Regulating and litigating in the public interest: regulating food marketing to young people worldwide: trends and policy drivers

When Students Patronize Fast-Food Restaurants near School: The Effects of Identification with the Student Community, Social Activity Spaces and Social Liability Interventions

US schools have fast-food restaurants nearby, encouraging student patronage, unhealthy consumption, and weight gain. Geographers have developed an activity space framework which suggests this nearby location effect will be moderated by whether people perceive the location as their activity space. Therefore, we study whether students perceive a fast-food restaurant near school as their activity space, and whether social marketing messages can change that perception. We conducted six studies: a secondary data analysis with 5986 students, a field experiment with 188 students, and four lab experiments with 188, 251, 178, and 379 students. We find that students who strongly identify with their student community patronize a fast-food restaurant near school (vs. farther away) because they view it as their activity space, while students who weakly identify do not. For example, in our field experiment, 44% vs. 7% of students who strongly identified with the student community patronized the near versus farther restaurant, while only 28% versus 19% of students who weakly identified patronized the near and farther restaurants comparably. We also find that to deter the strong identifiers, messages should convey that patronage is a social liability, e.g., portray student activism against fast food. We show that standard health messages do not change perceptions of restaurants as social activity spaces. Thus, to combat the problem of fast-food restaurants near schools causing unhealthy consumption, policy and educational interventions should focus on students who strongly identify with their student community and find ways to weaken their perceptions that fast-food restaurants near schools are their activity spaces.

Designing legislative responses to restrict children’s exposure to unhealthy food and non-alcoholic beverage marketing: a case study analysis of Chile, Canada and the United Kingdom

Introduction

Introducing legislation that restricts companies from exposing children to marketing of unhealthy food and beverage products is both politically and technically difficult. To advance the literature on the technical design of food marketing legislation, and to support governments around the world with legislative development, we aimed to describe the legislative approach from three governments.

Methods

A multiple case study methodology was adopted to describe how three governments approached designing comprehensive food marketing legislation (Chile, Canada and the United Kingdom). A conceptual framework outlining best practice design principles guided our methodological approach to examine how each country designed the technical aspects of their regulatory response, including the regulatory form adopted, the substantive content of the laws, and the implementation and governance mechanisms used. Data from documentary evidence and 15 semi-structured key informant interviews were collected and synthesised using a directed content analysis.

Results

All three countries varied in their legislative design and were therefore considered of variable strength regarding the legislative elements used to protect children from unhealthy food marketing. When compared against the conceptual framework, some elements of best practice design were present, particularly relating to the governance of legislative design and implementation, but the scope of each law (or proposed laws) had limitations. These included: the exclusion of brand marketing; not protecting children up to age 18; focusing solely on child-directed marketing instead of all marketing that children are likely to be exposed to; and not allocating sufficient resources to effectively monitor and enforce the laws. The United Kingdom’s approach to legislation is the most comprehensive and more likely to meet its regulatory objectives.

Conclusions

Our synthesis and analysis of the technical elements of food marketing laws can support governments around the world as they develop their own food marketing restrictions. An analysis of the three approaches illustrates an evolution in the design of food marketing laws over time, as well as the design strengths offered by a legislative approach. Opportunities remain for strengthening legislative responses to protect children from unhealthy food marketing practices.

Public Health Roles in Addressing Commercial Determinants of Health

The shared challenges posed by the production and distribution of health-harming products have led to growing recognition of the need for policy learning and transfer across problems, populations, and social contexts. The commercial determinants of health (CDoH) can serve as a unifying concept to describe the population health consequences arising from for-profit actors and activities, along with the social structures that sustain them. Strategies to mitigate harms from CDoH have focused on behavioral change, regulation, fiscal policies, consumer and citizen activism, and litigation. While there is evidence of effective measures for each strategy, approaches that combine strategies are generally more impactful. Filling gaps in evidence can inform ways of adapting these strategies to specific populations and social contexts. Overall, CDoH are addressed most effectively not through siloed efforts to reduce consumption of health-harming products, but instead as a set of integrated strategies to reduce exposures to health-harming commercial actors and activities.

Expected final online publication date for the Annual Review of Public Health, Volume 43 is April 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Providing Measurement, Evaluation, Accountability, and Leadership Support (MEALS) for Non-communicable Diseases Prevention in Ghana: Project Implementation Protocol

Background: This study describes the rationale, adaptation, and final protocol of a project developed to address the increase in obesity and nutrition-related non-communicable diseases (NR-NCDs) in Ghana. Code-named the Measurement, Evaluation, Accountability, and Leadership Support for NCDs (MEALS4NCDs) project, it aims to measure and support public sector actions that create healthy food marketing, retail, and provisioning environments for Ghanaian children using adapted methods from the International Network for Food and Obesity/NCDs Research Monitoring and Action Support (INFORMAS).

Methods: The protocol for this observational study draws substantially from the INFORMAS' Food Promotion and Food Provision Modules. However, to appraise the readiness of local communities to implement interventions with strong potential to improve food environments of Ghanaian children, the MEALS4NCDs protocol has innovatively integrated a local community participatory approach based on the community readiness model (CRM) into the INFORMAS approaches. The setting is Ghana, and the participants include health and nutrition policy-makers, nutrition and food service providers, consumers, school authorities, and pupils of Ghanaian basic schools.

Results: The study establishes a standardized approach to providing implementation science evidence for the prevention of non-communicable diseases (NCDs) in Ghana. It demonstrates feasibility and the innovative application of the INFORMAS expanded food promotion and food provision modules, together with the integration of the CRM in a lower-middle income setting.

Conclusion: The research will facilitate the understanding of the processes through which the INFORMAS approach is contextualized to a lower-middle income African context. The protocol could be adapted for similar country settings to monitor relevant aspects of food environments of children.

The policy implications of 'thinking problematically': problematizing Big Food's role in obesity policymaking

Practitioners need to engage with the contested nature of public health policymaking. This study, stemming from a concern that the involvement of Big Food is not widely problematized in health promotion practice, used 'What's the Problem Represented to Be?' discourse analysis to examine how Big Food, as a discursive actor, reacted to and shaped a problem representation of childhood obesity. Analysis of Big Food documents, including Coca-Cola and Burger King, developed during the regulation of broadcast advertising to children in Ireland found that Big Food constructs the problem of childhood obesity in a way which privileges its role as policy actor; it draws on and undermines public health discourses of obesity; and it negates the impact of corporate practices on obesity and on related policymaking. An in-depth analysis of Big Food's own documents provides access to the processes of knowledge production and governing undertaken by Big Food. The study offers two tools of resistance for health promotion practitioners to interrogate and challenge Big Food-problematization as a policy tool and 'corporate influence' as a critical public health discourse.

