The influence of front-of-pack portion size images on children's serving and intake of cereal

A systematic review of the relationship between portion size and indexes of adiposity in children

Research suggests that larger food portion sizes (PS) during a meal or snack increase daily energy intake in children. However, it remains unclear whether this 'PS effect' would lead to a sustained increase in consumption and affect body adiposity. This systematic review assesses the evidence for a relationship between served, consumed, and preferred PS (food or drink size in grams or kcal) and indexes of adiposity (e.g., BMI percentile, BMI z-scores) in children (< 19 years). A total of 17 articles were identified using six electronic databases (PsycINFO, MEDLINE, EMBASE, Web of Science, Cochrane Library, and ProQuest Dissertations & Theses Global). Articles were screened independently by 2 researchers; 21 studies were included (15 cross-sectional, 2 experimental, 1 case study, 1 longitudinal, and two interventions). A narrative review was conducted due to high levels of heterogeneity. Cross-sectional and experimental studies (n = 13) reported positive associations between PS and adiposity, but results differed according to the sex/gender of the participants and food type. Interventions (n = 2) showed that portion size reduction may be effective in reducing child adiposity. Due to the limited evidence on the causality and direction of the effect, and over-reliance on cross-sectional studies, more evidence on the longer-term impact of PS on indexes of body adiposity is required.

The effect of food packaging elements on children's food choices and intake: A systematic review

Little can be added about the worldwide concern over the exponential increase in obesity and child overweight problems. Much of the unhealthy eating habits occur at the time of food choice. The enormous influence of marketing strategies in general, and packaging in particular, has been highlighted here. In this respect, public policies that tend to direct choices toward healthier options have been developed. However, the usefulness of such policies will depend on evidence of how different packaging elements can influence children. This systematic review (SR) aims to compile the knowledge available to date on the influence of packaging on food choices and eating behaviours in children. Methodologically, the Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines have been followed to select papers. We also assessed the risk of bias in the studies analysed using the Newcastle-Ottawa Quality Assessment Scale (NOS). The initial search strategy found 2,627 articles, although only 20 of them met the eligibility criteria. Data from the studies were extracted, categorised, and analysed. The results indicate that most of the packaging elements have some effect on children's food choices or food intake. The use of Cartoon is the element with the most consistent evidence of influence. Despite the number of studies and public initiatives developed to promote this informative and persuasive element, less consistency has been found regarding the effect of Nutrition Labelling. Therefore, the results found should be considered by both governments and organisations when promoting public policies that work for the wellbeing of children.

Designing for downsizing: Home-based barriers and facilitators to reduce portion sizes for children

Evidence confirms that parents know that they should limit non-core foods for their children since these tend to be high in energy density (HED), fat, salt and sugar. However, it is unclear how knowledge of portion size limits, such as the 100 kcal guide from Public Health England are applied in practice. To observe in real-time children’s home food environment related to portion control and to explore with parents their reported portion size strategies, a mixed methods study was designed. Families with children aged 1–5 years were recruited (n = 21) to a three-part study: (1) to complete questionnaires and interviews on household food intake and portion control; (2) to report daily food intake for 4 days (n = 13) for one parent and their child(ren); (3) to observe home-based food provisioning via videorecording during dinner, breakfast and snack time (n = 6). Although the problem of large portion sizes of HED foods was recognised by mothers, strategies to downsize portions were not necessarily applied at home, as revealed in home observations and diaries. A mismatch between what was observed at home, what was reported in food diaries and what was said in interviews became apparent for some families. Mothers reported the need for greater support and guidance to downsize HED foods since they relied on pre-packaging as a guide to intake. Education and engagement were identified as important parameters for downsizing by mothers. One strategy which could be explored and applied by manufacturers is packaging design to faciliate the 100 kcal guidance using physical and engaging ways to assist parents in downsizing HED foods for their children. To facilitate effective government communication, innovative packaging design can be used to convey clear guidance and to tailor portion size messages for children. Packaging design, alongside government recommendations, can support parents’ goals to achieve healthy eating and can reinforce guidance for portion norms through innovation involving learning, playful engagement, and interaction.

Association of Food and Nonalcoholic Beverage Marketing With Children and Adolescents' Eating Behaviors and Health: A Systematic Review and Meta-analysis

IMPORTANCE

There is widespread interest in the effect of food marketing on children; however, the comprehensive global evidence reviews are now dated.

OBJECTIVE

To quantify the association of food and nonalcoholic beverage marketing with behavioral and health outcomes in children and adolescents to inform updated World Health Organization guidelines.

DATA SOURCES

Twenty-two databases were searched (including MEDLINE, CINAHL, Web of Science, Embase, and The Cochrane Library) with a publication date limit from January 2009 through March 2020.

