Children's everyday exposure to food marketing: an objective analysis using wearable cameras

Public health and harmful advertising: The nature and extent of children's real-time exposure to unhealthy commodity marketing

The consumption of unhealthy commodities (UHCs) - including unhealthy food, alcohol, tobacco and gambling products - contributes to substantial public health harm and significant social and economic costs. Consumption of UHCs is driven, in part, by increasingly sophisticated, persuasive and extensive product marketing. In Aotearoa New Zealand (NZ), UHC marketing is largely self-regulated by industry but varies by individual commodity. This paper aims to identify the nature and extent of children's exposure to UHC marketing in NZ and consider policy implications. Using data collected from wearable cameras, children's brand marketing exposures were analysed to identify their rate of exposure to UHC marketing, as well as 'Healthy' (core food/social marketing) and 'Other' marketing. Children (N = 90) were exposed to UHC marketing on average 76.2 times per day, nearly 2.5 times their daily exposure to 'Healthy' marketing. Children were exposed to UHC marketing through a more diverse range of settings and mediums than core food and social marketing. Over half of children's unhealthy food (54.9 %) and alcohol (51.9 %) marketing exposures were attributed to multinational corporations (MNCs). Children's exposure to each UHC category generally aligned with the level of regulation over that commodity in NZ. Overall, these findings support comprehensive statutory marketing regulation over UHCs, both in NZ and likely internationally given the global nature of UHCs. Statutory marketing regulation would reduce children's exposure to UHC marketing and protect public health. Given the extensive similarities among UHCs, policymakers should consider a joint regulatory approach.

Voicing residents' perception of (commercial) food cues in outdoor public spaces: a photovoice study

BACKGROUND

(Commercial) food cues in outdoor public spaces are environmental drivers of unhealthy diets. This study aimed to explore residents' perceptions of food cues in outdoor public spaces in relation to their perceived food environment, eating behaviour, and their opinion on governmental outdoor food cue regulations.

METHODS

A photovoice study, consisting of a photography assignment followed by semi-structured interviews, was conducted among 15 adult residents of the municipality of Wageningen, the Netherlands. Participants had one week to take photographs of outdoor food cues they encountered in their municipality, using a mobile app "myfoodenvironment", that were central to the interview afterwards.

RESULTS

Participants mainly noticed unhealthy food cues, which they viewed as constant 'reminders' that unhealthy food was easily accessible and affordable. Their views varied on the extent to which food cues affected their own eating behaviour, but generally believed that food cues affected that of others. Participants identified several factors that amplify outdoor food cues' influence on eating behaviour, including hunger, fatigue and attractiveness of the cues. The findings revealed support for government regulation of food cues, while acknowledging the complexity of this issue and the diverse perspectives on how such regulations should be designed (e.g., where, for whom), with one notable counterargument being concerns about feeling patronized by such policies.

CONCLUSIONS

Current findings may inform health professionals and (local) policy makers about the unhealthy food cues encountered by residents in outdoor public spaces, which unconsciously influence their eating behaviour, while also providing insights into designing food cue regulations that attract policy support by balancing public health goals with considerations of consumer autonomy and citizen preferences.

Trajectories of adherence to an obesogenic dietary pattern and changes in diet quality, food intake, and adiposity during adolescence

BACKGROUND AND AIMS

Contemporary longitudinal data on dietary patterns (DP) during adolescence are scarce. This study aimed to identify trajectories of adherence to an obesogenic DP and changes in diet quality (DQ), related food consumption, and adiposity markers during adolescence.

METHODS

A cohort of 600 adolescents (293 girls, 48.8%) attending 24 secondary schools enrolled on the SI! Program for Secondary Schools trial in Spain was assessed when participants were approximately 12, 14, and 16 years old. An energy-dense, high-fat, and low-fiber (obesogenic) DP was derived at each time point by reduced rank regression (RRR) using the percentage energy intake from fat, fiber density, and dietary energy density as intermediate variables. Based on each participant's resulting scores, trajectories of adherence to the obesogenic DP were identified by latent class trajectory modeling. Adjusted associations between trajectories, DQ and food consumption changes, and adiposity markers during adolescence were analyzed with generalized linear models.

RESULTS

Based on adherence to the obesogenic DP during adolescence, four stable trajectory groups (from lowest to highest adherence) were identified: trajectory 1 (44 participants [7.3%]), trajectory 2 (180 participants [30.0%]), trajectory 3 (292 participants [48.7%]), and trajectory 4 (84 participants [14.0%]). Overall DQ was moderate, but showed a gradient across trajectories, with trajectory 1 having the best quality. Although the identified trajectories were stable, individuals in the group with the lowest adherence to the obesogenic DP (trajectory 1) significantly improved their overall DQ over time, whereas those with the highest adherence (trajectory 4) showed the opposite trend. The group of adolescents in trajectory 4 had the least healthy central adiposity profile when ∼16 years old.

CONCLUSION

Four stable trajectories of adherence to an obesogenic DP were identified in a large cohort of adolescents, with DQ decreasing as adherence to the DP increased. Although adherence to the DP was stable, differences in food intake between trajectories widened over time, resulting in increased central adiposity in participants with the highest adherence to the pattern at the end of the study. Further research is needed to explore the determinants of adherence to obesogenic DPs in adolescence and to evaluate their effects on adiposity and overall health later in life.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03504059.

Impact of unhealthy food/drink marketing exposure to children in New Zealand: a systematic narrative review

Unhealthy food and drink marketing exposure to children is known to influence children's dietary choices and the World Health Organization recommends governments protect children from the marketing of unhealthy commodities. This study aims to explore and synthesize children's unhealthy food and drink marketing exposure in New Zealand. A systematic search strategy was undertaken following the PRISMA guidelines. Eight databases were searched for studies from inception to January 2024 on marketing exposure of unhealthy food and drink to children aged 2-17 years. A deductive coding analysis was used, with codes sourced from a modified coding framework developed using a diagram sourced from the ASEAN and UNICEF (2023) report. The diagram demonstrates the pathway from marketing exposure to unhealthy food- and drink-related diseases. A total of 1019 studies were screened for eligibility. Forty-five studies met the inclusion criteria-five qualitative, 34 quantitative and four mixed-method studies. The results are presented in a narrative review format. Findings demonstrated children's exposure to unhealthy food/drink marketing is ubiquitous with clear links to dietary preference and consumption. To improve child health now and over the life course, unhealthy food/drink marketing needs to be subjected to greater restriction with enforceable legislation to protect children from exposure to unhealthy marketing, breaking the chain from exposure to ill health.

Temptation at every corner: exploring public perceptions of food cues and policy support for governmental food cue regulation in outdoor public spaces

BACKGROUND

Unhealthy visual food cues in outdoor public spaces are external drivers of unhealthy diets. Food cues are visible situations associated with food-related memories. This study aimed to gain insight into the (un)healthy food cues residents notice in outdoor public spaces in Dutch municipalities. It also aimed to explore residents' perceptions of food cues' influence on eating behaviour to gain insight into the acceptability of food cues and support for governmental food cue regulation.

METHODS

An exploratory study was conducted among 101 adults who photographed outdoor visual food cues in their municipality and answered survey questions about the food cues using a bespoke app ('myfoodenvironment'). Participant and food cue characteristics were analysed. Associations between those characteristics, perceived influence on eating behaviour, acceptability of food cues and support for regulation were analysed.

RESULTS

Participants took 461 photographs of food cues. Most food cues visualised food (73.8%), 54.4% of which showed only unhealthy food. Food cues photographed by participants with a high level of education and those located near a food service outlet were more often perceived as stimulating others to eat compared to those photographed by participants with a middle education level and located near a food store or along the road (Fisher's exact test: p < 0.001 and p = 0.001, respectively). For most photographs, participants found the presence of food cues acceptable and were opposed to governmental cue regulation. However, when food cues visualised healthy food, they were more likely to be found acceptable than when visualising unhealthy food (χ2 (4; N = 333) = 16.955; p = 0.002). Besides, when food cues visualised unhealthy food, participants were less likely to oppose governmental regulation of those types of cues, than when visualising healthy food (Fisher's exact test: p = 0.002).

CONCLUSIONS

Unhealthy food cues in outdoor public spaces were predominantly photographed by the participants. Yet, for most photographs, participants found the food cues acceptable and opposed governmental food cue regulation, although acceptance was higher for healthy food cues and opposition was lower for unhealthy food cues. These findings can serve as input for policymakers to develop governmental food cue regulations that may gain public support.

Children's exposure to unhealthy food advertising on Philippine television: content analysis of marketing strategies and temporal patterns

BACKGROUND

This study conducted an exploratory content analysis of TV food advertisements on the top three most popular channels for Filipino children aged two to 17 during school and non-school days.

