Clinical Review & Education

From The JAMA Network

Food Marketing to Youth Serious Business H. Mollie Grow, MD, MPH; Marlene B. Schwartz, PhD

JAMA PEDIATRICS Children’s Reaction to Depictions of Healthy Foods in Fast-Food Television Advertisements

MAIN OUTCOMES AND MEASURES Children’s responses were independently content coded to food category by 2 researchers.

Amy M. Bernhardt, MEd; Cara Wilking, JD; Mark Gottlieb, JD; Jennifer

RESULTS Among the 99 children participating, only 51

Emond, PhD; James D. Sargent, MD

(52%) and 69 (70%) correctly identified milk from the McDonald’s and BK images, respectively, with a significantly greater percentage correct (P = .02 for both) among older children. The children’s recall of apples was significantly different by restaurant, with 79 (80%) mentioning apples when describing the McDonald’s image and only 10 (10%) for the BK image (P < .001). The percentage correct was not associated with age in either case. Conversely, although french fries were not featured in either image, 80 children (81%) recalled french fries after viewing the BK advertisement.

IMPORTANCE Since 2009, quick-service restaurant chains, or fast-food companies, have agreed to depict healthy foods in their advertising targeted at children.

OBJECTIVE To determine how children interpreted depictions

of milk and apples in television advertisements for children’s meals by McDonald’s and Burger King (BK) restaurants. DESIGN, SETTING, AND PARTICIPANTS Descriptive qualitative study in a rural pediatric practice setting in Northern New England. A convenience sample of 99 children (age range, 3-7 years) was shown depictions of healthy foods in fast-food advertisements that aired from July 1, 2010, through June 30, 2011. The images from McDonald’s and BK showed milk and apples. Children were asked what they saw and not prompted to respond specifically to any aspect of the images.

CONCLUSIONS AND RELEVANCE Of the 4 healthy food images, only depiction of apples by McDonald’s was communicated adequately to the target audience. Representations of milk were inadequately communicated to preliterate children. Televised depictions of apple slices by BK misled the children in this study, although no action was taken by government or self-regulatory bodies.

EXPOSURE Two still images drawn from advertisements for

healthy meals at McDonald’s and BK.

The food industry spends $1.8 billion a year marketing food and beverages to children and adolescents.1 The majority of food advertisements in the United States and globally promote products containing large amounts of ingredients associated with poor health— added sugar, saturated fat, and sodium.2,3 As a result, the companies that produce and market these products to children (ie, fast food, sugary cereals, sugary drinks, and candy) have been criticized for contributing to poor diet and childhood obesity. In response, the Children’s Food and Beverage Advertising Initiative (CFBAI) was launched in 2006.4 The CFBAI was created to demonstrate that the food industry can voluntarily self-regulate, thus eliminating the need for government action on food marketing to children. Participating companies pledge to “shift the mix of foods advertised to children under 12 to encourage healthier dietary choices and healthy lifestyles.”4 This pledge was strengthened in 2014 when participating companies agreed to only market to children foods that meet uniform nutrition criteria. Since the inception of CFBAI, many companies have made positive changes, including reformulating child-directed products (eg, 1918

JAMA Pediatr. 2014;168(5):422-426. doi:10.1001/jamapediatrics.2014.140.

reduced added sugar in cereals), offering healthier options in children’s meals (eg, McDonald’s offering apples in its Happy Meals), and creating advertisements that feature healthier choices. Although these improvements are notable,1 research is needed to assess the effect of these changes in children’s experiences of marketing. To date, independent research data show much room for improvement. A recent study found that more than 86% of the products marketed to children by CFBAI companies remain high in saturated fat, sugar, and sodium. 3 An examination of fast food advertisements in 2009-2010 found that child-directed ads emphasized movie tie-ins rather than food products.5 Further, the CFBAI definition of child-directed marketing (ie, marketing to an audience made up of at least 35% children aged ⱕ11 years) has been challenged as too narrow. A study of 2009 Nielsen data demonstrated that fewer than half of the food ads viewed by children were during shows that met this criterion.6 As highlighted in a JAMA Pediatrics article by Bernhardt and colleagues, 7 the CFBAI requirement to show only healthier options in child-directed advertisements may not be enough to

