Advertising and obesity: a behavioral perspective

Obesity prevention and related public health advertising versus competing commercial advertising expenditure in Australia

Mass media campaigns can change attitudes and behaviours to improve population health. However, a key challenge is achieving share of voice in a complex and cluttered media environment. The aim of this study was to compare advertising expenditure on public health campaigns for obesity prevention (and related healthy eating and physical activity campaigns) with competing commercial categories of (a) sugary drinks, (b) artificially sweetened drinks and (c) diet/weight loss products and programmes. These commercial products may either undermine or dilute public health messages by directly contributing to poor health or confusing the public about the best ways to sustain a healthy lifestyle. Monthly estimates of advertising expenditure in Australian media (television, outdoor, cinema, radio, newspapers, magazines and digital) were obtained from Nielsen Media for 2016–18. Eligible public health advertising expenditure for the entire period (total AUD$27M) was vastly outweighed by the commercial categories of sugary drinks (AUD$129M) and diet/weight loss products and services (AUD$122M). Artificially sweetened drinks accounted for an additional AUD$23M of expenditure. These results highlight the need to rebalance the ratio of advertising to support public health in Australia through increased funding for obesity prevention and related campaigns, and critically, through government regulation to limit competing commercial advertising.

Strategies used by the soft drink industry to grow and sustain sales: a case-study of The Coca-Cola Company in East Asia

BACKGROUND

The market and non-market activities of the food and beverage industry contribute to unhealthy and unsustainable dietary patterns, increasingly in low-income and middle-income countries (LMICs). We aimed to describe how The Coca-Cola Company (TCCC), as the world market leader in the sugar-sweetened beverage sector, operationalises their activities in LMICs in East Asia, among the world's most highly populated yet under-researched countries, to illustrate the ways in which these activities may negatively influence health outcomes.

METHODS

We adopted a theoretically-guided qualitative research design and documentary analysis method. Data sources included: industry documents and web pages, marketing case studies obtained from the World Advertising Research Centre, media reports, global trade summaries and websites of industry associations. To guide data analysis, we synthesised a conceptual framework from existing commercial determinants of health literature, to describe ways in which the market and non-market activities of TCCC influence health.

RESULTS

TCCC leverages subsidiary companies and investments in international networks to expand its supply chains. The company engages in frequent political activities to minimise the implementation of nutrition policies that may impact profits. The company markets products, particularly on digital and mobile devices, often targeting children, adolescents and mothers, and undertakes public relations activities related to human rights, environmental sustainability and community and economic supports, and these public relations activities are often integrated into marketing campaigns. The identified activities of TCCC are frequently in direct contrast to efforts to improve the healthfulness of population diets in East Asia LMICs.

CONCLUSIONS

A public health analysis of the market and non-market activities of corporations active in unhealthy commodity industries needs to be broad in scope to cover the diverse set of strategies used to increase their market power and influence. Governments should consider a suite of policy options to attenuate these commercial determinants of unhealthy diets.

The nutrition transition, food retail transformations, and policy responses to overnutrition in the East Asia region: A descriptive review

BACKGROUND

The East Asia region is facing an increasing burden of overweight, obesity and related noncommunicable diseases, resulting from an ongoing nutrition transition. This study aimed to document the growing burden of overweight and obesity, and the accompanying dietary shifts, in the East Asia region and describe the policy responses to this.

METHODS

We present noncommunicable disease risk factor collaboration data on trends in the burden of malnutrition, and Euromonitor International data on trends in dietary purchases, in the East Asia region. We searched the NOURISHING and GINA databases to identify food and nutrition policies implemented in these countries.

RESULTS

There is an ongoing nutrition transition in the East Asia region, notably in upper-middle and lower-middle income countries. The prevalence of overweight, obesity, and accompanying health conditions, purchases of ultra-processed foods and beverages, and purchasing from supermarkets, fast-food and takeaway outlets, and other convenience retailers, are increasing. The policy response to this nutrition transition is limited, with the majority of policies implemented in higher-income countries.