Governmental policies to reduce unhealthy food marketing to children

Reducing children's exposure to food marketing is an important obesity prevention strategy. This narrative review describes current statutory regulations that restrict food marketing; reviews available evidence on the effects of these regulations; and compares policy design elements in Chile and the United Kingdom. Currently, 16 countries have statutory regulations on unhealthy food marketing to children. Restrictions on television advertising, primarily during children's programming, are most common. Schools are also a common setting for restrictions. Regulations on media such as cinema, mobile phone applications, print, packaging, and the internet are uncommon. Eleven evaluations of policies in 4 jurisdictions found small or no policy-related reductions in unhealthy food advertising, in part because marketing shifted to other programs or venues; however, not all policies have been evaluated. Compared with the United Kingdom, Chile restricts marketing on more products, across a wider range of media, using more marketing techniques. Future research should examine which elements of food marketing policy design are most effective at reducing children's exposure to unhealthy food marketing.

Development of a Responsible Policy Index to Improve Statutory and Self-Regulatory Policies that Protect Children's Diet and Health in the America's Region

In 2010, 193 Member States of the World Health Organization (WHO) endorsed World Health Assembly Resolution WHA63.14 to restrict the marketing of food and beverage products high in fat, sugar and salt (HFSS) to children to prevent obesity and non-communicable diseases (NCDs). No study has examined HFSS marketing policies across the WHO regional office countries in the Americas. Between 2018 and 2019, a transdisciplinary team examined policies to restrict HFSS food and beverage product marketing to children to develop a responsible policy index (RESPI) that provides a quality score based on policy characteristics and marketing techniques. After designing the RESPI, we conducted a comprehensive literature review through October 2019 to examine policies in 14 countries in the WHO Americans Region. We categorized policies (n = 38) as either self-regulatory or statutory and calculated the RESPI scores, ranked from 0 (lowest) to 10 (highest). Results showed Brazil, Canada, Chile, and Uruguay had the highest RESPI scores associated with statutory policies that restricted point of sale, cartoon, licensed media characters and celebrities; and HFSS products in schools and child care settings, and broadcast and print media. Policymakers can use the RESPI tool to evaluate marketing policies within and across geopolitical boundaries to protect children's diet and health.

A Delphi study for exploring nutritional policy priorities to reduce prevalence of non-communicable diseases in Islamic Republic of Iran

Background: Identifying and prioritizing the most appropriate policies for enhancing nutritional habits are vital for the prevention and control of non-communicable diseases (NCDs). This study was conducted to prioritize the nutritional policies in Iran. Methods: A cross-sectional survey applying the two-round Delphi technique was used to prioritize policy options in preventing the burden of NCDs. In the first round, the experts in health and nutrition policy were asked to prioritize 21 policy options on a 5-point Likert scale. After analyzing the first-round questionnaire, the highest mean and lowest dispersion index were calculated as an indicator of high-priority options. In the second round, the policy options suggested by the participants were added to the second-round questionnaire. Finally, the questionnaires were sent to all the participants in case they desired to change their opinions. Results: The expert achieved consensus on "principles of healthy eating" courses in the curriculum of students as a high-priority policy option. In this regard, "promoting community education and customizing healthy food choice" was the next high priority policy option. On the other hand, the lowest policy priority option was "sending free/low-price healthy drinks at home". The three high priority policy categories were reformulating the content of food, enhancing the consumers' knowledge, and food labeling, respectively. Conclusion: Our findings showed that reformulation, food promotion, and food labeling had the highest priorities for preventing NCDs in Iran. Although food provision policies were cost effective in developing countries such as Iran, it is essential to provide sub-structures for the reformulation of food products.

"Responses to the Chilean law of food labeling and advertising: exploring knowledge, perceptions and behaviors of mothers of young children"

Background

In line with calls for action from international health organizations, Chile implemented in June 2016 a set of regulations to tackle the obesity epidemic. The new regulation includes the mandatory use of front-of-package warning labels on packaged foods/beverages high in energy, sugars, saturated fats and sodium. Additionally, such foods cannot be sold nor offered in daycares/schools and cannot be promoted to children under 14yo. The law is targeted to children; thus, this study examined mothers’ understanding, perceptions, and behaviors associated with the regulation one year after its implementation, using a qualitative approach.

Methods

Nine focus groups of mothers (7–10 people each) of children (2-14yo) were conducted in July 2017 in Santiago-Chile. They were stratified by socioeconomic status (SES) and children’s age. Macrocodes were developed by three researchers, combining an iterative process of deductive and inductive thematic analyses. Quotations representing each category were selected.

Results

Mothers understood the new regulation as a policy to fight child obesity and were aware that products with more labels were less healthy than products with fewer labels. Attention and use of labels in the buying decision-making process ranged from participants who did not pay attention to others who relied on them as a quick shortcut (mostly from middle and upper-SES); many mothers indicated changing their purchase habits only when buying new products. Mothers declared that young children accepted school environment changes while teens/preteens resisted them more. Many mothers agreed that schools have become key promoters of food behavioral change. Mothers were less aware about the food marketing regulations. Mothers declared that they perceived that the regulation was changing the perceptions, attitudes and behaviors toward healthier eating patterns.

Conclusion

After the first year of implementation, the regulation was well known by mothers of diverse SES and different children ages. The degree of use of warning labels was heterogeneous among participants, but most of them agreed that their children, particularly the youngest have positive attitudes toward the regulation and have become promoters of change in their families. Many mothers also expressed that they perceived an important shift toward healthier eating, which may lead to a change in eating social norms. This information contributes to better understand how regulatory actions may influence people’s consumer behaviors.

