1
Setting the Stage

What influence has food and beverage marketing had on the dietary patterns and health status of American children and youth? The answer to this question has the potential to shape the health of generations and is the focus of this report. The dramatic rise in the number of U.S. children and adolescents who are obese, have type 2 diabetes,1 have the metabolic syndrome,2 and are at increased risk for developing other chronic diseases in adulthood has been a complex and troubling trend over the past 40 years. There is growing evidence that the early life environment is an important determinant of obesity later in life (Reilly et al., 2005).

The term obesity is used in this report to refer to children and youth who have a body mass index (BMI) equal to or greater than the 95th percentile of the age- and gender-specific BMI charts developed by the Centers for Disease Control and Prevention (CDC) in 2000 (Kuczmarski et al., 2000). In most children, such BMI values are associated with elevated body fat and reflect the presence or risk of related chronic diseases (IOM, 2005). CDC uses the term overweight to refer to children and youth with

1  

Previously known as adult-onset diabetes, in the 1990s, cases of type 2 diabetes in children accounted for 8 to 45 percent of all newly diagnosed childhood cases of diabetes when compared to less than 4 percent before the 1990s (Fagot-Compagna et al., 2000).

2  

The metabolic syndrome is diagnosed when an individual has at least three of five metabolic abnormalities: glucose intolerance, abdominal obesity, elevated triglyceride level, low high-density lipoprotein (HDL) level, and high blood pressure.



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Food Marketing to Children and Youth: Threat or Opportunity? 1 Setting the Stage What influence has food and beverage marketing had on the dietary patterns and health status of American children and youth? The answer to this question has the potential to shape the health of generations and is the focus of this report. The dramatic rise in the number of U.S. children and adolescents who are obese, have type 2 diabetes,1 have the metabolic syndrome,2 and are at increased risk for developing other chronic diseases in adulthood has been a complex and troubling trend over the past 40 years. There is growing evidence that the early life environment is an important determinant of obesity later in life (Reilly et al., 2005). The term obesity is used in this report to refer to children and youth who have a body mass index (BMI) equal to or greater than the 95th percentile of the age- and gender-specific BMI charts developed by the Centers for Disease Control and Prevention (CDC) in 2000 (Kuczmarski et al., 2000). In most children, such BMI values are associated with elevated body fat and reflect the presence or risk of related chronic diseases (IOM, 2005). CDC uses the term overweight to refer to children and youth with 1   Previously known as adult-onset diabetes, in the 1990s, cases of type 2 diabetes in children accounted for 8 to 45 percent of all newly diagnosed childhood cases of diabetes when compared to less than 4 percent before the 1990s (Fagot-Compagna et al., 2000). 2   The metabolic syndrome is diagnosed when an individual has at least three of five metabolic abnormalities: glucose intolerance, abdominal obesity, elevated triglyceride level, low high-density lipoprotein (HDL) level, and high blood pressure.

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Food Marketing to Children and Youth: Threat or Opportunity? the same BMI values. Obese children have a greater chance of becoming obese adults than children of normal weight. Children of obese parents have an even greater likelihood of becoming obese. An obese preschooler with normal weight parents has approximately a 25 percent chance of becoming an obese adult; however, the same child with an obese parent has greater than a 60 percent chance of becoming an obese adult (Whitaker et al., 1997). Moreover, an obese 2- to 5-year-old is more than four times as likely to become an obese adult when compared to a child who is below the 50th percentile of the CDC BMI charts3 (Freedman et al., 2005). Although childhood-onset obesity accounts for only a quarter of adult obesity cases, obesity that is present before a child is 8 years of age, and persists into adulthood, is associated with severe obesity—a BMI greater than 40 kg/m2—in adulthood as compared with a BMI of 35 kg/m2 for adult-onset obesity (Freedman et al., 2001). Between 1990 and 2000, severe obesity, which is associated with more serious health complications, more than doubled, increasing from 0.78 percent to 2.2 percent in U.S. adults (Freedman et al., 2002). Additionally, concerns about childhood-onset obesity are supported by documented associations between childhood obesity and increased cardiovascular disease risk and mortality in adulthood (Li et al., 2004; Srinivasan et al., 2002). The most promising way to prevent future adult obesity is to promote an environment conducive to healthy eating among children and youth (Taylor et al., 2005). Obesity is not the only diet-related problem children and youth face. In addition to the consumption of excess calories and added sugars, the consumption of sodium, saturated fats, and trans fats are well above recommended levels and the consumption of vegetables, fruits, whole grains, and calcium are well below recommended levels. American children and youth are therefore at increased risk for developing conditions such as heart disease, stroke, certain cancers, type 2 diabetes, and osteoporosis later in life. As discussed in Chapter 2, the most current data indicate that the overall nutrient intakes of children and adolescents4 depart substantially from recommended patterns and reflect a pattern that puts young people’s health at risk (Box 1-1). 3   The CDC BMI charts are mathematically smoothed curves of the pooled growth parameters of children and adolescents sampled in cross-sectional national health surveys conducted from 1963 to 1994. The current CDC guidelines for healthy weight in children and youth are in the range of the 5th to the 85th percetiles. 4   See discussion later in this chapter for age categories and related terms used throughout this report.

