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Prevalence of child-directed marketing on breakfast cereal packages before and after Chile’s food marketing law: A pre-post quantitative content analysis

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Abstract and Figures

Food marketing has been identified as a contributing factor in childhood obesity, 20 prompting global health organizations to recommend restrictions on unhealthy food marketing to 21 children. Chile has responded to this recommendation with a restriction of child-directed marketing 22 for products that exceed certain regulation-defined thresholds in sugars, saturated fats, sodium or 23 calories. Child-directed strategies are allowed for products that do not exceed these thresholds. To 24 evaluate changes in marketing due to this restriction, we examined differences in the use of child-25 directed strategies on breakfast cereal packages that exceeded the defined thresholds vs. those that 26 did not exceed the thresholds before (n=168) and after (n=153) the restriction was implemented. 27 Photographs of cereal packages were taken from top supermarket chains in Santiago. Photographed 28 cereals were classified as "high-in" if they exceeded any nutrient threshold described in the 29 regulation. We found that the percentage of all cereal packages using child-directed strategies before 30 implementation (36%) was significantly lower after implementation (21%), p<.05. This overall 31 decrease is due to the decrease we found in the percentage of "high-in" cereals using child-directed 32 strategies after implementation (43% before implementation, 15% after implementation), p<.05. In 33 contrast, a greater percentage of packages that did not qualify as "high-in" used child-directed 34 strategies after implementation (30%), compared to before implementation (8%), p<.05. Results 35 suggest that the Chilean food marketing regulation can be effective at reducing the use of child-36 directed marketing for unhealthy food products.
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International Journal of
Environmental Research
and Public Health
Article
Prevalence of Child-Directed Marketing on
Breakfast Cereal Packages before and after Chile’s
Food Marketing Law: A Pre- and Post-Quantitative
Content Analysis
Fernanda Mediano Stoltze 1,2, Marcela Reyes 3, Taillie Lindsey Smith 2,4, Teresa Correa 5,
Camila Corvalán3and Francesca R. Dillman Carpentier 1, *
1Hussman School of Journalism and Media, University of North Carolina, Chapel Hill, NC 27599, USA,
fmediano@email.unc.edu
2Carolina Population Center, University of North Carolina, Chapel Hill, NC 27516, USA; taillie@unc.edu
3Institute of Nutrition and Food Technology, University of Chile, 7830489 Santiago, Chile;
mreyes@inta.uchile.cl (M.R.); ccorval@gmail.com (C.C.)
4
Department of Nutrition, Gillings School of Global Public Health, University of North Carolina, Chapel Hill,
NC 27599, USA
5School of Communication, Diego Portales University, 8370109 Santiago, Chile; teresa.correa@udp.cl
*Correspondence: francesca@unc.edu; Tel.: +1-919-962-1204
Received: 1 October 2019; Accepted: 13 November 2019; Published: 15 November 2019


Abstract:
Food marketing has been identified as a contributing factor in childhood obesity, prompting
global health organizations to recommend restrictions on unhealthy food marketing to children.
Chile has responded to this recommendation with a restriction on child-directed marketing for
products that exceed certain regulation-defined thresholds in sugars, saturated fats, sodium, or
calories. Child-directed strategies are allowed for products that do not exceed these thresholds.
To evaluate changes in marketing due to this restriction, we examined dierences in the use of
child-directed strategies on breakfast cereal packages that exceeded the defined thresholds vs.
those that did not exceed the thresholds before (n=168) and after (n=153) the restriction was
implemented. Photographs of cereal packages were taken from top supermarket chains in Santiago.
Photographed cereals were classified as “high-in” if they exceeded any nutrient threshold described
in the regulation. We found that the percentage of all cereal packages using child-directed strategies
before implementation (36%) was significantly lower after implementation (21%), p<0.05. This overall
decrease is due to the decrease we found in the percentage of “high-in” cereals using child-directed
strategies after implementation (43% before implementation, 15% after implementation), p<0.05.
In contrast, a greater percentage of packages that did not qualify as “high-in” used child-directed
strategies after implementation (30%) compared with before implementation (8%), p<0.05. The results
suggest that the Chilean food marketing regulation can be eective at reducing the use of child-directed
marketing for unhealthy food products.
Keywords: child-directed marketing; food marketing; food packages; marketing regulation
1. Introduction
Childhood obesity is of major worldwide concern, as it is a strong predictor of adult obesity
and other health, social, and economic consequences [
1
]. The development of overweightness and
obesity is associated, to a great extent, with the overconsumption of calories [
2
] and free sugars [
3
,
4
].
Unhealthy food and beverage marketing has been identified as a key contributor to childhood
Int. J. Environ. Res. Public Health 2019,16, 4501; doi:10.3390/ijerph16224501 www.mdpi.com/journal/ijerph
Int. J. Environ. Res. Public Health 2019,16, 4501 2 of 15
obesity [
5
], as products that are energy dense and high in sugars, such as sugary, sweetened beverages,
breakfast cereals, snacks, and candies [
6
] are often marketed with fun characters, collectible gifts,
and other strategies that appeal to children [
7
10
]. Because of their limited cognitive and executive
skills [
7
,
11
,
12
], children might be especially vulnerable to this type of marketing in advertising [
7
,
8
]
and on packages [9,10,13,14].
Food packages are of particular concern, as marketing strategies on packaging are an important
component of integrated marketing campaigns [
7
,
15
] designed to influence consumers at both the
point of purchase and during consumption [
16
22
]. Packages for sugary and energy-dense products in
general [
9
,
22
,
23
], and for sugary breakfast cereals in particular [
24
,
25
], have been shown to employ
child-directed strategies. These strategies, such as licensed or branded characters, have been shown, in
turn, to influence children’s food preferences and choices [
19
,
26
], as well as children’s taste perceptions
of food [13,27].
Given the significant evidence that child-directed marketing impacts children’s attitudes,
preferences, and eating practices [
7
,
8
,
28
,
29
], the World Health Organization recommended that
countries ensure healthier food environments by restricting child-directed marketing of energy-dense
and nutrient-poor foods and beverages, particularly products high in saturated fats, sugars, or salt [
30
].
To date, few countries have implemented statutory child-directed food marketing restrictions, and few
studies have assessed those policies [
31
,
32
]. Guided by international recommendations to encourage
diets that limit a person’s intake of saturated fats, free sugars, and sodium [
33
], Chile implemented
the Food Labeling and Advertising Regulation (Law 20.606) [
34
36
] aimed at preventing childhood
obesity through a labeling and marketing restriction on foods above certain defined thresholds in
energy, saturated fats, sugars, and sodium [
31
,
37
]. The Chilean law, implemented in June 2016, has
been considered the most comprehensive regulation of its kind to date [
35
], due to its wide scope of
restrictions on food marketing and its criteria for qualifying foods as “high-in” the above nutrients.
Chile also has one of the highest obesity prevalence rates worldwide—24% of children 6–7 years of
age [38] and 31% of people 15 years of age in Chile are obese [39].
The Chilean regulation features progressive cut-ovalues for energy, saturated fats, sugars, and
sodium per 100 g in foods or 100 mL in liquids. Products above these thresholds—“high-in” products
henceforth—must use front-of-package warning labels identifying the product as high in the excessive
nutrient (products might carry more than one label if they exceed the thresholds for more than one
nutrient). “High-in” products also cannot be promoted or sold within schools and are restricted from
marketing to children <14 years of age. Products that are not classified as “high-in” are exempted from
these restrictions [
35
,
36
]. The listed cut-ovalues only apply to products that contain an ingredient
(e.g., added sugar) that increases the content of one or more of the critical nutrients beyond the specified
thresholds. Table 1shows the progression in how these thresholds have been defined, beginning
with the least strict thresholds implemented in 2016 to the strictest thresholds implemented in 2019.
The present study focuses on the first thresholds implemented in 2016:
22.5 g for sugars,
6 g for
saturated fats,
800 mg for sodium,
350 kcal in energy density (per 100 g of food). An explanation of
the development of these thresholds has been previously published [40].
Table 1.
Progressive thresholds for defining “high-in” foods in the Chilean law of food labeling
and advertising.
Critical Nutrient Nutrient Threshold per 100 g of Food
June 2016 June 2018 June 2019
Energy (kcal) 3.5 32.75
Sodium (mg) 800 500 400
Total sugars (g) 22.5 15 10
Saturated fats (g) 654
Int. J. Environ. Res. Public Health 2019,16, 4501 3 of 15
The Chilean law also provides a list of child-directed appeals and incentives that are prohibited
from use in the marketing of products that qualify as “high-in” [
34
,
35
]. This marketing restriction
extends to advertising, as well as product packaging. To our knowledge, this is the first regulation to
ban the use of child-directed marketing strategies on product packages. Included in the list of banned
strategies is the use of characters, children and child-like figures, cartoons, references to children’s
daily lives, gifts, and games. Dierent from other regulations [
41
], the Chilean regulation does not
exempt trade brands (brand equity characters) from restriction. Therefore, licensed characters and
brand characters, such as Tony the Tiger or the Trix Rabbit, are banned from use [
13
,
14
,
24
,
42
]. However,
“high-in” products are allowed to use marketing strategies that are not included in the regulation’s list
of child-directed marketing appeals, for example health claims, actors >14 years of age, or emotional
appeals suggesting happiness.
