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The HFSS Beat Goes On: Awareness of marketing for high fat, salt and sugar foods and the association with consumption in the 2017 and 2019 Youth Obesity Policy Surveys.



Awareness of marketing for high, fat, salt and sugar foods and the association with consumption in the 2017 and 2019 Youth Obesity Policy Surveys.
First wave
2016 Childhood
Obesity, A Plan for
Action: Chapter 1
Second wave
2018 -
Soft Drinks Industry
Levy introduced
2018 Childhood
Obesity, A Plan for
Action: Chapter 2
2020 Tackling
obesity: Empowering
adults and children to
live healthier lives
2019 Prevention
Green Paper (including
Childhood Obesity Plan
Chapter 3)
χ ϕ
[1] Base = Those who provided a valid answer to each marketing activity in each YOPS wave; i.e. did not say not sure’ [YOPS 2017] or ‘not sure
if seen in past month’ [YOPS 2019]; [2] Percentages are weighted using cross-sectional weights; * Chi-square test statistically significant at
p<0.05; Further breakdown of % and Chi-square tests reported in Table A3 in appendix.
χ ϕ
χ ϕ
χ ϕ
O Indicates outlier
* Indicates extreme outlier
Δ Mann Whitney test was statistically significant between waves (p<0.05);
Base = Those who provided a valid answer to each activity in each YOPS wave; i.e. did not say ‘not sure’ [YOPS 2017] or ‘not sure if seen in past month
[YOPS 2019]; Breakdown of Mdn, IQR, and Mann Whitney Tests in Appendix Table A3
Estimated awareness of HFSS marketing in the past month
O Indicates outlier
Base = Those who provided a valid answer all marketing activities in each YOPS wave; i.e. did not say ‘not sure’ [YOPS 2017] or ‘not
sure if seen in past month’ [YOPS 2019] to any marketing activity (2017; n=1,1221; 2019: 1,115); To facilitate comparison, scores are
based on only the 10 activities included in both the 2017 and 2019 YOPS (i.e. excluding cinema advertising and internet celebrities).
Estimated awareness of HFSS marketing in the past month
6a: Medium past month awareness
of HFSS marketing (vs. low)
6b: High past month awareness of HFSS
marketing (vs. low)
Notes: All logistic regression models controlled for age, gender, ethnicity, country, IMD and survey wave; Marketing awareness groups based on splitting aggregate marketing awareness
score into unweighted tertiles (low, medium, and high; based on unweighted splits); Consumption of HFSS foods based on median splits of monthly consumption (lower<=median; higher
>median; unweighted); See Appendix A4-A7 for full tables and all technical notes.
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... Participants were also asked at baseline 'Since COVID-19, how often did you usually eat or drink...', and then at 3-months and 6-months follow-up, 'In the past month, how often did you usually eat or drink...' for the same nine food items. The HEBECO study food item questions are based on previous research study survey questions, and derived from Public Health England's sugar reduction programme definitions as policy relevant measures [36][37][38]. ...
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COVID-19 pandemic restrictions impacted dietary habits during the initial months of the pandemic, but long-term effects are unclear. In this longitudinal study, self-selected UK adults (n=1,733) completed three online surveys (May-June, August-September and November-December 2020, with a retrospective pre-pandemic component in the baseline survey), self-reporting sociodemographics, lifestyle and behaviours, including high fat, salt and sugar (HFSS) snacks, HFSS meals and fruit and vegetable (FV) intake. Data were analysed using generalised estimating equations. Monthly HFSS snacks portion intake increased from pre-pandemic levels (48.3) in May-June (57.6, p<0.001), decreased in August-September (43.7, p<0.001), before increasing back to pre-pandemic levels in November-December (49.2, p<0.001). 48.5% self-reported increased (25.9 [95% confidence interval: 24.1, 27.8]) and 47.7% self-reported decreased (24.1 [22.4,26.0]) monthly HFSS snacks portion intakes in November-December compared with pre-pandemic levels. Monthly HFSS meals portion intake decreased from pre-pandemic levels (7.1) in May-June (5.9, p<0.001), being maintained in August-September (5.9, p=0.897), and then increasing again in November-December (6.6, p<0.001), to intakes that remained lower than pre-pandemic levels (p=0.007). 