CONCLUSIONS

East Asian countries are facing a growing burden of malnutrition, due in part to the dietary shifts occurring here. An ecological approach to policy intervention is needed to drive transformative food systems change.

Bringing disgust in through the backdoor in healthy food promotion: a phenomenological perspective

Obesity has been pointed out as one of the main current health risks leading to calls for a so-called "war on obesity". As we show in this paper, activities that attempt to counter obesity by persuading people to adjust a specific behavior often employ a pedagogy of regret and disgust. Nowadays, however, public healthcare campaigns that aim to tackle obesity have often replaced or augmented the explicit negative depictions of obesity and/or excessive food intake with the positive promotion of healthy food items. In this paper, we draw on a phenomenological perspective on disgust to highlight that food-related disgust is connected to the character and behavior of a perceived individual even in the context of promoting healthy food items. We argue that the focus on "making the healthy food choice the easy choice" might be an important step towards the de-stigmatization of people that are affected by obesity. However, so we suggest, this focus threatens to bring back an image of individuals affected by obesity as disgusting "through the backdoor". It does so not by portraying bodies with overweight as disgusting, but instead by implying that lifestyle choices, character and habits of people that are affected by obesity are markers of a lack of control. We argue that the close relationship between disgust and the perception of self-control in the context of obesity should be taken into consideration in the context of assessing the implications of new health promotion strategies to minimize the risk of stigmatizing people.

Sugary drink advertising expenditure across Australian media channels 2016-2018

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Promoting Healthy Menu Choices in Fast Food Restaurant Advertising: Influence of Perceived Brand Healthiness, Brand Commitment, and Health Consciousness

Fast food restaurants have increasingly turned to healthier choices to counter criticisms of nutritionally poor menu offerings and to differentiate themselves from the competition. However, research has yet to specifically investigate how consumers respond to advertisements for these healthier foods. To address this knowledge gap, two experiments were conducted to examine how perceived brand healthiness, brand commitment, and health consciousness influence responses to nutrient-content claimed print advertisements for healthy foods. Findings indicate that consumer responsiveness varies across the three factors but is more positive for advertisements placed by perceivably healthy restaurant brands, and that brand commitment and health consciousness play significant roles in affecting how consumer respond to such advertising. Several theoretical and managerial implications of the findings are discussed.

Food and beverage television advertising exposure and youth consumption, body mass index and adiposity outcomes

This study examined the relationships between exposure to food and beverage product television advertisements and consumption and obesity outcomes among youth. Individual-level data on fast-food and soft drink consumption and body mass index (BMI) for young adolescents from the Early Childhood Longitudinal Study - Kindergarten Cohort (1998-1999) and adiposity measures for children from the U.S. National Health and Nutrition Examination Survey (2003-2004) were combined with designated market area (DMA) Nielsen media advertising ratings data. To account for unobserved individual-level and DMA-level heterogeneity, various fixed- and random-effects models were estimated. The results showed that exposure to soft drink and sugar-sweetened beverage advertisements are economically and statistically significantly associated with higher frequency of soft drink consumption among youth even after controlling for unobserved heterogeneity, with elasticity estimates ranging from 0.4 to 0.5. The association between fast-food advertising exposure and fast-food consumption disappeared once we controlled for unobservables. Exposure to cereal advertising was significantly associated with young adolescents' BMI percentile ranking but exposures to fast-food and soft drink advertisements were not. The results on adiposity outcomes revealed that children's exposure to cereal advertising was associated with both percent body and trunk fatness; fast-food advertising was significantly associated with percent trunk fatness and marginally significantly associated with percent body fatness; and, exposure to SSB advertising was marginally significantly associated with percent body and trunk fatness. The study results suggest that continued monitoring of advertising is important and policy debates regarding the regulation of youth-directed marketing are warranted.

Communicating with parents of obese children: which channels are most effective?

BACKGROUND

One of the strategies proven most successful in curbing rising rates of childhood obesity involves targeting parents as agents of change. Prior studies have focused on what messages to communicate, but few have investigated how they should be communicated.

