Effects of exposure to television advertising for energy-dense/nutrient-poor food on children's food intake and obesity in South Korea

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

Introduction

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

Materials and methods

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

Results

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

Conclusion

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

Revisiting 42 Years of literature on food marketing to children: A morphological analysis

Despite the preventive measures taken by the WHO, childhood obesity is still on the rise and is expected to increase by 100% between 2020 and 2035. Food marketing continues to permeate children's environments in numerous ways and influence the food behaviour of children, thus significantly contributing to the rise of obesity. Studies suggest that the literature on the effects of food marketing on children is complex and multidimensional. To fully understand these effects, a comprehensive and systematic approach is required. Nonetheless, existing reviews have focused only on specific aspects and have not comprehensively covered the literature on food marketing to children. Therefore, this review aims to navigate potential research gaps in the existing literature through a comprehensive examination of the literature by using morphological analysis (MA) methodology, the first time in this domain. Using PRISMA, 202 papers were considered eligible for inclusion and further analysed using MA. The articles were categorised into three dimensions to develop the MA framework: Stimuli (Food well-being), Organism, and Response, and 34 variants. The review has presented future research prospects by identifying at least 218 research gaps. With these findings, researchers can further explore the gaps and develop new research questions that could foster an understanding of the multifarious literature. Moreover, these findings can also provide marketers and practitioners with a better comprehension of the current state of the literature and develop more effective strategies for responsible marketing practices and policies.

The association between screen use and central obesity among children and adolescents: a systematic review and meta-analysis

Currently, there is no summative study evaluating the association between central obesity and screen time. This systematic review and meta-analysis aimed to summarize the results of studies evaluating the association between screen time and central obesity among children and adolescents. To this end, we performed a systematic search in three electronic databases, including Scopus, PubMed, and Embase to retrieve the related studies up to March 2021. Nine studies were eligible to be included in the meta-analysis. There was no association between odds of central obesity and screen time [odds ratio (OR) 1.136; 95% CI 0.965-1.337; P = 0.125]; however, waist circumference (WC) was 1.23 cm higher in those with highest screen time versus those in the lowest screen time category [weighted mean difference (WMD) = 1.23; 95% 95% CI 0.342-2.112; P = 0.007; Fig. 3]. Moreover, the possible sources of heterogeneity in the included studies were continent and sample size. No evidence of publication bias was reported. For the first time, the current systematic review and meta-analysis revealed that those with the highest screen time had higher WC compared with those with the lowest screen time. Although, there was no association between odds of central obesity and screen time. Due to the observational design of the included studies, it is impossible to infer the cause-effect relationship. Therefore, further interventional and longitudinal studies are warranted to better elucidate the causality of these associations.

Food Advertisement and Dietary Choices in Adolescents: An Overview of Recent Studies

Adolescents are exposed to food marketing through many routes, including television, movies, videos, print media, online games, and social media. The interplay between exposure to unhealthy food advertisements and food choices by adolescents is a field of special interest given the ongoing evolution of social media trends and marketing strategies. The purpose of this review was to synthesize the scientific findings in the last five years (2017–2022) regarding the possible influence of nutrition-related advertisements through television, social media, or video games on the choice and consumption of unhealthy foods and drinks in adolescents. Nineteen studies were included in this review. Adolescents exposed to unhealthy food and beverage advertising showed high desire and intention to consume the advertised foods, as evidenced by the majority of included studies. The effects of advertisements are reinforced by peer pressure and influencers and interact with socioeconomic, biological, and environmental factors. Food marketing represents part of the obesogenic environment of the present time.

Childhood obesity risk increases with increased screen time: a systematic review and dose-response meta-analysis

BACKGROUND

The role of screen time in promoting obesity among children has been reported in previous studies. However, the effects of different screen types and the dose-response association between screen time and obesity among children is not summarized yet. In the current meta-analysis we systematically summarized the association between obesity and screen time of different screen types in a dose-response analysis.

METHODS

A systematic search from Scopus, PubMed and Embase electronic databases was performed. Studies that evaluated the association between screen time and obesity up to September 2021 were retrieved. We included 45 individual studies that were drawn from nine qualified studies into meta-analysis.