35.2% self-reported increased (4.8 [4.3, 5.3]) and 44.5% self-reported decreased (5.1 [4.6,5.6]) monthly HFSS meals portion intakes in November-December compared with pre-pandemic levels. The proportion meeting FV intake recommendations was stable from pre-pandemic through to August-September (70%), but decreased in November-December 2020 (67%, p=0.034). Increased monthly HFSS snacks intake was associated with female gender, lower quality of life, and - in a time-varying manner - older age and higher HFSS meals intake. Increased monthly HFSS meals intake was associated with female gender, living with adults only and higher HFSS snacks intake. Reduced FV intake was associated with higher body mass index (BMI) and lower physical activity. These results suggest large interindividual variability in dietary change during the first year of the pandemic, with important public health implications in individuals experiencing persistent increases in unhealthy diet choices, associated with BMI, gender, quality of life, living conditions, physical activity and other dietary behaviours. What is currently known from previous studies The introduction of lockdown restrictions impacted on diet behaviours during the initial months of the pandemic. Changes in dietary behaviours have been wide ranging, with individuals making healthy and unhealthy dietary changes in high fat, salt and sugar (HFSS) snacks, HFSS meals and fruit and vegetable (FV) intake. These dietary changes are associated with multiple sociodemographic, lifestyle and behavioural factors. Whether dietary changes persist across longer periods of the pandemic, and which factors are associated with any long-term dietary behaviour change is yet to be identified. What this paper adds Average UK adult intakes of HFSS snacks and meals fluctuated across the pandemic, with the former returning to pre-pandemic levels and the latter remaining below pre-pandemic levels. FV intake was stable until the end of 2020, when the proportion meeting recommended intakes declined. Across the first year of the pandemic, being female and having a lower quality of life were associated with an increase in HFSS snacks intake, whereas the association of age and HFSS meals intake with HFSS snacks intake varied across the pandemic. Living with adults only and having a higher intake of HFSS snacks were associated with an increase in HFSS meals intake. A higher BMI and lower physical activity level were associated with reduced FV intake.
... HFSS foods intake, physical activity and alcohol consumption were assessed at each wave using previously validated measures (see Supplementary Materials). The food item questions are based on previous research study survey questions and derived from Public Health England's sugar reduction programme definitions as measures relevant for informing health policy [33][34][35]. The HFSS food items included HFSS meals (ready meals, fast food and takeaways) and HFSS snacks (sugary or sweetened drinks, sweets or chocolate, cakes and biscuits, desserts and savoury snacks). ...
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COVID-19-related restrictions impacted weight and weight-related factors during the initial months of the pandemic. However, longitudinal analyses are scarce. An online, longitudinal study was conducted among self-selected UK adults (n = 1818), involving three surveys (May–June, August–September, November–December 2020), covering anthropometric, sociodemographic, COVID-19-related and behavioural measures. Data were analysed using generalised estimating equations. Self-reported average weight/body mass index (BMI) significantly increased between the May–June period and the August–September period (74.95 to 75.33 kg/26.22 kg/m2 to 26.36kg/m2, p < 0.001, respectively), and then significantly decreased to November–December (to 75.06 kg/26.27 kg/m2, p < 0.01), comparable to May–June levels (p = 0.274/0.204). However, there was great interindividual variation, 37.0%/26.7% increased (average 3.64 kg (95% confidence interval: 3.32, 3.97)/1.64 kg/m2 (1.49, 1.79)), and 34.5%/26.3% decreased (average 3.59 kg (3.34, 3.85)/1.53 kg/m2 (1.42, 1.63)) weight/BMI between May–June and November–December. Weight/BMI increase was significantly negatively associated with initial BMI, and positively associated with monthly high fat, salt and sugar (HFSS) snacks intake and alcohol consumption, and for BMI only, older age. Associations were time-varying; lower initial BMI, higher HFSS snacks intake and high-risk alcohol consumption were associated with maintaining weight/BMI increases between August–September and November–December. The average weight/BMI of UK adults fluctuated between May–June and November–December 2020. However, the substantial interindividual variation in weight/BMI trajectories indicates long-term health impacts from the pandemic, associated with food and alcohol consumption.