The aim of the present study was to assess changes in the prevalence of marketing strategies
targeting children in breakfast cereal packages before and after the Chilean regulation, using a repeated
cross-sectional design, with one sample of Chilean breakfast cereal packages taken before the 2016
implementation and one sample of cereals taken half a year after the 2016 implementation. Breakfast
cereal packages were selected as the focus of this study, given that this product category is documented
to be heavily marketed to children [
25
,
43
]. This product category was also ideal for assessing the
Chilean regulation, because many child-directed cereals have been found to be higher in calories or
sugars [24,43,44] compared with their non-child-targeted counterparts.
The prevalence of child-directed strategies in each period was assessed according to the products’
regulation categorization (“high-in” or “non-high-in”) based on Chile’s first nutrient thresholds.
We expected to find a significantly lower proportion of “high-in” breakfast cereal packages with
child-directed strategies after the 2016 implementation compared with before this first implementation.
We were also interested in examining whether the use of child-directed strategies among packages that
did not qualify as “high-in” would change post-implementation, indicating an industry shift from
marketing “high-in” cereals to marketing “non-high-in” cereals to children.
2. Materials and Methods
This study examined the use of child-directed marketing strategies in Chilean breakfast cereal
packages before and after the June 2016 implementation of the Chilean Food Advertising and Labeling
Law. Using a quantitative content analysis of breakfast cereal package photographs, child-directed
strategies were identified and categorized by two coders who examined the front, sides, and back of
each package. The use of child-directed strategies was analyzed according to regulation categorization
(“high-in” or “non-high-in”) and time period (before and after implementation) to assess changes in
the prevalence of child-directed strategies before and after the regulation.
2.1. Sample
This study used photographs of breakfast cereal packages taken as part of an ongoing
food environment monitoring project conducted by the International Network for Food and
Obesity/Non-communicable Diseases Research, Monitoring and Action Support (INFORMAS-CHILE) [
45
]
and the University of Chile’s Nutrition and Food Technology Institute (INTA) [
46
]. In February–March
2015, before the regulation’s implementation, and again in January–February 2017, post-implementation,
six supermarkets in a high-income neighborhood belonging to five of the largest supermarket chains in
Santiago (two supermarkets from the same chain) were visited. The selected supermarket chains have
stores in all Chilean cities and represent 100% of the market share of supermarkets [
47
]. An agreement
between the Chilean National Association for Supermarkets (ASACH) and the University of Chile’s
Nutrition and Food Technology Institute was reached to obtain permission to take pictures in the
stores [
46
]. Supermarkets were selected on the basis of having the greatest variety of products per
chain within the neighborhood where photographs were taken. The breakfast cereals photographed in
Int. J. Environ. Res. Public Health 2019,16, 4501 4 of 15
2015 and 2017 included at least one product from all of the top brands listed in the Euromonitor report
of breakfast cereal sales (by retail sales price) per brand in Chile in the years 2015 and 2017 [48].
Trained nutritionists took photographs of all sides of all breakfast cereals encountered, avoiding
duplicates [
46
]. All versions of the same product were collected. In other words, if two products were
identical but used dierent marketing content on their packages, we collected images of both packages.
If a product used the same marketing content on packages of dierent sizes, the photographs of the
largest package were taken. Therefore, the nutritionists captured all marketing content for breakfast
cereal packages across these supermarkets [46].
A total of 168 Spanish-language breakfast cereals from the 2015 data collection and 146
Spanish-language packages from the 2016 data collection were included in this study. Eight packages
at pre-implementation and 25 packages at post-implementation were excluded, because they were not
written in Spanish. Across both samples, breakfast cereal photographs included ready-to-eat cereals
(n=269), such as flakes, pu, muesli, granola, and fiber cereals, and not-ready-to-eat cereals (n=45),
namely traditional and instant oats.
2.2. Coding of Marketing Strategies
Child-directed food marketing strategies were assessed with a comprehensive protocol that
included text and imagery. The protocol was built based on the Chilean food marketing regulation [
34
],
with procedural guidance taken from prior studies of child-directed marketing strategies [
7
,
10
,
49
54
].
Packages were coded for two overarching categories of child-directed marketing strategies: the use of
child-directed characters and the use of non-character-based elements that appeal to children. These
categories are described in greater detail below. Initially, the codebook also included mentions of
contests for children and the presence of celebrities. However, only one child-directed contest and one
celebrity were found in the sample. Therefore, contests and celebrities were excluded from the analysis.
For the remaining elements, the occurrence of at least one marketing appeal within a given strategy
(e.g., characters) was coded as the presence of that particular strategy, regardless of the number of
times the strategy appeared in the package.
2.3. Child-Directed Characters
Packages were considered to have child-directed characters if they included at least one image of
the following on any package face: human youth (i.e., images of people <14 years of age); fantastical
non-youth (i.e., human >14 years of age with a superhuman or magical appearance, such as wearing a
cape or flying in space); or personified objects (i.e., any anthropomorphized creature or item such as a
smiling fruit, spoon, or tiger). For human youth, if it was not clear that a human figure was under 14
years old, coders were instructed to code the figure as a non-youth.
For packages with at least one child-directed character, characters were further categorized as
cross-promotional (e.g., at least one character was licensed to entities outside the brand, such as a TV
show or movie) or as a sports reference (e.g., at least one character was engaged in sports or physical
activity).
2.4. Non-Character Strategies
Packages were considered to have non-character child-directed strategies if they included at least
one of the following strategies on any package face: child-oriented gifts (e.g., stickers and toys in or
on the package); games (e.g., word searches, puzzles, or other activities on the box); toy references
(e.g., depictions of cars, balls, or other items intended for play); school references (e.g., mention of
school supplies or images of backpacks or playgrounds); child words (words that specifically reference
children, such as “for kids”); and cross-promotions (e.g., names of movies, TV shows, or other brands).
Licensed characters were captured under the child-directed characters category.
Int. J. Environ. Res. Public Health 2019,16, 4501 5 of 15
2.5. Coding Reliability
Two Chilean coders trained for two weeks on how to apply the codebook to products outside
the samples used in this study. Then, both coders analyzed a random selection of 23% of the sample
(
n=73
) to assess inter-rater reliability. Simple percentage of agreement and two-rater chance-corrected
agreement coecient Gwet’s AC2 were calculated with AgreeStat 2015.6.1 [
55
]. Percentage of agreement
for individual codes ranged from 92.6% to 100% and Gwet AC2 ranged from 0.92 to 1. The code with
the lowest (92.6%) agreement pertained to the presence of “non-youth doing sports” and was intended
to be used in connection with the “fantastical non-youth” code to identify images of adults or teens
who were depicted as superhuman or magical through exaggerated sports or exercise performances.
However, the combination of “fantastical non-youth” and “non-youth doing sports” never occurred
within the sample, and so, this disagreement made no impact on the analysis. The remaining codes had
a percentage of agreement of at least 98%. Among those few instances of disagreement, we randomly
selected which coder’s decision would be included in the final dataset.
2.6. Product Categorization
Trained nutritionists recorded total sugars (g)/100 g, saturated fats (g)/100 g, sodium (mg)/100 g,
and energy (kcal)/100 g for each product using package nutrition facts panel data collected as part
of the INFORMAS-CHILE project [
45
]. Eight packages did not provide information for total sugars,
in which case, total sugars were imputed from similar products collected during the same year with
a similar list (and order) of ingredients. A dierent brand was used only if the same brand was not
available. For not-ready-to-eat cereals, nutrient content and energy were calculated based on 100 g of
reconstituted product. Packages in the pre-implementation and post-implementation samples were
categorized as “high-in” (=1) if they exceeded any of the 2016 nutrient thresholds in sugars, sodium,
saturated fats, or energy, provided they contained an ingredient that increased the natural content of
the given critical nutrient [
35
]. For the pre-implementation sample, a categorization of “high-in” was
given to products that exceeded at least one of the June 2016 nutrient thresholds and would be subject to
regulation if the thresholds were in eect at that time. For the post-implementation sample, a “high-in”
categorization was given to packages that were regulated at that time for exceeding at least one of the
2016 thresholds. Any packages that did not exceed a threshold in the pre- or post-implementation
sample were categorized as “non-high-in” (=0).