METHODS

Data were collected by manually recording of aired advertisements from 16 non-school days (July to September 2020) and 16 school days (January to April 2021). Descriptive and inferential statistical analyses were used to assess children's rates of exposure to food advertisements (mean ± SD of advertisements aired per channel per hour), the healthiness of promoted foods (as permitted (healthier) or not permitted (unhealthy) according to nutrient profiling models from the World Health Organization), and persuasive techniques used in food advertisements, including promotional characters and premium offers.

RESULTS

The results show that the rates of exposure to food advertisements were higher during school days (14.6 ± 14.8) than on non-school days (11.9 ± 12.0) (p < 0.01). Both periods yield a similarly higher proportion of non-permitted food advertisements (e.g. 9.3 ± 9.7 ads/channel/hour for school days and 8.3 ± 8.5 ads/channel/hour for non-school days) than permitted ones. More non-permitted food advertisements during children's peak viewing times were observed than non-peak viewing times (e.g. 11.8 ± 10. vs. 8.3 ± 9.2 ads/channel/hour for school days). Non-permitted food advertisements employed persuasive techniques more frequently, accounting for 64-91% of all food ads during peak viewing times.

CONCLUSION

Children are exposed to a large volume of television advertisements for foods that should not be permitted to be marketed to children based on authoritative nutrient criteria.

Unhealthy food outlets and outdoor advertisements in urban South African primary school students' food environments

Children's exposure to outlets selling, and outdoor advertisements marketing, unhealthy foods is an important risk factor for obesity. Yet few policies address the food retail and/or outdoor advertising environment, and research about children's perceptions is limited, especially in low- and middle-income countries. We used a participatory, multimodal visual/verbal approach to explore urban-dwelling South African primary school students' perceptions of unhealthy food outlets and outdoor advertisements they encountered on their journeys to school. Forty-one grade 7 students aged 11-14 years participated in drawing and/or photography activities and elicitation discussions. A mixed-methods, triangulated analysis involving the content analysis and extraction of data from research artefacts (33 journey to school drawings and 10 food advertisement photo collages) and thematic analysis of discussion transcripts was conducted. Drawings depicted 175 food outlets, two-thirds (64%) of which sold only unhealthy foods and 125 advertisements, most of which marketed unhealthy food. Unbranded, deep-fried foods prepared and sold by informal traders and independent shops were prominent. Informal and independent traders also sold unhealthy branded foods. Advertisements were primarily for unhealthy foods, especially branded, sugar-sweetened beverages. Participants thought extensive advertising bans, regulation of the sale of unhealthy food to children and other measures were needed to promote children's health in urban contexts. The results point to the need for food system-wide approaches that address multiple commercial determinants of health, including 'big food' advertising, unhealthy food sales by informal and independent traders and programs to address socio-economic influences such as poverty, unemployment and parents' poor work conditions.

Testing a nutrient composition threshold model to classify brands for marketing restrictions

INTRODUCTION

Food marketing restrictions often apply nutrient profile models (NPM) to distinguish unhealthy products that should not be advertised, however brand-only marketing remains largely unaddressed. We sought to test a threshold method for classifying packaged food, beverage, or fast-food brands as (non)permitted for marketing, based on the nutrient profile of their product-lines.

METHODS

We retrieved nutrient information from the Nutritrack databases for all products sold by the top 51 packaged food, beverage and fast-food brands in New Zealand, selected by market share. All products under each brand were classified as permitted (or not) to be marketed to children, using the NPM for WHO Western Pacific. The 25%, 50%, 75% and 90% threshold of brands' products permitted to market were compared. The 50% and 75% thresholds were compared to the WHO CLICK method, which is based on assessment of the brand's leading product.

RESULTS

The 90% threshold permitted 13% of the brands to be marketed to children. The 25% threshold permitted the marketing of 62% of brands. The 50% and 75% thresholds remained highly sensitive in identifying brands that should not be marketed to children. Comparison to the WHO CLICK method identified that a threshold method is more comprehensive and less arbitrary.

CONCLUSIONS

A threshold model based on product-line nutrient profiling provides a robust and option for brand classification. The 50% and 75% thresholds may be the most politically preferred options for use in regulation, while remaining highly effective.

PRACTITIONER POINTS

Brand marketing (e.g. sponsorship) remains largely unaddressed in existing restrictions on unhealthy food and beverage marketing to children.An established Nutrient Profile Model can be applied to a brand's entire product line, allowing calculation of the proportion of products that would not be permitted to be advertised to children.Restricting brand marketing for food and beverage brands with less than 50% or 75% of their products classified as 'permitted to be marketed to children' is a robust and evidence-based method that can be applied in regulation, with potential to mitigate industry challenges.

Children's self-reported exposure to sugary beverage advertisements and association with intake across six countries before and during the COVID-19 pandemic: a repeat cross-sectional study

BACKGROUND

Children's exposure to sugary beverage advertising may have changed during the COVID-19 pandemic due to shifts in media habits, which could subsequently have influenced intake. This study aimed to examine: 1) children's frequency and setting of exposure to advertisements of sugary beverages in six countries before and during the COVID-19 pandemic; 2) the association between exposure to sugary beverage advertisements and intake.

METHODS

Children aged 10-17 years (n = 28,908) in Australia, Canada, Chile, Mexico, the United Kingdom (UK) and the United States (US) completed online surveys in 2019, 2020 and 2021 as part of the International Food Policy Study using a repeat cross-sectional study design. Respondents self-reported frequency and setting of exposure to sugary beverage advertisements, location of school classes (in-person/online, 2020-2021 only), screen time, and sugary beverage intake. Adjusted weighted logistic and negative binomial regression models stratified by country examined associations between year and reported sugary beverage advertising exposure, and associations between sugary beverage advertising exposure and intake. Differences in reported advertising exposure between students taking online or in-person school classes were explored.

RESULTS

Self-reported exposure to advertisements for sugary beverages at least weekly was relatively stable across years within countries, with differences in settings of exposure. Exposure to sugary beverage advertisements increased on digital media independently of screen time from 2019 to 2021 in Australia, Canada, the UK and US, with a concomitant decrease in exposure in retail settings in all countries except the UK. In Australia and the UK, children attending all classes online were more likely to report at least weekly (vs less than once a week) exposure to sugary beverage advertisements, and children attending all classes online were more likely to report exposure to advertisements on digital media and in other settings (e.g., billboard, magazines) compared to children attending in-person classes in Australia, Canada and the UK. Exposure to sugary beverage advertisements at least weekly (IRR = 1.12,99%CI:1.09-1.15) and in each of the settings was associated with sugary beverage intake.

CONCLUSIONS

Exposure to digital advertisements for sugary beverages increased from 2019 to 2021 in most countries, and exposure was associated with sugary beverage intake. Reducing children's exposure to advertising of less healthy foods, including on digital media, may reduce sugary beverage intake.

Associations between exposure to advertising of foods high in fats, salt and sugar and purchase of energy and nutrients: a cross-sectional study

OBJECTIVE

To assess associations between self-reported advertising exposure to foods high in fats, salt and sugar and household purchases of energy, nutrients and specific product categories.

DESIGN

A cross-sectional design was used. Advertising exposure data were gathered using a questionnaire administered to the main shopper of each household, and purchase data from supermarkets and other stores for these households were accessed for a 4-week period during February 2019.

SETTING

Households in London and the North of England.

PARTICIPANTS

Representative households (N 1289) from the Kantar Fast Moving Consumer Goods Panel. Main shoppers were predominantly female (71 %), with a mean age of 54 years (±13).

RESULTS

Linear regression models identified that exposure to foods high in fats, salt and sugar advertising through traditional mediums (including broadcast and print), but not digital, transport, recreational or functional mediums, was associated with greater purchases of energy (9779 kcal; 95 % CI 3515, 16 043), protein (416 g; 95 % CI 161, 671), carbohydrate (1164 g; 95 % CI 368, 1886) and sugar (514 g; 95 % CI 187, 841). Generalised linear models showed that individuals who reported exposure to sugary drink advertising were more likely to purchase sugary drinks (1·16; 95 % CI 2·94, 4·99) but did not purchase more energy or nutrients from sugary drinks. There was no evidence of associations between exposure to advertising for sugary cereals or sweet snacks and purchases from these categories.

CONCLUSIONS

There was a strong influence of traditional advertising and sugar-sweetened beverage advertising on household food and drink purchases, thus supporting the need for advertising restrictions across traditional formats and for sugary drinks specifically.

Assessment of foods for infants and toddlers in Australia against the World Health Organization's Nutrient and Promotion Profile Model for food products for infants and young children

OBJECTIVE

Global public health agencies have recommended stronger regulation of food marketing to protect children's diets. This study assessed commercial foods for infants and toddlers available in Australian supermarkets for compliance with the World Health Organization (WHO) Regional Office for Europe's Nutrient and Promotion Profile Model: supporting appropriate promotion of food products for infants and young children 6-36 months in the WHO European Region (NPPM).

DESIGN

Dietitians assessed a sample of commercial foods for infants and toddlers against the composition, labelling and promotion requirements of the NPPM.