Race, Ethnicity, and Other Factors Predicting U.S. Parents' Support for Policies to Reduce Food and Beverage Marketing to Children and Adolescents

Purpose: Examine parents' support for policies to reduce unhealthy food and beverage marketing to children and adolescents and identify racial, ethnic, and other sociodemographic characteristics that predict support. Methods: Online survey of U.S. parents (N=3356) with children 2-17 years of age conducted annually (2009-2012). Participants provided attitudes about food marketing to their children, including perceived negative impact and support for food marketing-related policies. Sociodemographic characteristics examined were as follows: race, ethnicity, income, gender, political orientation, and child characteristics. Results: Overall, parents agreed that food marketing negatively impacts their children's eating habits (M=6.87±2.08 out of 10) and supported food marketing-related policies (M=6.73±2.37). Perceived negative impact predicted support and was highest among black and Hispanic parents. Controlling for income and age of children in the household, Hispanic and black parents expressed highest support for policies, as did women and parents who identified as liberal or moderate in political orientation. A significant interaction between parents' political orientation and race/ethnicity indicated similarly high support among all parents, except white non-Hispanic conservative parents. Conclusion: These findings are encouraging for efforts to enact policies to address unhealthy food marketing to youth. High levels of support among parents suggest advocates should continue to engage parents in their efforts. Findings also suggest that families of color would welcome policies limiting unhealthy food marketing to youth in their communities. Issues of targeted marketing and disproportionate exposure to unhealthy food marketing by black and Hispanic youth may be incorporated into campaigns to address food justice and health inequities in communities of color.

Cardiovascular Disease Prevention by Diet Modification: JACC Health Promotion Series

Reduction in excess calories and improvement in dietary composition may prevent many primary and secondary cardiovascular events. Current guidelines recommend diets high in fruits, vegetables, whole grains, nuts, and legumes; moderate in low-fat dairy and seafood; and low in processed meats, sugar-sweetened beverages, refined grains, and sodium. Supplementation can be useful for some people but cannot replace a good diet. Factors that influence individuals to consume a low-quality diet are myriad and include lack of knowledge, lack of availability, high cost, time scarcity, social and cultural norms, marketing of poor-quality foods, and palatability. Governments should focus on cardiovascular disease as a global threat and enact policies that will reach all levels of society and create a food environment wherein healthy foods are accessible, affordable, and desirable. Health professionals should be proficient in basic nutritional knowledge to promote a sustainable pattern of healthful eating for cardiovascular disease prevention for both healthy individuals and those at higher risk.

Association between parental consumer attitudes with their children's sensory taste preferences as well as their food choice

Background

We investigated the association between the consumer attitudes of European parents and their children’s taste preferences and food choice. Furthermore, we studied whether the parental consumer attitudes were related to education level.

Methods

This analysis included 1,407 IDEFICS study children aged 6.0 to 11.8 years and from 7 European countries, who participated in the sensory taste perception module between 2007 and 2010. Parental consumer attitude was operationalized as ‘trusting in foods known from advertisements’ (trusting advertisements) and as ‘not avoiding additives in food’ (not avoiding additives). Parents reported their educational attainment and completed a food frequency questionnaire for their children. Consumption frequencies of sweet, fatty and processed foods as well as a healthy diet adherence score were calculated. Children performed fat, sweet and umami taste preference tests. Multivariable logistic models were used to analyse the association between parental consumer attitudes and their children’s taste preference frequencies as well as parental education. Linear regression models were used to analyse the association between parental consumer attitudes and their children’s food consumption.

Results

Parental consumer attitudes were not associated with children’s fat, sweet and umami taste preferences. Children of parents trusting advertisements consumed more frequently processed foods (β = 1.21, 95% CI: 0.49; 1.93). Children of parents not avoiding additives consumed more often sweet, fatty and processed foods and had a lower healthy diet adherence score (β = 2.37, 95% CI: 1.03; 3.70; β = 2.27, 95% CI: 1.12; 3.43; β = 0.91, 95% CI: 0.22; 1.59; β = -2.87, 95% CI: -3.89; -1.85, respectively). Unfavourable parental consumer attitudes were associated with a lower parental education level across Europe (Compared to high education: Odds Ratio (OR) of trusting advertisements with medium education: 1.04, 95% CI: 0.77; 1.40; OR with low education: 2.01, 95% CI: 1.15; 3.54; OR of not avoiding additives with medium education: 1.91, 95% CI: 1.44; 2.54; OR with low education: 1.76, 95% CI: 0.96; 3.24).

Conclusions

Across Europe, unfavourable parental consumer attitudes are associated with a lower diet quality of their children. Parental consumer attitudes in turn were associated with their own level of education. This has implications for policy makers, interventions and health promotion programmes that aim to promote healthy eating.

Obesity and the food system transformation in Latin America

The Latin America and the Caribbean (LAC) region faces a major diet-related health problem accompanied by enormous economic and social costs. The shifts in diet are profound: major shifts in intake of less-healthful low-nutrient-density foods and sugary beverages, changes in away-from-home eating and snacking and rapid shifts towards very high levels of overweight and obesity among all ages along with, in some countries, high burdens of stunting. Diet changes have occurred in parallel to, and in two-way causality with, changes in the broad food system - the set of supply chains from farms, through midstream segments of processing, wholesale and logistics, to downstream segments of retail and food service (restaurants and fast food chains). An essential contribution of this piece is to marry and integrate the nutrition transition literature with the literature on the economics of food system transformation. These two literatures and debates have been to date largely 'two ships passing in the night'. This review documents in-depth the recent history of rapid growth and transformation of that broad food system in LAC, with the rapid rise of supermarkets, large processors, fast food chains and food logistics firms. The transformation is the story of a 'double-edged sword', showing its links to various negative diet side trends, e.g. the rise of consumption of fast food and highly processed food, as well as in parallel, to various positive trends, e.g. the reduction of the cost of food, de-seasonalization, increase of convenience of food preparation reducing women's time associated with that and increase of availability of some nutritious foods like meat and dairy. We view the transformation of the food system, as well as certain aspects of diet change linked to long-run changes in employment and demographics (e.g. the quest for convenience), as broad parameters that will endure for the next decades without truly major regulatory and fiscal changes. We then focus in on what are the steps that are being and can be taken to curb the negative effects on diet of these changes. We show that countries in LAC are already among the global leaders in initiating demand-related solutions via taxation and marketing controls. But we also show that this is only a small step forward. To shift LAC's food supply towards prices that incentivize consumption of healthier diets and demand away from the less healthy component is not simple and will not happen immediately. We must be cognizant that ultimately, food industry firms must be incentivized to market the components of healthy diets. This will primarily need to be via selective taxes and subsidies, marketing controls, as well as food quality regulations, consumer education and, in the medium term, consumers' desires to combine healthier foods with their ongoing quest for convenience in the face of busy lives. In the end, the food industry in LAC will orient itself towards profitable solutions, ie those demanded by the broad mass of consumers.