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Food Marketing to Children and Youth: Threat or Opportunity? BOX 1-1 Trends in U.S. Children’s and Adolescents’ Nutrient Intakes and Eating Patterns, 1970s to 2004 Children and youth are in energy imbalance as reflected by an aggregate calorie intake that has increased significantly for both younger children and adolescents, with modest increases also experienced among older children ages 6–11 years. Calorie intake by infants and toddlers substantially exceeds their estimated requirements. Carbohydrate intake has increased over the past 25 years among children and youth. Infants and toddlers are consuming diets disproportionately high in sweetened foods and beverages and fried potatoes, and disproportionately low in green leafy vegetables. Added sugars consumed by younger children are well above recommended levels, and older children and adolescents are consuming about double the recommended amounts of added sugars in their diets. Sweetened beverage consumption by children and youth has steadily increased over the past 35 years, and now represents a major source of calories and added sugars. Consumption of milk by children and youth, a major source of dietary calcium, has declined over the past 35 years, and most have lower calcium intakes than recommended. Total fat and saturated fats consumed by children and youth remain at levels that exceed dietary recommendations. Mean sodium intake of children and youth has increased over the past 35 years, and the majority of children and adolescents are consuming sodium in greater amounts than recommended levels. Consumption of vegetables, fruits, and whole grains falls short of the daily recommended servings for most children and youth. Snacking by children and youth has increased steadily over the past 25 years. Children and youth consume a large proportion of their total calories from foods and beverages that are of high-calorie and low-nutrient content. Foods consumed outside of the home have steadily increased and now represent about a third of the daily calories consumed by children and youth. Creating an environment in which children and youth can grow up healthy should be a high priority for the nation. Health is more than the absence of physical or mental illness—it also is the extent to which children and youth have the capacity to reach their full potential (NRC and IOM, 2004). Many factors affect children’s and youths’ dietary patterns and

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Food Marketing to Children and Youth: Threat or Opportunity? overall health. The Institute of Medicine’s (IOM’s) recent report, Preventing Childhood Obesity: Health in the Balance (IOM, 2005), recognizes that children, youth, and their parents are immersed in a modern milieu where the physical, social, commercial, and media environments have all undergone significant transformations over the past several decades. These broader environments now contribute to the rising prevalence of obesity in children and youth, thereby impacting their diets and health through a chain of events that can have profound effects extending far into adulthood (IOM, 2005; NRC and IOM, 2004). On the other hand, there exists unrealized potential to shift the broader environmental signals to encourage healthy lifestyles in which eating habits and physical activity behaviors promote healthy energy balance and nutritional status, and therefore work to prevent obesity and related chronic diseases (IOM, 2005; Peters et al., 2002). Like adults, children and adolescents acquire new information and knowledge through both explicit and implicit learning—that is, through the processes of dedicated, didactic, and educational experiences, as well as through passive, automatic, and unconscious acquisition of abstract knowledge that remains robust over time (Cleeremans et al., 1998). In addition, they acquire information through the socialization process that helps them to develop their roles and behaviors as consumers and as members of society. The family is the first socializing agent because parents and older siblings act as sources of information and provide social support and pressure that affect children’s behaviors (Moore et al., 2002). There are also diverse social and cultural norms and values that influence eating and physical activity. Whether influenced by their parents and siblings, or by other signals in their environments, children buy food and other goods and influence the purchasing decisions of their parents and caregivers (McNeal, 1999). Children acquire consumer socialization skills early in life, developing consumption motives and values as they are exposed to commercial activities. They develop knowledge about advertising, products, brands, pricing and shopping, and they adopt purchase requests and negotiation strategies that may be the result of marketing activities (John, 1999). Children must have certain basic information-processing skills to fully understand advertising messages (Gunter et al., 2005; Kunkel, 2001). They must be able to discriminate, at a perceptual level, commercial from noncommercial content, and they must be able to attribute persuasive intent to advertising and to adjust their interpretation of commercial messages based on that knowledge. Each of these capabilities develops over time, largely as a function of cognitive growth and development rather than the accumulation of any particular amount of experience with media content (John, 1999; Young, 1990), including the acquisition of media literacy skills. Although cognitive