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Objective To characterise the clinical features of patients admitted to hospital with coronavirus disease 2019 (covid-19) in the United Kingdom during the growth phase of the first wave of this outbreak who were enrolled in the International Severe Acute Respiratory and emerging Infections Consortium (ISARIC) World Health Organization (WHO) Clinical Characterisation Protocol UK (CCP-UK) study, and to explore risk factors associated with mortality in hospital. Design Prospective observational cohort study with rapid data gathering and near real time analysis. Setting 208 acute care hospitals in England, Wales, and Scotland between 6 February and 19 April 2020. A case report form developed by ISARIC and WHO was used to collect clinical data. A minimal follow-up time of two weeks (to 3 May 2020) allowed most patients to complete their hospital admission. Participants 20 133 hospital inpatients with covid-19. Main outcome measures Admission to critical care (high dependency unit or intensive care unit) and mortality in hospital. Results The median age of patients admitted to hospital with covid-19, or with a diagnosis of covid-19 made in hospital, was 73 years (interquartile range 58-82, range 0-104). More men were admitted than women (men 60%, n=12 068; women 40%, n=8065). The median duration of symptoms before admission was 4 days (interquartile range 1-8). The commonest comorbidities were chronic cardiac disease (31%, 5469/17 702), uncomplicated diabetes (21%, 3650/17 599), non-asthmatic chronic pulmonary disease (18%, 3128/17 634), and chronic kidney disease (16%, 2830/17 506); 23% (4161/18 525) had no reported major comorbidity. Overall, 41% (8199/20 133) of patients were discharged alive, 26% (5165/20 133) died, and 34% (6769/20 133) continued to receive care at the reporting date. 17% (3001/18 183) required admission to high dependency or intensive care units; of these, 28% (826/3001) were discharged alive, 32% (958/3001) died, and 41% (1217/3001) continued to receive care at the reporting date. Of those receiving mechanical ventilation, 17% (276/1658) were discharged alive, 37% (618/1658) died, and 46% (764/1658) remained in hospital. Increasing age, male sex, and comorbidities including chronic cardiac disease, non-asthmatic chronic pulmonary disease, chronic kidney disease, liver disease and obesity were associated with higher mortality in hospital. Conclusions ISARIC WHO CCP-UK is a large prospective cohort study of patients in hospital with covid-19. The study continues to enrol at the time of this report. In study participants, mortality was high, independent risk factors were increasing age, male sex, and chronic comorbidity, including obesity. This study has shown the importance of pandemic preparedness and the need to maintain readiness to launch research studies in response to outbreaks. Study registration ISRCTN66726260.
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Objectives: To explore awareness of alcohol marketing and ownership of alcohol branded merchandise in adolescents and young adults in the UK, what factors are associated with awareness and ownership, and what association awareness and ownership have with alcohol consumption, higher-risk drinking and susceptibility. Design: Online cross-sectional survey conducted during April–May 2017. Setting: The UK. Participants: Adolescents and young adults aged 11–19 years in the UK (n=3399). Main outcome measures: Alcohol Use Disorders Identification Test–Consumption (AUDIT-C) (0–12) and indication of higher-risk consumption (>5 AUDIT-C) in current drinkers. Susceptibility to drink (yes/no) in never drinkers. Results: Eighty-two per cent of respondents were aware of at least one form of alcohol marketing in the past month and 17% owned branded merchandise. χ2 tests found that awareness of marketing and ownership of branded merchandise varied within drinking variables. For example, higher awareness of alcohol marketing was associated with being a current drinker (χ2=114.04, p<0.001), higher-risk drinking (χ2=85.84, p<0.001), and perceived parental (χ2=63.06, p<0.001) and peer approval of consumption (χ2=73.08, p<0.001). Among current drinkers, multivariate regressions (controlling for demographics and covariates) found that marketing awareness and owning branded merchandise was positively associated with AUDIT-C score and higher-risk consumption. For example, current drinkers reporting medium marketing awareness were twice as likely to be higher-risk drinkers as those reporting low awareness (adjusted OR (AOR)=2.18, 95% CI 1.39 to 3.42, p<0.001). Among never drinkers, respondents who owned branded merchandise were twice as likely to be susceptible to drinking as those who did not (AOR=1.98, 95% CI 1.20 to 3.24, p<0.01). Conclusions: Young people, above and below the legal purchasing age, are aware of a range of alcohol marketing and almost one in five own alcohol branded merchandise. In current drinkers, alcohol marketing awareness was associated with increased consumption and greater likelihood of higher-risk consumption. In never drinkers, ownership of branded merchandise was associated with susceptibility.
