Content uploaded by Fernanda Mediano
Author content
All content in this area was uploaded by Fernanda Mediano on May 15, 2020
Content may be subject to copyright.
Content uploaded by Francesca R Dillman Carpentier
Author content
All content in this area was uploaded by Francesca R Dillman Carpentier on Nov 15, 2019
Content may be subject to copyright.
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 differences 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 effective 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-offvalues 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-offvalues 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 ≥3≥2.75
Sodium (mg) ≥800 ≥500 ≥400
Total sugars (g) ≥22.5 ≥15 ≥10
Saturated fats (g) ≥6≥5≥4
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. Different 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 different marketing content on their packages, we collected images of both packages.
If a product used the same marketing content on packages of different 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, puff, 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 coefficient 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 different 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 effect 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 differences 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 difference 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 difference 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.
Differences 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) Difference
(2017–2015) Pre-(2015) Post-(2017) Difference
(2017–2015) Pre-(2015) Post-(2017) Difference
(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 different breakfast cereals available in six different supermarkets from five different 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,
differences in how products might have been marketed in high-income urban supermarkets vs. other
venues, or differences 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 effective 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 effective 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 effect 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 effect
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 different nutrient thresholds, which progressively
become stricter over time, further research is needed to assess compliance at these different 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 different 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
References
1. Commission on Ending Childhood Obesity; World Health Organization: Geneva, Switzerland, 2014.
2.
McGuire, S. US Department of Agriculture and US Department of Health and Human Services, dietary
guidelines for Americans, 2010. 7th edition, Washington, DC: US Government Printing Office, January 2011.
Adv. Nutr. 2011,2, 293–294. [CrossRef]
3. Guideline: Sugars Intake for Adults and Children; World Health Organization: Geneva, Switzerland, 2015.
4.
Rippe, J.; Angelopoulos, T. Relationship between added sugars consumption and chronic disease risk factors:
Current understanding. Nutrients 2016,8, 697. [CrossRef] [PubMed]
5.
Zimmerman, F.J. Using marketing muscle to sell fat: The rise of obesity in the modern economy. Annu. Rev.
Public Health 2011,32, 285–306. [CrossRef]
6.
Kraak, V.I.; Gootman, J.A.; McGinnis, J.M. Food Marketing to Children and Youth: Threat or Opportunity?
National Academies Press: Washington, DC, USA, 2006.
7.
Cairns, G.; Angus, K.; Hastings, G.; Caraher, M. Systematic reviews of the evidence on the nature, extent
and effects of food marketing to children. A retrospective summary. Appetite
2013
,62, 209–215. [CrossRef]
[PubMed]
8.
Smith, R.; Kelly, B.; Yeatman, H.; Boyland, E. Food marketing influences children’s attitudes, preferences and
consumption: A systematic critical review. Nutrients 2019,11, 875. [CrossRef] [PubMed]
9.
Lapierre, M.A.; Brown, A.M.; Houtzer, H.V.; Thomas, T.J. Child-directed and nutrition-focused marketing
cues on food packaging: Links to nutritional content. Public Health Nutr. 2017,20, 765–773. [CrossRef]
10.
Mediano Stoltze, F.; Barker, J.O.; Kanter, R.; Corvalan, C.; Reyes, M.; Taillie, L.S.; Dillman Carpentier, F.R.
Prevalence of child-directed and general audience marketing strategies on the front of beverage packaging:
The case of Chile. Public Health Nutr. 2018,21, 454–464. [CrossRef]
11.
Moses, L.J.; Baldwin, D.A. What can the study of cognitive development reveal about children’s ability to
appreciate and cope with advertising? J. Public Policy Mark. 2005,24, 186–201. [CrossRef]
12.
Wilcox, B.L.; Kunkel, D.; Cantor, J.; Dowrick, P.; Linn, S.; Palmer, E. Report of the APA Task Force on Advertising
and Children; American Psychological Association: Washington, DC, USA, 2004.
13.