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Food Marketing to Children and Youth: Threat or Opportunity? defenses are critical, actual activation of these defenses must be assessed, as children as old as 11 years of age may not activate their defenses unless explicitly cued (Brucks et al., 1988; Moore and Lutz, 2000). FOOD AND BEVERAGE MARKETING TO CHILDREN AND YOUTH Choices are influenced by the way options are presented to individuals. Food and beverages are now marketed to children, youth, and their families in ways that are dramatically different from 40 years ago, and this marketing today strongly influences their preferences and choices. Advertising does not exist or operate in isolation from other aspects of marketing activities. In most advertising, the commercial is an element of a larger marketing design that includes competition for securing market share of branded products, attention to retailers, point-of-purchase displays, attractive packaging, strategic placement of items on store shelves, and the use of coupons, premiums, and price incentives to promote consumer purchases (Schudson, 1986). Children and youth are subsequently exposed to influences from an array of marketing venues and vehicles including school-based marketing, promotions, television and movie product placement, and marketing through the Internet, digital television, and mobile phones. Moreover, integrated marketing communications have begun to permeate the lives of children and youth. They are now being exposed to a changing landscape of media and promotional activities (Moore, 2005). It is not simply a proliferation of existing media, but the advent of newer media that are interactive and that blend entertainment with advertising and other forms of promotion. Thus, children and youth are now exposed to media and marketing influences to a much greater extent, and through many more diverse and integrated venues embedded in their daily lives, when compared to previous generations. With new outlets, attractions, and tools, children and youth collectively represent a powerful demographic segment. They are a primary market, spending discretionary income on a variety of products that they acquire by spending their own money; an influence market, determining a large proportion of what is spent by parents and households; and a future market, representing tomorrow’s adult customers for branded products and services (McNeal, 1999; MPA, 2004). Children and youth collectively spend more than $200 billion annually (MPA, 2004; Teenage Research Unlimited, 2004), and also determine a large proportion of what is spent by parents and households (Chapter 4). Parents and their children report that young people have the largest purchase influence on food when compared to other nonfood spending categories such as music, electronics, and home decor. Of the various spend-

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Food Marketing to Children and Youth: Threat or Opportunity? ing categories, one-third of children’s direct purchases are for sweets, snacks, and beverages, followed by toys and apparel (Schor, 2004). Of the top 10 items that children ages 8–12 years report they can select without parental permission, the leading four are food or beverage categories: candy or snacks, soft drinks, fast food from quick serve restaurants, and breakfast cereals (Chaplin, 1999). Similarly, food or beverages—particularly candy, sweetened soft drinks, and salty snacks—represent the top items that teens ages 13–17 years buy with their own money (MPA, 2004; Chapter 4). Approximately half of all commercials during children’s television programming consists of branded foods and beverages that are disproportionately high in salt and calories (e.g., high fat, high sugar), and low in essential nutrients (IOM, 2005)—primarily sweetened cereals, candies and snacks, carbonated soft drinks and sweetened beverages, and fast food (Gamble and Cotugna, 1999). Additionally, companies use advertising and other marketing techniques that associate these specific foods with fun and pleasurable experiences (Hawkes, 2002; Schlosser, 2001). When high-calorie and low-nutrient foods and beverages are marketed to infants, toddlers, and young children who have an innate biological preference for high-calorie foods that are sweet and salty (Benton, 2004; Mennella and Beauchamp, 1998), or when these types of products are marketed to parents, schools, or child-care settings and made easily available and accessible in their environments, there is a much greater opportunity and likelihood that children will develop sustained preferences for these products. Indeed, young children typically reject new foods and may need to be introduced to a new food as many as 5 to 10 times before they will accept it (Birch, 1999). Children’s preferences for foods that lack sweet and salty tastes are learned and require repeated positive experiences, especially to accept fruits, vegetables, and other nutrient-rich foods later in life (Birch 1999; Skinner et al., 2002; Chapter 3). When accompanied by physical inactivity, preferences for and consumption of high-calorie foods and beverages over time set in motion the circumstances that contribute to weight gain and obesity, especially for children and youth who are genetically predisposed to gaining weight in an obesogenic environment (IOM, 2005). Moreover, the contemporary media landscape offers many more options to market messages about foods and beverages to children and youth than just a decade ago, encompassing broadcast, satellite, and cable television; the video cassette recorder and digital video disk (DVD) recorder; portable audio media (e.g., radio, tapes, CDs, DVDs, MP3 players); print media (e.g., magazines, newspapers, books); computers and the online activities they provide with Internet access (e.g., e-mail, instant messaging, advergaming); and cell phones that can connect to the Internet and provide

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Food Marketing to Children and Youth: Threat or Opportunity? text messaging and digital screens (Roberts et al., 2005; Chapter 4). The entertainment industry focuses more time and resources than ever before on trying to understand the desires of children and youth (Schor, 2004), and there are cable television networks exclusively devoted to reaching young audiences (Nickelodeon, 2005). STUDY BACKGROUND AND RATIONALE In FY 2004, Congress directed the CDC to support a comprehensive, evidence-based review of the effects of food marketing on children’s and youths’ diet and health. With this congressional directive, the CDC turned to the IOM in July 2004 to assess the effects of food marketing on children’s and youths’ diet and health. It had been nearly 25 years since a similar review of the available evidence was undertaken in the United States for this topic (Elliott et al., 1981). Several notable changes and innovations have occurred with food and beverage marketing and the media environments that directly affect the lives of U.S. children and youth during this time frame. Committee Charge and Approach The IOM appointed a 16-member committee on Food Marketing and the Diets of Children and Youth in the fall of 2004 to undertake a comprehensive evidence-based review of the influence of food and beverage marketing on the diets and health of children and youth in the United States, including the characteristics of effective marketing of foods and beverages to promote healthful choices. The committee members have expertise in the areas of child and adolescent development, child and adolescent nutrition, psychology, behavioral economics, advertising, consumer marketing and behavior, media, social marketing, program evaluation, education, public health, public policy, industry (e.g., food, beverage, children’s entertainment), statistics, constitutional law, and business ethics (Appendix I). The committee was charged with the following six tasks: Assess what is known about the scope, amount, venues, and types of food and beverage product marketing (including market segmentation strategies) to children and youth; Conduct a comprehensive review of the available evidence about the extent to which this marketing affects their diets, including their nutrient intake and health; Synthesize lessons learned from relevant research and experience from other marketing-oriented health promotion efforts (e.g., youth to-

