increased mortality. Finally, we consider how greed and exploitative mindsets mirror cultural values and priorities, with trends for increasing collective narcissism at scale, recognizing that many of these attitudes are cultivated in early life. A healthier future will depend on navigating a path that balances material prosperity with physical and spiritual wellbeing. This will require cultural change that places higher value on kindness, reciprocity, and mutualistic values especially in early life, for more equitable flourishing.

A scoping review of outdoor food marketing: exposure, power and impacts on eating behaviour and health

BACKGROUND

There is convincing evidence that unhealthy food marketing is extensive on television and in digital media, uses powerful persuasive techniques, and impacts dietary choices and consumption, particularly in children. It is less clear whether this is also the case for outdoor food marketing. This review (i) identifies common criteria used to define outdoor food marketing, (ii) summarises research methodologies used, (iii) identifies available evidence on the exposure, power (i.e. persuasive creative strategies within marketing) and impact of outdoor food marketing on behaviour and health and (iv) identifies knowledge gaps and directions for future research.

METHODS

A systematic search was conducted of Medline (Ovid), Scopus, Science Direct, Proquest, PsycINFO, CINAHL, PubMed, the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials and a number of grey literature sources. Titles and abstracts were screened by one researcher. Relevant full texts were independently checked by two researchers against eligibility criteria.

RESULTS

Fifty-three studies were conducted across twenty-one countries. The majority of studies (n = 39) were conducted in high-income countries. All measured the extent of exposure to outdoor food marketing, twelve also assessed power and three measured impact on behavioural or health outcomes. Criteria used to define outdoor food marketing and methodologies adopted were highly variable across studies. Almost a quarter of advertisements across all studies were for food (mean of 22.1%) and the majority of advertised foods were unhealthy (mean of 63%). The evidence on differences in exposure by SES is heterogenous, which makes it difficult to draw conclusions, however the research suggests that ethnic minority groups have a higher likelihood of exposure to food marketing outdoors. The most frequent persuasive creative strategies were premium offers and use of characters. There was limited evidence on the relationship between exposure to outdoor food marketing and eating behaviour or health outcomes.

CONCLUSIONS

This review highlights the extent of unhealthy outdoor food marketing globally and the powerful methods used within this marketing. There is a need for consistency in defining and measuring outdoor food marketing to enable comparison across time and place. Future research should attempt to measure direct impacts on behaviour and health.

The Ultra-Processed Food Content of School Meals and Packed Lunches in the United Kingdom

British children have the highest levels of ultra-processed food (UPF) consumption in Europe. Schools are posited as a positive setting for impacting dietary intake, but the level of UPFs consumed in schools is currently unknown. This study determined the UPF content of school food in the UK. We conducted a pooled cross-sectional analysis of primary (4-11 years, n = 1895) and secondary schoolchildren (11-18 years, n = 1408) from the UK's National Diet and Nutrition Survey (2008-2017). Multivariable quantile regression models determined the association between meal-type (school meal or packed lunch) and lunchtime UPF intake (NOVA food classification system). We showed that on average, UPF intake was high in both primary (72.6% total lunch Kcal) and secondary schoolchildren (77.8% total lunch Kcal). Higher UPF intakes were observed in packed lunch consumers, secondary schoolchildren, and those in lower income households. This study highlights the need for a renewed focus on school food. Better guidance and policies that consider levels of industrial processing in food served in schools are needed to ensure the dual benefit of encouraging school meal uptake and equitably improving children's diets.

The distribution of harmful product marketing in public outdoor spaces and the effectiveness of marketing bans

Children's exposure to the marketing of harmful products in public outdoor spaces may influence their consumption of those products and affect health into adulthood. This study aimed to: i) examine the spatial distribution of children's exposure to three types of marketing-related 'harms' (alcohol, unhealthy food, and gambling) in outdoor spaces in the Wellington region, New Zealand/Aotearoa; ii) compare differences in the distribution of harms by socioeconomic deprivation; and iii) estimate the effectiveness of different policies that ban such marketing. Data were from 122 children aged 11-13y who wore wearable cameras and GPS devices for four consecutive days from July 2014 to June 2015. Images were analysed to identify harmful product marketing exposures in public outdoor spaces. Eight policy scenarios were examined to identify the effectiveness of marketing bans, for all children and by socioeconomic deprivation. Children's ratio of harmful marketing was higher for children from high deprivation households and was also found to cluster, with hots spots observed around city centers. The effectiveness of marketing bans depended on the target setting and ban area, with banning 400 m around bus stops leading to the largest reduction. Effectiveness varied also by type of harm and socioeconomic deprivation. For example, banning alcohol marketing in residential areas was estimated to have a larger effect on exposure reduction for children from high deprivation households. Our findings suggest that alcohol, unhealthy food and gambling marketing often cluster outdoors and that targeted bans of such marketing would likely improve child health and, for some banning scenarios, promote equity.