Letona, P.; Chacon, V.; Roberto, C.; Barnoya, J. Effects of licensed characters on children’s taste and snack
preferences in Guatemala, a low/middle income country. Int. J. Obes. (Lond.)
2014
,38, 1466–1469. [CrossRef]
14.
Chacon, V.; Letona, P.; Barnoya, J. Child-oriented marketing techniques in snack food packages in Guatemala.
BMC Public Health 2013,13, 967. [CrossRef]
15.
Hawkes, C. Food packaging: The medium is the message. Public Health Nutr.
2010
,13, 297–299. [CrossRef]
[PubMed]
16.
Harris, J.L.; Thompson, J.M.; Schwartz, M.B.; Brownell, K.D. Nutrition-related claims on children’s cereals:
What do they mean to parents and do they influence willingness to buy? Public Health Nutr.
2011
,14,
2207–2212. [CrossRef] [PubMed]
17.
Koenigstorfer, J.; Groeppel-Klein, A.; Kettenbaum, M.; Klicker, K. Eat fit. Get big? How fitness cues influence
food consumption volumes. Appetite 2013,65, 165–169. [CrossRef] [PubMed]
18.
Harris, J.L.; Schwartz, M.B.; Brownell, K.D. Marketing foods to children and adolescents: Licensed characters
and other promotions on packaged foods in the supermarket. Public Health Nutr.
2010
,13, 409–417. [CrossRef]
[PubMed]
19.
Roberto, C.A.; Baik, J.; Harris, J.L.; Brownell, K.D. Influence of licensed characters on children’s taste and
snack preferences. Pediatrics 2010,126, 88–93. [CrossRef]
20.
Enax, L.; Weber, B.; Ahlers, M.; Kaiser, U.; Diethelm, K.; Holtkamp, D.; Faupel, U.; Holzmuller, H.H.;
Kersting, M. Food packaging cues influence taste perception and increase effort provision for a recommended
snack product in children. Front. Psychol. 2015,6, 882. [CrossRef]
21.
Skaczkowski, G.; Durkin, S.; Kashima, Y.; Wakefield, M. The effect of packaging, branding and labeling on
the experience of unhealthy food and drink: A review. Appetite 2016,99, 219–234. [CrossRef]
22.
Ülger, B. Packages with cartoon trade characters versus advertising: An empirical examination of preschoolers’
food preferences. J. Food Prod. Mark. 2008,15, 104–117. [CrossRef]
23.
Signal, L.N.; Stanley, J.; Smith, M.; Barr, M.; Chambers, T.J.; Zhou, J.; Duane, A.; Gurrin, C.; Smeaton, A.F.;
McKerchar, C. Children’s everyday exposure to food marketing: An objective analysis using wearable
cameras. Int. J. Behav. Nutr. Phys. Act. 2017,114, 137. [CrossRef]
Int. J. Environ. Res. Public Health 2019,16, 4501 13 of 15
24.
Soo, J.; Letona, P.; Chacon, V.; Barnoya, J.; Roberto, C.A. Nutritional quality and child-oriented marketing of
breakfast cereals in Guatemala. Int. J. Obes. (Lond.) 2016,40, 39–44. [CrossRef]
25.
Page, R.; Montgomery, K.; Ponder, A.; Richard, A. Targeting children in the cereal aisle: Promotional
techniques and content features on ready-to-eat cereal product packaging. Am. J. Health Educ.
2008
,39,
272–282. [CrossRef]
26.
Kotler, J.A.; Schiffman, J.M.; Hanson, K.G. The influence of media characters on children’s food choices.
J. Health Commun. 2012,17, 886–898. [CrossRef] [PubMed]
27.
Lapierre, M.A.; Vaala, S.E.; Linebarger, D.L. Influence of licensed spokescharacters and health cues on
children’s ratings of cereal taste. Arch. Pediatr. Adolesc. Med. 2011,165, 229–234. [CrossRef] [PubMed]
28.