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Food Marketing to Children and Youth: Threat or Opportunity? bacco prevention, underage drinking prevention, obesity prevention, and the promotion of physical activity) that can contribute to the development of marketing strategies to promote healthful food choices among children and youth; Identify gaps in the knowledge base related to the impact of marketing on the diets and health of children and youth; Review the issues and strategic options for public policy and private stakeholders to promote public and commercial marketing strategies that foster healthful food and beverage choices by children and youth; and Prepare a consensus report that describes the state of food and beverage marketing to infants, toddlers, children, and adolescents; offers a coherent understanding about the impact of this exposure on their diets and health; and if feasible, provides benchmarks to evaluate progress toward healthful food and beverage promotion to young consumers. The committee acknowledges that a variety of interacting factors affect the health and weight of children and youth, including societal norms, culture, socioeconomic factors, race/ethnicity, education, and physical activity (Ebbeling et al., 2002; Goran et al., 1999; IOM, 2005; Kumanyika et al., 2001, 2002; NRC and IOM, 2004, Swinburn and Egger, 2002). Although important, these are not the subject of this report, which specifically examines the role of food and beverage marketing in the diets and diet-related health of children and youth. An important starting point for the committee was the set of recommendations regarding the marketing of foods and beverages to children and youth presented in the IOM report, Preventing Childhood Obesity: Health in the Balance (2005). This report concluded that concentrated efforts are urgently needed among various sectors and stakeholder groups to change social norms about childhood obesity and to create supportive environments and consistent messages that promote healthy lifestyles—including healthful eating habits and regular physical activity (IOM, 2005). The report recommended in particular that industry develop and strictly adhere to marketing and advertising guidelines that minimize the risk of obesity in children and youth (IOM, 2005). The work of the current committee was informed by a variety of sources. Four formal meetings were held during the study. The committee conducted a systematic literature review of evidence that addresses the linkages from food and beverage marketing to young people’s diets and diet-related health (Appendixes C, E, and F; Chapters 4 and 5). It also commissioned three papers: a synthesis of the literature on marketing to children over the past three decades; insights into future marketing tech-

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Food Marketing to Children and Youth: Threat or Opportunity? niques; and insights about the effectiveness of social marketing campaigns and its application to this issue. One committee meeting included a public workshop held in January 2005. The workshop, Marketing Strategies that Foster Healthy Food and Beverage Choices in Children and Youth, had two goals: to identify effective processes, actions, and campaigns for promoting healthful food and beverage choices and behaviors in children and youth, and to provide a public forum for interested individuals and groups to share their perspectives to the committee. Ten invited speakers presented their views on the food, beverage, and quick serve restaurant5 industries; youth-focused media and marketing approaches; and research. The public forum included 16 presenters who represented nonprofit organizations, trade organizations, professional associations, and interested individuals (Appendix H). FOCUS AND CONCEPTS Target Population The focus of the committee’s study was on children and youth from birth to 18 years of age. The committee recognized that among researchers, policy makers, and marketers, different age groups and terms are used to define this diverse population. In general, the committee used the terms “children,” “youth,” “young people,” “teenagers,” and “adolescents.” When greater precision was needed, the following age categories and terms were used throughout the report: infants and toddlers (children under 2 years of age), younger children (ages 2–5 years), older children (ages 6–11 years), and teens (ages 12–18 years). In selected sections of the report, particularly those drawing from the marketing literature, “tween” is used to describe young people ages 9–13 years. Marketing The focus of the committee’s inquiry was on the marketing of foods and beverages to children and youth. As discussed in greater depth in Chapter 4, marketing is a process by which a variety of strategies are used to stimulate consumer demand, promote frequency of purchases, build brand awareness and brand loyalty, and encourage potential or existing customers to try new foods and beverages. Marketing is defined as an 5   Quick serve restaurants are commonly known as “fast food restaurants” and represent a category of restaurants that supply food quickly after ordering with minimal service.