RESULTS

The results of the two-class meta-analysis showed that those at the highest category of screen time were 1.2 times more likely to develop obesity [odds ratio (OR) = 1.21; confidence interval (CI) = 1.113, 1.317; I2 = 60.4%; P < 0.001). The results of subgrouping identified that setting, obesity status and age group were possible heterogeneity sources. No evidence of non-linear association between increased screen time and obesity risk among children was observed (P-nonlinearity = 0.310).

CONCLUSION

In the current systematic review and meta-analysis we revealed a positive association between screen time and obesity among children without any evidence of non-linear association. Due to the cross-sectional design of included studies, we suggest further studies with longitudinal or interventional design to better elucidate the observed associations.

Screen time increases overweight and obesity risk among adolescents: a systematic review and dose-response meta-analysis

BACKGROUND

Adolescence is a critical period in human life, associated with reduced physical activity and increased sedentary behaviors. In this systematic review and dose-response meta-analysis, we evaluated the association between screen time and risk of overweight/obesity among adolescents.

METHODS

A systematic search in electronic databases, including PubMed, Embase, and Scopus was performed up to September 2021. All published studies evaluating the association between screen time and risk of overweight/obesity among adolescents were retrieved. Finally, a total of 44 eligible studies were included in the meta-analysis.

RESULTS

The results of the two-class meta-analysis showed that adolescents at the highest category of screen time were 1.27 times more likely to develop overweight/obesity (OR = 1.273; 95% CI = 1.166-1.390; P < 0.001; I-squared (variation in ES attributable to heterogeneity) = 82.1%). The results of subgrouping showed that continent and setting were the possible sources of heterogeneity. Moreover, no evidence of non-linear association between increased screen time and risk of overweight/obesity among adolescents was observed (P-nonlinearity = 0.311).

CONCLUSION

For the first time, the current systematic review and meta-analysis revealed a positive association between screen time and overweight/obesity among adolescents without any dose-response evidence.

TRIAL REGISTRATION

The protocol of the current work has been registered in the PROSPERO system (Registration number: CRD42021233899 ).

Breakfast Food Advertising and Prevention of Obesity: Analysis of the Nutritional Value of the Products and Discursive Strategies Used in the Breakfast Ads from 2015 to 2019

Breakfast is widely considered the most important meal of the day. Despite this, the consumption of ready to eat industrial products with low nutritional value is increasing. This study correlated longitudinally the nutritional value of breakfast products with advertising discursive strategies. The research design applied quantitative analysis to compile all media advertising data from 2015 to 2019, qualitative analysis of the content, and a study of the adverts’ discourse. Moreover, a Nutri-score analysis was used to determine the products’ nutritional value. Results indicated that breakfast products advertised in Spain presented a low or very low nutritional value. In addition, they showed that the lower the nutritional value of the product, the greater the proportion of positive emotions or moods that emerge from the discourse used in the advertisement. To establish effective policies for the prevention of obesity, greater involvement of the government, and better self-regulation mechanisms for the food industry, communication agencies, and advertisers are needed. In this sense, the hedonistic language used in advertisements for unhealthy food must treated as a priority. This measure would have the aim not only of protecting minors from ads for unhealthy food that are broadcast during breakfast time but would also generate healthy eating patterns within the family.

Television food advertisements and childhood obesity: A systematic review

The prevalence of childhood obesity has increased worldwide and various environmental factors have accelerated this trend. Several reports have suggested that food advertising causes childhood obesity. We proposed a review study to evaluate the relationship between TV food advertisements and obesity in children. By searching over electronic databases (including PubMed, Web of Science, Scopus, and Google Scholar), the reference lists of original studies, and reviews using key search terms, 1181 articles were identified. Out of these, only 9 articles met the inclusion and quality criteria. Most of the longitudinal study carried out at the national level have reported a significant association between commercial viewing and BMI in children. The duration of these studies varied between 7 months and 5 years. The children's TV viewing time was between 1.5 and 3.5 hours per day. Results of the reviewed studies have revealed a controversial attitude about the influence of TV food advertisements on obesity. However, three of four modeling studies indicated an increment in the prevalence of overweight and obesity following exposure to food advertisements. Further interventional and longitude studies are needed to achieve more precise results.