Hawkes, C.; Lobstein, T. Regulating the commercial promotion of food to children: A survey of actions
worldwide. Int. J. Pediat. Obes. 2011,6, 83–94. [CrossRef]
29.
Halford, J.C.; Boyland, E.J.; Hughes, G.M.; Stacey, L.; McKean, S.; Dovey, T.M. Beyond-brand effect of
television food advertisements on food choice in children: The effects of weight status. Public Health Nutr.
2008,11, 897–904. [CrossRef]
30.
Set of Recommendations on The Marketing of Foods and Non-Alcoholic Beverages to Children; World Health
Organization: Geneva, Switzerland, 2010.
31.
Taillie, L.S.; Busey, E.; Mediano Stoltze, F.; Dillman Carpentier, F.R. Governmental policies to reduce unhealthy
food marketing to children. Nutrition Rev. 2019. [CrossRef]
32.
Correa, T.; Fierro, C.; Reyes, M.; Dillman Carpentier, F.R.; Taillie, L.S.; Corvalan, C. Responses to the Chilean
law of food labeling and advertising: Exploring knowledge, perceptions and behaviors of mothers of young
children. Int. J. Behav. Nutr. Phys. Act. 2019,16, 21. [CrossRef]
33.
A Framework for Implementing the Set of Recommendations on the Marketing of Foods and Non-Alcoholic Beverages
to Children; World Health Organization: Geneva, Switzerland, 2012.
34.
Modifica Decreto Supremo n 977, de 1996, del Ministerio de Salud. Reglamento Sanitario de Los Alimentos. N 14;
Ministry of Health: Santiago, Chile, 2015.
35.
Corvalan, C.; Reyes, M.; Garmendia, M.L.; Uauy, R. Structural responses to the obesity and non-communicable
diseases epidemic: Update on the Chilean law of food labelling and advertising. Obes. Rev.
2019
,20, 367–374.
[CrossRef]
36.
Rodr
í
guez Osiac, L.; Cofr
é
, C.; Pizarro, T.; Mansilla, C.; Herrera, C.A.; Burrows, J.; Castillo, C. Using
evidence-informed policies to tackle overweight and obesity in Chile. Rev. Panam. de Salud P
ú
blica
2017
,41,
156. [CrossRef]
37.
OECD Reviews of Public Health: Chile; Organisation for Economic Co-operation and Development: Paris,
France, 2019.
38. Mapa Nutricional 2017; National Board for School Assistance and Scholarships: Santiago, Chile, 2017.
39.
Margozzini, P.P.
Á
. Encuesta Nacional de Salud, ENS 2016-2017, un aporte a la planificaci
ó
n sanitaria y
políticas públicas en Chile. ARS MEDICA Revista de Ciencias Médicas 2018,43. [CrossRef]
40.
Corvalan, C.; Reyes, M.; Garmendia, M.; Uauy, R. Structural responses to the obesity and non-communicable
diseases epidemic: The Chilean Law of Food Labeling and Advertising. Obes. Rev.
2013
,14, 79–87. [CrossRef]
41.
Broadcast Committee of Advertising Practice. The BCAP Code: The UK Code of Broadcast Advertising;
The Stationery Office: London, UK, 2010.
42.
Kraak, V.I.; Story, M. Influence of food companies’ brand mascots and entertainment companies’ cartoon
media characters on children’s diet and health: A systematic review and research needs. Obes. Rev.
2015
,16,
107–126. [CrossRef] [PubMed]
43.
Gim
é
nez, A.; Saldamando Ld Curutchet, M.R.; Ares, G. Package design and nutritional profile of foods
targeted at children in supermarkets in Montevideo, Uruguay. Cad. Saude Publica
2017
,33, 32116. [CrossRef]
44.
Schwartz, M.B.; Vartanian, L.R.; Wharton, C.M.; Brownell, K.D. Examining the nutritional quality of breakfast
cereals marketed to children. J. Am. Diet. Assoc. 2008,108, 702–705. [CrossRef]
45.