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Food Marketing to Children and Youth: Threat or Opportunity? “organizational function and a set of processes for creating, communicating, and delivering value to customers and for managing customer relationships in ways that benefit an organization and its stakeholders” (AMA, 2005). Marketing involves conducting research, defining the target market, analyzing the competition, and implementing the basic processes that constitute the marketing mix or drivers of business (McCarthy, 1975). The key components are the following: Product (i.e., features, quality, quantity, packaging) Place (i.e., location, outlets, distribution points used to reach the target market) Price (i.e., strategy, determinants, levels) Promotion (i.e., advertising, sales promotion, public relations, trade promotion) Advertising is a form of paid nonpersonal public presentation and the promotion of ideas, goods, or services by a sponsor (Kotler and Armstrong, 2004). It is a specific type of marketing that brings a product to the attention of consumers and may be delivered through a variety of media channels such as television, radio, print, billboards, personal contact, and the Internet (Boone and Kurtz, 1998). Advertising is the most visible form of marketing that contributes to the success of other strategies by (1) providing the conditions for developing a company’s brand image by building brand awareness and brand loyalty among potential consumers, and (2) creating perceived value by persuading consumers that they are getting more than the product itself (e.g., a meal, food, or beverage product). Ecological Perspective Consistent with the committee’s charge, the primary focus of this report is the evaluation of the available evidence for assessing the nature of the relationship between marketing and the diets and health of children and youth. The committee used a simplified ecological perspective to conceptualize the relationship of food marketing to other important influences on the diets and related health outcomes of children and youth (Figure 1-1; see also Chapter 3). This perspective places food and beverage marketing influences within a context that recognizes the multiple interactions among factors that also affect children’s and adolescents’ food preferences and choices, eating behaviors, total calorie intake, diet quality, and health outcomes. The use of an ecological perspective requires an understanding of processes and intertwining interactions among individuals, communities, and their social, economic, cultural, and physical environments over time (IOM, 2001). This approach considers the relative strengths of the multiple

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Food Marketing to Children and Youth: Threat or Opportunity? FIGURE 1-1 Influences on the diets and related health outcomes of children and youth.

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Food Marketing to Children and Youth: Threat or Opportunity? factors influencing diet, including the role of marketing in overall diet quality and quantity of foods consumed. The committee’s perspective views children, adolescents, and their families as functioning within broader social, economic, and political systems—including the food and agricultural system and the marketplace where products and services are exchanged. These systems also influence behaviors and may facilitate or impede availability and access to nutritious foods and beverages and to the resources necessary to maintain good health. Included among the systemic forces are the four components of the marketing mix—product, place, price, and promotion (discussed in more detail in Chapter 4); culture and values that influence societal norms and behaviors (Chapter 3); economic factors that influence food and beverage choices and consumption patterns including family income, food security status, and affordability (Chapter 3); and a broad range of policies that affect food and beverage availability, access, affordability, preferences, choices, and purchases (Chapters 4 and 6). These systematic factors interact with each other and with individual and developmental factors, family and home, school and peers, and neighborhood and community to influence children’s and youths’ diet and physical activity patterns (Chapter 3). Genetic and biological factors also influence these patterns and moderate the ways in which these patterns affect health outcomes for a given individual (Chapter 3). An important note is that this committee recognizes the fundamental nature of the interaction between diet and physical activity for children and youth to achieve energy balance at a healthy weight; however, an examination of marketing related to promoting physical activity and reducing sedentary behaviors was beyond the study charge. A review of this issue may be found in the IOM report, Preventing Childhood Obesity: Health in the Balance. RELATED BACKGROUND AND PERSPECTIVES Advertising and marketing play a central role in shaping the profile and vitality of the U.S. economy and culture (Klein and Donaton, 1999). Market forces create, modify, and respond to consumer demand; they influence the choices and preferences of individuals and populations, as well as the attitudes, opinions, and behaviors of consumers, industries, and governments. The pace at which change occurs is influenced by cultural and social norms and values that support or reject new private-sector offerings and innovations. Industry develops new products, ideas, and services in response to changing consumer demand and market forces (Kotler and Armstrong, 2004), and it also creates consumer demand for products, including foods and beverages consumed by individuals and populations over the long term