2.7. Analysis
Crosstabulations were used to examine the proportion of “high-in” vs. “non-high-in” breakfast
cereal packages at pre- vs. post-implementation that used child-directed characters, non-character
strategies, and the specific marketing elements described within the character and non-character strategy
categories. Fisher’s exact tests were used to evaluate whether dierences in proportions found in the
crosstabulations were statistically significant. A logistic regression was used to test whether regulation
status (“high-in” vs. “non-high-in”) interacted with time period (pre- vs. post-implementation)
to predict the presence of child-directed strategies in breakfast cereal packages. Post-hoc logistic
regressions were performed to interpret the significant interaction found between regulation status
and timeframe. All analyses were performed using STATA/SE 16.0.
3. Results
Table 2describes the number and percentage of products categorized as “high-in” or “non-high-in”
at pre- and post-implementation, showing the quantity of “high-in” products that exceeded sugars,
saturated fats, sodium, and energy thresholds. About 79% of products at pre-implementation were
categorized as “high-in”, 98% of which exceeded levels for calories, 66% for sugars, and 64% for both
calories and sugars. At post-implementation, 59% of the products were categorized as “high-in”, 98%
of which were high in calories, 59% high in sugars, and 58% high in both calories and sugars.
Int. J. Environ. Res. Public Health 2019,16, 4501 6 of 15
Table 3shows the percentage of packages using child-directed strategies before and after
implementation, according to regulation categorization. Not shown in Table 3, all child-directed
strategies were found in ready-to-eat breakfast cereals at pre- and post-implementation. As shown
in Table 3, the percentage of packages overall that used at least one child-directed strategy was
significantly lower after implementation (21%) compared with before implementation (36%), p<0.05.
This dierence was primarily due to the lower number of packages using non-character strategies in
the post-implementation sample, p<0.05.
Although the total percentage of packages that specifically used a character decreased from 30%
to 21% after implementation, this dierence was not statistically significant, p=0.07. In fact, the use of
characters, personified objects in particular, was the most prevalent child-directed strategy used in
breakfast cereal packages at pre- and post-implementation. However, among those packages with
characters, the total percentage of packages using a character that was licensed significantly decreased
from 13% to 0.8% after implementation, as did the percentage of packages featuring physically active
characters (from 5% to 0%), p<0.05.
Among packages categorized as “high-in”, the prevalence of packages with at least
one child-directed strategy significantly decreased from 43% at pre-implementation to 15% at
post-implementation, p<0.05. The use of characters decreased significantly from 36% of “high-in”
packages at pre-implementation to 15% of “high-in” packages at post-implementation, p<0.05. The use
of non-character strategies also decreased significantly from 23% at pre-implementation to 0% at
post-implementation, p<0.05.
Among packages categorized as “non-high-in”, the prevalence of packages using at least one
child-directed strategy was significantly higher, rising from 8% before implementation to 30% after
implementation, p<0.05. Both the use of characters (from 8% to 28%) and the use of non-character
strategies (from 0% to 10%) increased significantly within “non-high-in” packages, p<0.05. It is
worth noting that no packages categorized as “non-high-in” in the pre-implementation sample used
personified objects, yet the use of personified objects became the most prevalent child-directed strategy
within the post-implementation sample of “non-high-in” packages.
From the initial logistic regression, the pre-/post-implementation timeframe significantly interacted
with the product regulation status (“high-in” vs. “non-high-in”) to predict whether breakfast cereal
packages were likely to feature child-directed strategies,
χ2
(3) =30.51, p<0.001, Odds Ratio (OR):
0.05, 95% CI: 0.011, 0.217, p<0.001. Table 4shows the results of the post-hoc analyses used to further
interpret this interaction. At pre-implementation, “high-in” products were significantly more likely
to feature child-directed strategies compared with “non-high-in” products, OR: 8.36, 95% CI 2.44,
28.63. At post-implementation, “high-in” products were significantly less likely to use child-directed
strategies compared with “non-high-in” products, OR: 0.416, 95% CI 0.19, 0.93. These post-hoc findings
correspond with the observations (see Table 3) that 43% of “high-in” packages vs. 8% of “non-high-in”
packages contained a child-directed strategy at pre-implementation, whereas 15% of “high-in” packages
and 30% of “non-high-in” packages featured a child-directed strategy at post-implementation.
Int. J. Environ. Res. Public Health 2019,16, 4501 7 of 15
Table 2. Descriptive statistics for “high-in” and “non-high-in” breakfast cereal packages sampled pre- and post-implementation.
Critical Nutrient
Pre-Implementation (n=168) Post Implementation (n=146)
“non-high-in”
n=36 (21.4%)
“high-in”
n=132 (78.6%)
“non-high-in”
n=60 (41%)
“high-in”
n=86 (59%)
Content per 100 g of food Content per 100 g of food n(%) of “high-in” packages
above specific nutrient
threshold
Content per 100 g of food Content per 100 g of food n(%) of “high-in” packages
above specific nutrient
threshold
Mdn Min–Max Mdn Min–Max Mdn Min–Max Mdn Min–Max
Energy (kcal) 326 46.5–395 380 101.3–465 130 (98) 339 41.2–400 384 89.7–465 85 (98)
Sugars (g) 1.78 0–22.5 26 0-40 87 (66) 9.7 0–22.2 27.2 0–40 51 (59)
Saturated fats (g) 0.75 0–3.9 1.4 0–7.4 2 (2) 1.1 0.16–4.6 1.35 0–7.4 1 (1)
Sodium (mg) 78.2 0.3–604 184 4.9–689 0 66.6 0.7–430 150.5 2.8–585 0
“High-in” products are products exceeding at least one 2016 regulation-defined threshold in sugars, saturated fats, sodium, or energy. Products “high-in” for both calories and sugars
n=85 (64%
of “high-in” products) at pre-implementation and n=50 (58% of “high-in” products) at post-implementation. Mdn: Median. Min–Max: Minimum and maximum values. n(%):
Number (percentage).
Table 3.
Dierences in the percentage of packages using child-directed strategies within “high-in” and “non-high-in” breakfastcereals at pre- versus post-implementation.
Type of Child-Directed Strategy on Package
Percentage of “Non-High-In” Packages with at
Least One Child-Directed Strategy
Percentage of “High-In” Packages with at Least
One Child-Directed Strategy
Percentage of Total Packages Sampled with at
Least One Child-Directed Strategy
Pre-(2015) Post-(2017) Dierence
(2017–2015) Pre-(2015) Post-(2017) Dierence
(2017–2015) Pre-(2015) Post-(2017) Dierence
(2017–2015)
(n=36) (n=60) (n=132) (n=86) (n=168) (n=146)
Any child-directed strategy 8.33 30.00 21.67 * 43.18 15.12 28.07 * 35.71 21.23 14.48 *
Any character strategy 8.33 28.33 20.00 * 35.61 15.12 20.49 * 29.76 20.55 9.21
Personified object 0.00 21.67 21.67 * 30.30 13.95 16.35 * 23.81 17.12 6.69
Human youth 8.33 6.67 1.67 6.82 1.16 5.66 7.14 3.42 3.72
Fantastical non-youth 0.00 0.00 0.00 3.03 0.00 3.03 2.38 0.00 2.38
Licensed? 0 0.76 0.76 * 13.33 0 13.33 * 13.33 0.76 12.57 *
Doing exercise? 0 0 0 5.3 0 5.3 * 5.3 0 5.3 *
Any non-character strategy 0.00 10.00 10.00 * 23.48 0.00 23.48 * 18.45 4.11 14.34 *
School references 0.00 0.00 0.00 3.79 0.00 3.79 2.98 0.00 2.98
Toy references 0.00 1.67 1.67 * 7.58 0.00 7.58 * 5.95 0.68 5.27 *
Children words 0.00 5.00 5.00 * 8.33 0.00 8.33 * 6.55 2.05 4.49
Child-oriented gifts 0.00 3.33 3.33 1.52 0.00 1.52 1.19 1.37 0.18
Games 0.00 6.67 6.67 * 9.09 0.00 9.09 * 7.14 2.74 4.40
Cross-promotions 0.00 3.33 3.33 4.55 0.00 4.55 3.57 1.37 2.20
Regulated products are products exceeding at least one 2016 regulation-defined threshold in sugars, saturated fats, sodium, or energy. Comparisons of proportions of breakfast cereal
packages featuring the given child-directed strategy in the 2015 versus 2017 samples made using Fisher’s exact test. * p<0.05. All coded types of child-directed strategies were present on
at least one ready-to-eat breakfast cereal.
Int. J. Environ. Res. Public Health 2019,16, 4501 8 of 15
Table 4.
Likelihood of breakfast cereal packages featuring child-directed marketing strategies pre-
and post-implementation.
Pre- vs.