Civil society in global health policymaking: a critical review

BACKGROUND

A social science approach to the study of civil society's role and influence in global health policymaking is a new area of scholarly research. In this article, I conduct a critical literature review to assess the recent research done on this topic.

MAIN BODY

I find that most research has been narrowly focused on the agenda-setting and policy implementation stages, failing to account for all stages of the policymaking process and civil society's role in it. Additionally, very little effort has been made to test and develop theoretical and analytical policymaking frameworks, clearly and consistently defining and conceptualizing civil society's role and influence in global health policymaking, provide methodological specificity and diversity, while emphasizing the importance of causal mechanisms.

CONCLUSION

I conclude by encouraging scholars to address these lacuna in the literature and to explore the utility of political science theory and alternative policymaking models to better define and explain the complexity of civil society's role and influence in global health policymaking processes.

Fostering the Catalyst Role of Government in Advancing Healthy Food Environments

Effective approaches to non-communicable disease (NCD) prevention require intersectoral action targeting health and engaging government, industry, and society. There is an ongoing vigorous exploration of the most effective and appropriate role of government in intersectoral partnerships. This debate is particularly pronounced with regards to the role of government in controlling unhealthy foods and promoting healthy food environments. Given that food environments are a key determinant of health, and the commercial sector is a key player in shaping such environments (eg, restaurants, grocery stores), the relationship between government and the commercial sector is of primary relevance. The principal controversy at the heart of this relationship pertains to the potential influence of commercial enterprises on public institutions. We propose that a clear distinction between the regulatory and catalyst roles of government is necessary when considering the nature of the relationship between government and the commercial food sector. We introduce a typology of three catalyst roles for government to foster healthy food environments with the commercial sector and suggest that a richer understanding of the contrasting roles of government is needed when considering approaches NCD prevention via healthy food environments.

The obesogenic environment around elementary schools: food and beverage marketing to children in two Mexican cities

Background

Unhealthy environments and food advertisements are major determinants of childhood obesity. Recent regulation has banned unhealthy foods from schools in Mexico. However, currently there is no regulation limiting exposure to food marketing around schools. Thus, our objective was to analyze the characteristics of food advertising practices around 60 elementary schools in two cities and to evaluate compliance with the Pan American Health Organization (PAHO) recommendations and the local food industry self-regulatory marketing code.

Methods

Data were collected during the period of October 2012 to March 2013. A random sample of elementary schools was selected from two Mexican cities. Using geographic information systems, we drew a 100-m-diameter buffer around each school. Trained personnel obtained photographs to assess the locations and types of food advertisements. Our results were stratified by school type and by indicators of compliance with the PAHO and industry recommendations. We developed a multivariate negative binomial regression model to determine factors predicting the number of advertisements around schools.

Results

The number of advertisements was significantly higher around public schools than around private schools (6.5 ± 5.6 vs. 2.4 ± 3.5, p < 0.05). Printed posters were the most common type of marketing medium (97%), showing mostly sugar-sweetened beverages, sweet breads, candies, and bottled water. Promotions, such as special prices or gifts, were included on 30% of printed posters. Food advertising practices were often in compliance with industry recommendations (83%) but not with those from the PAHO (32%) (p < 0.001).

Conclusion

Our results support the importance of monitoring the obesogenic environment and identifying policy tools to protect children from food marketing not only inside schools but also around them, particularly in lower income communities.

Sugary drinks taxation, projected consumption and fiscal revenues in Colombia: Evidence from a QUAIDS model

The global shift towards diets high in sugar-sweetened beverages (SSBs) is linked to higher prevalence of obesity, diabetes and most other non-communicable diseases. In Colombia, one out of every two people was overweight or obese by 2010. This study estimates price-elasticities from a Quadratic Almost Ideal Demand System model, using the 2006-2007 Colombian Income and Expenditure survey. The food groups that were jointly considered were: unsweetened unflavored milks; coffee and tea; sugar sweetened beverages (SSBs); sweets and candies (including sugar); dairy products; meats and animal-based products; grains based staples; fruits and vegetables; and condiments and snacks. We take into account the high proportion of households not purchasing specific food and beverage groups (censored data) and endogeneity on both prices (as unit values) and total expenditure. Unhealthy beverages are price-elastic (-1.61 for SSBs) meaning that the change in consumption is proportionally larger with respect to a change in price. Also, there is a high complementarity among SSBs and major food groups (grains, meats and fruits and vegetables). In Colombia, the design of a meaningful tax to influence healthier diets is a next critical step. This study also shows that a tax of 20% on SSBs should prove to be effective, and can yield revenues of about 1% of the Colombian government's total annual fiscal revenue, which can potentially be directed towards public health promotion and investments.

The Development and Public Health Implications of Food Preferences in Children

Food preferences are a primary determinant of dietary intake and behaviors, and they persist from early childhood into later life. As such, establishing preferences for healthy foods from a young age is a promising approach to improving diet quality, a leading contributor to cardiometabolic health. This narrative review first describes the critical period for food preference development starting in utero and continuing through early childhood. Infants’ innate aversion to sour and bitter tastes can lead them to initially reject some healthy foods such as vegetables. Infants can learn to like these foods through exposures to their flavors in utero and through breastmilk. As solid foods are introduced through toddlerhood, children’s food preferences are shaped by parent feeding practices and environmental factors such as food advertising. Next, we discuss two key focus areas to improve diet quality highlighted by the current understanding of food preferences: (1) promoting healthy food preferences through breastfeeding and early exposures to healthy foods and (2) limiting the extent to which innate preferences for sweet and salty tastes lead to poor diet quality. We use an ecological framework to summarize potential points of intervention and provide recommendations for these focus areas, such as worksite benefits that promote breastfeeding, and changes in food retail and service environments. Individuals’ choices around breastfeeding and diet may ultimately be influenced by policy and community-level factors. It is thus crucial to take a multilevel approach to establish healthy food preferences from a young age, which have the potential to translate into lifelong healthy diet.

