Nutritional quality and marketing strategies of fast food children's combo meals in Guatemala

A systematic review of the adolescent-directed marketing strategies of transnational fast food companies in low- and middle-income countries

INTRODUCTION

Fast food consumption is associated with excessive intake of energy-dense foods; a major determinant of childhood obesity. The lack of data on the marketing strategies used to promote fast food to adolescents in low and middle-income countries (LMICs) acts as a barrier to global efforts to reduce the marketing of unhealthy foods to young people around the world.

OBJECTIVES

This systematic review aimed to identify the adolescent-directed marketing strategies of transnational fast food corporations in LMICs.

METHODS

A systematic search of eight scientific databases (PubMed, CINAHL, Medline, Embase, ProQuest, PsycInfo, Scopus and Google Scholar) was conducted. Following PRISMA guidelines, primary research articles written in English were included if they were published between 1 January 2010 and 30 December 2022, and reported any adolescent-directed marketing activity undertaken by a transnational fast food company operating in a LMIC. Articles were excluded if they were not peer reviewed. The quality of the included articles was assessed using a condensed version of the Consolidated Criteria for Reporting Qualitative Research tool.

RESULTS

Twelve articles met the eligibility criteria and were included in this review. A narrative synthesis of these articles revealed that the most documented strategies used to promote fast food to adolescents in LMICs were the use of incentives or premium offers, product appeals, promotional characters and brand familiarity. These strategies were mostly observed on social media, suggesting that there are serious concerns about adolescent exposure to fast food via social media in developing settings, especially as contextual differences in the nature of such marketing were identified.

DISCUSSION

The promotion of fast food to adolescents in LMICs is contextual in nature, with the nature of marketing strategies employed by transnational fast food corporations varying greatly across cultural and socio-economic contexts. These findings are crucial for the development of guidelines and regulations restricting the marketing of fast food to adolescents in lower income settings, contributing to global efforts to reduce adolescent exposure to unhealthy food promotion.

Price promotions offered by quick service restaurants in Australia: analysis from an obesity prevention perspective

OBJECTIVE

To assess the price promotions offered by major quick service restaurant (QSR) chains in Australia from an obesity prevention perspective.

DESIGN

Cross-sectional audit of ten of the largest QSR chains in Australia. We collected information regarding temporary price promotions and 'combination deals' offered by each chain over thirteen consecutive weeks in 2019-2020. We assessed the type of promotions, the magnitude of discount, and the energy content and healthiness of items promoted (based on Victorian Government criteria).

SETTING

Melbourne, Australia.

PARTICIPANTS

Ten major QSR chains.

RESULTS

Temporary price promotions (n 196) and combination deals (n 537 on regular menus, n 36 on children's menus) were observed across the ten selected QSR chains. In relation to temporary price promotions, the mean magnitude of discount for main menu items (n 75) was 41·7 %. The price reductions and energy content of combination deals varied substantially the by chain, the meal size and the sides/drinks selected as part of the 'deal'. When the lowest-energy options (e.g. small chips, small sugar-free drink) were included as part of each combination deal, the mean energy content was 2935 kJ, compared to 5764 kJ when the highest-energy options (e.g. large fries, large sugar-sweetened drink) were included. Almost all available products were classified as unhealthy.

CONCLUSION

Price promotions are ubiquitous in major QSR chains in Australia and provide incentives to consume high levels of energy. The action to restrict price promotions on unhealthy foods and ensure lower-energy default items as part of combination deals should be included as part of efforts to improve population diets and address obesity in Australia.

Energy, Sodium, Sugar and Saturated Fat Content of New Zealand Fast-Food Products and Meal Combos in 2020

This study aimed to benchmark the healthiness of the New Zealand (NZ) fast-food supply in 2020. There are currently no actions or policies in NZ regarding the composition, serving size and labeling of fast food. Data on serving size and nutrient content of products was collected from company websites and in-store visits to 27 fast-food chains. For each fast-food category and type of combo meal, medians and interquartile ranges were calculated for serving size and energy, sodium, total sugar, and saturated fat per serving. Nutrient contents/serving were benchmarked against the United Kingdom (UK) soft drinks levy sugar thresholds and targets for salt for away from home foods, the NZ daily intake guidelines for energy, sodium, and saturated fat, and the World Health Organization (WHO) recommendation for free sugars. Analyses were conducted for the 30.3% (n = 1772) of products with available nutrition information and for 176 meal combos. Most (n = 67; 91.8%) sugar-sweetened drinks would qualify for a UK soft drink industry levy and 47% (n = 1072) of products exceeded the relevant UK sodium target. Half of the meal combos provided at least 50.3% of the daily energy requirements and at least 88.6% of the maximum recommended intake of sodium. Fast-food products and combo meals in NZ contribute far more energy and negative nutrients to recommended daily intake targets than is optimal for good health. The NZ Government should set reformulation targets and serving size guidance to reduce the potential impact of fast- food consumption on the health of New Zealanders.