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Evidence indicates that screen advertising for unhealthy food results in significant increases in dietary intake among children. This review was undertaken with the main aim of estimating the quantitative effect of screen advertising in experimental and nonexperimental conditions on children's dietary intake. Systematic searches were undertaken of interdisciplinary databases. Studies from 1980 to April 2018, all geography and languages, were included; participants were children and adolescents aged between 2 and 18 years; the intervention was screen advertising; and the outcome was dietary intake. Meta‐analyses were conducted for measured and nonmeasured outcomes. Food advertising was found to increase dietary intake among children (age range 2‐14, mean 8.8 years) in experimental conditions for television (TV) advertising and advergames. Meta‐analysis revealed that children exposed to food advertising on TV (11 studies) and advergames (five studies) respectively consumed an average 60.0 kcal (95% confidence interval [CI], 3.1‐116.9) and 53.2 kcal (95% CI, 31.5‐74.9) more than children exposed to nonfood advertising. There was also an effect by body mass index (BMI). Findings from nonexperimental studies revealed that exposure to TV food advertising was positively associated with and predictive of dietary intake in children. Short‐term exposure to unhealthy food advertising on TV and advergames increases immediate calorie consumption in children.
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Background Policies restricting children’s exposure to unhealthy food marketing have been impeded by the lack of evidence showing a direct link between food advertising exposure and children’s energy intake and body weight. Food advertising exposure increases children’s immediate food consumption, but whether this increased intake is compensated for at later eating occasions is not known; consequently the sustained effect on diets remains unclear. Methods We conducted a within-subject, randomised, crossover, counterbalanced study across four, six-day holiday camps in New South Wales, Australia between April 2016 and January 2017. Children (7–12 years, n = 160) were recruited via local schools, email networks and social media. Two gender- and age-balanced groups were formed for each camp (n = 20), randomised to either a multiple- or single- media condition and exposed to food and non-food advertising in an online game and/or a television cartoon. Children’s food consumption (kilojoules) was measured at a snack immediately after exposure and then at lunch later in the day. Linear mixed models were conducted to examine relationships between food advertising exposure and dietary intake, taking into account gender, age and weight status. ResultsAll children in the multiple-media condition ate more at a snack after exposure to food advertising compared with non-food advertising; this was not compensated for at lunch, leading to additional daily food intake of 194 kJ (95% CI 80–308, p = 0.001, d = 0.2). Exposure to multiple-media food advertising compared with a single-media source increased the effect on snack intake by a difference of 182 kJ (95% CI 46–317, p = 0.009, d = 0.4). Food advertising had an increased effect among children with heavier weight status in both media groups. Conclusion Online (‘advergame’) advertising combined with TV advertising exerted a stronger influence on children’s food consumption than TV advertising alone. The lack of compensation at lunch for children’s increased snack intake after food advertising exposure suggests that unhealthy food advertising exposure contributes to a positive energy-gap, which could cumulatively lead to the development of overweight. Trial registrationAustralian New Zealand Clinical Trials Registry, number ACTRN12617001230347 (Retrospectively registered).
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A systematic review and meta-analysis was performed to investigate the ability of simple measures of childhood obesity such as body mass index (BMI) to predict future obesity in adolescence and adulthood. Large cohort studies, which measured obesity both in childhood and in later adolescence or adulthood, using any recognized measure of obesity were sought. Study quality was assessed. Studies were pooled using diagnostic meta-analysis methods. Fifteen prospective cohort studies were included in the meta-analysis. BMI was the only measure of obesity reported in any study, with 200,777 participants followed up. Obese children and adolescents were around five times more likely to be obese in adulthood than those who were not obese. Around 55% of obese children go on to be obese in adolescence, around 80% of obese adolescents will still be obese in adulthood and around 70% will be obese over age 30. Therefore, action to reduce and prevent obesity in these adolescents is needed. However, 70% of obese adults were not obese in childhood or adolescence, so targeting obesity reduction solely at obese or overweight children needs to be considered carefully as this may not substantially reduce the overall burden of adult obesity.
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Our aim was to determine if levels of television viewing (a proxy measure for habitual commercial exposure) affect children's food preference responses to television food commercials. A total of 281 children aged 6 to 13 years from northwest England viewed toy or food television commercials followed by a cartoon on 2 separate occasions; they then completed 3 food preference measures, a commercial recognition task, and a television viewing questionnaire. After viewing the food commercials, all children selected more branded and nonbranded fat-rich and carbohydrate-rich items from food preference checklists compared with after viewing the toy commercials. The food preferences of children with higher habitual levels of television viewing were more affected by food commercial exposure than those of low television viewers. After viewing food commercials, high television viewing children selected a greater number of branded food items compared with after the toy commercials as well as compared with the low television viewers. Children correctly recognized more food commercials than toy commercials. Exposure to television food commercials enhanced high television viewers' preferences for branded foods and increased reported preferences for all food items (branded and nonbranded) relative to the low television viewers. This is the first study to demonstrate that children with greater previous exposure to commercials (high television viewers) seemed to be more responsive to food promotion messages than children with lower previous advertising exposure.