Post-Implementation
Prevalence of Products Using at Least
One Child-Directed Strategy Logistic Regression
OR (95% CI) p-Value
“non-high-in” “high-in”
Pre-implementation 8.33% (3/36) 43.18% (57/132) 8.36 (2.44, 28.63) <0.01
Post-implementation 30% (18/60) 15.12% (13/86) 0.416 (0.19, 0.93) <0.05
Findings from the interpretation of significant interaction of timeframe X regulation categorization predicting the
presence of at least one child-directed strategy on breakfast cereal packages,
χ2
(3) =30.51, p<0.001, OR: 0.05,
95% CI: 0.011, 0.217. “high-in” products are products exceeding at least one 2016 regulation-defined threshold
in sugars, saturated fats, sodium, or energy. CI: Confidence Interval OR: Odds ratio. Note: Bold font indicates
statistical significance.
4. Discussion
This study compared the prevalence of child-directed strategies in breakfast cereal packages in a
sample of products collected before the Chilean food marketing regulation was implemented with a
similar sample collected after implementation. The Chilean regulation is the only statutory regulation
to date that restricts child-directed food marketing on unhealthy food packages [
31
] and provides
the most comprehensive list of strategies and techniques defining child-directed marketing for policy
implementation and evaluation purposes [35].
We found that the prevalence of breakfast cereal packages using child-directed strategies decreased
overall after the regulation’s implementation, driven by the significant reduction in the prevalence
of child-directed strategies used by breakfast cereals qualifying as “high-in” according to the first
implemented nutrient thresholds. Before implementation, cereals categorized as “high-in” for exceeding
regulation-defined thresholds in sugars, saturated fats, sodium, and/or calories per 100 g were more
likely to have child-directed strategies (43%) compared with cereals categorized as “non-high-in”
(8%). After the regulation’s first implementation, this relation was reversed. At post-implementation,
a larger percentage of “non-high-in” products used child-directed strategies (30%) compared with
“high-in” products (15%). When combining “non-high-in” and “high-in” products, the total percentage
of packages using child-directed strategies dropped from 36% before the June 2016 implementation to
21% after implementation.
Although we expected to find a decrease in child-directed marketing in “high-in” cereals and
anticipated a potential increase in child-directed marketing in “non-high-in” cereals, we are unable
to discern from our data what specific causes explain this shift. We did observe that the majority of
“non-high-in” packages with child-directed strategies that we found in the post-implementation sample
previously had higher sugar levels and had since been reformulated to fall just below the threshold.
In those cases, the products changed their nutritional composition rather than their marketing strategies.
More research is needed to understand the extent of reformulation as a possible strategy for retaining
the use of child-directed strategies across product categories.
As packaging is a predominant medium through which children are exposed to food marketing [
23
],
the reduction in child-directed strategies found in this study suggests that children in Chile are being
less exposed to child-directed marketing of products high in calories or sugar in their food environment.
This is highly relevant because child-directed marketing of unhealthy food has been associated with
obesity development [
8
]. We therefore interpret our findings as evidence that Chile’s Food Labeling
and Advertising Regulation is a promising tool for reducing children’s exposure to child-directed
marketing on unhealthy packaged foods.
Our findings indicate a slightly lower prevalence of the use of child-directed strategies before the
regulation’s implementation compared with research from other countries that focus on ready-to-eat
cereals [
24
,
44
]. In our pre-implementation sample, we found that more than one-third (36%) of breakfast
cereal packages, including ready-to-eat and not-ready-to-eat cereals, used at least one child-directed
strategy. This percentage increases to 43% if only ready-to-eat cereals are considered. This percentage
Int. J. Environ. Res. Public Health 2019,16, 4501 9 of 15
is lower than the 46% and 51% of packages using child-directed strategies found for ready-to-eat
breakfast cereals in studies conducted in the United States (US) [
44
] and Guatemala [
24
], respectively.
It is possible that our sample captured a wider range of products and therefore might have captured
more products that do not use child-directed strategies compared with the cited studies. The US study
collected data only from the four main breakfast cereal manufacturers in the US, and the Guatemalan
study collected all ready-to-eat breakfast cereals available in the one supermarket representing its
largest supermarket chain located in a middle-to-high socioeconomic status urban sector. Our sample
included all dierent breakfast cereals available in six dierent supermarkets from five dierent chains
in a high-income neighborhood of urban Santiago. It is possible that our sample might include more
products that did not feature child-directed marketing due to a greater variety of products captured,
dierences in how products might have been marketed in high-income urban supermarkets vs. other
venues, or dierences in definitions of what constituted child-directed marketing. Note that our
definitions of child-directed marketing were specific to evaluating the Chilean regulation, and therefore,
we excluded other appeals that might be attractive to children but that were not listed as appeals
subject to restriction.
If we only focus on the prevalence of products featuring child-directed characters at baseline, the
prevalence we found (29%) is higher than the prevalence (21%) reported in a study in New Zealand [
56
].
In their study, all breakfast cereals available for purchase (n=247), including ready-to-eat and
non-ready-to-eat cereals, were recorded in two major supermarkets in Auckland in 2013. This sample
collected in Auckland is markedly larger than our baseline sample. Therefore, it is possible that the
New Zealand study captured an even greater variety of products than we did, and to the extent that
they captured a greater variety of products that were not aimed toward children in their larger sample,
it is not surprising that the percentage of characters they found would be lower than the percentage we
found. It is also possible, of course, that the prevalence of child-directed strategies varies from country
to country, according to local market characteristics.
Consistent with reports across other countries [
6
], our study found the use of characters to be
the dominant child-directed strategy on the child-directed packages we analyzed. Even after Chile’s
regulation was first implemented, we continued to find child-directed characters on “high-in” breakfast
cereal packages, albeit the prevalence of these characters was significantly lower among “high-in”
packages compared with the baseline. In fact, the use of characters was the only child-directed strategy
that persisted among “high-in” packages after implementation. At the same time, we found that
“non-high-in” products were using more characters at post- than at pre-implementation. As a result,
characters remained the most used child-directed strategy across all breakfast cereals. This finding
highlights the key role that characters play in breakfast cereal’s child-directed marketing and supports
the development of regulations that limit the extent to which “high-in” products use these highly
child-attractive strategies [13,42,57,58].
To date, 16 countries have implemented statutory regulations to restrict unhealthy food marketing
to children. The most common regulations are partial restrictions on unhealthy food advertising on
television and restricted food promotions in schools. Unfortunately, the few policies that have been
assessed have shown little to no reduction in unhealthy food advertising [
31
]. Package marketing
restrictions have only been implemented in Chile, despite evidence showing that point-of-sale
promotions and marketing on packages have a significant influence on children’s food preferences and
choices [
13
,
18
,
19
,
21
]. According to our findings, after the food marketing regulation implementation,
we found that 85% of packages were compliant with the child-directed marketing restriction and
15% (n=13) of “high-in” packages did not comply with the restriction due to their continued use
of child-directed characters. This percentage of noncompliance is similar to the 18% noncompliance
across food marketing (including advertising and packaging) reported by the Chilean Ministry of
Health (MINSAL) during the first year of the regulation’s implementation [59].
Our findings support the adaptation and implementation of this type of intervention in other
countries interested in developing regulations to protect children from the influence of unhealthy
Int. J. Environ. Res. Public Health 2019,16, 4501 10 of 15
food marketing. However, our findings also highlight the challenges in obtaining 100% compliance.
One major consideration that might explain noncompliance is the application of Chile’s restriction
to brand characters. To our knowledge, this is the first regulation that bans the use of child-directed
characters without exemptions. Other countries with regulations that ban the use of child-directed
characters, such as the United Kingdom (UK), exempt brand equity characters from their restriction [
41
].
During the initial period of inspection in Chile, companies challenged noncompliance sanctions in
court, citing concerns about brand equity and a need to defend the intellectual property rights of their
trademarks as reasons for needing a judicial remedy for the sanction [
59
]. However, MINSAL argued
that the law prohibits any food advertising aimed at children under 14 years of age, irrespective of
whether these child-directed promotion strategies were registered trademarks [59].
We must also note that the product photographs collected for our post-implementation sample were
taken in the sixth and seventh months after the regulation was implemented. During this timeframe,
MINSAL was mainly giving reprimands and a deadline to comply with the new regulation, although
on a few occasions, MINSAL prohibited the sale of entire product lines that featured child-directed
characters. As such, the noncompliant products reported in this study may be understood as part of
the process of adaptation to the new regulated context. Thus, our study is limited to the timeframes
in which package photographs were taken from the six sampled supermarkets and the variety of
marketing strategies present on the breakfast cereal packages available in those months within 2015
and 2017. We cannot claim that the photographs analyzed constitute a nationally representative sample
of breakfast cereals packages. However, the group of photographs we analyzed did capture at least
one product of all the breakfast cereal brands listed in the Euromonitor report of sales per brand in
Chile in the years 2015 and 2017 [
48
]. Future studies would be needed to examine all breakfast cereals
available in the Chilean market to fully document the prevalence of child-directed strategies in this
product category.