SETTING

Australia.

PARTICIPANTS

Commercial foods for infants and toddlers (n 45) available in two major Australian supermarkets, purposely sampled across product categories and brands.

RESULTS

Fewer than one quarter (23 %) of the assessed products met all nutrient content requirements of the NPPM. No products met all of the labelling or promotional requirements. All products included at least one promotional marketing claim that was not permitted under the NPPM.

CONCLUSIONS

The NPPM is useful to assess and monitor the nutritional composition and prevalence of marketing claims on commercial foods for infants and toddlers. Findings of noncompliance with the NPPM recommendations indicate an urgent need for stronger government regulation of the composition, labelling and marketing of commercial foods for infants and toddlers in Australia.

Is food and drink advertising across various settings associated with dietary behaviours and intake among Australian adolescents? Findings from a national cross-sectional survey

ISSUE ADDRESSED

The pervasive promotion of energy-dense, nutrient-poor food and drinks undermines efforts by adolescents and their parent/carers to maintain a nutritious diet during a crucial developmental period. This study examined the association between awareness of food and drink advertisements and adolescents' dietary behaviours and intake.

METHODS

A sample of Australian secondary students aged 12-17 years (N = 8763) self-reported their awareness of food and drink advertisements across seven settings, whether they had tried a new product or asked a parent/carer to purchase a product they had seen advertised, and their consumption of various unhealthy food and drink types. Analyses used multilevel mixed-effects generalised linear models adjusted for school-level clustering, socio-demographic factors and television viewing.

RESULTS

Students with higher advertising awareness were more likely to have tried a new product they had seen advertised (adjusted prevalence ratio [APR] = 1.62, 95% CI = 1.51-1.73, p < .001) and asked their parent/carer to buy an advertised product (APR = 1.62, 95% CI = 1.51-1.73, p < .001) at least once in the past month. As advertising awareness increased, so too did students' likelihood of reporting these dietary behaviours. A high unhealthy food intake was more commonly reported among students with higher advertising awareness (APR = 1.45, 95% CI = 1.32-1.58, p < .001), as was a high unhealthy drink intake (APR = 1.29, 95% CI = 1.18-1.42, p < .001).

CONCLUSIONS

Australian adolescents are vulnerable to the persuasive effects of food and drink marketing. SO WHAT?: Greater restrictions on the way the food and drink industry can market their products to adolescents are needed to better support them in developing and maintaining positive dietary behaviours.

Comparison of ten policy options to equitably reduce children's exposure to unhealthy food marketing

OBJECTIVE

Reducing children's exposure to unhealthy food marketing is crucial to combat childhood obesity. We aimed to estimate the reduction of children's exposure to food marketing under different policy scenarios and assess exposure differences by socio-economic status.

DESIGN

Data on children's exposure to unhealthy food marketing were compiled from a previous cross-sectional study in which children (n 168) wore wearable cameras and Global Positioning System (GPS) units for 4 consecutive days. For each exposure, we identified the setting, the marketing medium and food/beverage product category. We analysed the percentage reduction in food marketing exposure for ten policy scenarios and by socio-economic deprivation: (1) no product packaging, (2) no merchandise marketing, (3) no sugary drink marketing, (4) no confectionary marketing in schools, (5) no sugary drink marketing in schools, (6) no marketing in public spaces, (7) no marketing within 400 m of schools, (8) no marketing within 400 m of recreation venues, (9) no marketing within 400 m of bus stops and (10) no marketing within 400 m of major roads.

SETTING

Wellington region of New Zealand.

PARTICIPANTS

168 children aged 11-14 years.

RESULTS

Exposure to food marketing varied by setting, marketing medium and product category. Among the ten policy scenarios, the largest reductions were for plain packaging (60·3 %), no sugary drink marketing (28·8 %) and no marketing in public spaces (22·2 %). There were no differences by socio-economic deprivation.

CONCLUSIONS

The results suggest that plain packaging would result in the greatest decrease in children's exposure to food marketing. However, given that children are regularly exposed to unhealthy food marketing in multiple settings through a range of marketing mediums, comprehensive bans are needed to protect children's health.

Front-of-pack marketing on infant and toddler foods: Targeting children and their caregivers

OBJECTIVE

To identify and quantify child- and caregiver-appeal on front-of-pack marketing on infant and toddler foods in the Australian food supply.

METHODS

Content analysis of the presence and type of front-of-pack marketing techniques displayed on the front-of-pack of infant and toddler foods (for children aged up to 36 months) available in Australia's two major supermarkets' online stores.

RESULTS

Infant and toddler foods are promoted by up to 15 unique marketing techniques on the front-of-pack with an average of eight unique features per pack. A majority of food packages included marketing techniques targeting children, and all food packages included marketing techniques targeting caregivers, most commonly promoting health and nutrition.

CONCLUSIONS

Infant and toddler food packages are saturated with front-of-pack marketing features that target children and caregivers. To adequately protect young children's diets from the harmful influence of food marketing, and to promote the development of optimal feeding behaviours, government-led controls of all marketing intended to influence children's diets are required. In the context of marketing infant and toddler foods, this includes regulation of front-of-pack marketing techniques targeted to children and their caregivers.

IMPLICATIONS FOR PUBLIC HEALTH

Comprehensive government-led food marketing controls are required to protect children's diets from the harmful influence of marketing. The scope of these controls must include all unhealthy food marketing that children are exposed to and all other forms of unhealthy food marketing intended to influence children's diets.

School-Based Nutrition Programs in the Eastern Mediterranean Region: A Systematic Review

This systematic review aims at documenting government-led school nutrition programs/interventions in countries of the Eastern Mediterranean Region (EMR). A systematic review of the available literature on this topic was conducted between 25 October 2022 and 15 November 2022 using 15 electronic databases as well as grey literature. The search was limited to materials published post 2000 in English, Arabic, or French. Articles/Reports were included in the review if they provided information on school-based nutrition programs/interventions developed, adopted or implemented by a governmental entity in the EMR countries, irrespective of study design. In total, 158 documents were retained until 16 May 2023. School-based programs/interventions were categorized into 13 types. In total, 298 school-based nutrition programs/interventions were identified. The most common were school meals and school feeding programs (all EMR countries) followed by nutrition education within the curriculum (77% of countries), extracurricular nutrition education (64%), standards for school canteens or foods/beverages available in schools (64%), and training of school staff (59%). Approximately half reported the inclusion of fruit and vegetable schemes (54%) or the establishment of hygienic cooking facilities (50%), while less than half reported standards for the marketing of food/beverages (45%), bans/standards for vending machines, milk feeding schemes, or micronutrient supplementation programs (41%). The least common interventions were school gardens (32%) and take-home rations (14%). Countries with the lowest gross domestic product and lowest government effectiveness score had the lowest number of programs/interventions. Many of the programs have tackled both school-aged children as well as preschoolers. We were able to identify monitoring and process evaluation for 21 programs in 14 countries. Few programs have undergone impact assessment.

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.

School-Level Socioeconomic Status and Nutrient Content of Outdoor Food/Beverage Advertisements

We examined if areas around schools with more students of lower socioeconomic status (SES) have more total food/beverage advertisements and/or more advertisements with poorer nutritional content as compared to areas around schools with fewer students with lower SES. All outdoor food/beverage advertisements within a half-mile radius of 47 middle and high schools in the United States were objectively documented in 2012 and coded for nutritional content. The total number of advertisements and the macronutrient and micronutrient contents (total calories, fat (g), protein (g), carbohydrate (g), sugar (g), and sodium (mg)) of food and beverage items depicted in the advertisements were calculated. In total, 9132 unique advertisements were recorded, with 3153 ads displaying food and beverages that could be coded for nutrient content. Schools located in areas of lower SES (≥60% students receiving free/reduced-price lunch) had significantly more advertisements displaying food and beverages that could be coded for nutrient content (z = 2.01, p = 0.04), as well as advertisements that contained more sodium (z = 2.20, p = 0.03), as compared to schools located in areas of higher SES. There were no differences in calorie, fat, protein, carbohydrate, or sugar content. Policies to reduce the prevalence of outdoor food and beverage advertising are warranted.

The conceptualisation and operationalisation of 'marketing' in public health research: a review of reviews focused on food marketing using principles from critical interpretive synthesis

BACKGROUND

Extensive public health research reports the nature, scope and effects of various marketing activities used by food and drinks companies to support the sale of their products. Such literature informs the regulation of food marketing that encourages unhealthy eating behaviours and poor diet-related health outcomes. However, it is not clear whether this literature consistently conceptualises and applies marketing, which could in turn influence the approach and efficacy of policies to regulate food marketing. We aimed to understand the conceptualisation and operationalisation of marketing in public health research of food marketing, eventually focusing on the conceptualisation of integrated marketing.