OBJECTIVE

To identify the channels most effective for communicating with parents of overweight and obese children and understand whether their use of parenting information sources differs from others in the community.

DESIGN/SETTING

This study utilizes data from the Longitudinal Study of Australian Children (LSAC). Families were included if weight and height information was available for parents and children at three data collection points: Waves 1, 2 and 4 (collected 2004, 2006 and 2010, respectively, n = 5107).

ANALYSIS

A priori and a posteriori segmentation methods identified groups of parents that were similar in the sources used to obtain information about parenting, and examined whether some segments were more likely to have obese children.

RESULTS

Four segments were identified that differed in their information source use: the 'personal networks', 'books', 'official sources' and 'mixed approach' segments. The 'official sources' and 'mixed approach' segments were most likely to have obese children, and they used doctors, government/community organizations and friends to obtain information on parenting. These segments were also less educated and had lower employment.

CONCLUSIONS

Messages are most likely to reach families with obese children if communicated through doctors, government publications and community organizations. Further, messages targeting social groupings of parents will leverage the power of advice from friends, which is another valuable information source for this group.

Behavioral Medicine Review: Weight Control in a Land of Milk and Honey

Obesity and its cardiometabolic comorbidities are on a skyrocketing trajectory with ominous public health implications. Focusing on primary care as a microcosm of the broader obesity crisis, this review discusses considerations for the prevention and management of obesity and its associated risks.

Differential Impact of Message Appeals, Food Healthiness, and Poverty Status on Evaluative Responses to Nutrient-Content Claimed Food Advertisements

A 2 × 3 × 2 mixed factorial experimental design was used to examine how three message appeals (benefit-seeking vs. risk-avoidance vs. taste appeals), food healthiness (healthy vs. unhealthy foods), and consumer poverty status (poverty vs. nonpoverty groups) impact evaluative responses to nutrient-content claimed food advertisements. Subjects were partitioned into two groups, those below and those above the poverty line, and exposed to nutrient-content claimed advertisement treatments for healthy and unhealthy foods featuring the three appeals. The findings reaffirmed the interaction effects between perceivably healthy and unhealthy foods and different appeals reported in previous studies, and found interaction effects between consumer poverty level and response to the message appeals featured in the experimental food advertisements. Age, body mass index, current dieting status, education, and gender were examined as covariates.

How to use health and nutrition-related claims correctly on food advertising: comparison of benefit-seeking, risk-avoidance, and taste appeals on different food categories

This study applies the concepts of health halos and unhealthy = tasty intuition to examine how the different health and nutrition-related (HNR) appeal types interact with different food product types compared with taste claims. The experiment investigated the impact of benefit-seeking and risk-avoidance HNR appeals compared with that of taste appeals on different food types. The authors found that although respondents evaluated food ads with the two HNR appeals as less risky/more beneficial and healthier than food ads with a taste claim, the respondents showed better ad-related evaluations on the HNR appeals for perceivably healthy food and on taste appeal for perceivably unhealthy food. The findings provide several theoretical and practical implications for health food marketing and public health policy.

Game on: do children absorb sports sponsorship messages?

Objective

It is likely that there are substantial subconscious effects of organizations’ efforts to associate their products with sport via sponsorships, but most research methods are unable to capture these effects. The present study employed a novel projective technique to explore children's implicit associations between popular sports and a range of sports sponsors.

Design

Children participated in an activity using magnets bearing the logos of numerous sports and sponsors. They were invited to arrange the magnets on a whiteboard without being advised that the activity related to sponsorship.

Setting

Perth, Western Australia.

Subjects

Children (n 164) aged 5–12 years.

Results

Three-quarters (76 %) of the children aligned at least one correct sponsor magnet with the relevant sport. Just over half the children (54 %) correctly matched the most popular sport (an Australian Football League team) with its relevant sponsor (a fast-food chain).