Swinburn, B.; Sacks, G.; Vandevijvere, S.; Kumanyika, S.; Lobstein, T.; Neal, B.; Barquera, S.; Friel, S.;
Hawkes, C.; Kelly, B.; et al. INFORMAS (International Network for Food and Obesity/non-communicable
diseases Research, Monitoring and Action Support): Overview and key principles. Obes. Rev.
2013
,14
(Suppl. 1), 1–12. [CrossRef]
46.
Kanter, R.; Reyes, M.; Corval
á
n, C. Photographic methods for measuring packaged food and beverage
products in supermarkets. Curr Dev. Nutr. 2017,1, 1016. [CrossRef]
Int. J. Environ. Res. Public Health 2019,16, 4501 14 of 15
47.
Kanter, R.; Reyes, M.; Swinburn, B.; Vandevijvere, S.; Corvalan, C. The food supply prior to the implementation
of the Chilean Law of Food Labeling and Advertising. Nutrients 2019,11, 52. [CrossRef]
48. Breakfast cereals in Chile; Euromonitor International: London, UK, 2019.
49.
Uribe Bravo, R. “Un momento y ya volvemos”: Un an
á
lisis de contenido de la publicidad infantil en la
televisión chilena. Comunicación y Sociedad 2012,18, 79–106.
50.
Elliott, C.D. Packaging fun: Analyzing supermarket food messages targeted at children. Can. J. Commun.
2012,37, 303–318. [CrossRef]
51.
Warren, R.; Wicks, R.H.; Wicks, J.L.; Fosu, I.; Chung, D. Food and beverage advertising on U.S. television: A
comparison of child-targeted versus general audience commercials. J. Broadcast. Electron. Media
2008
,52,
231–246. [CrossRef]
52.
Hebden, L.; King, L.; Kelly, B. Art of persuasion: An analysis of techniques used to market foods to children.
J. Paediatr. Child. H 2011,47, 776–782. [CrossRef]
53.
Hawley, K.L.; Roberto, C.A.; Bragg, M.A.; Liu, P.J.; Schwartz, M.B.; Brownell, K.D. The science on
front-of-package food labels. Public Health Nutr. 2013,16, 430–439. [CrossRef] [PubMed]
54.
Correa, T.; Reyes, M.; Smith Taillie, L.P.; Dillman Carpentier, F.R. The prevalence and audience reach of food
and beverage advertising on Chilean television according to marketing tactics and nutritional quality of
products. Public Health Nutr. 2019,22, 1113–1124. [CrossRef]
55.
Gwet, K.L. Computing inter-rater reliability and its variance in the presence of high agreement. Br. J. Math.
Stat. Psychol. 2008,61, 29–48. [CrossRef] [PubMed]
56.
Devi, A.; Eyles, H.; Rayner, M.; Mhurchu, C.N.; Swinburn, B.; Lonsdale-Cooper, E.; Vandevijvere, S.
Nutritional quality, labelling and promotion of breakfast cereals on the New Zealand market. Appetite
2014
,
81, 253–260. [CrossRef]
57.
Ogle, A.D.; Graham, D.J.; Lucas-Thompson, R.G.; Roberto, C.A. Influence of cartoon media characters on
children’s attention to and preference for food and beverage products. J. Acad. Nutr. Diet.
2017
,117, 265–270.
[CrossRef]
58.
Hurwitz, L.B.; Montague, H.; Lauricella, A.R.; Alvarez, A.L.; Pietrantonio, F.; Ford, M.L.; Wartella, E. Crowd
pleasers: Media characters in food company websites and apps for children. Young Consum.
2019
,20, 44–58.
[CrossRef]
59.
Informe de Evaluaci
ó
n de la Implementaci
ó
n de la Ley Sobre Composici
ó
n Nutricional de los Alimentos y su Publicidad;
Ministry of Health: Santiago, Chile, 2017; p. 77.
60.
Ultra-Processed Food and Drink Products in Latin America: Sales, Sources, Nutrient Profiles, and Policy Implications;
Pan American Health Organization: Washington, DC, USA, 2019; p. 72.
