Obesity rates among US children aged 2 to 5, 6 to 11, and 12 to 19 years were estimated to be 12.4%, 17.0%, and 17.6%, respectively, in 2003 through 2006.1 US children have poor diets with an excess intake of fat, sugar, sodium, sweetened beverages, and low-nutrient snacks while fruit, vegetable, and micronutrient intake is lower than recommended.2- 4 There has been an upward trend in total energy intake derived from away-from-home, particularly fast food, outlets.5,6 Excess fat and sugar intake and consumption of items such as sugar-sweetened beverages and fast food have been linked with higher energy intake and obesity.7- 10 Obesity increases risk of poorer health11,12 and is shown to track from childhood to adulthood.13
In 2007, children and teens watched, on average, 3 hours 25 minutes and 3 hours 21 minutes, respectively, of television per day14 and television remains the primary advertising medium used to reach children and youths.15 Content analyses that have examined food advertising specifically on children's programming, often with a focus on Saturday morning programming, have found that food products generally dominated television advertising.16- 27 Studies examining broader exposure to food ads based on advertising ratings of television shows viewed by children that include both children's and general audience programming have found food ads to compose less than one-half of ads28- 30 and showed that exposure fell modestly between 1977 and 2004.30 Adolescents were exposed to fewer food advertisements compared with younger children, with fast food instead of cereal as the most prevalent ads.30,31 Whether measured just on child-oriented programming or more broadly to account for children's overall viewing exposure, the vast majority of food ads seen by children were for products high in sugar, fat, or sodium.17,18,32- 34 Further, recent evidence shows that fun and happiness themes were the most common persuasive appeals used, appearing in 47% of food ads overall and 83% of fast food ads targeted to children, and tactics continued to include product-based spokescharacters.18,35 Further, emotional appeals of social enhancement and peer acceptance were found in 34% of food advertisements, in general, and 54% of fast food ads.36
The Institute of Medicine concluded that there is strong evidence for children aged 2 to 11 years that television advertising influences short-term food consumption and moderate evidence that it influences usual dietary intake, but there is insufficient corresponding evidence for teens.15 Exposure to food advertising significantly influences children's food preferences/choices,37- 39 caloric intake,40- 45 and purchase requests among young children.44,46- 48 While television viewing has been significantly associated with adiposity among both children and adolescents,15 limited evidence links advertising exposure to weight outcomes independent of television viewing time. Fast food ad exposure was associated with higher overweight prevalence among children and adolescents but once television viewing time was accounted for the association between advertising exposure and overweight was statistically significant only for adolescents.49
In response to calls by the Institute of Medicine15 and a joint Federal Trade Commission and Department of Health and Human Services workshop,50 in 2006 the Council of Better Business Bureaus launched the Children's Food and Beverage Advertising Initiative (CFBAI) wherein 10 major US food companies pledged to devote at least half of their child-targeted advertising to promote healthier or “better-for-you” products as nutritional choices and/or encourage good nutrition and healthy lifestyles.51 In 2007, the CFBAI included 13 companies51 and by 2009 it comprised 16 companies.52 Currently, 4 companies (Cadbury Plc, Coca-Cola Company, Hershey Company, and Mars Inc) have pledged not to engage in any advertising of food or beverage products on programming primarily directed to children younger than 12 years and the remaining companies have pledged to engage in 100% “better-for-you” advertising.53 Given that each company defined their own better-for-you products and also had different definitions of what constituted children's programming, key questions remain. Has the amount and content of food advertising seen by children changed? Has the landscape of television food advertising viewed by adolescents who are not covered by the self-regulation changed? Are there disparities by race in changes in advertising exposure?
This study used television ratings data to examine changes in the extent and content of food advertising seen by children and adolescents over the 2003 to 2007 period. Changes in food advertising were assessed separately by age groups and race and for specific food categories. Trends were also examined categorized by parent companies that were part of the CFBAI by the end of 2007 to assess the extent of changes following the early implementation stage of the CFBAI and to provide a benchmark against which future change can be assessed as pledges are fully implemented and as more companies pledge to self-regulate.