Conclusions

Given the unstructured nature of the projective task, the results provide some support for the argument that sports sponsorship can effectively reach child audiences. This is of concern given the current extent of sponsorship by alcohol and fast-food companies.

Outdoor advertising, obesity, and soda consumption: a cross-sectional study

Background

Recent research has shown that neighborhood characteristics are associated with obesity prevalence. While food advertising in periodicals and television has been linked to overweight and obesity, it is unknown whether outdoor advertising is related to obesity.

Methods

To test the association between outdoor food advertising and obesity, we analyzed telephone survey data on adults, aged 18–98, collected from 220 census tracts in Los Angeles and Louisiana. We linked self-reported information on BMI and soda consumption with a database of directly observed outdoor advertisements.

Results

The higher the percentage of outdoor advertisements promoting food or non-alcoholic beverages within a census tract, the greater the odds of obesity among its residents, controlling for age, race and educational status. For every 10% increase in food advertising, there was a 1.05 (95% CI 1.003 - 1.093, p<0.03) greater odds of being overweight or obese, controlling for other factors. Given these predictions, compared to an individual living in an area with no food ads, those living in areas in which 30% of ads were for food would have a 2.6% increase in the probability of being obese.

Conclusions

There is a relationship between the percentage of outdoor food advertising and overweight/obesity.

Sucrose exposure in early life alters adult motivation and weight gain

The cause of the current increase in obesity in westernized nations is poorly understood but is frequently attributed to a 'thrifty genotype,' an evolutionary predisposition to store calories in times of plenty to protect against future scarcity. In modern, industrialized environments that provide a ready, uninterrupted supply of energy-rich foods at low cost, this genetic predisposition is hypothesized to lead to obesity. Children are also exposed to this 'obesogenic' environment; however, whether such early dietary experience has developmental effects and contributes to adult vulnerability to obesity is unknown. Using mice, we tested the hypothesis that dietary experience during childhood and adolescence affects adult obesity risk. We gave mice unlimited or no access to sucrose for a short period post-weaning and measured sucrose-seeking, food consumption, and weight gain in adulthood. Unlimited access to sucrose early in life reduced sucrose-seeking when work was required to obtain it. When high-sugar/high-fat dietary options were made freely-available, however, the sucrose-exposed mice gained more weight than mice without early sucrose exposure. These results suggest that early, unlimited exposure to sucrose reduces motivation to acquire sucrose but promotes weight gain in adulthood when the cost of acquiring palatable, energy dense foods is low. This study demonstrates that early post-weaning experience can modify the expression of a 'thrifty genotype' and alter an adult animal's response to its environment, a finding consistent with evidence of pre- and peri-natal programming of adult obesity risk by maternal nutritional status. Our findings suggest the window for developmental effects of diet may extend into childhood, an observation with potentially important implications for both research and public policy in addressing the rising incidence of obesity.

The brain, appetite, and obesity

Food intake and energy expenditure are controlled by complex, redundant, and distributed neural systems that reflect the fundamental biological importance of adequate nutrient supply and energy balance. Much progress has been made in identifying the various hormonal and neural mechanisms by which the brain informs itself about availability of ingested and stored nutrients and, in turn, generates behavioral, autonomic, and endocrine output. While hypothalamus and caudal brainstem play crucial roles in this homeostatic function, areas in the cortex and limbic system are important for processing information regarding prior experience with food, reward, and emotion, as well as social and environmental context. Most vertebrates can store a considerable amount of energy as fat for later use, and this ability has now become one of the major health risks for many human populations. The predisposition to develop obesity can theoretically result from any pathological malfunction or lack of adaptation to changing environments of this highly complex system.

Internet food marketing on popular children's websites and food product websites in Australia

OBJECTIVE

The aim of the present study was to describe the nature and extent of food marketing on popular children's websites and food product websites in Australia.

METHODS

Food product websites (n 119) and popular children's websites (n 196) were selected based on website traffic data and previous research on frequently marketed food brands. Coding instruments were developed to capture food marketing techniques. All references to food on popular children's websites were also classified as either branded or non-branded and according to food categories.