Exploring the dynamics of food-related policymaking processes and evidence use in Fiji using systems thinking

BACKGROUND

Obesity and non-communicable diseases are significant public health issues globally and particularly in the Pacific. Poor diet is a major contributor to this issue and policy change is a powerful lever to improve food security and diet quality. This study aims to apply systems thinking to identify the causes and consequences of poor evidence use in food-related policymaking in selected government ministries in Fiji and to illicit strategies to strengthen the use of evidence in policymaking.

METHODS

The Ministry of Health and Medical Services and the Ministry of Agriculture in Fiji were invited through their respective Permanent Secretaries to participate in the study. Three 180-minute group model building (GMB) workshops were conducted separately in each ministry over three consecutive days with selected policymakers who were instrumental in developing food-related policies designed to prevent non-communicable diseases. The GMB workshops mapped the process of food-related policymaking and the contribution of scientific and local evidence to the process, and identified actions to enhance the use of evidence in policymaking.

RESULTS

An average of 10 policymakers participated from each ministry. The causal loop diagrams produced by each ministry illustrated the causes and consequences of insufficient evidence use in developing food policies or precursors of the specific actions. These included (1) consultation, (2) engagement with stakeholders, (3) access and use of evidence, and (4) delays in policy processes. Participants agreed to potential leverage points on the themes above, addressing pertinent policymaker challenges in precursor control, including political influence, understanding of trade policies, competing government priorities and level of awareness on the problem. Specific actions for strengthening evidence use included training in policy development and research skills, and strengthening of coordination between ministries.

CONCLUSIONS

The GMB workshops improved participants' understanding of how different parts of the policy system interact. The causal loop diagrams and subsequent action plans enabled the identification of systems-level interventions in both ministries to improve evidence-informed policy development. A guide for integrating multi-sectoral consultation and stakeholder engagement in developing cross-cutting policies is currently being developed.

Designing a food tax to impact food-related non-communicable diseases: the case of Chile

The global shift towards diets high in sugar-sweetened beverages (SSBs) and energy dense ultra-processed foods is linked to higher prevalence of obesity, diabetes and most other noncommunicable diseases (NCDs), causing significant health costs. Chile has the highest SSB consumption in the world, very high junk food intake and very rapid increases in these poor components of the diet plus obesity prevalence. This study's purpose is to compare the effect of different tax schemes for SSBs and ultra-processed foods on nutrient availability, utilizing price-elasticities, which are estimated from a Quadratic Almost Ideal Demand System model, using the 2011-2012 Income and Expenditure survey. We take into account the high proportion of households not purchasing various food and beverage groups (censored nature of data). The food groups considered were: sweets and desserts; salty snacks and chips; meat products and fats; fruits, vegetables and seafood; cereals and cereal products; SSB ready-to-drink; SSB from concentrate; plain water, coffee and tea; and milk, which together represent 90% of food expenditures. The simulated taxes were: (1) 40% price tax on SSBs(22% above the current tax level); (2) a 5 cents per gram of sugar tax on products with added sugar; and (3) 30% price tax on all foods(27% above current tax levels) and beverages (12% above the current tax level) exceeding thresholds on sodium, saturated fat, and added sugar and for which marketing is restricted (based on a Chilean law, effective June 16 2016). Unhealthy foods are price-elastic (-1.99 for salty snacks and chips, -1.06 for SSBs ready-to-drink, and -1.27 for SSBs from concentrate), meaning that the change in consumption is proportionally larger with respect to a change in price. Results are robust to different model specification, and consistent among different socioeconomic sub-populations. Overall, the tax on marketing controlled foods and beverages is associated with the largest reduction in household purchases of sodium, added sugar, saturated fat and calorie purchases. Chile is unique in currently having instituted a small current SSB tax as well as marketing controls and front-of-package labeling of unhealthy foods and beverages. The design of a larger, more comprehensive tax to enhance the overall effect of these policies on healthier diets is a next critical step. This study shows that a large tax on the same foods and beverages already delineated as unhealthy by the marketing controls and front-of-pack labeling should prove to be more effective for promoting a healthier diet.

Energy balance and obesity: what are the main drivers?

PURPOSE

The aim of this paper is to review the evidence of the association between energy balance and obesity.

METHODS

In December 2015, the International Agency for Research on Cancer (IARC), Lyon, France convened a Working Group of international experts to review the evidence regarding energy balance and obesity, with a focus on Low and Middle Income Countries (LMIC).

RESULTS

The global epidemic of obesity and the double burden, in LMICs, of malnutrition (coexistence of undernutrition and overnutrition) are both related to poor quality diet and unbalanced energy intake. Dietary patterns consistent with a traditional Mediterranean diet and other measures of diet quality can contribute to long-term weight control. Limiting consumption of sugar-sweetened beverages has a particularly important role in weight control. Genetic factors alone cannot explain the global epidemic of obesity. However, genetic, epigenetic factors and the microbiota could influence individual responses to diet and physical activity.

CONCLUSION

Energy intake that exceeds energy expenditure is the main driver of weight gain. The quality of the diet may exert its effect on energy balance through complex hormonal and neurological pathways that influence satiety and possibly through other mechanisms. The food environment, marketing of unhealthy foods and urbanization, and reduction in sedentary behaviors and physical activity play important roles. Most of the evidence comes from High Income Countries and more research is needed in LMICs.

Effects of cognitive overweight status on food choice

Obesity is a serious concern from a personal and public health perspective. This research examines the effects of consumer cognitive overweight status (COS) on food choice. The results show that COS is a significant predictor of consumer food choices, and gender, age, and education differences are found. While the literature shows that many years of efforts by the public and private sectors do have positive influences on consumer food choices, more efforts should be made to help the public engage in weight control behaviors. Managerial and public health policy implications are provided.

Obesogenic Environments: Access to and Advertising of Sugar-Sweetened Beverages in Soweto, South Africa, 2013

INTRODUCTION

Rates of obesity and overweight among South Africans are increasing. Food marketing has a profound impact on children and affects their lifelong eating patterns; in urban areas of South Africa, disposable incomes are growing and ultra-processed food is increasingly available at low cost. The combination of these factors will strain an already fragile health system. Our aim was to investigate the density of outdoor sugar sweetened beverage (SSB) advertising and the number of formal and informal vendors selling SSBs in a transforming, historically disadvantaged urban setting of South Africa.