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Food Marketing to Children and Youth: Threat or Opportunity? (Hawkes, 2002). For this reason the issues often emphasized by industry—sales trends, marketing opportunities, product appeal, advertising exposure, brand awareness, brand recognition, brand loyalty, brand equity, and expanding market share for specific product categories and product brands (Barbour, 2003; Moore et al., 2002; Roberts, 2004)—can also be important issues for healthier and more active lifestyles, including the promotion of healthful foods and beverages, more nutritious diets, more vigorous activity patterns, and healthier weights. Although food manufacturers and producers have not historically or predominantly viewed their roles and responsibilities in terms of changing consumers’ preferences toward healthier choices, the recent trend toward heavier children and youth—and the broader increased prevalence of obesity-related chronic disease among adults—places a compelling priority on industry’s work with other groups and sectors to play a central role in achieving this goal (IOM, 2005). This is a complex challenge in a marketplace driven by profit margins and market shares. There are encouraging examples of food and beverage companies that are making changes to their product portfolios. However, shifting the proportion of companies’ overall product portfolios from high-calorie and low-nutrient options to more healthful foods and beverages will require substantial change and evaluation of these efforts to understand if they can retain market share for their products (Chapters 4 and 6). Also complex is the potential use of policy levers to guide marketing practices when it comes to children and youth. Our legal traditions balance the protection of the right to advertise and promote products and ideas through various communication channels with the duty to protect the welfare of children and youth. For example, with increasing understanding of the lifelong and life-threatening consequences of tobacco use, restrictions have been imposed on tobacco advertising and promotion directed to youth. Yet tobacco companies have continued to use an extensive array of marketing communication practices that reach youth. In this case, the compelling state interest in promoting public health by protecting children has generally prevailed over protecting the right to advertise as a form of free speech. The Federal Trade Commission Case and Beyond With respect to foods and beverages, Congress has been reluctant to impose mandatory constraints on advertising to children. The illustrative case is a Federal Trade Commission (FTC) exploration through a rulemaking process more than 25 years ago on restricting or banning advertising to young children (Beales, 2004; Elliott et al., 1981; Ratner et al., 1978). In the late 1970s, consumer groups and members of a concerned American public engaged Congress, industry representatives, and other stake-

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Food Marketing to Children and Youth: Threat or Opportunity? holders in a multiyear FTC deliberation to consider the possible need for government intervention to regulate advertising because of the perceived adverse effects of television advertising directed to young children. At that time, strong scientific evidence connected the consumption of sugar to the development of dental caries, which became a public health concern. The argument favoring regulation focused on the increased number of sweetened food and beverage advertisements that were reaching children through television (the primary media channel at that time), combined with the social concern that young children were unable to discern the difference between television advertisements and educational programming (Beales, 2004; Ratner et al., 1978). The FTC proposed a rulemaking process in 1978—known as “Kidvid”—that would either restrict or ban advertising to young children as a protective measure, and FTC staff sought public comment on the issues, including three proposed alternative actions (Ratner et al., 1978). During this process, the FTC provisionally concluded, based upon its review of scientific evidence, that television advertising directed at young children was unfair and deceptive (Elliott et al., 1981). Congress subsequently objected to intrusions on private-sector advertising and pressured the FTC to withdraw its proposed rule and to conclude that evidence of adverse effects of advertising on children was inconclusive (Elliott et al., 1981). Acknowledging that there was some cause for concern, the FTC stated that it would be difficult to develop a workable rule that would alleviate harm without also infringing on First Amendment rights. Congress barred any rule based on unfairness, and the FTC terminated the rulemaking process in 1981 (Beales, 2004; Elliott et al., 1981). In the agency’s final report to Congress (Elliott et al., 1981), the FTC concluded that young children lack the capacity to distinguish between persuading and informing. The American Psychological Association Task Force on Advertising and Children reiterated the same conclusion in a report nearly a quarter of a century later (Kunkel et al., 2004). Although some have called for extension of the FTC conclusions on television advertising to vulnerabilities from other sources of marketing to children, the influence of other forms of consumer promotion and marketing strategies to children has not been systematically studied, in part because of the newness of the techniques and also because of the lack of peer-reviewed evidence and difficulties in accessing propriety data. Common issues raised include not only concern with the content and integrated nature (i.e., multiple channels and venues) of advertising and other forms of marketing to children and adolescents, but also the types and overall quality of foods and beverages that are advertised and marketed to young consumers and their parents. Branding, for example, has become a routine part of children’s lives. Some believe that parental abil-

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Food Marketing to Children and Youth: Threat or Opportunity? ity to guide their children’s consumption of food and beverages has been compromised by an environment that exposes children to an array of advertising and marketing messages for junk food6 (CSPI, 2003; IACFO, 2003; Schor, 2004). Market research shows that children as young as 2 years have beliefs about specific brands that are promoted by television advertising and parental usage (Hite and Hite, 1995). Young children ages 3 to 6 years recognize brand logos for all types of products, and this recognition increases with television viewing, age, and the use of visual cues in advertising (Fischer et al., 1991; Henke, 1995; Macklin, 1994; Chapter 5). Brand choices are intergenerationally influenced (Moore et al., 2002). Thus, it has been asserted that commercialism and consumerism pervade the daily life of young children to an extent that is far greater than that experienced by previous generations. Children’s consumer desires are now considered natural even though children and youth in previous generations and in different cultures vary widely in how much they care about consumer trends and engage in consumer activities (Schor, 2004). Since the FTC case was initiated in the 1970s, a lively debate has persisted about the nature and extent of the influence of marketing on children’s food and beverage choices, eating behaviors, and diet-related health conditions. This debate has intensified recently in the face of growing concern over childhood obesity, and reflects diverse values and strongly discordant viewpoints. It has been difficult to reconcile among these distinct viewpoints, partly because of the paucity of robust evidence on causal relationships among advertising, other forms of promotion, and consumption patterns. Some view marketing as a form of information that contributes to consumer choice in the marketplace. For adults the differentiation of brands creates choices that provide the opportunity for individuals to make decisions based on their own needs, preferences, desires, and lifestyles. To the extent that children are to be educated and socialized into the autonomous practices of adults, certain groups believe that they must learn to make such decisions for themselves. Proponents of an unrestricted advertising perspective, such as the Alliance for American Advertising, created by the food and beverage, advertising, and media industries (ANA, 2005; Office of the Clerk and U.S. House of Representatives, 2004), have asserted that the First Amendment protects their rights to advertise to children (ANA, 2005; Egerstrom, 2005; Ellison, 2005). 6   There is no widely accepted definition for junk food although it is often used by popular culture to describe high-calorie (e.g., high fat, high sugar), and low-nutrient foods and beverages. In this report, fast food is defined as any food designed for ready availability, use, or consumption and sold at eating establishments for quick availability or takeout.

