Building the case for independent monitoring of food advertising on Australian television

Legal and regulatory instruments for NCD prevention: a scoping review and descriptive analysis of evaluations in OECD countries

CONTEXT

Public health law is an important tool in non-communicable disease (NCD) prevention. There are different approaches available for achieving policy objectives, including government, co-, quasi- and self-regulation. However, it is often unclear what legal design features drive successes or failures in particular contexts. This scoping review undertakes a descriptive analysis, exploring the design characteristics of legal instruments that have been used for NCD prevention and implemented and evaluated in OECD countries.

METHODS

A scoping review was conducted across four health and legal databases (Scopus, EMBASE, MEDLINE, HeinOnline), identifying study characteristics, legal characteristics and regulatory approaches, and reported outcomes. Included studies focused on regulation of tobacco, alcohol, unhealthy foods and beverages, and environmental pollutants.

FINDINGS

We identified 111 relevant studies evaluating 126 legal instruments. Evaluation measures most commonly assessed implementation, compliance and changes to the built and lived environment. Few studies evaluated health or economic outcomes. When examining the design and governance mechanisms of the included legal instruments, government regulation was most commonly evaluated (n = 90) and most likely to be reported effective (64%). Self-regulation (n = 27) and quasi-regulation (n = 5) were almost always reported to be ineffective (93% and 100% respectively). There were few co-regulated instruments evaluated (n = 4) with mixed effectiveness. When examining public health risks, food and beverages including alcohol were more likely to be self- or quasi-regulated and reported as ineffective more often. In comparison, tobacco and environmental pollutants were more likely to have government mandated regulation. Many evaluations lacked critical information on regulatory design. Monitoring and enforcement of regulations was inconsistently reported, making it difficult to draw linkages to outcomes and reported effectiveness.

CONCLUSIONS

Food and alcohol regulation has tended to be less successful in part due to the strong reliance on self- and quasi-regulation. More work should be done in understanding how government regulation can be extended to these areas. Public health law evaluations are important for supporting government decision-making but must provide more detail of the design and implementation features of the instruments being evaluated - critical information for policy-makers.

A comparative analysis of unhealthy food and beverage television advertising to children in Thailand, between 2014 and 2022

BACKGROUND

Food marketing is a key factor that influences children's dietary behaviors. This study assessed the nature and extent of food and beverage advertising on television (TV) in 2014 and 2022 in Thailand.

METHODS

TV was recorded for one week in March 2014 and in May 2022 from 7-9am and 3-7 pm on weekends, and 3-7 pm on weekdays across two channels (64 h recorded each year). The nutrient profile model from Bureau of Nutrition, Ministry of Public Health Thailand was used to classify food and non-alcoholic beverages as: Group A ('healthy'), Group B ('less unhealthy') or Group C ('unhealthy').

RESULTS

In 2014, 475 food advertisements were identified, with on average of 6.3 unhealthy food advertisements per hour. In 2022, 659 food advertisements were identified, with an average of 9.2 unhealthy food advertisement per hour. In both time periods, the most frequently advertised food products were non-alcoholic beverages. The rate of unhealthy food advertising per hour of broadcast was significantly higher than for other moderately unhealthy and healthy foods, and was also significantly higher in 2022 than in 2014.

CONCLUSIONS

Food and beverage advertising on Thai television is predominantly promotes unhealthy foods and, in particular, sugar-sweetened beverages. Therefore, Thai Government should enact new legislation to protect children from food TV ads in order to control both the frequency and nature of unhealthy TV food marketing to protect the health of Thai children.