RESULTS

Websites contained a range of marketing features. On food product websites these marketing features included branded education (79.0% of websites), competitions (33.6%), promotional characters (35.3%), downloadable items (35.3%), branded games (28.6%) and designated children's sections (21.8%). Food references on popular children's websites were strongly skewed towards unhealthy foods (60.8% v. 39.2% healthy food references; P<0.001), with three times more branded food references for unhealthy foods. Branded food references displayed similar marketing features to those identified on food product websites.

CONCLUSIONS

Internet food marketing uses a range of techniques to ensure that children are immersed in brand-related information and activities for extended periods, thereby increasing brand familiarity and exposure. The relatively unregulated marketing environment and increasing use of the Internet by children point to the potential increase in food marketing via this medium. Further research is required to investigate the impact of Internet food marketing on children's food preferences and consumption, and regulatory options to protect children.

Childhood obesity: are we missing the big picture?

Childhood obesity is increasing worldwide, raising alarm about future trends of cardiovascular disease, diabetes and cancer. This article discusses what may underlie our failure to respond effectively to the obesity epidemic, and presents a wider perspective for future research and public health agendas. So far targeting individual-level determinants and clinical aspects of childhood obesity has produced limited success. There is growing interest in understanding the wider determinants of obesity such as the built environment (e.g. walkability), social interactions, food marketing and prices, but much needs to be learned. Particularly, we need to identify distal modifiable factors with multiple potential that would make them attractive for people and policymakers alike. For example, walking-biking-friendly cities can reduce obesity as well as energy consumption, air pollution and traffic delays. Such agenda needs to be driven by strong evidence from research involving multi-level influences on behaviour, as well as the study of wider politico-economic trends affecting people's choices. This article highlights available evidence and arguments for research and policy needed to curb the obesity epidemic. The upstream approach underlying these arguments aims to make healthy choices not only the most rational, but also the most feasible and affordable.

Behavioral Medicine Review: Weight Control in a Land of Milk and Honey

Obesity and its cardiometabolic comorbidities are on a skyrocketing trajectory with ominous public health implications. Focusing on primary care as a microcosm of the broader obesity crisis, this review discusses considerations for the prevention and management of obesity and its associated risks.

The effects of television advertisements for junk food versus nutritious food on children's food attitudes and preferences

Television (TV) food advertising has attracted criticism for its potential role in promoting unhealthy dietary practices among children. Content analyses indicate junk food advertising is prevalent on Australian children's TV; healthy eating is rarely promoted. This paper presents (a) a cross-sectional survey examining associations between children's regular TV viewing habits and their food-related attitudes and behaviour; and (b) an experiment assessing the impact of varying combinations of TV advertisements (ads) for unhealthy and healthy foods on children's dietary knowledge, attitudes and intentions. The experimental conditions simulated possible models for regulating food ads on children's TV. Participants were 919 grade five and six students from schools in Melbourne, Australia. The survey showed that heavier TV use and more frequent commercial TV viewing were independently associated with more positive attitudes toward junk food; heavier TV use was also independently associated with higher reported junk food consumption. The experiment found that ads for nutritious foods promote selected positive attitudes and beliefs concerning these foods. Findings are discussed in light of methodological issues in media effects research and their implications for policy and practice. It is concluded that changing the food advertising environment on children's TV to one where nutritious foods are promoted and junk foods are relatively unrepresented would help to normalize and reinforce healthy eating.