STUDY SELECTION

Preferred Reporting Items for Systematic Reviews and Meta-Analyses reporting guidelines were followed. Inclusion criteria were primary studies assessing the association of food marketing with specified outcomes in children and adolescents (aged 0-19 years). Exclusion criteria were qualitative studies or those on advertising of infant formula. Of 31 063 articles identified, 96 articles were eligible for inclusion in the systematic review, and 80 articles in the meta-analysis (19 372 participants).

DATA EXTRACTION AND SYNTHESIS

Two reviewers independently extracted data. Random-effects models were used for meta-analyses; meta-regressions, sensitivity analyses, and P curve analyses were also performed. Where appropriate, pooling was conducted using combining P values and vote counting by direction of effect. Grading of Recommendations Assessment, Development, and Evaluation was used to judge certainty of evidence.

MAIN OUTCOMES AND MEASURES

Critical outcomes were intake, choice, preference, and purchasing. Important outcomes were purchase requests, dental caries, body weight, and diet-related noncommunicable diseases.

RESULTS

Participants totaled 19 372 from 80 included articles. Food marketing was associated with significant increases in intake (standardized mean difference [SMD], 0.25; 95% CI, 0.15-0.35; P < .001), choice (odds ratio, 1.77; 95% CI, 1.26-2.50; P < .001), and preference (SMD, 0.30; 95% CI, 0.12-0.49; P = .001). Substantial heterogeneity (all >76%) was unexplained by sensitivity or moderator analyses. The combination of P values for purchase requests was significant but no clear evidence was found for an association of marketing with purchasing. Data on dental health and body weight outcomes were scarce. The certainty of evidence was graded as very low to moderate for intake and choice, and very low for preference and purchasing.

CONCLUSIONS AND RELEVANCE

In this systematic review and meta-analysis, food marketing was associated with increased intake, choice, preference, and purchase requests in children and adolescents. Implementation of policies to restrict children's exposure is expected to benefit child health.

The impact of food packaging on measured food intake: A systematic review of experimental, field and naturalistic studies

Chronic, excess energy intake contributes to overweight and obesity. Solutions are needed to guide consumers towards portion control, especially for high energy density (HED), palatable foods. Food packaging, a key element of the eating environment, offers a potential solution. To investigate whether packaging design influences measured food intake, a systematic search was undertaken in four electronic databases (Ovid Medline; Ovid PsycInfo; Ovid Embase and Web of Science) across the previous decade. This process yielded 1671 discrete papers, of which 23 articles containing 40 relevant studies were retrieved. Most (n = 36) of the manipulated packaging features influenced consumption quantity with the largest effect sizes observed for packaging which guided consumers either by on-pack cues or structural features. For example, images on the front of the pack, packaging size, as well as partitioning and resealability all helped to reduce food intake. However, individual differences and attentional focus mediate packaging effects. Overall, packaging features can help to limit intake of HED foods and increase intake of nutrient-dense foods (e.g., carrots). Future studies on packaging for portion control (downsizing) might benefit from long term, randomised control trials to test effects outside of the laboratory context and applied to everyday consumer usage.

Use of advertising strategies to target children in sugar-sweetened beverages packaging in Mexico and the nutritional quality of those beverages

BACKGROUND

A product package can be a powerful marketing tool to persuade and attract consumers at the point-of-sale. Evidence shows that most advertised products have low nutritional quality. Currently, Mexico has incorporated advertising regulations on food and beverage packaging.

OBJECTIVES

To analyze the advertising strategies used to target children on packaging and to assess the nutritional quality of sugar-sweetened beverages available in the Mexican market.

METHODS

Photographs of 2380 beverages available in retail stores in Mexico City from January to March 2017 were analyzed. Beverages were classified as displaying child-directed strategies or nondirected strategies. Nutrition quality was evaluated using the Pan American Health Organization nutrient profile model.

RESULTS

The use of characters was the most frequent strategy among beverages with child-directed strategies (82.0%). The evaluation of nutrition quality found that 88.0% (P < .001) of sugar-sweetened beverages with child-directed strategies were excessive in free sugars and 56.9% (P < .001) contained other sweeteners. Beverages with more than two advertising strategies have the highest proportion of excessive free sugars (93.4%, 95% CI 82.8-98.6).

CONCLUSIONS

The use of characters and other visual strategies were frequently used in the packaging of sugar-sweetened beverages with child-directed strategies. In addition, these beverages are excessive in free sugars and contain a large number of products with other sweeteners.

Analysing Credibility of UK Social Media Influencers' Weight-Management Blogs: A Pilot Study

Social media influencers (SMI) are individuals with large follower engagement, who can shape the thoughts and dietary behaviours of their audience. Concerns exist surrounding the spread of dietary misinformation by SMI, which may impact negatively on public health, yet no standards currently exist to assess the credibility of their information. This study aimed to evaluate the credibility of key SMI weight management (WM) blogs (n = 9), piloting a pre-prepared credibility checklist. SMI were included if they had a blue-tick verification on ≥2 social media (SM) and an active WM blog. A sample of blog posts were systematically evaluated against thirteen credibility indicators under four themes: ‘transparency’, ‘use of other resources’, ‘trustworthiness and adherence to nutritional criteria’ and ‘bias’. Indicators were yes/no questions to determine an overall credibility percentage for each SMI. The ten most recent meal recipes from each blog were evaluated against Public Health England’s (PHE) calorie targets and the UK ‘traffic light’ food labelling scheme to assess nutritional quality. Percentages ranged from 23–85%, the highest gained by a Registered Nutritionist. SMI blogs may not be credible as WM resources. Given the popularity and impact of SM in the context of overweight, obesity and WM, this study may inform the methodological approach for future research.