This study drew on television ratings data licensed from Nielsen Media Research54 for children and adolescents to assess total annual exposure to food advertising for the calendar years 2003, 2005, and 2007. Ratings measure the percentage of households with televisions watching a program or advertisement over a specified interval providing actual advertisement exposure rather than giving all advertisements equal weight based simply on the airing of the commercial. Ratings data were assessed separately for 3 age groups: children aged 2 to 5 and 6 to 11 years and adolescents aged 12 to 17 years. Total annual age-specific targeted rating points from Nielsen Media Research were used to assess exposure to broadcast network, cable network, syndicated, and spot television food advertising. Separate analyses were also undertaken based on race-specific ratings data for white and African American individuals drawn for each age group based on head of household race. Race-specific ratings were available for broadcast network, cable network, and syndicated but not spot television food advertising, and therefore, the analyses by race used the average ratings for spot by age group. This study did not include data for programming aired on Spanish-language television. Based on the television ratings, this study examined changes in children's and adolescents' total exposure to food advertising, not just exposure based on programming targeted at children.
Total annual targeted rating points were aggregated at the brand level and then categorized across food product categories to assess exposure for each category. Nielsen Media Research assigned each product advertisement a product classification code that defined its product category based on that used by the Publisher's Information Bureau.55 In this study, in 2003, 2005, and 2007, respectively, a total of 4436, 4928, and 5392 food brands fell into 182, 188, and 197 product categories. Based on the product classification codes, descriptions, and major group categories, products were classified as cereal, sweets, snacks, beverages, fast food restaurants, full-service restaurants, and other food products (eAppendix).
This study examined trends in exposure to food advertising by age and race and changes in exposure to ads in specific food product categories. The beverage and sweets categories were disaggregated, given that these categories had the greatest reductions in advertising exposure during the sample period. Trends in exposure to ads for fast food restaurants were analyzed at the brand level, given high initial exposure levels and significant increases in exposure over time. Finally, trends in advertising exposure were examined by parent companies.
Table 1 shows that, in 2003, children aged 2 to 5, 6 to 11, and 12 to 17 years saw, on average, 13.3, 13.6, and 13.1 food ads per day, respectively. By 2007, the number of food ads seen daily fell by 13.7% and 3.7% to 11.5 and 13.1 ads per day, respectively, among children aged 2 to 5 and 6 to 11 years. Among adolescents, however, exposure to food advertising increased slightly (+3.7%) to 13.6 ads per day. By race, African American children in all age groups in all 3 years saw more food ads per day compared with white children. The racial gap in exposure grew between 2003 and 2007 because the reductions in the number of food ads seen among the younger children were greater for white children (−16.2% vs −13.0% for 2- to 5-year-olds and −6.8% vs −0.9% for 6- to 11-year-olds). In addition, white compared with African American teens had a substantially smaller increase in exposure (+0.7% vs +5.2%).
By food product categories, across all age groups and by race, exposure to ads for beverages and sweets declined the most while exposure to ads for fast food restaurants and full-service restaurants increased the most. For example, among children aged 2 to 5 years, the overall reductions were largely explained by drops in exposure to beverage (−30.1%) and sweets (−41.0%) ads, followed by reduced exposure to cereal (−23.1%) and snack (−21.9%) ads. Exposure to fast food ads increased at an increasing rate with age between 2003 and 2007 with increases of 4.7%, 12.2%, and 20.4% among children aged 2 to 5, 6 to 11, and 12 to 17 years, respectively. By 2007, fast food ads were the most frequently seen food ads for all 3 age groups: they were seen more frequently by children 2 to 5 years of age (2.4 ads per day) than were cereal ads; 6- to 11-year-olds and 12- to 17-year-olds saw, on average, 3 and 4 fast food ads per day, respectively. Fast food advertising exposure increased substantially more among African American individuals (+6.7%, +16.7%, and +29.9% among those aged 2-5, 6-11, and 12-17 years, respectively).