Gender representation in food and beverage print advertisements found in corner stores around schools in Peru and Guatemala

Objective

The objective of this study is to assess gender representation in food and beverage print advertisements.

Results

The study follows a quantitative descriptive approach. Using a content analysis technique, we assessed the gender representation in 200 food and beverage print advertisements found in corner stores located in four areas around schools in Lima, Peru, and Guatemala City, Guatemala (100 advertisements per country). A total of 36% of the print advertisements exhibited a male main character for the case of Guatemala, while in Peru 14% of the print advertisements presented a male main character. Furthermore, in Guatemala, 22% of the main characters were male animated characters. Moreover, 27% of the print advertisements in Guatemala and 17%, in Peru were visually male-oriented. Overall, male characters appeared alongside sports references and in varied settings, whereas female characters were usually holding or consuming the product. In conclusion, although the majority of variables used to assess the representation of gender in food and beverage print advertisements were gender-neutral, those showing gender representation were mostly male-oriented. Despite its limited findings, the study provides evidence for the formulation of public policies and educational content aimed to protect children’s and adolescents’ health from the effects of food marketing.

Soft drinks and premiums with children's meals marketed on the websites of the top restaurant chains worldwide

OBJECTIVE

To assess the frequency with which soft drinks and premiums are available with children's meals marketed on the top restaurant chains' websites worldwide.

DESIGN

Cross-sectional structured observational assessment of secondary information about top international restaurant chain children's meals.

SETTING

Websites of top restaurant chains for 193 countries and five regions of the United Nations.

PARTICIPANTS

Top restaurant chains (including McDonald's, Subway, Burger King and KFC) across 193 countries. Children's meal images and descriptions were reviewed to determine if the meal was marketed with a soft drink as a beverage option and whether the meal offered a premium.

RESULTS

Children's meals were marketed online on restaurant websites by at least one of the four chains in a total of seventy eight of the 193 countries (40·4 %). Overall, 56·3 % of countries with any online children's meal marketing by the four chains included at least one chain that marketed soft drinks and 92·3 % marketed premiums with the meal.

CONCLUSIONS

Every region in the world includes marketing of children's meals on the websites of the top restaurant chains. The high prevalence of premiums marketed online with children's meals is of concern. Similarly, with over 50 % of countries with online children's meal marketing having at least one chain that offers soft drinks as part of the meals, additional regulation and education may be warranted.

Nutrition composition of children's meals in twenty-six large US chain restaurants

OBJECTIVE

To compare the nutritional quality of children's combination meals offered at large US chain restaurants characterised by three versions - default (advertised), minimum (lower-energy) and maximum (higher-energy).

DESIGN

We identified default children's meals (n 92) from online restaurant menus, then constructed minimum and maximum versions using realistic additions, substitutions and/or portion size changes for existing menu items. Nutrition data were obtained from the MenuStat database. Bootstrapped linear models assessed nutrition differences between meal versions and the extent to which meal components (main dish, side dish, beverage) drove differences across versions. For each version, we examined the proportion of meals meeting the Guidelines for Responsible Food Marketing to Children.

SETTING

Twenty-six fast-food and fast-casual restaurants, in 2017.

PARTICIPANTS

None.

RESULTS

Nutrient values differed significantly across meal versions for energy content (default 2443 kJ (584 kcal), minimum 1674 kJ (400 kcal), maximum 3314 kJ (792 kcal)), total fat (23, 17, 33 g), saturated fat (8, 6, 11 g), Na (1046, 915, 1287 mg) and sugar (35, 14, 51 g). The substitution of lower-energy beverages resulted in the greatest reduction in energy content (default to minimum, -418 kJ (-100 kcal)) and sugar (-20 g); choosing lower-energy side dishes resulted in the greatest reduction in total fat (default to minimum, -4 g), saturated fat (-1·1 g) and Na (-69 mg). Only 3 % of meals met guidelines for all nutrients.

CONCLUSIONS

Realistic modifications to children's combination meals using existing menu options can significantly alter a meal's nutrient composition. Promoting lower-energy items as the default option, especially for beverages and side dishes, has a potential to reduce fat, saturated fat and/or sugar in children's meals.

Scoping review of studies on food marketing in Latin America: Summary of existing evidence and research gaps

OBJECTIVE

To document the evidence about marketing of ultra-processed foods and "non-alcoholic" beverages in Latin America.

METHODS

We performed a structured search of quantitative and qualitative studies in PubMed, SciELO and LILACS, published between January 2000 and May 2017 and conducted in Latin America. We conducted a quality assessment following a standardized tool and a thematic analysis to identify key typologies of marketing across studies.

RESULTS

Out of 521 studies screened by title and abstract, we included 36 in this review; 27 of them analyzed television advertisement. Other marketing channels studied were food packaging, point of sale and outdoor advertisement. Studies found television advertises foods and beverages that are mostly ultraprocessed foods and have low nutritional value, particularly those promoted during children's programming. We also observed children have a literal interpretation of images printed on food packaging, so this can be deceiving. Several studies also found proximity to unhealthy foods may increase their consumption. Finally, the thematic analysis identified the following typologies of food marketing: a) television advertisement, b) food packaging marketing, c) marketing strategies at points of sale and d) other marketing strategies. We found almost no advertisements for unprocessed or minimally processed foods such as fruits and vegetables. We did not find any studies on digital marketing conducted in the region.