METHODS

We conducted a review of reviews that drew on scoping review methods and applied principles of critical interpretive synthesis. Five databases of peer-reviewed literature and websites of relevant organisations were searched in June - August 2020. Articles were screened against inclusion criteria to identify reviews examining food marketing in a health context. Informative text segments from included articles were coded using NVivo. Codes were grouped into synthetic constructs and a synthesising argument.

RESULTS

After screening against inclusion criteria, 60 publications were eligible for inclusion. Informative text segments from 24 publications were coded, after which no new codes were identified. Our synthesising argument was that the understanding of integrated marketing appeared inconsistent across publications, such as by differences in use of underlying conceptual frameworks and in the application of terms such as marketing strategy and tactics.

CONCLUSIONS

Using our synthesising argument, we suggest ways to improve the future study of food marketing in public health research, for example by using in-depth case studies to understand the integrated operation and effect of multi-component marketing strategies. Improving conceptual clarity in the study of food marketing in public health research has the potential to inform policy that is more reflective of the true nature of marketing, and thus more effective in combating food marketing effects and protecting public health.

PROTOCOL REGISTRATION

The review protocol was made publicly available on Open Science Framework prior to the start of the study (DOI: https://doi.org/10.17605/OSF.IO/VSJCW ).

Identifying stakeholder priorities in use of wearable cameras for researching parent-child interactions

Wearable Cameras (WCs) enable researchers to capture objective descriptions of what participants see and experience as they go about their normal lives. When studying interactions between individuals (e.g. between a parent and child), using multiple WCs can provide highly detailed descriptions of interactions with levels of ecological validity not possible with other methods. However, the use of WCs brings challenges too, and understanding these is key to developing and optimising these methods. We captured the challenges experienced by a variety of stakeholders, namely parents and a range of different researcher roles (academics, field-workers and data processors) involved in a large UK study exploring parent-child interactions using low-cost, off-the-shelf WCs. High among the challenges identified were difficulties caused when subjects are temporarily not in view in the video footage captured. This and other factors identified were used as criteria to select a new, improved WC. The new WCs reduced the time faces were not in view by 75%. We report this and the other challenges identified, and suggest how these can be used to guide and help optimise future studies of this kind.

Capturing children food exposure using wearable cameras and deep learning

Children's dietary habits are influenced by complex factors within their home, school and neighborhood environments. Identifying such influencers and assessing their effects is traditionally based on self-reported data which can be prone to recall bias. We developed a culturally acceptable machine-learning-based data-collection system to objectively capture school-children's exposure to food (including food items, food advertisements, and food outlets) in two urban Arab centers: Greater Beirut, in Lebanon, and Greater Tunis, in Tunisia. Our machine-learning-based system consists of 1) a wearable camera that captures continuous footage of children's environment during a typical school day, 2) a machine learning model that automatically identifies images related to food from the collected data and discards any other footage, 3) a second machine learning model that classifies food-related images into images that contain actual food items, images that contain food advertisements, and images that contain food outlets, and 4) a third machine learning model that classifies images that contain food items into two classes, corresponding to whether the food items are being consumed by the child wearing the camera or whether they are consumed by others. This manuscript reports on a user-centered design study to assess the acceptability of using wearable cameras to capture food exposure among school children in Greater Beirut and Greater Tunis. We then describe how we trained our first machine learning model to detect food exposure images using data collected from the Web and utilizing the latest trends in deep learning for computer vision. Next, we describe how we trained our other machine learning models to classify food-related images into their respective categories using a combination of public data and data acquired via crowdsourcing. Finally, we describe how the different components of our system were packed together and deployed in a real-world case study and we report on its performance.

Child-appealing packaged food and beverage products in Canada-Prevalence, power, and nutritional quality

BACKGROUND

Children are frequently exposed to marketing on food packaging. This study evaluated the presence, type and power of child-appealing marketing and compared the nutritional quality of child-appealing vs. non-child-appealing Canadian packaged foods and examined the relationship between nutrient composition and marketing power.

METHODS

Child-relevant packaged foods (n = 5,850) were sampled from the Food Label Information Program 2017 database. The presence and power (# of techniques displayed) of child-appealing marketing were identified. Fisher's Exact test compared the proportion of products exceeding Health Canada's nutrient thresholds for advertising restrictions and Mann Whitney U tests compared nutrient composition between products with child- /non-child-appealing packaging. Pearson's correlation analyzed the relationship between nutrient composition and marketing power.

RESULTS

13% (746/5850) of products displayed child-appealing marketing; the techniques used, and the power of the marketing varied ([Formula: see text] 2.2 techniques; range: 0-11). More products with child-appealing packaging than with non-child appealing packaging exceeded Health Canada's thresholds (98% vs. 94%; p < .001). Products with child-appealing packaging (vs. non-child-appealing) were higher in total sugars (median: 14.7 vs. 9 g/RA; p < .001) and free sugars (11.5 vs. 6.2 g/RA; p < .001), but lower in all other nutrients. There was weak overall correlation between marketing power and nutrient levels. Results varied by nutrient and food category.

CONCLUSIONS

Unhealthy products with powerful child-appealing marketing displayed on package are prevalent in the food supply. Implementing marketing restrictions that protect children should be a priority.

Unhealthy food and beverage marketing to children on digital platforms in Aotearoa, New Zealand

BACKGROUND

Children's exposure to unhealthy food and beverage marketing has a direct impact on their dietary preference for, and consumption of, unhealthy food and drinks. Most children spend time online, yet marketing restrictions for this medium have had slow uptake globally. A voluntary Children's and Young People's Advertising (CYPA) Code was implemented in Aotearoa, New Zealand (NZ) in 2017. This study explores the Code's limitations in protecting children from harmful food and beverage marketing practices on digital platforms accessible to children.

METHODS

A cross-sectional content analysis of company websites (n = 64), Facebook pages (n = 32), and YouTube channels (n = 15) of the most popular food and beverage brands was conducted between 2019 and 2021 in NZ. Brands were selected based on market share, web traffic analysis and consumer engagement (Facebook page 'Likes' and YouTube page views). Analysis focused on volume and type of food posts/videos, level of consumer interaction, nutritional quality of foods pictured (based on two different nutrient profile models), and use of specific persuasive marketing techniques.

RESULTS

Eighty-one percent of websites (n = 52) featured marketing of unhealthy food and beverages. Thirty-five percent of websites featuring unhealthy food and beverages used promotional strategies positioning their products as 'for kids'; a further 13% used 'family-oriented' messaging. Several websites featuring unhealthy products also had designated sections for children, 'advergaming,' or direct messaging to children. Eighty-five percent of all food and drink company Facebook posts and YouTube videos were classified as unhealthy. Twenty-eight percent of Facebook posts for unhealthy products featured persuasive promotional strategies, and 39% premium offers. Nearly 30% of YouTube videos for unhealthy food and beverages featured promotional strategies, and 13% premium offers. Ten percent of Facebook posts and 13% of YouTube videos of unhealthy food and beverages used marketing techniques specifically targeting children and young people.

CONCLUSIONS

The voluntary CYPA Code has been in effect since 2017, but the inherent limitations and loopholes in the Code mean companies continue to market unhealthy food and beverages in ways that appeal to children even if they have committed to the Code. Comprehensive and mandatory regulation would help protect children from exposure to harmful marketing.

The commercial determinants of Indigenous health and well-being: a systematic scoping review

INTRODUCTION

Health inequity within Indigenous populations is widespread and underpinned by colonialism, dispossession and oppression. Social and cultural determinants of Indigenous health and well-being are well described. Despite emerging literature on the commercial determinants of health, the health and well-being impacts of commercial activities for Indigenous populations is not well understood. We aimed to identify, map and synthesise the available evidence on the commercial determinants of Indigenous health and well-being.

METHODS

Five academic databases (MEDLINE Complete, Global Health APAPsycInfo, Environment Complete and Business Source Complete) and grey literature (Australian Indigenous HealthInfoNet, Google Scholar, Google) were systematically searched for articles describing commercial industry activities that may influence health and well-being for Indigenous peoples in high-income countries. Data were extracted by Indigenous and non-Indigenous researchers and narratively synthesised.

RESULTS

56 articles from the USA, Canada, Australia, New Zealand, Norway and Sweden were included, 11 of which were editorials/commentaries. The activities of the extractive (mining), tobacco, food and beverage, pharmaceutical, alcohol and gambling industries were reported to impact Indigenous populations. Forty-six articles reported health-harming commercial practices, including exploitation of Indigenous land, marketing, lobbying and corporate social responsibility activities. Eight articles reported positive commercial industry activities that may reinforce cultural expression, cultural continuity and Indigenous self-determination. Few articles reported Indigenous involvement across the study design and implementation.

CONCLUSION

Commercial industry activities contribute to health and well-being outcomes of Indigenous populations. Actions to reduce the harmful impacts of commercial activities on Indigenous health and well-being and future empirical research on the commercial determinants of Indigenous health, should be Indigenous led or designed in collaboration with Indigenous peoples.