At a disaggregated level, Table 2 shows changes between 2003 and 2007 in the most advertised beverages. Fruit drinks and regular soft drinks made up the greatest proportion of beverage ad exposure in 2003, across all age groups, and exposure to these ads decreased the most, whereas bottled water and diet soft drink ads, among the least seen beverage ads in 2003, had the greatest increases in ad exposure. Among 2- to 5- and 6- to 11-year-old children, fruit drinks composed a little more than a quarter of all beverage ad exposure in 2003 and fell by 75% and 71.7%, respectively, while exposure to regular soft drink ads fell by 68.2% and 69.2%. Among teens, in 2003 regular soft drink ads were by far the most frequently seen beverage ads; however, by 2007 isotonic ads were most prevalent. Among all ages, the decline in fruit drink ad exposure occurred to a significantly lesser extent on shows watched more heavily by African American children.
The greatest percentage increase in beverage ad exposure was for bottled water. Among 2- to 5-year-olds, exposure increased from its small original base of 0.03 ad per day by 375.5%; thereby, in 2007 bottled water ads were the most often seen beverage ads (0.13 ad per day) among young children. Similarly, ads for bottled water increased substantially (+364%) among 6- to 11-year-olds, making them the second most frequently seen beverage ad type by 2007. Exposure to bottled water ads reached 0.20 ad per day for teens. Exposure to diet soft drink ads also increased among all age groups (by 72.0%, 82.7%, and 106.3% among 2- to 5-, 6- to 11-, and 12- to 17-year-olds, respectively).
Table 3 shows changes in the disaggregated product categories for sweets. Exposure to candy bar and cookie ads fell the most in all age categories, with reductions of more than 60% for 2- to 5- and 6- to 11-year-olds. There was a significant increase, however, in the relative exposure to cookie ads for African American children vs white children. Exposure to candy advertising fell across all age groups (−20.6% among teens to −37.2% among 2- to 5-year-olds) but remained the most seen type of sweets ads.
Table 4 shows that among fast food brands, children of all ages were most frequently exposed to ads for McDonald's in all years. Whereas teens saw significantly more fast food ads overall per day compared with their younger counterparts, children younger than 12 years saw more McDonald's ads, suggesting targeted branding. Among 2- to 5-year-olds, exposure to McDonald's ads fell by 13.6% to about 5 ads every week but exposure among 6- to 11-year-olds increased slightly (+2.9%). Burger King ad exposure was similar across ages at about 0.4 ad per day; exposure fell slightly (−3.8%) among 2- to 5-year-olds but increased among 6- to 11-year-olds (+14.6%) and 12- to 17-year-olds (+2.5%). Exposure to ads for Subway, Taco Bell, and KFC increased among 2- to 5- and 6- to 11-year-olds, but they continued to be dominated by McDonald's and Burger King ads. Interestingly, exposure to Sonic ads more than doubled among all age groups but remained low in absolute numbers. By race, there was an increase in relative exposure to fast food ads seen by African American children and teens compared with their white counterparts for a number of fast food brands.
Table 5 presents changes in exposure to food brand advertising among the 13 companies that were members of the CFBAI in 2007, separating those companies that had implemented their pledges by the end of 2007 vs those whose pledges were not fully implemented until after 2007. Total exposure was lower across all age groups for ads from 5 of the 6 companies whose pledges were implemented by the end of 2007. Among both 2- to 5- and 6- to 11-year-olds, the largest percentage reductions in exposure by company came from the Hershey Company (−78.6% for 2- to 5-year-olds and −74.4% for 6- to 11-year-olds), the Coca Cola Company (−55.6% for 2- to 5-year-olds and −52.4% for 6- to 11-year-olds), and Mars Inc (−50.5% for 2- to 5-year-olds and −38.7% for 6- to 11-year-olds), all of whom were companies that pledged not to engage in child-directed advertising and had implemented pledges by 2007. Among the 7 companies whose pledges were not implemented by 2007, exposure among 2- to 5-year-olds fell for ads from 5 of them; however, among 6- to 11-year-olds, exposure to ads from 5 of the companies was up. While the 12- to 17-year age group was not covered by the pledges, there appeared to be spillover effects, with changes in exposure by parent company mirroring those for the 6- to 11-year-olds, just to a lesser extent.