In addition, other product categories should also be examined to evaluate the impact of
the regulation for other types of foods and beverages. Sugar-sweetened beverages might be
of particular interest, given that the per capita sugar-sweetened beverage sales in Chile are the
highest
worldwide [60,61]
. One study of beverage packaging in Chile before the regulation was first
implemented noted that beverages featuring child-directed characters had higher sugar and energy
levels than beverages that did not feature those child-directed strategies on their packages [
10
]. Future
work could examine changes in marketing strategies, as well as reformulation, among beverages sold
in Chile after the regulation.
As noted above, our study is also limited in its focus on child-directed strategies banned by the
Chilean regulation [
34
]. Thus, our findings support the conclusion that regulations with defined lists
of child-directed content strategies can be eective at reducing those defined child-directed marketing
strategies on packages. However, we acknowledge there are other known marketing strategies that
can be appealing to children. For example, the regulation does not include restrictions on general fun
appeals, images of adolescents or teens, and design techniques, such as unconventional colors and fonts,
which are all strategies that are commonly used to target children [
14
,
15
,
19
,
62
]. For example, research
shows that emotional strategies, such as fun or happiness, are eective across age groups at influencing
attitudes and behaviors toward brands and products by creating an association between the positive
emotion and the brand [
63
]. Images of youth >14 years of age might be highly influential models
to older children, especially given their susceptibility to peer norms and aspirational images [
64
,
65
].
The Chilean regulation only restricts strategies that were deemed by MINSAL to clearly reference
or target young children, allowing the use of strategies that might have a wider appeal across age
ranges. This is a limitation of the regulation itself. To fully evaluate all possible appeals that might
attract children to unhealthy foods and beverages, it is important to find ways to monitor marketing
strategies that are not covered by this regulation. Using a more comprehensive concept, such as
“child-appealing”, rather than “child-directed”, marketing would broaden the scope of this type of
study and assist in examining the limits of this regulation.
Int. J. Environ. Res. Public Health 2019,16, 4501 11 of 15
Additionally, the Chilean regulation does not ban the use of health- and nutrition-related claims
in “high-in” products, with the exception that products cannot contradict the warning label they carry,
e.g., claiming low sugar when they qualify for a “high in sugar” label [
34
,
35
]. Even though health
claims are not specifically child-directed, there is evidence of a health halo eect associated with the
use of health claims in food advertising, leading young [
66
,
67
] and adult consumers [
68
71
] to perceive
the entire product as being healthy, regardless of its overall nutritional quality. This health halo eect
is problematic, given evidence that health claims are widely used in products high in sugars, sodium,
fats, or calories [
9
,
72
,
73
]. Further research is needed to evaluate the changes in the prevalence of these
strategies and the potential these strategies have on children’s attitudes and preferences toward food
products that carry warning labels [66,67].
Finally, given that the regulation has three dierent nutrient thresholds, which progressively
become stricter over time, further research is needed to assess compliance at these dierent stages of
implementation. Likewise, a broader analysis of the changes in marketing strategies used to promote
regulated and unregulated food products is needed across these dierent stages. It remains to be seen
how the reduction of child-directed strategies in food packages are reflected in the population’s food
attitudes and preferences or if these changes generate the intended improvement on Chilean children’s
diets and health. Based on the extant literature [
1
,
8
,
74
], the changes in breakfast cereal marketing we
have shown in this study have promising potential for contributing to an eventual positive impact on
attitudinal, behavioral, and health indicators.
5. Conclusions
The present study assessed the changes on breakfast cereal packages’ marketing strategies
after the implementation of the first statutory regulation of child-directed marketing, which limits
marketing content on food packages. Our study found that 85% of “high-in” breakfast cereal packages
were compliant with the child-directed marketing restriction seven months after the regulation
was implemented, showing a significant reduction of child-directed marketing in products with
high levels of critical nutrients and calories. In contrast, after the regulation was implemented,
“non-high-in” products with child-directed strategies were significantly more prevalent than before
the implementation. These findings reflect the scope of the Chilean regulation with respect to its ability
to change the prevalence of child-directed marketing strategies on food packages.
Author Contributions:
F.M.S., F.R.D.C., and M.R. conceptualized the study and developed the codebook. T.C.
contributed to codebook development. T.L.S. led nutritional profiling. F.M.S. led coding. F.M.S. and F.R.D.C. led
data analysis and manuscript writing. All authors contributed to data interpretation and manuscript editing.
F.D.C. took final responsibility for the manuscript.
Funding:
The study support comes from Bloomberg Philanthropies with additional support from IDRC Grant
108180 (INTA-UNC) and 107731 (International Network for Food and Obesity/Non-Communicable Diseases
Research, Monitoring and Action Support, INFORMAS) and CONICYT Fondecyt #1161436. F.M.S. received a
doctoral fellowship from the Commission for Scientific and Technological Research (CONICYT) of the Ministry of
Education of Chile: DOCTORADO BECAS CHILE, 2017, No. 72180276.
Acknowledgments:
We thank Bloomberg Philanthropies, the International Development Research Centre, and
the Carolina Population Center for their financial support. We thank Pablo Mino for help with coding, Donna
Miles for exceptional assistance with data management, Frances Dancy for administrative assistance, Barry Popkin
for leadership and support, and the Carolina Population Center for general support. We also thank the Center for
Research in Food Environments and Prevention of Chronic Diseases Associated with Nutrition (CIAPEC) and the
INFORMAS group at the University of Chile’s Institute of Nutrition and Food Technology for their support with
data collection. We also thank the Asociaci
ó
n de Supermercados de Chile (ASACH), who provided permission for
data collection within the supermarkets.
Conflicts of Interest: The authors declare that they have no conflict of interest.
Int. J. Environ. Res. Public Health 2019,16, 4501 12 of 15
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2019 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access
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... McCullough, 25 Brindal et al., 51 Dembek et al., 27 Frazier & Harris, 30 Huang & Yang, 31 Ofcom, 35 Ofcom, 36 Otten et al., 43 Potvin Kent et al., 42 Powell et al., 38 Powell et al., 37 Silva et al. 44 5 CS content analysis: Neyens & Smits, 57 Potvin Kent et al., 67 Potvin Kent & Pauze, 50 Théodore et al., 59 Vergeer et al., 60 10 repeated CS content analysis: Campos et al., 26 Effertz & Wilcke, 29 Galloway & Calvert, 52 Kim et al., 32 King et al., 65 King et al., 64 Kunkel et al., 66 Landwehr & Hartmann, 56 Mediano et al., 39 Warren et al. 40 1 CS content analysis and survey: Potvin Kent et al. 49 3 repeated CS content analysis and survey: Dillman Carpentier et al., 28 Hebden et al., 63 Lwin et al, 2020. ...
... 2. Mandatory policy vs. no policy 10 1 CS survey: Clark 47 5 repeated CS survey: Adams et al., 24 Ofcom, 35 Ofcom, 36 Otten et al., 43 Silva et al. 44 3 repeated CS content analysis: Campos et al. 26 Kim et al., 32 Mediano et al. 39 1 repeated CS content analysis and survey: Dillman Carpentier et al. 28 3. Voluntary measures vs. no voluntary measure 29 6 CS survey: Harris et al., 55 Harris et al., 53 Harris and Kalnova, 54 Potvin Kent et al., 61 Powell et al., 58 Vaala & Ritter 62 8 repeated CS survey: Berning & McCullough, 25 Brindal et al., 51 Dembek et al., 27 Frazier & Harris, 30 Huang & Yang, 31 Potvin Kent et al., 42 Powell et al., 38 Powell et al. 37 5 Théodore et al., 59 Vergeer et al. 60 7 repeated CS content analysis: Effertz & Wilcke, 29 Galloway & Calvert, 52 King et al., 65 King et al., 64 Kunkel et al., 66 Landwehr & Hartmann, 56 Warren et al. 40 None of the included studies reported on the critical outcomes of food preferences or food choice. ...
... regulations. 39 The U.K. Office of Communication (Ofcom)'s repeated cross-sectional surveys reported reduced impacts (a measure of advertisement viewing) of TV advertisements for HFSS foods in and around programming dedicated to children or "of particular appeal" to children post-U.K. Government policy compared with pre-policy. 35,36 In other studies, the mean number of TV food advertisements viewed by children per day reduced post-CFBAI implementation 38 reported that a repeated cross-sectional survey found that RCMI signatory companies were responsible for a greater proportion of noncore food advertisements as a percentage of all food advertisements on the main free to air TV channels compared with non-signatories. ...