Systematic review of the effect of policies to restrict the marketing of foods and non-alcoholic beverages to which children are exposed

This systematic review examined the effectiveness of policies restricting the marketing of foods and/or non-alcoholic beverages to children to inform updated World Health Organization (WHO) guidelines. Databases were searched to March 2020. Inclusion criteria were primary studies of any design assessing implemented policies to restrict food marketing to children (0-19 years). Critical outcomes were exposure to and power of marketing, dietary intake, choice, preference, and purchasing. Important outcomes were purchase requests, dental caries, body weight, diet-related noncommunicable diseases, product change, and unintended consequences. Forty-four observational studies met inclusion criteria; most were moderate quality. Pooling was conducted using vote counting by direction of effect, and GRADE was used to judge evidence certainty. Evidence suggests food marketing policies may result in reduced purchases of unhealthy foods and in unintended consequences favorable for public health. Desirable or potentially desirable (for public health) effects of policies on food marketing exposure and power were also found. Evidence on diet and product change was very limited. The certainty of evidence was very low for four outcomes (exposure, power, dietary intake, and product change) and low for two (purchasing and unintended consequences). Policies can effectively limit food marketing to children; policymakers should prioritize mandatory approaches aligned with WHO recommendations.

Sugary drink advertising expenditure across Australian media channels 2016-2018

OBJECTIVE

The aim of this study was to describe advertising expenditure for sugary drinks compared with alternative cold non-alcoholic beverages (artificially sweetened beverages, plain water, plain milk) between 2016 and 2018 across Australian media channels.

METHODS

Monthly estimates of advertising expenditure for non-alcoholic beverages were obtained from Nielsen Media and aggregated by product type and media.

RESULTS

Total sugary drink advertising expenditure between 2016 and 2018 ($129.5M) significantly exceeded expenditure on artificially sweetened drinks ($23.26M), plain water ($14.27M), and plain milk ($31.30M). Television and out-of-home advertising accounted for the largest share of sugary drink advertising (45%, 35%). Expenditure on out-of-home advertising was more heavily dominated by sugary drinks (75%) than advertising in all media combined (65%). Sugary drink advertising peaked in warmer months and was lowest in August. Soft drinks (26%), flavoured milks (24%) and energy drinks (21%) accounted for the majority of sugary drink advertising.

CONCLUSIONS

Cold non-alcoholic beverage advertising in Australian media is dominated by the advertising of sugary drinks. Implications for public health: Restricting unhealthy beverage advertising on television and out-of-home media may be most effective initially. However, comprehensive restrictions capturing a broader range of media and settings would be optimal to prevent displacement and limit advertising reach and exposure.

Curtis C, Frieden TR, Cobb LK. Priority Actions to Advance Population Sodium Reduction

High sodium intake is estimated to cause approximately 3 million deaths per year worldwide. The estimated average sodium intake of 3.95 g/day far exceeds the recommended intake. Population sodium reduction should be a global priority, while simultaneously ensuring universal salt iodization. This article identifies high priority strategies that address major sources of sodium: added to packaged food, added to food consumed outside the home, and added in the home. To be included, strategies needed to be scalable and sustainable, have large benefit, and applicable to one of four measures of effectiveness: (1) Rigorously evaluated with demonstrated success in reducing sodium; (2) suggestive evidence from lower quality evaluations or modeling; (3) rigorous evaluations of similar interventions not specifically for sodium reduction; or (4) an innovative approach for sources of sodium that are not sufficiently addressed by an existing strategy. We identified seven priority interventions. Four target packaged food: front-of-pack labeling, packaged food reformulation targets, regulating food marketing to children, and taxes on high sodium foods. One targets food consumed outside the home: food procurement policies for public institutions. Two target sodium added at home: mass media campaigns and population uptake of low-sodium salt. In conclusion, governments have many tools to save lives by reducing population sodium intake.