61.
Popkin, B.; Hawkes, C. Sweetening of the global diet, particularly beverages: Patterns, trends, and policy
responses. Lancet Diabetes Endocrinol. 2015,4, 174–186. [CrossRef]
62.
Elliott, C. Assessing “un foods”: Nutritional content and analysis of supermarket foods targeted at children.
Obes. Rev. 2008,9, 368–377. [CrossRef]
63.
Harris, J.L.; Fleming-Milici, F. Food marketing to adolescents and young adults: Skeptical but still under
the influence. In Current Issues in Social Psychology: The Psychology of Food Marketing and (Over) Eating;
Folkword, F., Ed.; Routledge: London, UK, 2019; pp. 25–44.
64.
Kelly, K.J.; Slater, M.D.; Karan, D. Image advertisements’ influence on adolescents’ perceptions of the
desirability of beer and cigarettes. J. Public Policy Mark. 2002,21, 295–304. [CrossRef]
65.
Pechmann, C.; Levine, L.; Loughlin, S.; Leslie, F. Impulsive and self-conscious: adolescents’ vulnerability to
advertising and promotion. J. Public Policy Mark. 2005,24, 202–221. [CrossRef]
66.
Arrua, A.; Curutchet, M.R.; Rey, N.; Barreto, P.; Golovchenko, N.; Sellanes, A.; Velazco, G.; Winokur, M.;
Gimenez, A.; Ares, G. Impact of front-of-pack nutrition information and label design on children’s choice of
two snack foods: Comparison of warnings and the traffic-light system. Appetite
2017
,116, 139–146. [CrossRef]
[PubMed]
67.
Arrua, A.; Vidal, L.; Antunez, L.; Machin, L.; Martinez, J.; Curutchet, M.R.; Gimenez, A.; Ares, G. Influence of
Label Design on Children’s Perception of 2 Snack Foods. J. Nutr. Educ. Behav.
2017
,49, 211–217. [CrossRef]
[PubMed]
68.
Abrams, K.M.; Evans, C.; Duff, B.R. Ignorance is bliss. How parents of preschool children make sense of
front-of-package visuals and claims on food. Appetite 2015,87, 20–29. [CrossRef]
Int. J. Environ. Res. Public Health 2019,16, 4501 15 of 15
69.
Choi, H.; Yoo, K.; Hyun Baek, T.; Reid, L.N.; Macias, W. Presence and effects of health and nutrition-related
(HNR) claims with benefit-seeking and risk-avoidance appeals in female-orientated magazine food
advertisements. Int. J. Advert. 2015,32, 587–616. [CrossRef]
70.
Sutterlin, B.; Siegrist, M. Simply adding the word “fruit” makes sugar healthier: The misleading effect of
symbolic information on the perceived healthiness of food. Appetite 2015,95, 252–261. [CrossRef]
71.
Bialkova, S.; Sasse, L.; Fenko, A. The role of nutrition labels and advertising claims in altering consumers’
evaluation and choice. Appetite 2016,96, 38–46. [CrossRef]
72.
Colby, S.E.; Johnson, L.; Scheett, A.; Hoverson, B. Nutrition marketing on food labels. J. Nutr. Educ. Behav.
2010,42, 92–98. [CrossRef]
73.
Taillie, L.S.; Ng, S.W.; Xue, Y.; Busey, E.; Harding, M. No fat, no sugar, no salt no problem? Prevalence
of low-content" nutrient claims and their associations with the nutritional profile of food and beverage
purchases in the United States. J. Acad. Nutr. Diet. 2017,117, 1366–1374. [CrossRef]
74.
Dhar, T.; Baylis, K. Fast-food consumption and the ban on advertising targeting children: The Quebec
experience. J. Mark. Res. 2011,48, 799–813. [CrossRef]
©
2019 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access
article distributed under the terms and conditions of the Creative Commons Attribution
(CC BY) license (http://creativecommons.org/licenses/by/4.0/).