Effects of Advertising on Food Consumption Preferences in Children

(1) Background: Childhood obesity is a public health problem. The purpose of this study was to know if exposure to commercial messages which advertise food products exerts any effect on the short-term consumption preferences of 4- to 6-year-old children. (2) Methods: A double-blind and randomized experimental design. Sample consisted of 421 boys and girls from twelve schools in a city in Spain. (3) Results: In three of the four product pairs shown, the products advertised in the intervention were preferred. In the results of applying the model for the first product pair presented, sugared cereals, the predictive variable which best explains the behavior of the preferences expressed is gender (Odds Ratio 0.285 (0.19–0.42); p < 0.05). For the second pair, chocolate cookies, the family’s nationality has a strong weight in the model. As regards the regression model calculated for the last pair (filled rolls), the predictive variable which showed having more influence was gender. Boys had a 1.39 times higher risk of selecting the advertised product than girls. (4) Conclusions: The persuasive effect of commercials has shown to be influential in a general, immediate, and significant way only in the case of products with wide brand awareness. This study reinforces the importance of advertising and emphasizes the need to initiate measures to control the content of TV commercials.

Sedentary Behaviors of a School Population in Brazil and Related Factors

Background. Overweight and obesity arise from a complex range of genetic, environmental, behavioral, educational, and socioeconomic factors. The present study explored the sedentary practices and some life habits related to health among children from the school population of Uruguaiana (Rio Grande do Sul, Brazil). Methods: A cross-sectional descriptive study was conducted to characterize the life habits of the school boys and girls from fourth grade (9-10 years old). Results: A total of 470 fourth-grade boys and girls (9-10 years old) participated in the study. As regards the variables linked to habits, 24% of the boys and girls answered they had not had breakfast the day they completed the questionnaire and 51.8% stated they did not have breakfast any given day of the week. Regarding sedentary habits, 25.3% of children watched TV or played video games five or more hours a day and 9% rarely played sports with their parents or caregivers. Statistical significance was recorded between "number of hours watching TV and playing video games" and "playing sports with parents or caregivers" (p < 0.05). Conclusions: Association between the times spent watching TV or playing video games and the practice of physical exercise in the family proves once again the importance of the family in education for the health of children. The school provides direct access to schoolchildren and their parents to launch numerous health education programs.

Soft Drinks and Sugar-Sweetened Beverages Advertising in Spain: Correlation between Nutritional Values and Advertising Discursive Strategies

Spain ranks fifth among European countries for childhood obesity. Sugar-sweetened beverages (SSBs) and soft drinks (SDs) are consumed by 81% of the Spanish children weekly. Advertising is one of the factors that contributes to an obesogenic environment. This study correlated longitudinally the nutritional values of SSBs and SDs and advertising discursive strategies between 2013 and 2018 for all media. A mixed-methods approach was applied that included a quantitative analysis of advertising spend data, a content analysis and a study of the discursive strategies used in advertisements. In addition, the Nutri-score system was used in order to determine the nutritional quality of the beverages. The results were analyzed applying the Spanish advertising regulatory framework for obesity prevention. The main findings indicate an association between low nutritional value beverage advertisements and a discourse based on hedonistic elements. In order to prevent childhood obesity in Spain, a stricter regulation of advertising is necessary, especially in aspects such as the language used to present products and celebrity endorsements.

Food Advertising and Prevention of Childhood Obesity in Spain: Analysis of the Nutritional Value of the Products and Discursive Strategies Used in the Ads Most Viewed by Children from 2016 to 2018

In Spain, 40% of children are overweight or obese. Television advertising is a widely acknowledged factor contributing to high-calorie food intake. This study longitudinally correlates some variables involved in childhood obesity prevention strategies in Spain. A mixed-methods approach was used. A quantitative analysis of audience data was conducted to determine the advertising campaigns most viewed by Spanish children from 2016 to 2018. The Nutri-score system was applied to determine the nutritional quality of the food advertised. A content analysis and a study of the discursive strategies used as an advertising ploy was undertaken. The results were examined in relation to the regulatory framework of the Spanish PAOS Code for the co-regulation of food advertising aimed at children. The study shows that Spanish advertising aimed at children mostly advertises very low nutritional value products. Moreover, these campaigns violate the PAOS Code in terms of the use of language in relation to the product, its benefits, and the appearance of popular characters. Our findings suggest a direct association between low nutritional value food ads and discursive strategies based on the intangible and extrinsic characteristics of these products. There remains the need for stricter legislation that takes into consideration the nutritional value of advertised foods and the language used in their hedonistic advertising.