Food Advertising to Children in New Zealand: A Critical Review of the Performance of a Self-Regulatory Complaints System Using a Public Health Law Framework

New Zealand has the second highest overweight and obese child population in the Organisation for Economic Co-operation and Development (OECD). This paper evaluates whether New Zealand’s self-regulatory controls on the advertising of unhealthy food and beverages to children and young people adequately protects children from the exposure to, and power of, such marketing in order to limit its impact on children’s food and beverage preferences. First, an analysis of the relevant New Zealand Advertising Standards Authority (ASA) Codes was conducted, including the ASA Complaints Board and Appeals Board decisions from 2017–2019 to determine the application of the Codes in practice. Second, a public health law framework was applied to the self-regulatory system. Of the 16 complaints assessed, 12 were not upheld, and only one was upheld under the Children and Young People’s Advertising Code (CYPA Code). Three complaints were upheld under the Advertising Standards Code (ASC) but not the CYPA Code. An analysis of the Codes and their interpretation by the Complaints Board found that many facets of the public health law framework were not met. The self-regulatory system does not adequately protect children from the exposure to, and power of, unhealthy food and beverage marketing, and government-led, comprehensive, and enforceable marketing restrictions are required.

The impact of junk food marketing regulations on food sales: an ecological study

OBJECTIVE

To evaluate the impact of junk food broadcast marketing policies on nationwide junk food sales and identify policy characteristics effective in reducing sales.

METHODS

Country policy data (n = 79) were categorized in a thorough literature review and analysed using a repeated measures design against data on food sales per capita. Study conducted in United States, 2017.

RESULTS

Countries with junk food broadcast marketing policies saw a decrease in junk food sales per capita after implementation, while those without said policies saw an increase (p = 0.013). Countries with statutory policies saw a decrease in sales per capita, while those with only self-regulation saw an increase (p = 0.004). Audience restrictions (p = 0.024) and standardized nutrition criteria (p = 0.008) were policy characteristics significantly associated with a decrease in sales per capita.

CONCLUSIONS

Utilizing a novel approach to evaluate junk food broadcast marketing policies, the study demonstrated that countries with statutory policies saw a significant decrease in junk food sales per capita not seen in countries with no or only self-regulatory policies. To effectively reduce exposure to child-targeted junk food marketing, governments should establish strong, comprehensive statutory regulations. Additionally, countries that implement junk food marketing policies can use food sales data to track policy effectiveness.

A path analysis model of factors influencing children's requests for unhealthy foods

Little is known about the complex combination of factors influencing the extent to which children request unhealthy foods from their parents. The aim of this study was to develop a comprehensive model of influencing factors to provide insight into potential methods of reducing these requests. A web panel provider was used to administer a national online survey to a sample of 1302 Australian parent-child dyads (total sample n=2604). Initial univariate analyses identified potential predictors of children's requests for and consumption of unhealthy foods. The identified variables were subsequently incorporated into a path analysis model that included both parents' and children's reports of children's requests for unhealthy foods. The resulting model accounted for a substantial 31% of the variance in parent-reported food request frequency and 27% of the variance in child-reported request frequency. The variable demonstrating the strongest direct association with both parents' and children's reports of request frequency was the frequency of children's current intake of unhealthy foods. Parents' and children's exposure to food advertising and television viewing time were also positively associated with children's unhealthy food requests. The results highlight the need to break the habitual provision of unhealthy foods to avoid a vicious cycle of requests resulting in consumption.

Factors associated with parents' attitudes to unhealthy foods and beverages

AIM

Previous research has identified convenience, enjoyment, value for money and perceived goodness as primary dimensions of parents' attitudes to foods and beverages. The aim of the present study was to examine the factors associated with parents' scores on each of these attitudinal dimensions to identify key issues for future interventions designed to improve parents' food provision behaviours and children's diets.

METHODS

A sample of 1302 Australian parents of children aged 8 to 14 years completed an online survey relating to their food-related beliefs. Linear regression analyses were undertaken to examine factors associated with parents' attitudes to soft drinks and energy-dense nutrient-poor foods.

RESULTS

Consistent factors were identified for both energy-dense, nutrient-poor foods and soft drinks, indicating that similar approaches could be adopted in interventions for both product categories. The primary factors were social norms, child pestering, television viewing and exposure to food advertising.