Benchmarking unhealthy food marketing to children and adolescents in Canada: a scoping review

INTRODUCTION

Unhealthy food and beverage marketing in various media and settings contributes to children's poor dietary intake. In 2019, the Canadian federal government recommended the introduction of new restrictions on food marketing to children. This scoping review aimed to provide an up-to-date assessment of the frequency of food marketing to children and youth in Canada as well as children's exposure to this marketing in various media and settings in order to determine where gaps exist in the research.

METHODS

For this scoping review, detailed search strategies were used to identify relevant peer-reviewed and grey literature published between October 2016 and November 2021. Two reviewers screened all results.

RESULTS

A total of 32 relevant and unique articles were identified; 28 were peer reviewed and 4 were from the grey literature. The majority of the studies (n = 26) examined the frequency of food marketing while 6 examined actual exposure to food marketing. Most research focussed on children from Ontario and Quebec and television and digital media. There was little research exploring food marketing to children by age, geographical location, sex/gender, race/ethnicity and/or socioeconomic status.

CONCLUSION

Our synthesis suggests that unhealthy food marketing to children and adolescents is extensive and that current self-regulatory policies are insufficient at reducing the presence of such marketing. Research assessing the frequency of food marketing and preschooler, child and adolescent exposure to this marketing is needed across a variety of media and settings to inform future government policies.

A scoping review of outdoor food marketing: exposure, power and impacts on eating behaviour and health

BACKGROUND

There is convincing evidence that unhealthy food marketing is extensive on television and in digital media, uses powerful persuasive techniques, and impacts dietary choices and consumption, particularly in children. It is less clear whether this is also the case for outdoor food marketing. This review (i) identifies common criteria used to define outdoor food marketing, (ii) summarises research methodologies used, (iii) identifies available evidence on the exposure, power (i.e. persuasive creative strategies within marketing) and impact of outdoor food marketing on behaviour and health and (iv) identifies knowledge gaps and directions for future research.

METHODS

A systematic search was conducted of Medline (Ovid), Scopus, Science Direct, Proquest, PsycINFO, CINAHL, PubMed, the Cochrane Database of Systematic Reviews, the Cochrane Central Register of Controlled Trials and a number of grey literature sources. Titles and abstracts were screened by one researcher. Relevant full texts were independently checked by two researchers against eligibility criteria.

RESULTS

Fifty-three studies were conducted across twenty-one countries. The majority of studies (n = 39) were conducted in high-income countries. All measured the extent of exposure to outdoor food marketing, twelve also assessed power and three measured impact on behavioural or health outcomes. Criteria used to define outdoor food marketing and methodologies adopted were highly variable across studies. Almost a quarter of advertisements across all studies were for food (mean of 22.1%) and the majority of advertised foods were unhealthy (mean of 63%). The evidence on differences in exposure by SES is heterogenous, which makes it difficult to draw conclusions, however the research suggests that ethnic minority groups have a higher likelihood of exposure to food marketing outdoors. The most frequent persuasive creative strategies were premium offers and use of characters. There was limited evidence on the relationship between exposure to outdoor food marketing and eating behaviour or health outcomes.

CONCLUSIONS

This review highlights the extent of unhealthy outdoor food marketing globally and the powerful methods used within this marketing. There is a need for consistency in defining and measuring outdoor food marketing to enable comparison across time and place. Future research should attempt to measure direct impacts on behaviour and health.

The distribution of harmful product marketing in public outdoor spaces and the effectiveness of marketing bans

Children's exposure to the marketing of harmful products in public outdoor spaces may influence their consumption of those products and affect health into adulthood. This study aimed to: i) examine the spatial distribution of children's exposure to three types of marketing-related 'harms' (alcohol, unhealthy food, and gambling) in outdoor spaces in the Wellington region, New Zealand/Aotearoa; ii) compare differences in the distribution of harms by socioeconomic deprivation; and iii) estimate the effectiveness of different policies that ban such marketing. Data were from 122 children aged 11-13y who wore wearable cameras and GPS devices for four consecutive days from July 2014 to June 2015. Images were analysed to identify harmful product marketing exposures in public outdoor spaces. Eight policy scenarios were examined to identify the effectiveness of marketing bans, for all children and by socioeconomic deprivation. Children's ratio of harmful marketing was higher for children from high deprivation households and was also found to cluster, with hots spots observed around city centers. The effectiveness of marketing bans depended on the target setting and ban area, with banning 400 m around bus stops leading to the largest reduction. Effectiveness varied also by type of harm and socioeconomic deprivation. For example, banning alcohol marketing in residential areas was estimated to have a larger effect on exposure reduction for children from high deprivation households. Our findings suggest that alcohol, unhealthy food and gambling marketing often cluster outdoors and that targeted bans of such marketing would likely improve child health and, for some banning scenarios, promote equity.

Use of environmental scan to assess density, content, and variation of predatory food and beverage marketing in New York City

To explore the presence of predatory food and beverage marketing in different neighborhoods in New York City (NYC), this study describes the methodology of an outdoor environmental scan of the physical environment. The study was conducted in four NYC neighborhoods over a three-week period, in which pairs of trained researchers canvassed designated neighborhoods to document the presence of food and beverage marketing using photographs taken on digital smart phone devices. Commercial areas in the vicinity of NYC Public Schools and NYC Housing Authority campuses located in four neighborhoods with the highest and lowest nutrition related health indicators were studied: South Bronx, Pelham Throggs Neck, Upper West Side, Chelsea/Greenwich Village. Advertisements were coded against 50+ indicators to quantify pertinent variables including the frequency and content of food and beverages advertised and all forms of predatory marketing observed. Comparisons of prevalence and content of food and beverage advertisements and predatory marketing were made across neighborhoods with the highest and lowest health indicators, using chi-squared analysis, and a significance level of p < 0.05. This article demonstrates a disproportionate presence of predatory marketing in low income NYC neighborhoods with negative health outcomes compared to wealthier neighborhoods. Further, this paper demonstrates the benefits and limitations of using an environmental scan methodology to assess predatory food and beverage marketing in a large urban area such as NYC.

Oral health of children in Aotearoa New Zealand-time for change

Aotearoa New Zealand (NZ) has a long tradition of providing publicly funded oral health care for children and young people; however, substantial inequities in child oral health remain. Dental caries is the most prevalent non-communicable childhood disease in NZ, with Māori and Pasifika, those from low socio-economic backgrounds, and those without access to community water fluoridation most affected. Children and whānau with dental caries suffer consequences that seriously affect their day-to-day lives; it is critical not to underestimate the disease or fail to include it when considering children's overall health. Dental caries is a complex disease, as is its prevention. This is particularly so in the current social context of child poverty, our food environment, the exploitation of children in advertising of non-healthy foods and drinks, and the immense challenges of meeting demand for oral health care in primary, secondary and tertiary care within current constraints. We review children's oral health in NZ and make recommendations for change among oral health professionals, all health professionals, health services and society. Further research in oral health services will be an essential part of improving oral health, recognising that there is an urgent need for a shift towards much greater prevention of caries.Glossary of Māori terms: Aotearoa: New Zealand; He Korowai Oranga: New Zealand Māori Health Strategy; Hui: meeting; Manaakitanga: hospitality, kindness, generosity and support; Mana Motuhake: self-determination; Māori: the indigenous people of Aotearoa New Zealand; Mātauranga Māori: Māori knowledge; Rangatahi: adolescents; Tamariki: children; Te Ao Māori: the Māori worldview; Te Kauae Parāoa: Division of Health Sciences Policy on Admissions; Te reo Māori: the indigenous Māori language; Te Tiriti o Waitangi: Māori language version of the Treaty of Waitangi; Tikanga: customs; Whānau: family; Whakamaua: Māori Health Action Plan 2020-2025; Whakawhanaungatanga: the process of establishing relationships and relating well to others.

Marketing of Food and Beverages to Children in the Eastern Mediterranean Region: A Situational Analysis of the Regulatory Framework

Marketing of food items high in added saturated and/or trans-fat, sugar, or sodium (HFSS) negatively affect consumption patterns of young children. The World Health Organization (WHO) advised countries to regulate the marketing of foods and non-alcoholic beverages to young populations. The aim of this manuscript is to provide a situational analysis of the regulatory framework of food marketing policies targeting children in the Eastern Mediterranean Region (EMR). A semi structured questionnaire was shared with the focal points of EMR member states inquiring about the reforms and monitoring initiatives in place. Electronic databases were searched for relevant publications between 2005 and 2021. Results revealed that even though 68% of countries discussed the recommendations, progress toward the WHO set goals has been slow with only 14% of countries implementing any kind of restrictions and none executing a comprehensive approach. Reforms have focused on local television and radio marketing and left out several loopholes related to marketing on the internet, mobile applications, and cross border marketing. Recent monitoring initiatives revealed a slight improvement in the content of advertised material. Yet, unhealthy products are the most promoted in the region. This review identified the need to intensify the efforts to legislate comprehensive food marketing policies within and across EMR countries.