Identifying food marketing to teenagers: a scoping review

BACKGROUND

Teenagers are aggressively targeted by food marketing messages (primarily for unhealthy foods) and susceptible to this messaging due to developmental vulnerabilities and peer-group influence. Yet limited research exists on the exposure and power of food marketing specifically to teenage populations. Research studies often collapse "teenagers" under the umbrella of children or do not recognize the uniqueness of teen-targeted appeals. Child- and teen-targeted marketing strategies are not the same, and this study aims to advance understanding of teen-targeted food marketing by identifying the teen-specific promotion platforms, techniques and indicators detailed in existing literature.

METHODS

A systematic scoping review collected all available literature on food marketing/advertising with the term "teenager" or "adolescent" from nine databases, as well as Google Scholar for grey literature, and a hand search of relevant institutional websites. Included were all peer-reviewed journal articles, book chapters, and grey literature in which food marketing to youth was the central topic of the article, of any study type (i.e., original research, reviews, commentaries and reports), and including any part of the 12-17 age range.

RESULTS

The 122 articles reviewed define the scope of existing literature on food marketing to young people age 17 and under, identifying leading trends in countries studied (United States, 52%), populations identified (children and teens studied concurrently, 36%), outcomes measured (advertising exposure, 54%), study type (cross-sectional, 58%) and methods used (content analysis, 46%). The promotion platforms and techniques used by food marketers to appeal to young people (as reported in the literature) are also identified and classified. Few studies (7%) use indicators to identify teen-targeted food marketing.

CONCLUSIONS

Unique treatments of teen populations are limited in food marketing literature, as is the application of clear indicators to identify and differentiate teen-targeted food marketing from child- or adult-targeted content. Given the need to better measure the presence and power of teen food marketing, this is a significant oversight in existing literature. The indicators identified will help researchers to develop more accurate strategies for researching and monitoring teen-targeted food promotion.

The effect of screen advertising on children's dietary intake: A systematic review and meta-analysis

Evidence indicates that screen advertising for unhealthy food results in significant increases in dietary intake among children. This review was undertaken with the main aim of estimating the quantitative effect of screen advertising in experimental and nonexperimental conditions on children's dietary intake. Systematic searches were undertaken of interdisciplinary databases. Studies from 1980 to April 2018, all geography and languages, were included; participants were children and adolescents aged between 2 and 18 years; the intervention was screen advertising; and the outcome was dietary intake. Meta-analyses were conducted for measured and nonmeasured outcomes. Food advertising was found to increase dietary intake among children (age range 2-14, mean 8.8 years) in experimental conditions for television (TV) advertising and advergames. Meta-analysis revealed that children exposed to food advertising on TV (11 studies) and advergames (five studies) respectively consumed an average 60.0 kcal (95% confidence interval [CI], 3.1-116.9) and 53.2 kcal (95% CI, 31.5-74.9) more than children exposed to nonfood advertising. There was also an effect by body mass index (BMI). Findings from nonexperimental studies revealed that exposure to TV food advertising was positively associated with and predictive of dietary intake in children. Short-term exposure to unhealthy food advertising on TV and advergames increases immediate calorie consumption in children.

Child-targeted fast-food television advertising exposure is linked with fast-food intake among pre-school children

OBJECTIVE

To determine whether exposure to child-targeted fast-food (FF) television (TV) advertising is associated with children's FF intake in a non-experimental setting.

DESIGN

Cross-sectional survey conducted April-December 2013. Parents reported their pre-school child's TV viewing time, channels watched and past-week FF consumption. Responses were combined with a list of FF commercials (ads) aired on children's TV channels during the same period to calculate children's exposure to child-targeted TV ads for the following chain FF restaurants: McDonald's, Subway and Wendy's (MSW).

SETTING

Paediatric and Women, Infants, and Children (WIC) clinics in New Hampshire, USA.

SUBJECTS

Parents (n 548) with a child of pre-school age.