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Food Marketing to Children and Youth: Threat or Opportunity? Others are concerned about the ways marketing might undermine parental authority and social morality, and the promotion of less healthful lifestyles (Bjurstrom, 1994; Haefner, 1991; Schor, 2004). Contemporary thinking about the long-term socialization effects of media suggests that children’s unintended exposure to advertisements intended for other target audiences (e.g., older teens and adults) may influence their expectations, values, and world views (Haefner, 1991). Prompted by concerns about the possible adverse health impact of food and beverage marketing to children and youth, a variety of states, localities, and school districts have taken steps to restrict marketing and distribution of certain foods and beverages in schools, and various advocacy groups and legislative bodies have turned stronger attention to the issues in the United States (Chapter 6). International Perspectives The rising concern about obesity in children and youth has prompted some groups to call for collective international action among many stakeholder groups and changing behaviors across multiple sectors. The World Health Organization’s Global Strategy on Diet, Physical Activity and Health was endorsed by the 57th World Health Assembly in 2004 (WHO, 2004). The Global Strategy provides member states with a range of policy options to address less healthful dietary practices and physical inactivity, including provisions for marketing, advertising, sponsorship, and promotion to support international public health goals. These provisions recommended that “food and beverage advertisements should not exploit children’s inexperience or credulity,” should discourage messages that promote less healthful dietary practices, and should encourage positive healthful messages (WHO, 2004). The European Heart Network, concerned about the 20 percent of school-aged European children who are either obese or at risk for obesity, documented marketing trends for children in 20 European countries. The Network is developing an action plan to address childhood obesity throughout the region of the European Union. The plan includes protection of children from less healthful food marketing as one of many interventions to address childhood obesity (Matthews et al., 2005). Several strong government and professional positions have been taken on the issue of advertising and marketing to children. Bans on television advertising were adopted in the Canadian province of Quebec in 1980, Sweden in 1991, and Norway in 1992. The prevailing principle in these countries is that children should have the right to grow up in a commercial-free environment, especially younger children who are trusting and do not understand the difference between information and the persuasive intent of

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Food Marketing to Children and Youth: Threat or Opportunity? advertisements or commercials (Bjurstrom, 1994; Government of Quebec, 2005; Haefner, 1991; Jarlbro, 2001; Norwegian Ministry of Children and Family Affairs, 2005; The Consumer Ombudsman, 1999; Chapter 6). However, comprehensive evaluations of the effects of the television advertising bans are currently not available to assess their impact (Chapter 6). The Australian obesity prevention action plan supports stricter national regulations on food advertising directed at children, and is considering a ban during children’s television viewing time (NSW Centre for Public Health Nutrition, 2005). The British Medical Association recommended a ban on advertising of less healthful foods, including certain sponsorship programs targeted at school children, and a ban on less healthful foods and beverages purchased from school vending machines (British Medical Association and Board of Science, 2005). REVIEW OF THE EVIDENCE The committee drew from several sources of evidence that were directly relevant to the committee’s charge—What is the effect of food and beverage marketing on the diets and health of children and youth? In order to be comprehensive, the committee reviewed a broad range of material drawn from both academic, peer-reviewed literature and industry and marketing sources. In addition, the committee commissioned papers examining past, present, and future food and beverage marketing trends affecting children and youth and describing effective elements of social marketing campaigns. The committee also reviewed presentations and comments provided during the January 2005 public workshop, as well as documents received and placed in the National Academies’ public access file. Particular attention was given to the process of gathering and considering the relevant scientific, peer-reviewed literature. Prior to this IOM study, the most recent systematic review of such literature was the report of Hastings et al. (2003). That review, sponsored by the Food Standards Agency in the United Kingdom, found that food advertising to children affected their preferences, purchase behaviors, and consumption, not just for different brands but also for different food categories. The committee’s search for relevant literature included an online bibliographic search of several databases, outreach to experts in relevant fields, examination of published literature reviews, and acquisition of references cited in articles found to be relevant (Appendix C). From this search, the committee selected 123 empirical studies that were subjected to a systematic evidence review using a committee-established protocol. Each study was coded on several dimensions, including the relationship of marketing to diet, cause and effect variables, methods of research, and the compara-