Children's Community Nutrition Environment, Food and Drink Purchases and Consumption on Journeys between Home and School: A Wearable Camera Study

Children's community nutrition environments are an important contributor to childhood obesity rates worldwide. This study aimed to measure the type of food outlets on children's journeys to or from school, children's food purchasing and consumption, and to determine differences by ethnicity and socioeconomic status. In this New Zealand study, we analysed photographic images of the journey to or from school from a sample of 147 children aged 11-13 years who wore an Autographer camera which recorded images every 7 s. A total of 444 journeys to or from school were included in the analysis. Camera images captured food outlets in 48% of journeys that had a component of active travel and 20% of journeys by vehicle. Children who used active travel modes had greater odds of exposure to unhealthy food outlets than children who used motorised modes; odds ratio 4.2 (95% CI 1.2-14.4). There were 82 instances of food purchases recorded, 84.1% of which were for discretionary foods. Of the 73 food and drink consumption occasions, 94.5% were for discretionary food or drink. Children on their journeys to or from school are frequently exposed to unhealthy food outlets. Policy interventions are recommended to limit the availability of unhealthy food outlets on school routes.

Testing a Mobile App for Participatory Research to Identify Teen-Targeted Food Marketing: Mixed Methods Study

Background

Mobile apps are not only effective tools for promoting health to teenagers but are also useful for engaging teenagers in participatory research on factors that influence their health. Given the impact of food marketing messages on teenagers’ food attitudes and consumption choices, it is important to develop effective methods for capturing the food advertisements targeted at this population to assess their content.

Objective

The aim of this study was to test the feasibility and usability of a mobile app, “GrabFM!” (“Grab Food Marketing!”), designed for teenagers to facilitate monitoring of self-identified targeted food marketing messaging.

Methods

A mixed methods approach, including quantitative user response rates and qualitative focus group discussion feedback, was used in the evaluation process.

Results

A total of 62 teenagers (ages 13-17) completed GrabFM! app pilot testing over a 7-day data collection period. Teenagers submitted a total of 339 examples of food marketing, suggesting high feasibility for the app. Participants also took part in focus group discussions about their experience, providing positive feedback on usability, including ease of use and design aesthetic appeal.

Conclusions

The GrabFM! app had high feasibility and usability, suggesting its efficacy in capturing accurate data relevant to the teenage population’s experience with food marketing messaging.

Validation of an Automated Wearable Camera-Based Image-Assisted Recall Method and the 24-h Recall Method for Assessing Women's Time Allocation in a Nutritionally Vulnerable Population: The Case of Rural Uganda

Accurate data are essential for investigating relationships between maternal time-use patterns and nutritional outcomes. The 24 h recall (24HR) has traditionally been used to collect time-use data, however, automated wearable cameras (AWCs) with an image-assisted recall (IAR) may reduce recall bias. This study aimed to evaluate their concurrent criterion validity for assessing women’s time use in rural Eastern Ugandan. Women’s (n = 211) time allocations estimated via the AWC-IAR and 24HR methods were compared with direct observation (criterion method) using the Bland–Altman limits of agreement (LOA) method of analysis and Cronbach’s coefficient alpha (time allocation) or Cohen’s κ (concurrent activities). Systematic bias varied from 1 min (domestic chores) to 226 min (caregiving) for 24HR and 1 min (own production) to 109 min (socializing) for AWC-IAR. The LOAs were within 2 h for employment, own production, and self-care for 24HR and AWC-IAR but exceeded 11 h (24HR) and 9 h (AWC-IAR) for caregiving and socializing. The LOAs were within four concurrent activities for 24HR (−1.1 to 3.7) and AWC-IAR (−3.2 to 3.2). Cronbach’s alpha for time allocation ranged from 0.1728 (socializing) to 0.8056 (own production) for 24HR and 0.2270 (socializing) to 0.7938 (own production) for AWC-IAR. For assessing women’s time allocations at the population level, the 24HR and AWC-IAR methods are accurate and reliable for employment, own production, and domestic chores but poor for caregiving and socializing. The results of this study suggest the need to revisit previously published research investigating the associations between women’s time allocations and nutrition outcomes.

Community Co-Design of Regional Actions for Children's Nutritional Health Combining Indigenous Knowledge and Systems Thinking

Children's nutrition is highly influenced by community-level deprivation and socioeconomic inequalities and the health outcomes associated, such as childhood obesity, continue to widen. Systems Thinking using community-based system dynamics (CBSD) approaches can build community capacity, develop new knowledge and increase commitments to health improvement at the community level. We applied the formal structure and resources of a Group Model Building (GMB) approach, embedded within an Indigenous worldview to engage a high deprivation, high Indigenous population regional community in New Zealand to improve children's nutrition. Three GMB workshops were held and the youth and adult participants created two systems map of the drivers and feedback loops of poor nutrition in the community. Māori Indigenous knowledge (mātauranga) and approaches (tikanga) were prioritized to ensure cultural safety of participants and to encourage identification of interventions that take into account social and cultural environmental factors. While the adult-constructed map focused more on the influence of societal factors such as cost of housing, financial literacy in communities, and social security, the youth-constructed map placed more emphasis on individual-environment factors such as the influence of marketing by the fast-food industry and mental wellbeing. Ten prioritized community-proposed interventions such as increasing cultural connections in schools, are presented with the feasibility and likely impact for change of each intervention rated by community leaders. The combination of community-based system dynamics methods of group model building and a mātauranga Māori worldview is a novel Indigenous systems approach that engages participants and highlights cultural and family issues in the systems maps, acknowledging the ongoing impact of historical colonization in our communities.

Parents' Perceptions of Children's Exposure to Unhealthy Food Marketing: a Narrative Review of the Literature

Purpose of Review

A key driver of unhealthy diets in children is the marketing of unhealthy foods and beverages. Attempts to regulate children’s exposure to unhealthy food marketing through government-led policies are challenged by commercial interests. Parents shoulder the responsibility of counteracting the effects of omnipresent unhealthy food marketing that children are exposed to within the food environment. In this narrative review we aimed to synthesise the evidence over the last 10 years on parents' perceptions of children’s exposure to unhealthy food marketing and parents support for policies to restrict this marketing.

Recent Findings

The evidence indicates that unhealthy food marketing leads parents to feel undermined in their ability to provide healthy foods to their children. Despite this concern, parents tend to underestimate the levels of exposure to, and impacts of, unhealthy food marketing to their children, especially in the digital ecosystem.

Summary

The voices and support of parents represent a significant opportunity to accelerate policy action on food marketing. Increasing awareness among parents and caregivers to the high levels and harmful impacts of children’s exposure to unhealthy food marketing, focusing on their right not to be undermined by such action, may drive support for policy change. Further research is needed to understand parents’ attitudes and perceptions related to their children’s exposure to contemporary unhealthy food marketing, specifically in digital environments, and the perspectives of fathers and parents from low and middle-income countries. 

Rebalancing the marketing of healthier versus less healthy food products

Jean Adams discusses the evidence around food marketing restrictions and how they may be an effective way to support public health.

Choice, Motives, and Mixed Messages: A Qualitative Photo-Based Inquiry of Parents' Perceptions of Food and Beverage Marketing to Children in Sport and Recreation Facilities

Unhealthy food and beverage availability and sponsorship undermine healthy food practices in sport and recreation. We conducted a focused ethnography with reflexive photo-interviewing to examine parents' awareness, reactions, and experiences of food and beverage marketing in and around their children's physical activity in public sport and recreation facilities. Eleven parents took photos of what they thought their facility was 'saying about food and eating'. Photos guided semi-structured interviews on the '4Ps' of marketing (product, pricing, placement, promotion). Thematic analysis was conducted by holistic coding followed by in vivo, versus, and value coding. Photo-taking increased parents' awareness of food marketing in facilities. Reactions to food and beverage marketing were positive or negative depending on parents' perspectives of healthy food availability (choice), marketers' motives, and mixed messages within the facility. Parents experienced their children requesting 'junk' food at the facility leading to parents actively attempting to reduce the frequency of these requests. Healthy eating promotion in sport and recreation facilities was misaligned with the foods and beverages available which contributed to parents' distrust of social marketing initiatives. Critically evaluating the alignment of commercial and social marketing in recreation and sport may help inform effective healthy eating interventions that are accepted and supported by parents.

An objective assessment of children's exposure to brand marketing in New Zealand (Kids'Cam): a cross-sectional study

BACKGROUND

Marketing promotes values of consumerism and overconsumption, and negatively affects children's wellbeing and psychological development. The threat marketing poses to planetary health is just being realised. However, little is known about children's exposure to marketing at an aggregate level. Using an objective method of wearable cameras, we aimed to determine the nature and extent of children's exposure to marketing.