RESULTS

Children's mean age was 4·4 years; 43·2 % ate MSW in the past week. Among the 40·8 % exposed to MSW ads, 23·3 % had low, 34·2 % moderate and 42·5 % high exposure. McDonald's accounted for over 70 % of children's MSW ad exposure and consumption. Children's MSW consumption was significantly associated with their ad exposure, but not overall TV viewing time. After adjusting for demographics, socio-economic status and other screen time, moderate MSW ad exposure was associated with a 31 % (95 % CI 1·12, 1·53) increase and high MSW ad exposure with a 26 % (95 % CI 1·13, 1·41) increase in the likelihood of consuming MSW in the past week. Further adjustment for parent FF consumption did not change the findings substantially.

CONCLUSIONS

Exposure to child-targeted FF TV advertising is positively associated with FF consumption among children of pre-school age, highlighting the vulnerability of young children to persuasive advertising and supporting recommendations to limit child-directed FF marketing.

Adolescent Maturational Transitions in the Prefrontal Cortex and Dopamine Signaling as a Risk Factor for the Development of Obesity and High Fat/High Sugar Diet Induced Cognitive Deficits

Adolescence poses as both a transitional period in neurodevelopment and lifestyle practices. In particular, the developmental trajectory of the prefrontal cortex (PFC), a critical region for behavioral control and self-regulation, is enduring, not reaching functional maturity until the early 20 s in humans. Furthermore, the neurotransmitter dopamine is particularly abundant during adolescence, tuning the brain to rapidly learn about rewards and regulating aspects of neuroplasticity. Thus, adolescence is proposed to represent a period of vulnerability towards reward-driven behaviors such as the consumption of palatable high fat and high sugar diets. This is reflected in the increasing prevalence of obesity in children and adolescents as they are the greatest consumers of “junk foods”. Excessive consumption of diets laden in saturated fat and refined sugars not only leads to weight gain and the development of obesity, but experimental studies with rodents indicate they evoke cognitive deficits in learning and memory process by disrupting neuroplasticity and altering reward processing neurocircuitry. Consumption of these high fat and high sugar diets have been reported to have a particularly pronounced impact on cognition when consumed during adolescence, demonstrating a susceptibility of the adolescent brain to enduring cognitive deficits. The adolescent brain, with heightened reward sensitivity and diminished behavioral control compared to the mature adult brain, appears to be a risk for aberrant eating behaviors that may underpin the development of obesity. This review explores the neurodevelopmental changes in the PFC and mesocortical dopamine signaling that occur during adolescence, and how these potentially underpin the overconsumption of palatable food and development of obesogenic diet-induced cognitive deficits.

Systematic review of sedentary behaviour and health indicators in school-aged children and youth: an update

This systematic review is an update examining the relationships between objectively and subjectively measured sedentary behaviour and health indicators in children and youth aged 5–17 years. EMBASE, PsycINFO, and Medline were searched in December 2014, and date limits were imposed (≥February 2010). Included studies were peer-reviewed and met the a priori-determined population (apparently healthy children and youth, mean age: 5–17 years), intervention (durations, patterns, and types of sedentary behaviours), comparator (various durations, patterns, and types of sedentary behaviours), and outcome (critical: body composition, metabolic syndrome/cardiovascular disease risk factors, behavioural conduct/pro-social behaviour, academic achievement; important: fitness, self-esteem) study criteria. Quality of evidence by outcome was assessed using the Grading of Recommendations Assessment, Development, and Evaluation framework. Due to heterogeneity, a narrative analysis was conducted. A total of 235 studies (194 unique samples) were included representing 1 657 064 unique participants from 71 different countries. Higher durations/frequencies of screen time and television (TV) viewing were associated with unfavourable body composition. Higher duration/frequency of TV viewing was also associated with higher clustered cardiometabolic risk scores. Higher durations of TV viewing and video game use were associated with unfavourable behavioural conduct/pro-social behaviour. Higher durations of reading and doing homework were associated with higher academic achievement. Higher duration of screen time was associated with lower fitness. Higher durations of screen time and computer use were associated with lower self-esteem. Evidence ranged from “very low” to “moderate” quality. Higher quality studies using reliable and valid sedentary behaviour measures should confirm this largely observational evidence.

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.