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This systematic review examined the effectiveness of policies restricting the marketing of foods and/or non‐alcoholic beverages to children to inform updated World Health Organization (WHO) guidelines. Databases were searched to March 2020. Inclusion criteria were primary studies of any design assessing implemented policies to restrict food marketing to children (0–19 years). Critical outcomes were exposure to and power of marketing, dietary intake, choice, preference, and purchasing. Important outcomes were purchase requests, dental caries, body weight, diet‐related noncommunicable diseases, product change, and unintended consequences. Forty‐four observational studies met inclusion criteria; most were moderate quality. Pooling was conducted using vote counting by direction of effect, and GRADE was used to judge evidence certainty. Evidence suggests food marketing policies may result in reduced purchases of unhealthy foods and in unintended consequences favorable for public health. Desirable or potentially desirable (for public health) effects of policies on food marketing exposure and power were also found. Evidence on diet and product change was very limited. The certainty of evidence was very low for four outcomes (exposure, power, dietary intake, and product change) and low for two (purchasing and unintended consequences). Policies can effectively limit food marketing to children; policymakers should prioritize mandatory approaches aligned with WHO recommendations.
... En Latinoamérica, en Estados Unidos y en el ámbito global, las investigaciones documentan una y otra vez una alta exposición a la publicidad televisiva de alimentos ultraprocesados, especialmente en horario infantil y de máxima audiencia [65][66][67][68][69][70] . Las técnicas de marketing que atraen desmesuradamente a los niños, como el uso de personajes de dibujos animados o series, promociones y mensajes de diversión y emociones son habituales en la televisión y en los envases de los productos [71][72][73][74] . No hay tanta investigación sobre otros tipos de marketing de alimentos dirigidos a la infancia. ...
... Dos años después de implementar esta normativa disminuyó la publicidad en televisión de alimentos con alto contenido de nutrientes críticos no solo en los programas dirigidos principalmente a los niños, sino también al público en general94 . También disminuyó el uso de estrategias dirigidas a los niños en los envases de cereales y aumentó el consumo de cereales de desayuno con menos azúcar73 . Estos estudios serán fundamentales para mejorar la normativa sobre el marketing de alimentos en otros países y para desarrollar normativas eficaces.3.2 │ Agenda de investigaciónEs preciso seguir investigando para evaluar el impacto de las políticas integrales en comparación con las que utilizan un enfoque gradual. ...
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Resumen El entorno alimentario es un factor importante que contribuye a las dietas poco saludables en la niñez y, por tanto, a las crecientes tasas de obesidad. Los países de Latinoamérica han recibido el reconocimiento internacional por su liderazgo en la implementación de políticas dirigidas a distintos aspectos del entorno alimentario. Sin embargo, los datos sobre la naturaleza y la gravedad de la exposición de los niños a entornos alimentarios poco saludables en la región latinoamericana y entre los latinos que viven en Estados Unidos son aún insuficientes. El objetivo de esta revisión es utilizar el marco conceptual de la Red Internacional para la Investigación, Monitoreo y Apoyo a la Acción para la Alimentación, Obesidad y Enfermedades No Transmisibles (INFORMAS, por sus siglas en inglés) para crear un entorno alimentario saludable con el que (i) comparar los elementos clave de los entornos alimentarios en relación con la obesidad en Latinoamérica y entre los latinos que viven en Estados Unidos; (ii) describir la evidencia sobre soluciones que podrían contribuir a mejorar los entornos alimentarios relacionados con la obesidad infantil; y (iii) establecer prioridades de investigación que permitan identificar estrategias de lucha contra la obesidad en estas poblaciones. Hemos detectado la necesidad de un amplio conjunto integrado de evidencias que sirva de respaldo para establecer un conjunto adecuado de políticas que mejoren el entorno alimentario al que están expuestos los niños de Latinoamérica y los niños latinos que viven en Estados Unidos y para traducir de forma más eficiente las soluciones políticas, de manera que contribuyan a reducir los crecientes niveles de obesidad infantil en estos países.
... The Chile Warning Octagon (CWO) 2019 was selected as it assesses nutrients of concern linked only to poor health outcomes (sugar, sodium, saturated fat and energy) that need to be restricted through food policy. A number of studies indicate its success in Chile [44][45][46][47][48], and other countries have used Chile's NPM [49,50]. The SA HNC NPM assessed health and nutrition claims in draft SA regulation [14] and was adopted from Food Standards Australia and New Zealand's (FSANZ) NPM (which relied on the UK Ofcom NPM in its development [29]). ...
... A number of other countries have already adopted this NPM into their regulation, including Peru [49] and Israel [50]. Furthermore, the Chilean NPM has shown some promising results in the food policies it is underpinning in Chile [44][45][46][47][48]. ...
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South Africa (SA) is facing a rising prevalence of obesity and diet-related chronic diseases. The government is seeking to develop effective, evidence-based policy measures to address this. A well-designed, fit-for-purpose nutrient profiling model (NPM) can aid policy development. The aim of this study was to develop a fit-for-purpose NPM in SA. Steps included: (1) determining the purpose and target population; (2) selecting appropriate nutrients and other food components to include; (3) selecting a suitable NPM type, criteria and base; and (4) selecting appropriate numbers and thresholds. As part of the evaluation, the nutritional composition of packaged foods containing nutritional information (n = 6747) in the SA food supply chain was analyzed, a literature review was undertaken and various NPMs were evaluated. Our findings indicated that it is most appropriate to adapt an NPM and underpin regulation with a restrictive NPM that limits unhealthy food components. The Chile 2019 NPM was identified as suitable to adapt, and total sugar, saturated fat, sodium and non-sugar sweetener were identified as appropriate to restrict. This NPM has the potential to underpin restrictive policies, such as front-of-package labelling and child-directed marketing regulations in SA. These policies will support the fight against obesity and NCDs in the country.
... A robust body of evidence exists regarding the performance and efficacy of restrictions on unhealthy food marketing to children [17][18][19][20][21][22][23][24]. Self-regulatory approaches are shown to be substantially less effective than mandatory measures at reducing children's total exposure to unhealthy food marketing and are therefore an inappropriate and inadequate regulatory response to the issue [17,[25][26][27][28][29][30]. ...
Article
Full-text available
Introduction Introducing legislation that restricts companies from exposing children to marketing of unhealthy food and beverage products is both politically and technically difficult. To advance the literature on the technical design of food marketing legislation, and to support governments around the world with legislative development, we aimed to describe the legislative approach from three governments. Methods A multiple case study methodology was adopted to describe how three governments approached designing comprehensive food marketing legislation (Chile, Canada and the United Kingdom). A conceptual framework outlining best practice design principles guided our methodological approach to examine how each country designed the technical aspects of their regulatory response, including the regulatory form adopted, the substantive content of the laws, and the implementation and governance mechanisms used. Data from documentary evidence and 15 semi-structured key informant interviews were collected and synthesised using a directed content analysis. Results All three countries varied in their legislative design and were therefore considered of variable strength regarding the legislative elements used to protect children from unhealthy food marketing. When compared against the conceptual framework, some elements of best practice design were present, particularly relating to the governance of legislative design and implementation, but the scope of each law (or proposed laws) had limitations. These included: the exclusion of brand marketing; not protecting children up to age 18; focusing solely on child-directed marketing instead of all marketing that children are likely to be exposed to; and not allocating sufficient resources to effectively monitor and enforce the laws. The United Kingdom’s approach to legislation is the most comprehensive and more likely to meet its regulatory objectives. Conclusions Our synthesis and analysis of the technical elements of food marketing laws can support governments around the world as they develop their own food marketing restrictions. An analysis of the three approaches illustrates an evolution in the design of food marketing laws over time, as well as the design strengths offered by a legislative approach. Opportunities remain for strengthening legislative responses to protect children from unhealthy food marketing practices.
... Children are a main target for food marketing, with the strongest strategy focusing on generating remarkable familiarity mostly with contextual animated cartoon characters [41]. In our experiment, cartoon characters displayed on the front of the package of food products labelled with WL led to a lower percentage of children correctly identifying the least healthy product, but not the healthiest option. ...