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Food Marketing to Children and Youth: Threat or Opportunity? tive quality of the evidence. Both the process and the results are described in detail in Chapter 5 and Appendix F. In order to fully understand the status and influences of food and beverage marketing in U.S. children and youth, the committee also drew on publicly available industry and commercial marketing research. This material was acquired through marketing, advertising, or industry trade journals; food and beverage companies’ annual reports; foundation and nonprofit organization reports and briefs; government, company, and trade organization materials; popular magazines and books relevant to advertising and marketing; news releases; government, company, and trade organization websites; and selected marketing research briefs, executive summaries, or full reports that were requested by and provided to the committee. Much of this material focused on specific brands and products in target markets, including brand or product awareness, product purchases, brand loyalty, perceived differentiation from competitors, marketing costs, and scalability. A discussion of this material is presented in Chapter 4. The committee faced several notable challenges to acquiring and using this commercial marketing research. Businesses are increasingly using integrated marketing strategies to ensure that young consumers are exposed to messages that will stimulate demand, build brand loyalty, and encourage potential or existing customers to purchase new products. A variety of measured media channels (e.g., television, radio, magazines, Internet) and unmeasured media channels (e.g., product placement, video games, advergames, in-store promotions, special events) and other venues (e.g., schools) are used to deliver promotional messages to young consumers. Many of these strategies are new, and are not well researched or evaluated. Additionally, a large proportion of this research is conducted for paying clients and is therefore considered to be proprietary information that is not publicly accessible or is available only for purchase at considerable cost to the committee and with prohibitive constraints on public availability of the data. Another challenge faced by the committee was understanding and reconciling the differences in the evidence derived from the various sources of information presented in Chapters 4 and 5. For instance, in general, the industry and marketing information presented in Chapter 4 is of short-term duration, the analyses tend to be descriptive, and they only rarely use multivariate statistical designs. The peer-reviewed literature reviewed in Chapter 5, on the other hand, uses distinct research methodologies to answer different research questions than those questions explored by marketing research firms. The committee considered both of these sources in developing its findings and recommendations.

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Food Marketing to Children and Youth: Threat or Opportunity? GUIDE TO THE REPORT This report describes the committee’s findings and conclusions, identifies promising strategies, and offers recommendations for public and private stakeholders to foster healthful food and beverage choices in children and youth. Chapter 2 provides a summary of the health, diet, and eating patterns of children and youth. Chapter 3 reviews the factors shaping the food and beverage consumption of children and youth, including age-related developmental factors involved in consumer socialization—the process by which children acquire skills, knowledge, and attitudes relevant to functioning as consumers in the marketplace. Chapter 4 describes the status and trends of food and beverage marketing to children and youth and draws from a range of evidentiary sources. Chapter 5 systematically considers the evidence from peer-reviewed literature on the influence of food and beverage marketing on the diets and diet-related health of children and youth. Chapter 6 considers relevant public policy issues. Chapter 7 summarizes the committee’s findings, conclusions, recommendations, and priorities for moving forward. For reference throughout the report, a list of acronyms and a glossary of terms are provided in Appendixes A and B. REFERENCES AMA (American Marketing Association). 2005. Marketing Definitions. [Online]. Available: http://www.marketingpower.com/content4620.php [accessed August 4, 2005]. ANA (Association of National Advertisers). 2005. ANA Compendium of Legislative, Regulatory, and Legal Issues 2004. New York: Association of National Advertisers, Inc. Barbour J. 2003. The U.S. Market for Kids’ Food and Beverages—5th Edition. [Online]. Available: http://www.marketresearch.com/product/display.asp?productid=849192&SID=46320173-327969985-290367212/ [accessed August 4, 2005]. Beales JH. 2004. Advertising to Kids and the FTC: A Regulatory Retrospective that Advises the Present. [Online]. Available: http://www.ftc.gov/speeches/beales/040802adstokids.pdf [accessed October 3, 2005]. Benton D. 2004. Role of parents in the determination of the food preferences of children and the development of obesity. Int J Obes Relat Metab Disord 28(7):858–869. Birch LL. 1999. Development of food preferences. Annu Rev Nutr 19:41–62. Bjurstrom E. 1994. Children and Television Advertising. Report No. 1994/95:8. Stockholm, Sweden: Swedish Consumer Agency. Boone LE, Kurtz DL. 1998. Contemporary Marketing Wired. 9th ed. Orlando, FL: Harcourt Brace College Publishers. British Medical Association and Board of Science. 2005. Preventing Childhood Obesity. London, UK: British Medical Association. Brucks M, Armstrong GM, Goldberg ME. 1988. Children’s use of cognitive defenses against television advertising: A cognitive response approach. J Consum Res 14:471–482. Chaplin H. 1999. Food fight! Am Demographics 21(6):64–65. Cleeremans A, Destrebecqz A, Boyer M. 1998. Implicit learning: News from the front. Trend Cogn Sci 2(10):406–416. CSPI (Center for Science in the Public Interest). 2003. Pestering Parents: How Food Companies Market Obesity to Children. Washington, DC: CSPI.

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