CONCLUSIONS

Food advertising represents a common link between the primary factors, indicating that it constitutes a critical component of future interventions designed to modify parents' attitudes to unhealthy food products and to reduce the frequency with which these foods are consumed by children.

Television advertising, not viewing, is associated with negative dietary patterns in children

BACKGROUND

Children's exposure to unhealthy food marketing is a contributor to poor diets and weight gain. Television food advertising, in particular, has been the focus of research and policy discussions.

OBJECTIVES

We aimed to quantify the specific impact of television advertising, as distinct from television viewing generally, on children's usual diet. Methods Four hundred seventeen Australian children aged 10-16 participated in an online survey, which assessed television viewing habits and consumption of 12 frequently advertised unhealthy foods/drinks. Consumption of these foods/drinks was dichotomized (less weekly, weekly or more) and summed (1 point for each item consumed weekly or more) to give cumulative consumption scores.

RESULTS

After adjusting for age and socioeconomic status, there was strong evidence of an increase in unhealthy food score (P < 0.001), drink score (P = 0.002) and food/drink combined score (P < 0.001), with increasing commercial television viewing.

CONCLUSIONS

The link between television viewing and poor diet was strongest for children who watched the most commercial television, and those who were actually exposed to advertisements embedded within programs. This association between advertisement exposure and poor diet emphasizes the need for public policy intervention to reduce children's food advertising exposures.

Government action on diabetes prevention: time to try something new

Type 2 diabetes mellitus, driven by overweight and obesity linked to unhealthy diets, is the fastest-growing non-communicable disease in Australia. Halting the rise of diabetes will require a paradigm shift from personal to shared responsibility, with greater accountability from Australian governments and the food industry. It will also require governments to try something different to the prevailing approaches emphasising education and the provision of information. We propose four priority areas where government regulation could strengthen Australia's response. Those areas relate to mandatory front-of-pack food labelling, regulating junk food advertising, better oversight of food reformulation and taxing sugar-sweetened beverages.

Measuring Food Brand Awareness in Australian Children: Development and Validation of a New Instrument

BACKGROUND

Children's exposure to food marketing is one environmental determinant of childhood obesity. Measuring the extent to which children are aware of food brands may be one way to estimate relative prior exposures to food marketing. This study aimed to develop and validate an Australian Brand Awareness Instrument (ABAI) to estimate children's food brand awareness.

METHODS

The ABAI incorporated 30 flashcards depicting food/drink logos and their corresponding products. An abbreviated version was also created using 12 flashcards (ABAI-a). The ABAI was presented to 60 primary school aged children (7-11 yrs) attending two Australian after-school centres. A week later, the full-version was repeated on approximately half the sample (n=27) and the abbreviated-version was presented to the remaining half (n=30). The test-retest reliability of the ABAI was analysed using Intra-class correlation coefficients. The concordance of the ABAI-a and full-version was assessed using Bland-Altman plots. The 'nomological' validity of the full tool was investigated by comparing children's brand awareness with food marketing-related variables (e.g. television habits, intake of heavily promoted foods).

RESULTS

Brand awareness increased with age (p<0.01) but was not significantly correlated with other variables. Bland-Altman analyses showed good agreement between the ABAI and ABAI-a. Reliability analyses revealed excellent agreement between the two administrations of the full-ABAI.

CONCLUSIONS

The ABAI was able to differentiate children's varying levels of brand awareness. It was shown to be a valid and reliable tool and may allow quantification of brand awareness as a proxy measure for children's prior food marketing exposure.