CONCLUSIONS

This review found that the main channel of food marketing was television advertising. This synthesis provides insights to the challenges unhealthy eating represents to the public health of Latin America and identifies knowledge gaps to guide future research.

The food environment in Latin America: a systematic review with a focus on environments relevant to obesity and related chronic diseases

OBJECTIVE

Food environments may be contributing to the rapid increase in obesity occurring in most Latin American (LA) countries. The present study reviews literature from LA that (i) describes the food environment and policies targeting the food environment (FEP); and (ii) analytic studies that investigate associations between the FEP and dietary behaviours, overweight/obesity and obesity related chronic diseases. We focus on six dimensions of the FEP: food retail, provision, labelling, marketing, price and composition.

DESIGN

Systematic literature review. Three databases (Web of Science, SciELO, LILACS) were searched, from 1 January 1999 up to July 2017. Two authors independently selected the studies. A narrative synthesis was used to summarize, integrate and interpret findings.

SETTING

Studies conducted in LA countries.

PARTICIPANTS

The search yielded 2695 articles of which eighty-four met inclusion criteria.

RESULTS

Most studies were descriptive and came from Brazil (61 %), followed by Mexico (18 %) and Guatemala (6 %). Studies were focused primarily on retail/provision (n 27), marketing (n 16) and labelling (n 15). Consistent associations between availability of fruit and vegetable markets and higher consumption of fruits and vegetables were found in cross-sectional studies. Health claims in food packaging were prevalent and mostly misleading. There was widespread use of marketing strategies for unhealthy foods aimed at children. Food prices were lower for processed relative to fresh foods. Some studies documented high sodium in industrially processed foods.

CONCLUSIONS

Gaps in knowledge remain regarding policy evaluations, longitudinal food retail studies, impacts of food price on diet and effects of digital marketing on diet/health.

Progress Evaluation for Transnational Restaurant Chains to Reformulate Products and Standardize Portions to Meet Healthy Dietary Guidelines and Reduce Obesity and Non-Communicable Disease Risks, 2000-2018: A Scoping and Systematic Review to Inform Policy

Transnational restaurant chains sell food and beverage products in 75 to 139 countries worldwide linked to obesity and non-communicable diseases (NCDs). This study examined whether transnational restaurant chains reformulated products and standardized portions aligned with healthy dietary guidelines and criteria. Firstly, we describe the transnational restaurant industry structure and eating trends. Secondly, we summarize results from a scoping review of healthy dietary guidelines for restaurants. Thirdly, we describe a systematic review of five electronic databases (2000-2018) to identify studies on nutrient profile and portion size changes made by transnational restaurants over 18 years. We used Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines, identified 179 records, and included 50 studies conducted in 30 countries across six regions. The scoping review found a few expert-recommended targets for restaurants to improve offerings, but no internationally accepted standard for portions or serving sizes. The systematic review results showed no standardized assessment methods or metrics to evaluate transnational chain restaurants' practices to improve menu offerings. There was wide variation within and across countries, regions, firms, and chains to reduce energy, saturated and trans fats, sodium, and standardized portions. These results may inform future research and encourage transnational chain restaurants to offer healthy product profiles and standardized portions to reduce obesity and NCD risks worldwide.

Development of a nonlinear hierarchical model to describe the disposition of deuterium in mother-infant pairs to assess exclusive breastfeeding practice

The World Health Organization recommends exclusive breastfeeding (EBF) for the first 6 months after birth. The deuterium oxide dose-to-the-mother (DTM) technique is used to distinguish EBF based on a cut-off (< 25 g/day) of water intake from sources other than breastmilk. This value is based on a theoretical threshold and has not been verified in field studies. The aim of this study was to estimate the water intake cut-off value that can be used to define EBF practice. One hundred and twenty-one healthy infants, aged 2.5-5.5 months who were deemed to be EBF were recruited. After administration of deuterium to the mothers, saliva was sampled from mother and infant pairs over a 14-day period. Validation of infant feeding practices was conducted via home observation over six non-consecutive days with caregiver recall. A fully Bayesian framework using a gradient-based Markov chain Monte Carlo approach implemented in Stan was used to estimate the cut-off of non-milk water intake of EBF infants. From the original data set, 113 infants were determined to be EBF and provided 1500 paired mother-infant observations. The deuterium saliva concentrations were best described by two linked 1-compartment models (mother and infant), with body weight as a covariate on the mother's volume of distribution and infant's body weight on infant's water clearance rate. The cut-off value was based on the 90th percentile of the posterior distribution of non-milk water intake and was 86.6 g/day. This cut-off value can be used in future field studies in other geographic regions to determine exclusivity of breast feeding practices in order to determine their potential public health needs.