METHODS

A digital camera and global positioning system navigation system were used to record the location of SSB advertisements and food vendors in a demarcated area in Soweto. Data were collected by walking or driving through each street; a food inventory was completed for every food vendor. Spatial analyses were conducted using a geographic information system.

RESULTS

A total of 145 advertisements for SSBs were found over a driven or walked distance of 111.9 km. The density of advertisements was 3.6 per km(2) in relation to schools, and 50% of schools had branded advertising of SSBs on their school property. Most (n = 104; 58%) of the 180 vendors in the study sold SSBs.

CONCLUSION

This is the first study in South Africa to document the location of billboard advertisements and vendors in relation to schools. Marketing of products that contribute to obesity is common in urban Soweto. Our findings have implications for policies that regulate SSB advertising, especially in the proximity of schools.

Using a Qualitative Vignette to Explore a Complex Public Health Issue

This article discusses how qualitative vignettes were combined with interviews to explore a complex public health issue; that is, promoting unhealthy foods and beverages to children and adolescents. It outlines how the technique was applied in practice and the combination of vignette-based interviews with a broader approach involving Gadamerian hermeneutics. Twenty-one participants from the public health community and the marketing and food and beverage industries took part in vignette-based interviews between March and September 2012. Overall, the qualitative vignette method afforded an efficient, generally well-received technique that effectively explored the issue of promoting unhealthy foods and beverages to children and adolescents. The vignette provided structure to interviews but allowed certain responses to be investigated in greater depth. Through this research, we argue that qualitative vignettes allow researchers to explore complex public health issues. This article also provides a valuable resource for researchers seeking to explore this technique.

Inverting the pyramid! Extent and quality of food advertised on Austrian television

BACKGROUND

Research showed that food marketing for children frequently contradicts national dietary guidelines. Children, unlike adults, are not able to understand the persuasiveness of the advertisements with its short- and long-term effects on health, thus the common international tenor is to restrict food marketing. In the European Union, marketing restriction based on self-regulation have been initiated (EU Pledge Nutrition Criteria). The study aims contribute to depict the status quo of television advertisement targeted at children before the pledged initiative came into full effect.

METHODS

In this study we analyze the quality and displaying frequency of a set of advertisements targeted at children broadcasted on Austrian television. Promoted food products targeted at children or adults were identified. Category-based analysis of the displayed food was performed based on the Austrian Nutrition guidelines (number of displayed food per food category). The children's food content was analyzed according to the newly established nutritional quality criteria for advertised food in the EU to assess the nutritional quality of the depicted food.

RESULTS

In total, 360 h of video material was recorded in February and March 2014. A set of 1919 food advertisements, with 15.1 % targeted at children were broadcasted. Of all food advertisements targeted at children, 92.4 % was for fatty, sweet and salty snacks, while no advertisements for vegetables, legumes or fruits were shown. From all food advertisements for children, 65.9 % originated from participating companies of the EU Pledge Nutrition Criteria. Further analysis revealed that 95.9 % of the advertised food for children showed at least one aspect of nonconformity with the EU Pledge Nutrition Criteria; on the contrary 64.7 % of the displayed food advertisement also featured at least one desirable food component (e.g. high fibre content, high protein content).

CONCLUSIONS

The present research suggests that the majority of advertised food for children do not conform with the pledged criteria as defined in the EU Pledge Nutrition Criteria and almost all advertisements would be prohibited. We discuss our findings in the context of public health nutrition and present a perspective for future directions in this important field of research.

How Can We Better Prevent Obesity in Children?

The aim of this review is to discuss the state of the art regarding the field of health promotion in the context of childhood obesity prevention in order to learn how we can better prevent childhood obesity. Challenges have been identified that exist within the different steps of health promotion programme development and implementation. Important steps forward include studying behaviours and determinants of behaviours as clusters, upgrading the importance of distal environmental factors in modelling determinants and understanding determinants as a dynamic system: a complex of interacting elements. An important note is that the process of implementation and the analysis thereof should more often come before the analysis of behaviours and the determinants of behaviour. In applied research, the expertise from the 'real world' practitioners should be used in an early stage to find out whether the answers on research questions really help us in preventing childhood obesity.

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.

Reducing the volume, exposure and negative impacts of advertising for foods high in fat, sugar and salt to children: A systematic review of the evidence from statutory and self-regulatory actions and educational measures

PURPOSE

To identify and review evidence on 1) the effectiveness of statutory and self-regulatory actions to reduce the volume, exposure or wider impact of advertising for foods high in fat, sugar and salt (HFSS) to children, and 2) the role of educational measures.

DESIGN/METHODOLOGY/APPROACH

A systematic review of three databases (Medline, CINAHL and PsycINFO) and grey literature was carried out. Relevant evidence included studies evaluating advertising bans and restrictions, advertising literacy programmes and parental communication styles. Relevant media included TV, internet, radio, magazines and newspaper advertising. No studies were excluded based on language or publication date.

FINDINGS

Forty-seven publications were included: 19 provided evidence for the results of statutory regulation, 25 for self-regulation, and six for educational approaches. Outcome measures varied in approach, quality and results. Findings suggested statutory regulation could reduce the volume of and children's exposure to advertising for foods HFSS, and had potential to impact more widely. Self-regulatory approaches showed varied results in reducing children's exposure. There was some limited support for educational measures.

DISCUSSION

Consistency in measures from evaluations over time would assist the development and interpretation of the evidence base on successful actions and measures to reduce the volume, exposure and impact of advertising for foods HFSS to children.

Liking them thin: adolescents' favorite television characters and body image

Considering the alarming worldwide increases in eating disorders among adolescents, thought to be linked with body image, this study uses social cognitive theory as a framework to combine the examination of adolescent body image with the topic of mediated characters. The study places a new focus in this realm on favorite television characters, extending past research on general social comparison tendencies or comparisons with unfamiliar mediated models. A survey of 756 students in Grades 7-8 and 10-11 identified their favorite same-gender television characters as well as the adolescents' body image and social comparison with the characters. The survey was accompanied by a content analysis of the favorite characters and their body sizes. Adolescents' favorite television characters were mostly identified as thin or average in body size. The thinner the characters, the more adolescents self-compared with them. The discrepancy between the adolescents' body size and that of their favorite characters significantly and negatively predicted adolescents' body image both directly and indirectly through its relationship with social comparison with the character. The study finds that television characters are important references for adolescents and may serve as targets for social comparison in the context of body image.