METHODS

Kids'Cam was a cross-sectional study of children aged 11-13 years in New Zealand, from which we randomly selected a sample of 90 children. Children wore cameras from when they woke up until they went to sleep for four consecutive days (Thursday-Sunday) that captured images at an angle of 136° every 7 s for exposure to marketing. Marketing brands were categorised into three groups: core food and social marketing messages, harmful commodities (eg, non-core food, alcohol, and gambling), or other. Exposure rates by marketing medium, setting, and product category were calculated using negative binomial regression models.

FINDINGS

From June 21, 2014, to June 30, 2015, we recruited 168 children, and randomly selected data from 90 children for the present study. Children in this study were exposed to a mean of 554 brands per 10 h day (95% CI 491-625), nearly a brand a minute, through multiple mediums (predominantly brand labels [36% of exposures] and product packaging [22%]) and mostly in schools (43%) and at home (30%). Food and beverages (20% of exposures) were the dominant product category. The most pervasive marketing brands typically sold a range of products across more than one product category (eg, children were exposed to Nike on average 20 exposures per day). Children were exposed to more than twice as many harmful commodities (mean 76 per 10 h day [95% CI 55-105]) as core food and social marketing messages (32 [26-39]) per day.

INTERPRETATION

We found that children are repeatedly exposed to marketing through multiple mediums and across all settings, and our findings suggests that marketing privileges particular messages, for example, marketing of harmful commodities. Given the key role marketing plays in establishing and supporting consumption norms, and perpetuating the normalisation of overconsumption which contributes to environmental degradation, these findings suggest an urgent need to reduce marketing to promote planetary health.

FUNDING

This research was funded by a University of Otago, Dean's Research Grant. The Kids'Cam study was funded by a Health Research Council of New Zealand Programme Grant (13/724).

Concerns and priorities of Aboriginal and Torres Strait Islander peoples regarding food and nutrition: a systematic review of qualitative evidence

BACKGROUND

Aboriginal and Torres Strait Islander Australians experience persistent health and social inequities. Chronic conditions, many of which are diet-related, are leading contributors to the burden of disease and health inequity in Australia. First Nations Peoples have the right to be involved in all policy decisions affecting them. This review aimed to synthesise Aboriginal and Torres Strait Islander Peoples' concerns and priorities about food and nutrition in order to inform policies to improve health equity.

METHODS

MEDLINE, CINAHL, Informit and Google Scholar were systematically searched to identify qualitative studies-published from January 2008-that included data from Aboriginal and/or Torres Strait Islander Peoples about their concerns and priorities related to food and nutrition. Data were extracted from included studies using a pre-determined template and study quality was assessed using the Aboriginal and Torres Strait Islander Quality Appraisal Tool. Qualitative findings were synthesised using inductive thematic analysis and categorised based on an ecological model of health.

RESULTS

Twenty-one studies were included. Key factors influencing food and nutrition were identified across all levels of the ecological framework. These included interpersonal and institutional racism, junk food availability and marketing, food accessibility and affordability, housing conditions, food knowledge and cooking skills, and connection to family and culture.

CONCLUSIONS

Documenting Aboriginal and Torres Strait Islander Peoples' lived experiences of the colonised food system is one step necessary for informing policy to tackle food and nutrition inequities. Based on existing qualitative research, food and nutrition policymakers should prioritise building a supportive food environment by focusing on self-determination; ensuring access to healthy, affordable food and safe housing; and by eliminating systemic racism.

Where do the children play? An objective analysis of children's use of green space

Green space is important for health, yet, objective research on children's use of green space is sparse. This study aimed to objectively assess children's use of green space in both public and private settings during their summer leisure time, using wearable cameras. Images from cameras worn by 74 children were analysed for green space use over 4 days. Children spent an average of ∼1/10 h of leisure time in green space in the summer months, were physically active 68%, and with others 85%, of the time. Green spaces are important places for children's health because they are places they frequent and places where they are physically active and socialize. Wearable cameras provide an effective method for objective assessment of green space use.

Seeing the food swamp for the weeds: Moving beyond food retail mix in evaluating young people's food environments

Nutritional health of children and youth is an increasing cause for concern in Canada. Through food and beverage messaging in multiple environments, young people develop eating behaviours with ramifications throughout their life course. Unhealthy food retailers near schools, recreation facilities, and childcare centres-key activity settings for healthy eating promotion-present repeated, compounding exposures to commercial geomarketing. Geomarketing impacts nutritional health by promoting highly processed, calorie-dense, and nutrient-poor foods and beverages across urban landscapes. While food retail mix (as a ratio of healthy to unhealthy food retailers) can be used to assess food environments at multiple scales, such measures may misrepresent young people's unique experience of these geographic phenomena. Moving beyond uniform conceptualization of food environments, new research methods and tools are needed for children and youth. We investigated young people's food environments in the major Canadian cities of Calgary and Edmonton. Using government-initiated nutrition guidelines, we categorized 55.8% of all food retailers in Calgary, and 59.9% in Edmonton as 'unhealthy'. A Bernoulli trial at the 0.05 alpha level indicated few differences in prevalence proximal to activity settings versus elsewhere in both cities, demonstrating the limited applicability of food retail mix for characterizing young people's food environments. To model unhealthy food retailers geomarketing to children and youth, we considered their proximity to multiple activity settings, using overlapping radial buffers at the 250 m, 500 m, 1000 m, and 1500 m scales. Examining young people's food environments relative to the spaces where they learn and play, we determined that as many as 895 out of 2663 unhealthy food retailers fell within 1500 m of 21+ activity settings. By conceptualizing, measuring, and problematizing these "super-proximal" unhealthy food retailers, urban planners and public health researchers can use these techniques to pinpoint unhealthy food retailers, or "weeds in the food swamp," as a critical site for healthy eating promotion in municipalities.

A comparison of self-reported exposure to fast food and sugary drinks marketing among parents of children across five countries

Exposure to unhealthy food and beverage marketing is an important environmental determinant of dietary intake. The current study examined self-reported exposure to marketing of unhealthy foods and beverages across various media channels and settings among parents of children younger than 18 years in five high and upper-middle income countries. Data from 4827 parents living with their children were analyzed from the International Food Policy Study (2017), a web-based survey of adults aged 18-64 years from Canada, the United States (US), the United Kingdom (UK), Australia, and Mexico. Respondents reported their exposure to marketing of fast food and of sugary drinks across media channels/settings overall and how often they see fast food and sugary drink marketing while viewing media with their children. Regression models examined differences across countries and correlates of marketing exposure. Parents in Mexico and the US reported greater exposure to marketing for fast food and sugary drinks compared to parents in Australia, Canada, and the UK. Patterns of exposure among parents were generally consistent across countries, with TV, digital media, and radio being the most commonly reported media channels for both fast food and sugary drinks. Exposure to marketing of fast food and sugary drinks was associated with a variety of sociodemographic factors, most strongly with ethnicity and education, and sociodemographic trends differed somewhat between countries. The findings demonstrate differences in self-reported parental exposure to marketing of fast food and sugary drinks between countries, and may help to evaluate the impact of marketing restrictions implemented over time.

Food and drink marketing on social media and dietary intake in Australian adolescents: Findings from a cross-sectional survey

Unhealthy food and drink marketing is prominent on social media and use of such platforms is widespread among adolescents. This study aims to examine the association between exposure to and engagement with food or drink advertisements on social media and unhealthy food and drink intake in Australian adolescents. In 2018, a representative sample of secondary school students aged 12-17 years (N = 8708) self-reported how frequently they saw food or drink advertisements on social media (exposure), 'liked' or 'shared' food or drink posts (engagement), and consumption of various unhealthy food and drinks. Multilevel logistic regression assessed the association between exposure to and engagement with food marketing on social media and high intake of unhealthy food and drinks. Fifty-five percent of students reported seeing a food or drink advertisement on social media at least weekly, while engagement was less frequent. Exposure to a food or drink advertisement on social media at least once in the last week was associated with a high intake of unhealthy drinks, while liking or sharing a food or drink post at least once in the last month was associated with a high intake of unhealthy food and drinks (all p < 0.01). As frequency of engagement with this type of marketing increased, so too did the likelihood of a high intake of unhealthy food and drinks. The association between exposure to and engagement with food or drink marketing and high unhealthy drink intake was driven by males, while all associations persisted irrespective of age. Holding manufacturers to higher standards in their digital marketing of unhealthy food and drink products through improved policy design and enforcement capability may be crucial in enabling young individuals to maintain a healthy diet.