Can Visual Cues to Portion Size Reduce the Number of Portions of Consumed? Two Randomized Controlled Trials

Background

Since 1950, the portion size of many snack foods has more than doubled and obesity rates have tripled. Portion size determines energy intake, often unwittingly.

Purpose

This paper tests whether salient visual cues to portion size on the packaging of high fat, sugar, or salty (HFSS) snacks can reduce consumption.

Methods

Two preregistered randomized controlled trials (N = 253 and N = 674) measured consumption in a lab and the home environment. Cues were salient, labeled stripes that demarcated single portions. Participants were randomized to cue condition or control. Consumption was measured without awareness.

Results

The main preregistered effect of the visual cue was not statistically significant. There was some variation by subgroup. In Study 1, men were more likely to eat the whole can of potato chips than women but significantly reduced consumption when visual cues were on the pack. The effect size was large: the number of men eating more than the recommended portion fell by 33%. Study 2 monitored household consumption of chocolate biscuits (cookies) sent to family homes in gift packs. Again, the main effect was nonsignificant but there was significant subgroup variation. When the person receiving the biscuits was female, households were more likely to eat more than the recommended portion per person per day, but less likely when the visual cues were displayed. The gender of the eaters was not known. The effect size was again large: the number of households eating more than the recommended portion fell by 26%. Households with children were also less likely to open packs with visual cues compared to control packs. Both studies recorded significant increases in the likelihood of observing serving size information, together with confusion about what it means.

Conclusions

The studies offer some evidence that salient visual cues could play a role in tackling the high consumption of unhealthy snacks, but the effects are confined to specific subgroups and warrant further investigation.

The Homeostatic Theory of Obesity: An Empirical Verification of the Circle of Discontent with an Assessment of Its Relationship to Restrained and Uncontrolled Eating among Children and Adolescents

The purpose of the present study was to provide an empirical verification of the Circle of Discontent with an assessment of its relationship to restrained and uncontrolled eating among children and adolescents. This study examined whether our results confirm a new hypothesized model. The total sample comprised 282 children and adolescents (148 girls and 134 boys; 141 participants with normal body weight and 141 with obesity). The mean age was 12.23 years (SD = 2.80), and the average BMI (body mass index) was 23.29 kg/m² (SD = 6.27). The following were used: Positive and Negative Affect Scale for Children, Children’s Body Image Scale, Figure Rating Scale, Three-Factor Eating Questionnaire and Eating Disorders in Youth. The obtained values of the model fit indices proved the goodness of fit. Our findings show that obesity accompanies body dissatisfaction and uncontrolled and restrictive eating. Moreover, the higher the level of restrictive eating, the lower the level of uncontrolled eating. The relationships between body dissatisfaction, negative affect and restrictive eating, as well as that between uncontrolled eating and high-energy consumption, are significant and positive. Other relationships are non-significant. The above-mentioned relationships established in the Circle of Discontent, as well as relationships of restrained and uncontrolled eating with variables described in the circle, were confirmed. Based on our results, preventive strategies and psychological interventions can be created and may include changes in body image, eating behaviors and emotional functioning.

The influence of front-of-pack portion size images on children's serving and intake of cereal

BACKGROUND

Consumption of large portions of energy-dense foods promotes weight gain in children. Breakfast cereal boxes often show portions much larger than the recommended serving size.

OBJECTIVE

This experimental study investigated whether front-of-package portion size depictions influence children's self-served portions and consumption.

METHODS

In a between-subjects design, 41 children aged 7-11 years (M= 9.0 ± 1.5y) served themselves breakfast cereal from a box, the front of which depicted either a recommended serving size of cereal (30g) or a larger, more typical front-of-pack portion (90g). Cereal served and consumed and total caloric intake (including milk) was recorded. Height and weight, demographic information and measures of children's food responsiveness and enjoyment of food were collected.

RESULTS

MANOVA revealed that children exposed to the larger portion size served themselves (+7g, 37%) and consumed (+6g, 63%) significantly more cereal than those exposed to the smaller portion. Despite this, overall caloric intake (milk included) did not differ between conditions, and no other measured variables (hunger, BMI) significantly affected the outcomes.

CONCLUSION

This study provides novel evidence of the influence portion-size depictions on food packaging have on children's eating behaviour. This offers possible avenues for intervention and policy change; however, more research is needed.