Article
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Background: Warning Labels (WL) highlight excessive amounts of critical nutrients in order to discourage consumption of unhealthful packaged food products. This study aimed to evaluate among Mexican school children, the objective understanding of traditional and numeric WL (aimed at small products) considered by the Mexican regulation, and whether cartoon characters influenced the understanding of WL. We also tested some communication strategies to facilitate the correct use of the WL. Methods: We carried out a randomized experiment in July 2019 in public elementary schools from Morelos, Mexico. Participants aged 6-13 years, were randomly assigned to one of four groups: 1) Nutrient Facts Panel (NF) (n = 120), 2) Nutrient Facts Panel with cartoon characters (NF + C) (n = 83), considered the control groups, 3) Warning Labels (WL) (n = 109), and 4) Warning Labels with cartoon characters (WL + C) (n = 96). After allocation, children assigned to both WL groups (WL or WL + C), were randomly required to watch two posters simultaneously or a video explaining how to correctly interpret WLs. Logistic regression models adjusted by sex, age and cluster (school) were fitted. Results: The percentage of children correctly choosing the healthiest or the unhealthiest option was higher for WL groups (56.8, 95%CI; 40.8-72.8) compared to NF groups (24.3, 95%CI; 20.4-28.3, p < 0.05). The understanding of traditional WL was higher (28.7, 95%CI: 22.8-35.4) than the numeric WL (19, 95%CI: 14.2-25.0, p < 0.05). But, correct answers for identifying healthy and unhealthy products were higher for numeric WL than for NF groups. Cartoon characters reduced the percentage of correct answers for choosing unhealthiest products (WL + C: 48.9, 95%CI: 25.6-72.4 vs WL: 58.7, 95%CI: 36.4-81.1, p < 0.05). The video was 2.23 times more helpful than the posters to the correct interpretation of the WL (p < 0.05). Conclusions: In scholar Mexican children, traditional and numeric WL were useful to identify healthier and unhealthier packaged products in comparison to NF, suggesting that both WL formats may effectively communicate the excessive content of nutrients of concern among children. Cartoon characters may reduce the objective understanding of the WL, underscoring the need to regulate advertising directed to children along with the implementation of front-of-pack labeling.
... 145 Figures 8 and 9 summarize the key results. [146][147][148] Additionally, implementation of the policies did not impact labor market outcomes, such as employment and wages, of the related sectors likely to be affected by the regulations. 149 This shows that reformulation was important, particularly for sodium and added sugar and that consumers found other healthier options. ...
Article
Full-text available
The Nutrition Transition model is presented with the nature and pace of change in key stages varying by location and subpopulations. At present, all high‐income and many low‐ and middle‐income countries are in a stage of the transition where nutrition‐related noncommunicable diseases including obesity, type 2 diabetes, and hypertension are dominating adult morbidity and mortality and are very high or growing rapidly in prevalence. Some countries still have key subpopulations facing hunger and undernutrition defined by stunting or extreme thinness among adults. We call these double burden of malnutrition countries. All low‐ and middle‐income countries face rapid growth in consumption of ultra‐processed food and beverages, but it is not inevitable that these countries will reach the same high levels of consumption seen in high‐income countries, with all the negative impacts of this diet on health. With great political and civil society commitment to adoption of policies shown in other countries to have improved dietary choices and social norms around foods, we can arrest and even reverse the rapid shift to diets dominated by a stage of high ultra‐processed food intake and increasing prevalence of nutrition‐related noncommunicable diseases.
... Solutions to encourage healthier food purchases in retail settings are urgently needed. Nutrition-related point-ofsale policies and interventions that have shown promise include excise taxes on sugary drinks and ultra-processed food [4][5][6][7]; marketing restrictions [8,9]; and requiring warning labels on sugary drinks and ultra-processed food [9][10][11][12]12]. Most evidence on these policies comes from either real-world observational studies or laboratory-based experimental studies. ...
Article
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Point-of-sale policies such as warnings and taxes are promising tools for improving the nutritional quality of food purchases. Research studies conducted in naturalistic store laboratories could improve the quality of evidence about point-of-sale interventions by allowing for realistic exposure in a controlled setting. This study aimed to assess whether purchasing behavior in a naturalistic store laboratory setting was similar to real-life purchasing behavior and to evaluate participants’ perceptions of store realism and the acceptability of research study protocols in this setting. In a longitudinal observational study in 2019, Latinx parents in North Carolina (n = 61) attended five weekly visits at the UNC Mini Mart, a naturalistic store laboratory that resembled a small convenience store. At each visit, participants purchased a week’s supply of beverages. Purchases of beverages in the Mini Mart were compared to participants’ purchases from receipts submitted the week prior to the study. Analyses compared the percentage of participants buying sugary drinks and non-sugary drinks in the Mini Mart vs. in real stores using Chi-Square tests with Fisher’s p. The percentage of parents who purchased sugary drinks in the Mini Mart (93%) was not significantly different from the percentage who purchased sugary drinks during the week before the study (74%, p = 0.28). The percentage purchasing non-sugary drinks was similar in the two settings (85% in the Mini Mart vs. 85% from receipts, p = 0.33). Nearly all participants reported that their Mini Mart purchases were similar to real-life purchases (96%); the Mini Mart felt like a real store (94%); they could find all the beverages they were looking for (92%); and they could imagine doing their real-life beverage shopping in the Mini Mart (92%). Moreover, retention was high, with 97% of participants attending the final study visit. These results indicate that naturalistic store laboratories are a promising method for increasing the ecological validity of trials to evaluate point-of-sale interventions.
... This study builds on previous evaluations of the Chilean law, which found that the law improved the nutritional content of the food supply, 17 reduced unhealthy food marketing to children, 18,19 reduced availability of unhealthy foods in schools, 20 and helped people better identify unhealthy products and dis couraged their consumption. 21 Although we were not able to disentangle the effects of the labelling, marketing, and school components of the law in this study, the body of results from the previous evaluations shows how each aspect of the law contributed to changes in the food environment and behaviour. ...
Article
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Background In 2016, Chile implemented a unique law mandating front-of-package warning labels, restricting marketing, and banning school sales for products high in calories, sodium, sugar, or saturated fat. We aimed to examine changes in the calorie, sugar, sodium, and saturated fat content of food and beverage purchases after the first phase of implementation of this law. Methods This before and after study used longitudinal data on food and beverage purchases from 2381 Chilean households from Jan 1, 2015, to Dec 31, 2017. Nutrition facts panel data from food and beverage packages were linked to household purchases at the product level using barcode, brand name, and product description. Nutritionists reviewed each product for nutritional accuracy and categorised it as high-in if it contained added sugar, sodium, or saturated fat and exceeded phase 1 nutrient or calorie thresholds, and thus was subject to the labelling, marketing, and school regulations. Using fixed-effects models, we examined the mean nutrient content (overall calories, sugar, saturated fat, and sodium) of purchases in the post-policy period compared to a counterfactual scenario based on pre-policy trends. Findings Compared with the counterfactual scenario, overall calories purchased declined by 16·4 kcal/capita/day (95% CI –27·3 to –5·6; p=0·0031) or 3·5%. Overall sugar declined by 11·5 kcal/capita/day (–14·6 to –8·4; p<0·0001) or 10·2%, and saturated fat declined by 2·2 kcal/capita/day (–3·8 to –0·5; p=0·0097) or 3·9%. The sodium content of overall purchases declined by 27·7 mg/capita/day (–46·3 to –9·1; p=0·0035) or 4·7%. Declines from high-in purchases drove these results with some offset by increases in not-high-in purchases. Among high-in purchases, relative to the counterfactual scenario, there were notable declines of 23·8% in calories purchased (–49·4 kcal/capita/day, 95% CI –55·1 to –43·7; p<0·0001), 36·7% in sodium purchased (–96·6 mg/capita/day,–105·3 to –87·8; p<0·0001), and 26·7% in sugar purchased (–20·7 kcal/capita/day, –23·4 to –18·1; p<0·0001). Interpretation The Chilean phase 1 law of food labelling and advertising policies were associated with reduced high-in purchases, leading to declines in purchased nutrients of concern. Greater changes might reasonably be anticipated after the implementation of phases 2 and 3. Funding Bloomberg Philanthropies, International Development Research Center, and Eunice Kennedy Shriver National Institute of Child Health and Human Development of the National Institutes of Health.
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Food packaging design has become a key component of the marketing mix of companies to ensure the long-term success of their products, and to convey information that set apart their products from competitors. The aim of this review is to critically discuss the role of food packaging on children's diet. Food package design plays a key role in attracting children and parents' attention, shaping product associations, and influencing their purchase decisions. Packaging elements attracting children's attention and misleading health-related visual and textual cues may encourage children and their parents to choose energy-dense food products with excessive content of sugar, fat, and sodium. Results from this review suggest that comprehensive packaging regulations are necessary to protect children's health and encourage healthier eating habits from early years. Such regulations should go beyond products targeted to children, making informed decisions easier to encourage healthier choices, and including restrictions on the use of health-related cues on all products, as it ultimately influences the diet and the food available in the household.
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Objective: To investigate the New South Wales (NSW) community's support for obesity prevention policies and concern for food marketing and promotion issues, and to determine any demographic differences or changes over time. Methods: In 2013 (n=2474), 2016 (n=1602) and 2019 (n=1613) a sample of adults who were representative of the NSW population for age, gender, education and location was asked about support for policy initiatives that influence the food environment. Analysis identified the characteristics of those who supported policies and variation in support over time. Results: There were limited changes in support over time; however, support for many policies was strong and sustained. In 2019, support was highest for regulation of claims about nutrition (77.2%), and health warning labels (75.7%). Support for a ban on unhealthy food advertising that targets children (64.6%) had decreased since 2013. Women, older people and those who were aware that obesity was a risk factor for cancer were generally more likely to support policies. Parents were more likely than non-parents to be concerned about positioning unhealthy food at supermarket checkouts (OR 1.32) and unhealthy outdoor advertisements (OR 1.22). Concern increased in 2019 for unhealthy marketing on the internet (OR 1.21). Conclusions: This study shows public support for policy options at moderate to high levels but not increasing in the six-year study period. Implications for public health: These results form part of a package that, along with the well-established evidence, makes the case for policy action in Australia.