The 2 most predominant advertisers to children, General Mills Inc and Kellogg's Company, had not fully implemented their pledges by the end of 2007. However, in terms of changes in the number of ads seen, the largest absolute reduction among 2- to 5-year-olds was from ads from General Mills Inc, with reduced exposure of 0.7 ad per day (−29.8%). Exposure to Kellogg's ads fell by 0.16 ad per day (−11.5%) among 2- to 5-year-olds but was up 6.6% among the 6- to 11-year-olds. The largest decrease in ads per day (−0.4 ad per day) among 6- to 11-year-olds came from Kraft Foods Inc. Interestingly, advertising from Cadbury, which pledged not to engage in child-directed advertising effective January 2008, increased substantially (+149% and +211% among 2- to 5- and 6- to 11-year-olds, respectively) between 2003 and 2007, suggesting an advertising blitz prior to implementing their CFBAI pledge.
Trends in exposure to televised food advertising between 2003 and 2007 showed that the number of food ads seen daily fell by 13.7% and 3.7% among children aged 2 to 5 and 6 to 11 years, respectively, but increased by 3.7% among teens. By food product categories, across all age groups, exposure to ads for sweets and beverages declined the most while the greatest increases were in fast food and full-service restaurant ads.
In line with the “better-for-you” pledges that applied to children's programming, overall exposure to sweets ads fell 41%, 29.3%, and 12.1%, respectively, for 2- to 5-, 6- to 11-, and 12- to 17-year-olds, with the largest decreases in exposure to candy bar and cookie ads. There were substantial decreases in both children's and teens' exposure to ads for the most heavily advertised sugar-sweetened beverages (fruit drinks and regular soft drinks), a positive change given links between consumption of sugar-sweetened beverages and increased risks for obesity and poor health outcomes, such as diabetes mellitus.10,56 Additional “better-for-you” changes occurred with substantial increases in exposure to ads for bottled water in all 3 age groups. However, there was a marked increase in diet soft drink advertising, which could still build soft drink brand loyalty.
Exposure to fast food ads increased at an increasing rate with age over the 2003 to 2007 period. By 2007, fast food ads were the most frequently seen food ad category for all 3 age groups. The prevalence of fast food ads, in particular McDonald's ads, among younger audiences suggests the importance of branding.57 Indeed, children have been found to recognize brand logos at very young ages58 and a recent study found that preschoolers exhibited significantly higher preferences for food and beverage items in branded vs plain packaging.59
The increases in exposure to fast food advertising, particularly among teens, suggest that greater scrutiny is needed going forward in this area. Survey data on food consumption patterns and household expenditures show a marked upward trend in total energy intake derived from away-from-home sources, in particular fast food outlets, and adolescents consume the largest proportion of calories away from home at fast food restaurants.5,6,60 Fast food consumption has been associated with higher total energy intake and higher intake of fat, saturated fat, carbohydrates, sugar, and carbonated soft drinks and lower intake of micronutrients and fruit and vegetables.9,61- 67 Further, studies have found significant associations between fast food consumption and increased body mass index,62 increased body weight,63 and a higher probability of being overweight.66
By race, African American children in all age groups in all 3 years saw more food ads per day than their white counterparts. These findings are consistent with previous studies that have reported that African American children and teens watch more hours of television than their white counterparts15 and that more food advertisements appeared on African American vs general audience after-school68 and prime-time69 programming. Of key concern is the finding that the racial gap in exposure grew between 2003 and 2007, given that reductions in the number of food ads seen among children aged 2 to 5 and 6 to 11 years were greater for white children and white teens had a substantially smaller increase in exposure compared with African American teens. By 2007, African American children aged 2 to 5, 6 to 11, and 12 to 17 years saw 1.5, 1.4, and 1.6 times as many foods ads per day, respectively, compared with white children of the same ages. In particular, African American children and teens had more than double the rate of increase in exposure to fast food ads compared with their white counterparts.