Background: Several studies have assessed the effects of food and nonalcoholic beverage (hereafter collectively referred to as food) advertising on food consumption, but the results of these studies have been mixed. This lack of clarity may be impeding policy action. Objective: We examined the evidence for a relation between acute exposure to experimental unhealthy food advertising and food consumption. Design: The study was a systematic review and meta-analysis of published studies in which advertising exposure (television or Internet) was experimentally manipulated, and food intake was measured. Five electronic databases were searched for relevant publications (SCOPUS, PsycINFO, MEDLINE, Emerald Insight, and JSTOR). An inverse variance meta-analysis was used whereby the standardized mean difference (SMD) in food intake was calculated between unhealthy food advertising and control conditions. Results: Twenty-two articles were eligible for inclusion. Data were available for 18 articles to be included in the meta-analysis (which provided 20 comparisons). With all available data included, the analysis indicated a small-to-moderate effect size for advertising on food consumption with participants eating more after exposure to food advertising than after control conditions (SMD: 0.37; 95% CI: 0.09; 0.65; I(2) = 98%). Subgroup analyses showed that the experiments with adult participants provided no evidence of an effect of advertising on intake (SMD: 0.00; P = 1.00; 95% CI: -0.08, 0.08; I(2) = 8%), but a significant effect of moderate size was shown for children, whereby food advertising exposure was associated with greater food intake (SMD: 0.56; P = 0.003; 95% CI: 0.18, 0.94; I(2) = 98%). Conclusions: Evidence to date shows that acute exposure to food advertising increases food intake in children but not in adults. These data support public health policy action that seeks to reduce children's exposure to unhealthy food advertising.
The aim of this study was to quantify the nature and extent of use of persuasive marketing techniques in television advertisements (adverts) to promote foods to children. Popular UK commercial television channels broadcasting children's/family viewing were recorded for 2 days (6 am-10 pm) every month in 2008 and recordings were screened for adverts. Eighteen thousand eight hundred and eighty eight adverts were for food and these were coded for peak/non-peak children's viewing time and representation of core (healthy)/non-core (unhealthy)/miscellaneous foods. The analysis assessed use of persuasive appeals, premium offers, promotional characters (brand equity and licensed characters), celebrity endorsers and website promotion in food adverts. Promotional characters, celebrity endorsers and premium offers were used more frequently to promote non-core than core foods, even on dedicated children's channels. Brand equity characters featured on a greater proportion of food adverts than licensed characters. A food brand website was promoted in a third of food adverts (websites are not covered by the statutory regulation on food advertising). This extensive analysis of television adverts demonstrated that the use of persuasive marketing techniques to promote unhealthy foods was extensive in broadcasting popular with children despite regulations. Further studies should incorporate an analysis of the content of websites promoted during food adverts.
The present study examined associations between food marketing exposure and adolescents' food choices and reported consumption of energy-dense and nutrient-poor (EDNP) foods. A cross-sectional survey of 12,188 Australian secondary students aged 12-17 years was conducted, using a web-based self-report questionnaire. Measures included students' level of exposure to commercial television and non-broadcast types of food marketing, whether they had tried a new product or requested a product they had seen advertised, and their reported consumption of fast food, sugary drinks and sweet and salty snacks. Results indicated greater exposure to commercial television, print/transport/school food marketing and digital food marketing were all independently associated with students' food choices. High commercial television viewers (>2h/day) were more likely to report higher consumption of EDNP foods (ORs ranged from 1.31 for fast food to 1.91 for sweet snacks). Some associations between digital food marketing exposure and students' eating behaviors were found; however, print/transport/school food marketing was only related to sweet snack consumption. These study results suggest that cumulative exposure to television food advertising and other food marketing sources are positively linked to adolescents' food choices and eating behaviors. Policy changes to restrict food marketing to young people should include both television and non-broadcast media.
The fraction of cancer attributable to modifiable risk factors in England
  • K F Brown
  • H Rumgay
  • C Dunlop
Brown, K.F., H. Rumgay, C. Dunlop, et al., The fraction of cancer attributable to modifiable risk factors in England, Wales, Scotland, Northern Ireland, and the United Kingdom in 2015. British Journal of Cancer, 2018. 118(8): p. 1130-1141. DOI: 10.1038/s41416-018-0029-6.