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From The JAMA Network Clinical Review & Education

improve children’s experience of these television commercials. This study used a convenience sample of 99 children (age range, 3-7 years) and examined what children thought they saw in McDonald’s and Burger King ads. Nearly half of the children looking at the McDonald’s ad did not notice the milk, and 81% of children recalled seeing french fries in the Burger King ad, although these were actually apples. Younger children who could not read were most likely to be unaware of the healthier choices in the ads. The study by Bernhardt et al7 suggests that young children were misled and did not recognize healthier foods in ads covered under CFBAI. Another limitation of the CFBAI is that it defines children as 11 years old and younger. The decision by the food industry to not include children and teens aged 12 years and older in CFBAI reflects a misunderstanding of adolescents and their needs. These youth are uniquely vulnerable, arguably more influenced by ads because of their psychological state of development.8 Teens represent half of the industry spending on food marketing to youth.1 Since the inception of CFBAI, many companies appear to have shifted their marketing dollars away from very young children and toward young teens, who have experienced a 23% increase in exposure to food marketing from 2007 to 2011.8 Parents should oversee media use at home, but this is becoming more difficult as children spend more time with digital technology. Food marketing to children through new media has increased 50% since 2006, including social media, company websites, banner ads, online games, and apps.1 Unlike television ads, which a parent can see by walking into the room, children’s exposure to digital marketing on phones and tablets is less easily monitored. Further, ARTICLE INFORMATION Author Affiliations: University of Washington, Seattle Children’s Research Institute, Seattle (Grow); Yale University, New Haven, Connecticut (Schwartz). Corresponding Author: H. Mollie Greves Grow, MD, MPH, University of Washington, Seattle Children’s Hospital, PO Box 5371, M/S OC.7.830, Seattle, WA 98145-5005 ([email protected]). Conflict of Interest Disclosures: Both authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported. REFERENCES 1. A review of food marketing to children and adolescents: follow-up report [2012]. Federal Trade Commission.

some educational websites recommended by teachers, such as, include food marketing. Parents can do their part, but they need the school system, community, and government to create policies that support parental efforts. What can be done to effectively reduce unhealthy food marketing to youth? One federal policy strategy is to eliminate the tax write-offs companies receive for advertising unhealthy foods to children. The additional tax revenue could be used for further health promotion, such as providing fresh fruits and vegetables in schools. At the local level, communities can enact policies eliminating food marketing from venues serving children, such as playgrounds, parks, and community centers. In schools, district wellness policies may be used to limit or eliminate food marketing on school grounds and school buses. At home, parents should limit TV time and keep screens (televisions, tablets, etc) out of children’s bedrooms. Parents can also use alternative TV formats that preclude ads, such as DVR or Netflix. Perhaps technology could help, such as extending V-chips to include advertisements. Researchers must continue to independently study and draw attention to potentially misleading marketing approaches and assess the outcomes of industry self-regulation. Physicians and public health advocates should advocate for improved government oversight and monitoring of food marketing to youth, as was done with tobacco and alcohol advertising.9 Children deserve to grow up in environments free from a barrage of messages to eat and drink unhealthy food. Given the effect on children’s health and future health care costs, food marketing to youth represents a serious business that warrants attention.

-food-marketing-children-adolescents-follow -report. Accessed June 24, 2014. 2. Kelly B, Halford JC, Boyland EJ, et al. Television food advertising to children: a global perspective. Am J Public Health. 2010;100(9):1730-1736. 3. Powell LM, Schermbeck RM, Chaloupka FJ. Nutritional content of food and beverage products in television advertisements seen on children’s programming. Child Obes. 2013;9(6):524-531. 4. Children’s Food and Beverage Advertising Initiative (CFBAI). /the-national-partner-program/national-advertising -review-services/childrens-food-and-beverage -advertising-initiative/. Accessed June 25, 2014. 5. Bernhardt AM, Wilking C, Adachi-Mejia AM, Bergamini E, Marijnissen J, Sargent JD. How television fast food marketing aimed at children compares with adult advertisements. PLoS One. 2013;8(8):e72479.

6. Harris JL, Sarda V, Schwartz MB, Brownell KD. Redefining “child-directed advertising” to reduce unhealthy television food advertising. Am J Prev Med. 2013;44(4):358-364. 7. Bernhardt AM, Wilking C, Gottlieb M, Emond J, Sargent JD. Children’s reaction to depictions of healthy foods in fast-food television advertisements. JAMA Pediatr. 2014;168(5):422-426. 8. Harris JL, Heard A, Schwartz MB. Older but still vulnerable: all children need protection from unhealthy food marketing [2014]. Yale Rudd Center. /upload/docs/what/reports/Protecting_Older _Children_3.14.pdf. Accessed September 29, 2014. 9. Sharma LL, Teret SP, Brownell KD. The food industry and self-regulation: standards to promote success and to avoid public health failures. Am J Public Health. 2010;100(2):240-246.

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Food marketing to youth: serious business.

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