Nutrition labelling, marketing techniques, nutrition claims and health claims on chip and biscuit packages from sixteen countries

Objective

Food packages were objectively assessed to explore differences in nutrition labelling, selected promotional marketing techniques and health and nutrition claims between countries, in comparison to national regulations.

Design

Cross-sectional.

Setting

Chip and sweet biscuit packages were collected from sixteen countries at different levels of economic development in the EPOCH (Environmental Profile of a Community’s Health) study between 2008 and 2010.

Subjects

Seven hundred and thirty-seven food packages were systematically evaluated for nutrition labelling, selected promotional marketing techniques relevant to nutrition and health, and health and nutrition claims. We compared pack labelling in countries with labelling regulations, with voluntary regulations and no regulations.

Results

Overall 86 % of the packages had nutrition labels, 30 % had health or nutrition claims and 87 % displayed selected marketing techniques. On average, each package displayed two marketing techniques and one health or nutrition claim. In countries with mandatory nutrition labelling a greater proportion of packages displayed nutrition labels, had more of the seven required nutrients present, more total nutrients listed and higher readability compared with those with voluntary or no regulations. Countries with no health or nutrition claim regulations had fewer claims per package compared with countries with regulations.

Conclusions

Nutrition label regulations were associated with increased prevalence and quality of nutrition labels. Health and nutrition claim regulations were unexpectedly associated with increased use of claims, suggesting that current regulations may not have the desired effect of protecting consumers. Of concern, lack of regulation was associated with increased promotional marketing techniques directed at children and misleadingly promoting broad concepts of health.

Food Policy Approaches to Obesity Prevention: An International Perspective

This paper provides a comprehensive overview of the recent obesity prevention-related food policies initiated in countries worldwide. We searched and reviewed relevant research papers and government documents, focusing on those related to dietary guidelines, food labeling, regulation of food marketing, and policies affecting food prices. We also commented on the effects and challenges of some of the related policy options. There are large variations regarding what, when, and how policies have been implemented across countries. Clearly, developed countries are leading the effort, and developing countries are starting to develop some related policies. The encouraging message is that many countries have been adopting policies that might help prevent obesity and that the support for more related initiatives is strong and continues to grow. Communicating information about these practices will help researchers, public health professionals, and policy makers around the world to take action to fight the growing epidemic of obesity and other nutrition-related diseases.

The Possible Experts: How Epistemic Communities Negotiate Barriers to Knowledge Use in Ecosystems Services Policy

The increased salience of how to value ecosystems services has driven up the demand for policy-relevant knowledge. It is clear that advice by epistemic communities can show up in policy outcomes, yet little systematic analysis exists prescribing how this can actually be achieved. This paper draws on four decades of knowledge utilisation research to propose four types of ‘possible expert’ who might be influential on ecosystems services. Broad findings of a literature review on knowledge use in public policy are reported, and the four-fold conceptualisation pioneered by Carol Weiss that defines the literature is outlined. The field is then systematised by placing these four modes of knowledge use within an explanatory typology of policy learning. With how, when, and why experts and their knowledge are likely to show up in policy outcomes established, the paper then proposes the boundaries of the possible in how the ecosystems services epistemic community might navigate the challenges associated with each learning mode. Four possible experts emerge: with political antenna and epistemic humility; with the ability to speak locally and early to the hearts and minds of citizens; with a willingness to advocate policy; and, finally, with an enhanced institutional awareness and peripheral policy vision. The paper concludes with a brief discussion of the utility of the analysis.

Nutritional quality of foods marketed to children in Honduras

Evidence suggests that exposure to advertising of unhealthy foods may contribute to increased rates of obesity in children. This study examined the extent to which television stations marketed unhealthy foods to children during after-school programming aired over one week in La Ceiba, Honduras. Content analysis was performed on four television stations, including one broadcast station and three cable networks. Eighty hours of programming were recorded and analyzed. Advertised products were categorized as food or non-food items, with food items further classified as healthy or unhealthy. Advertisements were coded as those aimed at children, adults, or both, and chi-square tests were used to compare the proportion of unhealthy advertisements by target audience. A total of 2271 advertisements aired during the observation period, with 1120 marketing products (49.3%). Of those, 397 (35.4%) promoted foods-30.2% were for healthy foods and 69.8% for unhealthy foods. The unhealthy foods were all advertised on cable networks and not the broadcast station. Children appeared to be targeted more than adults in advertisements for unhealthy foods (92.1%, p<0.001). Cable television programming during after-school hours advertised primarily unhealthy foods. Exposure to these advertisements may promote consumption of unhealthy foods by children, increasing their risk of obesity.

Public say food regulatory policies to improve health in Western Australia are important: population survey results

OBJECTIVE

To investigate the level of support among Western Australian adults for food control policies to improve diet, reduce obesity and protect the environment.

METHODS

Attitudes towards government food control policies on food labelling, food advertising, and the supply of environmentally friendly food data were pooled from two Nutrition Monitoring Survey Series telephone surveys of 2,147 adults aged 18-64 years collected in 2009 and 2012. Descriptive and logistic regression analyses were conducted using survey module of STATA 12.

RESULTS

The majority of adults believe it is important that government regulates food policy options under consideration: nutrition information on food labels (97% versus 2% who think it is not important); health rating on food labels (95% versus 3%); food advertising (83% versus 11%); and the supply of environmentally friendly food (86% versus 9%).

CONCLUSIONS

Community perception is that government control or regulation of food labelling, food advertising and the supply of environmentally friendly food is important.

IMPLICATIONS

Curbing excess weight gain and related disease burden is a public health priority. Australian governments are considering food regulatory interventions to assist the public to improve their dietary intake. These findings should provide reassurance to government officials considering these regulatory measures.

Food branding and young children's taste preferences: a reassessment

OBJECTIVES

This study examines the effects of branding and packaging on young children's taste preferences.

METHODS

Preschool children aged 3 to 5 (n=65) tasted five pairs of identical foods in packaging from McDonald's and in matched packaging that was either plain, Starbucks-branded, or colourful (but unbranded). Children were asked if the foods tasted the same or if one tasted better.

RESULTS

Children preferred the taste of foods wrapped in decorative wrappings, relying more on aesthetics than on familiar branding when making their choices.