Factors influencing the frequency of children's consumption of soft drinks

Among other focus areas, interventions designed to improve children's diets need to address key factors contributing to children's consumption of sugar-sweetened beverages. The present study employed structural equation modelling to investigate the relationship between a broad range of predictor variables and the frequency with which Australian children consume soft drinks. In total, 1302 parents of children aged 8 to 14 years responded to an online survey about their children's food consumption behaviours. Soft drink consumption frequency was primarily influenced by parents' attitudes to soft drinks, children's pestering behaviours, and perceived social norms relating to children's consumption of these products. Importantly, pestering and social norms had significant direct effects on consumption frequency in addition to indirect effects via their impact on parents' attitudes to soft drink.

Obesogenic television food advertising to children in Malaysia: sociocultural variations

BACKGROUND

Food advertising on television (TV) is well known to influence children's purchasing requests and models negative food habits in Western countries. Advertising of unhealthy foods is a contributor to the obesogenic environment that is a key driver of rising rates of childhood obesity. Children in developing countries are more at risk of being targeted by such advertising, as there is a huge potential for market growth of unhealthy foods concomitant with poor regulatory infrastructure. Further, in developing countries with multi-ethnic societies, information is scarce on the nature of TV advertising targeting children.

OBJECTIVES

To measure exposure and power of TV food marketing to children on popular multi-ethnic TV stations in Malaysia.

DESIGN

Ethnic-specific popular TV channels were identified using industry data. TV transmissions were recorded for each channel from November 2012 to August 2013 (16 hr/day) for randomly selected weekdays and weekend days during normal days and repeated during school holidays (n=88 days). Coded food/beverage advertisements were grouped into core (healthy), non-core (non-healthy), or miscellaneous (unclassified) food categories. Peak viewing time (PVT) and persuasive marketing techniques were identified.

RESULTS

Non-core foods were predominant in TV food advertising, and rates were greater during school holidays compared to normal days (3.51 vs 1.93 food ads/hr/channel, p<0.001). During normal days' PVT, the ratio of non-core to core food advertising was higher (3.25 food ads/hr/channel), and this more than trebled during school holidays to 10.25 food ads/hr/channel. Popular channels for Indian children had the lowest rate of food advertising relative to other ethnic groups. However, sugary drinks remained a popular non-core product advertised across all broadcast periods and channels. Notably, promotional characters doubled for non-core foods during school holidays compared to normal days (1.91 vs 0.93 food ads/hr/channel, p<0.001).

CONCLUSIONS

This study highlights non-core food advertising, and predominantly sugary drinks are commonly screened on Malaysian TV channels. The majority of these sugary drinks were advertised by multinational companies, and this observation warrants regulatory attention.

Industry self-regulation and TV advertising of foods to Australian children

AIM

The aim of this study is to examine the amount of non-core (unhealthy) food advertising currently on Australian television (i) during children's programmes and viewing times; (ii) since the introduction of food industry self-regulatory initiatives in 2009; and (iii) whether advertising differs according to signatory status to industry initiatives.

METHODS

We systematically searched PubMed, Embase.com and JSTOR (media/marketing) databases; grey literature; and reference lists of relevant articles for studies published since 2009 that reported on food advertising on Australian television.

RESULTS

The title and abstract of 316 articles were screened, yielding 25 articles considered potentially eligible, of which eight met the pre-defined selection criteria. Meta-analysis was not possible because of temporal and methodological differences across studies. The advertising of non-core foods was found to be negligible during programmes with a C-(children's) classification but ranged from 1.5 to 6.5/h during children's peak viewing times. From 2006 to 2011, non-core food advertising decreased by 0.18 advertisements per hour every year, whereas fast food advertising increased by 0.09/h; however, these analyses are based on one study with only five time points. During children's viewing times, signatories to industry initiatives advertise non-core foods at higher rates than non-signatories.

CONCLUSIONS

Although it is not possible to determine whether advertising has changed since the industry initiatives were introduced, signatories to the initiatives continue to advertise non-core foods at times when many children watch television. Future efforts to reduce children's exposure to food advertising should be focused on advertising during children's peak viewing times rather than by programme classifications.