The review by parent company showed that among the 13 companies that were members of the CFBAI in 2007, a number of positive changes in advertising occurred. However, several key issues with self-regulation potentially limit the realization of significant improvements in the landscape of food adverting. First, companies create their own definitions of “better-for-you” products without uniform standards. Second, CFBAI companies have their own definitions of what constitutes programming primarily directed at children. Most participants' definitions are based on percentages of child (age 2-11 years) audience composition, ranging from 25% to 50%.51 Trends showing a fall in exposure among 2- to 5-year-olds but a rise in exposure among 6- to 11-year-olds suggest that some companies may be shifting their advertising to programs that fall just under the threshold for their definition of “children’s” programming. Further, if 90% of children watch popular television programs alongside large older populations and therefore only make up 20% of the audience, then self-regulation limited to children's programming defined by audience percentages younger than 12 years will be limited in its effectiveness. From a public health point of view, program definitions need to address the total number of children reached, not just the percentage who watch a given show. The challenge in this area is that there are likely to be legal arguments on the extent to which restrictions on truthful food advertising can be placed on shows where children are not the majority of the audience. One possibility would be to extend the definition of child audience composition to include children up to the age of 17 years. This also relates to our next point about teens.
Third, the self-regulations do not apply to children older than 11 years. Regulation of advertising to younger children has been argued for on the basis that they do not have the cognitive defenses to understand the nature and persuasive intent of advertising.70,71 However, some studies suggest that older children may still lack an understanding of the intentions of the advertising and are not able to cope with these intentions because of deficits in their capacity to process information.72 Teens are an important consumer market, with US adolescents aged 12 to 19 years estimated to have spent $159 billion in 2005.73 Despite improvements in some areas (eg, sweets and sugar-sweetened beverages), there was a substantial increase in teen exposure to fast food advertising.
Finally, membership in the CFBAI is voluntary and in 2009 there were just 16 members, including only 2 fast food companies. In 2007, the 13 members represented 60.8% and 62.0% of food advertising exposure among 2- to 5- and 6- to 11-year-old children. There is clearly room for membership expansion. A starting point would be the 44 companies assessed by the Federal Trade Commission that spent $745 million dollars to promote food and beverages on television in programs where 30% or more of the audience was between the ages of 2 and 17 years.35
Continued monitoring of children's television food ad exposure along with nutritional assessments of advertised products will improve understanding of the extent to which self-regulation can translate into a reduction in the promotion of unhealthy food products. The bar was set so low, with more than 9 of 10 ads seen by children for products high in fat, sugar, or sodium,17,34 that the move to “better-for-you” advertising is likely to be inadequate. Rather, regulatory calls requiring “good-for-you” advertising for healthy products may lead companies to compete to reformulate products and to make the monetary investments and harness the effective persuasion techniques typically used to market unhealthy foods to children.
Correspondence: Lisa M. Powell, PhD, Institute for Health Research and Policy, University of Illinois at Chicago, 1747 W Roosevelt Ave, Room 558 M/C 275, Chicago, IL 60608 (email@example.com).
Accepted for Publication: March 18, 2010.
Published Online: July 5, 2010. doi:10.1001/archpediatrics.2010.139
Author Contributions: The authors had full access to the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Powell, Szczypka, and Chaloupka. Acquisition of data: Powell and Szczypka. Analysis and interpretation of data: Powell, Szczypka, and Chaloupka. Drafting of the manuscript: Powell. Critical revision of the manuscript for important intellectual content: Powell, Szczypka, and Chaloupka. Statistical analysis: Powell and Szczypka. Obtained funding: Chaloupka. Administrative, technical, and material support: Szczypka. Study supervision: Powell.
Financial Disclosure: None reported.
Funding/Support: We gratefully acknowledge research support from the Robert Wood Johnson Foundation through the Bridging the Gap program for the ImpacTeen project.
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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