CONCLUSIONS

The findings suggest the need to explore questions beyond commercial advertising (and brand promotion) on television and other media platforms. More attention should be directed at the important role of packaging in directing children's food preferences.

Experimental evidence on the impact of food advertising on children's knowledge about and preferences for healthful food

To understand the rising prevalence of childhood obesity in affluent societies, it is necessary to take into account the growing obesity infrastructure, which over past decades has developed into an obesogenic environment. This study examines the effects of one of the constituent factors of consumer societies and a potential contributory factor to childhood obesity: commercial food communication targeted to children. Specifically, it investigates the impact of TV advertising on children's food knowledge and food preferences and correlates these findings with their weight status. Evaluations of traditional information- and education-based interventions suggest that they may not sustainably change food patterns. Based on prior consumer research, we propose five hypotheses, which we then test using a subsample from the IDEFICS study, a large-scale pan-European intervention study on childhood obesity. The results indicate that advertising has divergent effects on children's food knowledge and preferences and that food knowledge is unrelated to food preferences. This finding has important implications for both future research and public policy.

Redefining "child-directed advertising" to reduce unhealthy television food advertising

BACKGROUND

Food and beverage companies have pledged to reduce unhealthy marketing to children through the Children's Food and Beverage Advertising Initiative (CFBAI). However, public health experts question the initiative's effectiveness because pledges apply to only some types of marketing. For instance, the CFBAI covers only TV advertising that is "child-directed," defined as advertising during programs for which children make up 35% or more of the viewing audience.

PURPOSE

To quantify the proportion of food and beverage TV advertisements (ads) viewed by children that is covered by current CFBAI pledges and examine the potential impact of broader definitions of child-directed advertising.

METHODS

Nielsen data were used to quantify percentages of children (aged 2-11 years) in the audience (i.e., child-audience share), as well as absolute numbers of child viewers, for all national TV programs in 2009. Nielsen advertising data provided the number of food and beverage ads viewed by preschoolers (aged 2-5 years); older children (aged 6-11 years); and adults (aged 18-49 years) during programs with various child-audience compositions. Data were collected in 2010 and analyzed in 2011.

RESULTS

Just 45%-48% of food ads viewed by children met current CFBAI definitions of child-directed advertising. Expanding this definition to include advertising during programs with a child-audience share of 20% or higher and/or 100,000 or more child viewers would cover 70%-71% of food advertising seen by children but just one third of ads seen by adults.

CONCLUSIONS

Children viewed an estimated 35% fewer food ads during TV programs with a high child-audience share (≥50%) in 2009 compared with 2004. However, ensuring that nutrition standards apply to the majority of food ads viewed by children requires broader definitions of child-directed advertising.

Tackling the global NCD crisis: innovations in law and governance

35 million people die annually of non-communicable diseases (NCDs), 80% of them in low- and middle-income countries - representing a marked epidemiological transition from infectious to chronic diseases and from richer to poorer countries. The total number of NCDs is projected to rise by 17% over the coming decade, absent significant interventions. The NCD epidemic poses unique governance challenges: the causes are multifactorial, the affected populations diffuse, and effective responses require sustained multi-sectorial cooperation. The authors propose a range of regulatory options available at the domestic level, including stricter food labeling laws, regulation of food advertisements, tax incentives for healthy lifestyle choices, changes to the built environment, and direct regulation of food and drink producers. Given the realities of globalization, such interventions require global cooperation. In 2011, the UN General Assembly held a High-level meeting on NCDs, setting a global target of a 25% reduction in premature mortality from NCDs by 2025. Yet concrete plans and resource commitments for reaching this goal are not yet in the offing, and the window is rapidly closing for achieving these targets through prevention - as opposed to treatment, which is more costly. Innovative global governance for health is urgently needed to engage private industry and civil society in the global response to the NCD crisis.

Global obesity: trends, risk factors and policy implications

The worldwide increase in obesity and related chronic diseases has largely been driven by global trade liberalization, economic growth and rapid urbanization. These factors continue to fuel dramatic changes in living environments, diets and lifestyles in ways that promote positive energy balance. Nutritional transitions in low-income and middle-income countries are typically characterized by increases in the consumption of animal fat and protein, refined grains, and added sugar. This change is coupled with reductions in physical activity owing to more mechanized and technologically driven lifestyles. Given the high costs of obesity and comorbidities in terms of health-care expenditure and quality of life, prevention strategies are paramount, particularly in low-income and middle-income countries that must manage coexisting infectious diseases and undernutrition in addition to the obesity epidemic. As countries become increasingly urbanized, undernutrition and obesity can exist side by side within the same country, community or household, which is a particular challenge for health systems with limited resources. Owing to the scope and complexity of the obesity epidemic, prevention strategies and policies across multiple levels are needed in order to have a measurable effect. Changes should include high-level global policies from the international community and coordinated efforts by governments, organizations, communities and individuals to positively influence behavioural change.

Evaluation of food and beverage television advertising during children's viewing time in Spain using the UK nutrient profile model

OBJECTIVE

To evaluate the nutritional quality of products advertised on television (TV) during children’s viewing time in Spain, applying the UK nutrient profile model (UKNPM).

DESIGN

We recorded 80 h of four general TV station broadcasts during children’s time in May and June 2008, and identified all advertisements for foods and beverages. Nutritional information was obtained from the product labels or websites and from food composition tables. Each product was classified as healthy (e.g. gazpacho, a vegetable juice) or less healthy (e.g. potato crisp snacks) according to the UKNPM criteria.

SETTING

Four free-of-charge TV channels in Spain: two national channels and two regional ones.

SUBJECTS

TV commercials of food and beverages.

RESULTS

A total of 486 commercials were broadcast for ninety-six different products, with a mean frequency of 5?1 advertisements per product. Some 61?5% of the ninety-six products were less healthy, and the percentage was higher for foods (74?1 %). All (100 %) of the breakfast cereals and 80% of the non-alcoholic drinks and soft drinks were less healthy. Of the total sample of commercials, 59?7% were for less healthy products, a percentage that rose to 71?2% during children’s reinforced protection viewing time.

CONCLUSIONS

Over half the commercials were for less healthy products, a proportion that rose to over two-thirds during the hours of special protection for children. This suggests that applying the UKNPM to regulate food advertising during this slot would entail the withdrawal of most food commercials in Spain. TV advertising of products with low nutritional quality should be restricted.