The aetiology of childhood obesity: a review

Whilst the prevention of childhood obesity is the only viable, enduring, cost-effective solution to the obesity epidemic, effective methods for it remain elusive. Furthermore, strategies to influence obesogenic environments remain relatively unexplored. In order to be able to develop powerful population-level interventions and public health policies to prevent childhood obesity, it is important to understand its aetiology and those environments that are most amenable to measurable change. First, the present paper considers why we should be concerned about obesity in children, from both the perspective of the increased health risk to the individual and the high economic cost of treatment of obesity and related diseases, highlighting why the prevention of childhood obesity is important. Next, the determinants of health behaviour and the obesogenic environment are explored, which helps us to understand why the aetiology is so complex and that potential causal factors should not be considered in isolation, as the interaction between these factors is also important. The paper then considers the multi-factorial aetiology of childhood obesity and the rationale for the increasing trends in obesity that are evident, in order to understand what is changing in society and our children's behaviour that is triggering the positive energy balance leading to obesity. The review emphasises the need for multi-level approaches if we truly want to prevent childhood obesity. It also serves to highlight that there is a need to extend the current research base in order to build a well-founded framework to form the basis of a strategy for the prevention of childhood obesity.

Successful weight loss surgery improves eating control and energy metabolism: a review of the evidence

Eating behavior is determined by a balance of memories in terms of reward and punishment to satisfy the urge to consume food. Refilling empty energy stores and hedonistic motivation are rewarding aspects of eating. Overfeeding, associated adverse GI effects, and obesity implicate punishment. In the current review, evidence is given for the hypothesis that bariatric surgery affects control over eating behavior. Moreover, any caloric overload will reduce the feeling of satiety. Durable weight loss after bariatric surgery is probably the result of a new equilibrium between reward and punishment, together with a better signaling of satiation due to beneficial metabolic changes. We propose to introduce three main treatment goals for bariatric surgery: 1) acceptable weight loss, 2) improvement of eating control, and 3) metabolic benefit. To achieve this goal, loss of 50% to 70% of excess weight will be appropriate (i.e. 30% to 40% loss of initial weight), depending on the degree of obesity prior to operation.

Moving nutrition upstream: the case for reframing obesity

Currently, nutrition is described primarily as a matter of individual responsibility, which results in a focus on limited strategies that are unlikely to be successful. Public health advocates need to change the terms of debate or "reframe" the issue so that the context around individuals-the social, economic, and political context--comes into view. This paper uses obesity as an example of the need for reframing in nutrition. The authors also offer some suggestions on reframing based on lessons learned from other public health issues.

Communication and diet: an overview of experience and principles

As nutrition officials face the need to address widespread chronic obesity and its associated diseases, many have turned to media campaigns as a strategy for reaching large audiences. In the past, such efforts have had mixed results. Examples of successful and unsuccessful major public health campaigns are presented, including a small number related to diet. One implication of the analysis of those cases is the importance of obtaining high levels of exposure to messages. Several strategies for maximizing exposure are elaborated, including the use of paid advertising, relying on donated time, and earning coverage through media advocacy.

Interactions between the "cognitive" and "metabolic" brain in the control of food intake

If the new environment and modern lifestyle cause obesity in individuals with thrifty genes by increasing energy intake, it is important to know by what mechanisms hyperphagia occurs and why energy balance is not kept in check by the homeostatic regulator. The argument is developed that procuring and ingesting food is an evolutionarily conserved survival mechanism that occupies large parts of the brain's computing capacity including not only the hypothalamus but also a number of cortico-limbic structures. These forebrain systems evolved to engage powerful emotions for guaranteed supply and ingestion of beneficial foods from a sparse and often hostile environment. They are now simply overwhelmed with an abundance of food and food cues that is no longer interrupted by frequent famines. After briefly reviewing structure and functions of the relevant cortico-limbic structures and the better-known hypothalamic homeostatic regulator, the review focuses mainly on interactions between the two systems. Although several cortico-limbic processes are sensitive to metabolic depletion and repletion signals, it appears that they are underlying the same reversible leptin resistance that renders hypothalamic circuits insensible to continuously high leptin levels during periods of feast. It is hypothesized that this naturally occurring leptin resistance allowed temporary neutralization of satiety mechanisms and evolved as a response to survive subsequent periods of famine. With today's continuous and abundant food availability for a segment of the population, the powerful cognitive processes to eat and the resulting overweight can partially escape negative feedback control in prone individuals most strongly expressing such thrifty genes.