Quantifying Child-Appeal: The Development and Mixed-Methods Validation of a Methodology for Evaluating Child-Appealing Marketing on Product Packaging

There is no standardized or validated definition or measure of “child-appeal” used in food and beverage marketing policy or research, which can result in heterogeneous outcomes. Therefore, this pilot study aimed to develop and validate the child-appealing packaging (CAP) coding tool, which measures the presence, type, and power of child-appealing marketing on food packaging based on the marketing techniques displayed. Children (n = 15) participated in a mixed-methods validation study comprising a binary classification (child-appealing packaging? Yes/No) and ranking (order of preference/marketing power) activity using mock breakfast cereal packages (quantitative) and focus group discussions (qualitative). The percent agreement, Cohen’s Kappa statistic, Spearman’s Rank correlation, and cross-classification analyses tested the agreement between children’s and the CAP tool’s evaluation of packages’ child-appeal and marketing power (criterion validity) and the content analysis tested the relevance of the CAP marketing techniques (content validity). There was an 80% agreement, and “moderate” pairwise agreement (κ [95% CI]: 0.54 [0.35, 0.73]) between children/CAP binary classifications and “strong” correlation (r_s [95% CI]: 0.78 [0.63, 0.89]) between children/CAP rankings of packages, with 71.1% of packages ranked in the exact agreement. The marketing techniques included in the CAP tool corresponded to those children found pertinent. Pilot results suggest the criterion/content validity of the CAP tool for measuring child-appealing marketing on packaging in accordance with children’s preferences.

Sociodemographic differences in self-reported exposure to high fat, salt and sugar food and drink advertising: a cross-sectional analysis of 2019 UK panel data

OBJECTIVES

To explore sociodemographic differences in exposure to advertising for foods and drinks high in fat, salt and sugar (HFSS) and whether exposure is associated with body mass index (BMI).

DESIGN

Cross-sectional survey.

SETTING

UK.

PARTICIPANTS

1552 adults recruited to the Kantar Fast Moving Consumer Goods panel for London and the North of England.

OUTCOME MEASURES

Self-reported advertising exposure stratified by product/service advertised (processed HFSS foods; sugary drinks; sugary cereals; sweet snacks; fast food or digital food delivery services) and advertising setting (traditional; digital; recreational; functional or transport); BMI and sociodemographic characteristics.

RESULTS

Overall, 84.7% of participants reported exposure to HFSS advertising in the past 7 days. Participants in the middle (vs high) socioeconomic group had higher odds of overall self-reported exposure (OR 1.48; 95% CI 1.06 to 2.07). Participants in the low (vs high) socioeconomic group had higher odds of reporting exposure to advertising for three of five product categories (ORs ranging from 1.41 to 1.67), advertising for digital food delivery services (OR 1.47; 95% CI 1.05 to 2.05), traditional advertising (OR 1.44; 95% CI 1.00 to 2.08) and digital advertising (OR 1.50; 95% CI 1.06 to 2.14). Younger adults (18-34 years vs ≥65 years) had higher odds of reporting exposure to advertising for digital food delivery services (OR 2.08; 95% CI 1.20 to 3.59), digital advertising (OR 3.93; 95% CI 2.18 to 7.08) and advertising across transport networks (OR 1.96; 95% CI 1.11 to 3.48). Exposure to advertising for digital food delivery services (OR 1.40; 95% CI 1.05 to 1.88), digital advertising (OR 1.80; 95% CI 1.33 to 2.44) and advertising in recreational environments (OR 1.46; 95% CI 1.02 to 2.09) was associated with increased odds of obesity.

CONCLUSIONS

Exposure to less healthy product advertising was prevalent, with adults in lower socioeconomic groups and younger adults more likely to report exposure. Broader restrictions may be needed to reduce sociodemographic differences in exposure to less healthy product advertising.

Eating context and ultraprocessed food consumption among UK adolescents

We aimed to evaluate the association between eating context patterns and ultraprocessed food consumption at two main meal occasions in a representative sample of UK adolescents. Data were acquired from 4-d food records of adolescents aged 11-18 years, who participated in the 2014-2016 UK National Diet and Nutrition Survey (n 542). The eating context was assessed considering the location of the meal (lunch and dinner) occasion, the individuals present, whether the television was on and if the food was consumed at a table. Ultraprocessed foods were identified using the NOVA classification. Exploratory factor analysis was used to identify eating context patterns for lunch and dinner. Linear regression models adjusted for the covariates were utilised to test the association between eating context patterns and the proportion of total daily energy intake derived from ultraprocessed foods. Their contribution was about 67 % to energy intake. Three patterns were retained for lunch ('At school with friends', 'TV during family meal' and 'Out-of-home (no school)'), and three patterns were retained for dinner ('Watching TV alone in the bedroom', 'TV during family meal' and 'Out-of-home with friends'). At lunch, there was no significant association between any of the three patterns and ultraprocessed food consumption. At dinner, the patterns 'Watching TV alone in the bedroom' (coefficient: 4·95; 95 % CI 1·87, 8·03) and 'Out-of-home with friends' (coefficient: 3·13; 95 % CI 0·21, 6·14) were associated with higher consumption of ultraprocessed food. Our findings suggest a potential relationship between the immediate eating context and ultraprocessed food consumption by UK adolescents.

Ensuring the right to food for indigenous children: a case study of stakeholder perspectives on policy options to ensure the rights of tamariki Māori to healthy food

BACKGROUND

The United Nations Convention on the Rights of the Child confirms a child's right to adequate food, and to the highest attainable standard of health. For indigenous children, these rights are also recognised in the UN Declaration on the Rights of Indigenous Peoples. However, Indigenous children endure higher rates of obesity and related health conditions than non-indigenous children, including in Aotearoa New Zealand (NZ). For indigenous tamariki (Māori children) in NZ, high levels of obesity are interconnected with high rates of food insecurity. Therefore there is a need for action. This study aimed to investigate policy options that would safeguard the rights of indigenous children to healthy food. We explored with key stakeholder's policy options to ensure the rights of indigenous children to healthy food, through a case study of the rights of tamariki.

METHODS

Interviews were conducted with 15 key stakeholders, with experience in research, development or delivery of policies to safeguard the rights of tamariki to healthy food. Iterative thematic analysis of the transcripts identified both deductive themes informed by Kaupapa Māori theory and literature on rights-based approaches and inductive themes from the interviews.

RESULTS

The analysis suggests that to ensure the right to adequate food and to healthy food availability for tamariki, there needs to be: a comprehensive policy response that supports children's rights; an end to child poverty; food provision and food policy in schools; local government policy to promote healthy food availability; and stronger Māori voices and values in decision-making.

CONCLUSIONS

The right to food for indigenous children, is linked to political and economic systems that are an outcome of colonisation. A decolonising approach where Māori voices and values are central within NZ policies and policy-making processes is needed. Given the importance of food to health, a broad policy approach from the NZ government to ensure the right to adequate food is urgent. This includes economic policies to end child poverty and specific strategies such as food provision and food policy in schools. The role of Iwi (tribes) and local governments needs to be further explored if we are to improve the right to adequate food within regions of NZ.

The Frequency and Context of Snacking among Children: An Objective Analysis Using Wearable Cameras

Snacking is a common eating behaviour, but there is little objective data about children’s snacking. We aimed to determine the frequency and context of children’s snacking (n = 158; mean age = 12.6 years) by ethnicity, gender, socioeconomic deprivation and body mass index (BMI) children. Participants wore wearable cameras that passively captured images of their surroundings every seven seconds. Images (n = 739,162) were coded for snacking episodes, defined as eating occasions in between main meals. Contextual factors analysed included: snacking location, food source, timing, social contact and screen use. Rates of total, discretionary (not recommended for consumption) and healthful (recommended for consumption) snacking were calculated using negative binomial regression. On average, children consumed 8.2 (95%CI 7.4, 9.1) snacks per day, of which 5.2 (95%CI 4.6, 5.9) were discretionary foods/beverages. Children consumed more discretionary snacks than healthful snacks in each setting and at all times, including 15.0× more discretionary snacks in public spaces and 2.4× more discretionary snacks in schools. Most snacks (68.9%) were sourced from home. Girls consumed more total, discretionary and healthful snacks than boys, and Māori and Pacific consumed fewer healthful snacks than New Zealand (NZ) Europeans. Results show that children snack frequently, and that most snacking involves discretionary food items. Our findings suggest targeting home buying behaviour and environmental changes to support healthy snacking choices.

An objective methodology capturing online commodity marketing and other harms

Increasingly life is lived online, yet little is known about the actual nature and extent of online content that people view due to the difficulty of recording real time exposure. This includes people's exposure to harmful commodity marketing. This study aimed to develop a methodology to assess the nature and extent of exposure to, and engagement with, unhealthy commodity marketing and other public health harms online, particularly children's exposure. A convenience sample of 16 young adult participants (aged 21-29) recorded their device usage for 2 days using Zoom software. Data were coded and analysed to assess the nature and extent of marketing for alcohol, gambling, junk food and smoking products. Four focus groups were conducted with participants to explore their data collection and coding experiences, and results assessed using thematic analysis. The study found that, with some modifications, this method was feasible for gathering real-time objective data from the online world that can be analysed for a range of public health harms, including marketing of unhealthy commodities. Larger studies are recommended to build global evidence for public health action in the online world.