An analysis of food and beverage advertising on bus shelters in a deprived area of Northern England

OBJECTIVE

To quantify the extent of food and beverage advertising on bus shelters in a deprived area of the UK, to identify the healthfulness of advertised products, and any differences by level of deprivation. The study also sought to assess the creative strategies used and extent of appeal to young people.

DESIGN

Images of bus shelter advertisements were collected via in person photography (in 2019) and Google Street View (photos recorded in 2018). Food and beverage advertisements were grouped into one of seventeen food categories and classified as healthy/less healthy using the UK Nutrient Profile Model. The deprivation level of the advertisement location was identified using the UK Index of Multiple Deprivation.

SETTING

Middlesbrough and Redcar and Cleveland in South Teesside.

PARTICIPANTS

N/A.

RESULTS

Eight hundred and thirty-two advertisements were identified, almost half (48·9 %) of which were for foods or beverages. Of food and non-alcoholic beverage adverts, 35·1 % were less healthy. Most food advertisements (98·9 %) used at least one of the persuasive creative strategies. Food advertisements were found to be of appeal to children under 18 years of age (71·9 %). No differences in healthiness of advertised foods were found by level of deprivation.

CONCLUSIONS

Food advertising is extensive on bus shelters in parts of the UK, and a substantial proportion of this advertising is classified as less healthy and would not be permitted to be advertised around television programming for children. Bus shelter advertising should be considered part of the UK policy deliberations around restricting less healthy food marketing exposure.

Socio-economic patterning of food and drink advertising at public transport stops in Edinburgh, UK

OBJECTIVE

Outdoor advertisements for food and drink products form a large part of the food environment and they disproportionately promote unhealthy products. However, less is known about the social patterning of such advertisements. The main aim of this study was to explore the socio-economic patterning of food and drink advertising at bus stops in Scotland's capital city, Edinburgh.

DESIGN

Bus stop advertisements were audited to identify food/drink adverts and classify them by food/drink category (i.e. 'advert category'). This data were then linked to area-based deprivation and proximity measures. Neighbourhood deprivation was measured using the bus stop x/y co-ordinates, which were converted to postcodes to identify the matching 2012 deprivation level via the Scottish Index of Multiple Deprivation. Distance to schools and leisure centres were also collected using location data. Generalised estimating equations and linear regression analyses were used to assess associations between the promotion of advert categories and deprivation and proximity to schools/leisure centres, respectively.

SETTING

Edinburgh city, United Kingdom.

RESULTS

561 food/drink advertisements were identified across 349 bus stops, with 8 advertisement categories noted and included in the final analysis, including alcohol, fast food outlets and confectionary. The majority of adverts were for 'unhealthy' food and drink categories, however there was no evidence for any socio-economic patterning of these advertisements. There was no evidence of a relationship between advertisements and proximity to schools and leisure centres.

CONCLUSIONS

While there is no evidence for food and drink advertising being patterned by neighbourhood deprivation, the scale of unhealthy advertising is an area for policy evaluations and interventions on the control of such outdoor advertising.

Earth Dreams: Reimagining ARPA for Health of People, Places and Planet

Bold new approaches are urgently needed to overcome global health challenges. The proposed Advanced Research Projects Agency for Health (ARPA-H) is intended to provide rapid health breakthroughs. While new technologies for earlier disease detection and more effective treatment are critical, we urge equal attention be given to the wider (physical, emotional, social, political, and economic) environmental ecosystems driving the non-communicable disease (NCD) crisis in the first place. This requires an integrated, cross-sectoral vision that spans the interwoven connections affecting health across the scales of people, places, and planet. This wider "exposome" perspective considers biopsychosocial factors that promote resilience and reduce vulnerabilities of individuals and communities over time-the many variables driving health disparities. Since life course health is strongly determined by early life environments, early interventions should be prioritized as a matter of effectiveness and social justice. Here, we explore the origins of the Advanced Research Project Agency and point to its potential to build integrated solutions, with wisdom and ethical value systems as a compass. Since the planned ARPA-H is anticipated to spawn international collaborations, the imagined concept is of relevance to a broad audience of researchers. With appropriate input, the quest for health equity through personalized, precision medicine while deconstructing unacceptable structural inequities may be accelerated.