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Reducing children's exposure to food marketing is an important obesity prevention strategy. This narrative review describes current statutory regulations that restrict food marketing; reviews available evidence on the effects of these regulations; and compares policy design elements in Chile and the United Kingdom. Currently, 16 countries have statutory regulations on unhealthy food marketing to children. Restrictions on television advertising, primarily during children's programming, are most common. Schools are also a common setting for restrictions. Regulations on media such as cinema, mobile phone applications, print, packaging, and the internet are uncommon. Eleven evaluations of policies in 4 jurisdictions found small or no policy-related reductions in unhealthy food advertising, in part because marketing shifted to other programs or venues; however, not all policies have been evaluated. Compared with the United Kingdom, Chile restricts marketing on more products, across a wider range of media, using more marketing techniques. Future research should examine which elements of food marketing policy design are most effective at reducing children's exposure to unhealthy food marketing.
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Exposure to the marketing of unhealthy foods and beverages is a widely acknowledged risk factor for the development of childhood obesity and noncommunicable diseases. Food marketing involves the use of numerous persuasive techniques to influence children’s food attitudes, preferences and consumption. This systematic review provides a comprehensive contemporary account of the impact of these marketing techniques on children aged 0–18 years and critically evaluates the methodologies used. Five electronic academic databases were searched using key terms for primary studies (both quantitative and qualitative) published up to September 2018; 71 eligible articles were identified. Significant detrimental effects of food marketing, including enhanced attitudes, preferences and increased consumption of marketed foods were documented for a wide range of marketing techniques, particularly those used in television/movies and product packaging. Together, these studies contribute strong evidence to support the restriction of food marketing to children. However, the review also signposted distinct gaps: Firstly, there is a lack of use of qualitative and physiological methodologies. Secondly, contemporary and sophisticated marketing techniques used in new media warrant increased research attention. Finally, more research is needed to evaluate the longer-term effects of food marketing on children’s weight.
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Background In line with calls for action from international health organizations, Chile implemented in June 2016 a set of regulations to tackle the obesity epidemic. The new regulation includes the mandatory use of front-of-package warning labels on packaged foods/beverages high in energy, sugars, saturated fats and sodium. Additionally, such foods cannot be sold nor offered in daycares/schools and cannot be promoted to children under 14yo. The law is targeted to children; thus, this study examined mothers’ understanding, perceptions, and behaviors associated with the regulation one year after its implementation, using a qualitative approach. Methods Nine focus groups of mothers (7–10 people each) of children (2-14yo) were conducted in July 2017 in Santiago-Chile. They were stratified by socioeconomic status (SES) and children’s age. Macrocodes were developed by three researchers, combining an iterative process of deductive and inductive thematic analyses. Quotations representing each category were selected. Results Mothers understood the new regulation as a policy to fight child obesity and were aware that products with more labels were less healthy than products with fewer labels. Attention and use of labels in the buying decision-making process ranged from participants who did not pay attention to others who relied on them as a quick shortcut (mostly from middle and upper-SES); many mothers indicated changing their purchase habits only when buying new products. Mothers declared that young children accepted school environment changes while teens/preteens resisted them more. Many mothers agreed that schools have become key promoters of food behavioral change. Mothers were less aware about the food marketing regulations. Mothers declared that they perceived that the regulation was changing the perceptions, attitudes and behaviors toward healthier eating patterns. Conclusion After the first year of implementation, the regulation was well known by mothers of diverse SES and different children ages. The degree of use of warning labels was heterogeneous among participants, but most of them agreed that their children, particularly the youngest have positive attitudes toward the regulation and have become promoters of change in their families. Many mothers also expressed that they perceived an important shift toward healthier eating, which may lead to a change in eating social norms. This information contributes to better understand how regulatory actions may influence people’s consumer behaviors.
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This study aimed to evaluate the composition of the food supply ahead of the implementation of the Chilean Law of Food Labeling and Advertising (Law 20.606) in June 2016. The INFORMAS (International Network for Food and Obesity/Non-communicable Diseases (NCDs) Research, Monitoring and Action Support) framework for monitoring the composition of the food supply was used. The Law’s initial (2016) and final (2019) limits were used to evaluate if foods would receive a “High in” warning for Calories, Sodium, Sugars and/or Saturated Fats (initial/final, solids: >350/275 kcal; >800/400 mg; >22.5/10 g; >6/4 g; liquids: >100/70 kcal; >100/100 mg; >6/5 g; >3/3 g respectively). Foods were excluded if they required reconstitution, had missing information or if total labeled energy was estimated as incorrect (n = 942). In February 2015 and 2016, fieldworkers photographed a purposeful sample of packaged food and beverage products (n = 5421 and n = 5479) from 6 different supermarkets in Santiago, Chile. Seven percent of foods had no added critical nutrients (n = 720). Two-thirds of products had critical nutrients exceeding at least one initial limit indicative of a “high in” warning. Under the final phase limits, only 17% of foods would have zero warning labels. By 2019, 10 of the 17 food and beverage categories studied are predicted to have less than half of their products without a high in sodium warning label. While 8 of the 17 categories studied are predicted to have less than half their products without a high in total sugars or a high in total calories warning label, respectively; while even fewer food and beverage categories are predicted to be without a high in saturated fat warning label. Most products will have to be reformulated to avoid at least one front-of-package warning label.
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Chile approved the law of food labelling and advertising in 2012; this law aims to address the obesity epidemic, particularly in children. The implementation details were published in 2015, and the law was implemented finally in 2016, as described in the current article. Regulated foods were defined based on a specially developed nutrient profiling, which considered natural foods as gold standard. For liquid foods, amounts of energy, sugars, saturated fats, and sodium in 100 mL of cow's milk were used as cut‐offs. For solid foods, values within the 90th ‐ 99th percentile range for energy and critical nutrients were selected as cut‐off within a list of natural foods. A stop sign stating “High in ” was chosen as warning label for packaged regulated foods. Regulated foods were also forbidden to be sold or offered for free at kiosks, cafeterias, and feeding programme at schools and nurseries. Besides, regulated foods cannot be promoted to children under 14 years. A staggered implementation of the regulation was decided, with nutrients cut‐offs becoming increasingly stricter over a 3‐year period. These regulatory efforts are in the right direction but will have to be sustained and complemented with other actions to achieve their ultimate impact of halting the obesity epidemic.
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Objective In the light of Chile’s comprehensive new restriction on unhealthy food marketing, we analyse food advertising on Chilean television prior to the first and final phases of implementation of the restriction. Design Content analysis of marketing strategies of 6976 advertisements, based on products’ nutritional quality. Statistical analysis of total and child audience reached using television ratings data. Setting Advertising from television aired between 06.00 and 00.00 hours during two random composite weeks across April–May 2016 from the four broadcast and four cable channels with the largest youth audiences. Results Food ads represented 16 % of all advertising; 34 % of food ads featured a product high in energy, saturated fats, sugars and/or salt (HEFSS), as defined by the initial regulation. HEFSS ads were seen by more children and contained more child-directed marketing strategies than ads without HEFSS foods. If HEFSS advertising was restricted only in programmes where 20 % are children aged 4–12 years, 31 % of children’s and 8 % of the general audience’s HEFSS advertising exposure would be reduced. The newest 06.00–22.00 hours restriction captures 80 % of all audience exposure. Conclusions HEFSS advertising was seen by a large proportion of children before Chile’s regulation. Chile’s first implementation based on audience composition should reduce a third of this exposure and its second restriction across the television day should eliminate most of the exposure. The current study is a crucial first step in evaluating how Chile’s regulation efforts will impact children’s diets and obesity prevalence.
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Overweight and obesity are a global epidemic with rates having risen to alarming levels in both developed and developing countries. Chile has been no exemption, with sharp increases in obesity prevalence, especially among school-age children. This paper describes the policy actions and strategies implemented to tackle this major public health concern in Chile over the last 10 years, and highlights the main challenges and nuances of the process. Chile has taken policy action that includes front-of-package labelling, advertising regulations, and school-food restrictions. New policies focus on the social determinants of health as they relate to food environments and people’s behavior. These actions are not only suitable to the current context in Chile, but are also supported by the best available scientific evidence. Moreover, the implementation of these policies has produced a broad debate involving public institutions and the food industry, with discussions issues ranging from property rights to trade barriers. Despite some differences among stakeholders, a valuable political consensus has been achieved, and several international organizations are eager to evaluate the impact of these pioneer initiatives in Latin America
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