5
Influence of Marketing on the Diets and Diet-Related Health of Children and Youth

INTRODUCTION

This chapter identifies and assesses the research on the influence of food and beverage marketing on the diets and the diet-related health of U.S. children and youth. The work of this chapter should be understood within the context of what is known about these two areas. Chapter 1 describes the breadth and complexity of these factors as well as their multidirectional quality. Chapter 2 discusses the strong evidence that the food and beverage consumption patterns of U.S. children and youth do not meet recommendations for a health-promoting diet and that an estimated 16 percent are obese. Increasing numbers of children and youth also have a variety of physical and psychosocial problems associated with diet and weight.

Chapter 3 discusses the various factors that influence young people’s food and beverage consumption habits. Chapter 4 reviews the ways in which young people are targeted for food and beverage marketing of both product categories and new product lines. A substantial proportion of such marketing is for high-calorie and low-nutrient foods and beverages. The corporate investment in advertising and other marketing practices is aimed at promoting consumer purchases—which are presumably related to consumption of the product advertised and the dietary practices and diet-related health profiles of today’s children and youth.

This chapter reviews and assesses the evidence that explores various aspects of marketing’s influence on the diets and diet-related health of our young people. The three core sections in the middle of the chapter present



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Food Marketing to Children and Youth: Threat or Opportunity? 5 Influence of Marketing on the Diets and Diet-Related Health of Children and Youth INTRODUCTION This chapter identifies and assesses the research on the influence of food and beverage marketing on the diets and the diet-related health of U.S. children and youth. The work of this chapter should be understood within the context of what is known about these two areas. Chapter 1 describes the breadth and complexity of these factors as well as their multidirectional quality. Chapter 2 discusses the strong evidence that the food and beverage consumption patterns of U.S. children and youth do not meet recommendations for a health-promoting diet and that an estimated 16 percent are obese. Increasing numbers of children and youth also have a variety of physical and psychosocial problems associated with diet and weight. Chapter 3 discusses the various factors that influence young people’s food and beverage consumption habits. Chapter 4 reviews the ways in which young people are targeted for food and beverage marketing of both product categories and new product lines. A substantial proportion of such marketing is for high-calorie and low-nutrient foods and beverages. The corporate investment in advertising and other marketing practices is aimed at promoting consumer purchases—which are presumably related to consumption of the product advertised and the dietary practices and diet-related health profiles of today’s children and youth. This chapter reviews and assesses the evidence that explores various aspects of marketing’s influence on the diets and diet-related health of our young people. The three core sections in the middle of the chapter present

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Food Marketing to Children and Youth: Threat or Opportunity? the results of a systematic evidence review of peer-reviewed literature in the area. They include enough of the technical and analytic detail to support the committee’s findings about the contributions of marketing. Prior to these three sections are several that explain how the systematic evidence review was conducted, and following them are sections that address related elements such as comparison with other recent reviews and needed research. Throughout the chapter, care is taken to consider the role of marketing as one of multiple factors influencing diet and diet-related health. The chapter begins with a description of the systematic evidence review undertaken to assess the influence of marketing on the diet and diet-related health of children and youth, including how it was organized, the criteria used for including evidence, the dimensions addressed, the coding process, the nature of the evidence examined, and the process used to review this evidence. This is followed by three sections that present the results of the systematic evidence review relevant to three relationships: (1) the relationship between marketing and precursors of diet, (2) the relationship between marketing and diet, and (3) the relationship between marketing and diet-related health. The role of factors with the potential to moderate these three relationships is then discussed. Finally, the systematic evidence review and its findings are considered in relationship to the results of other recent reports, and areas for future research are identified. A summary of the key findings concludes the chapter. SYSTEMATIC EVIDENCE REVIEW The committee conducted a systematic evidence review in order to investigate and summarize the empirical evidence that is directly relevant to the core question: What is the influence of food and beverage marketing on the diets and diet-related health of children and youth? The committee’s review included 123 published empirical studies identified from a set of nearly 200 in the published literature. Systematic evidence reviews are qualitatively different from meta-analyses or traditional narrative reviews (Petticrew, 2001). Systematic evidence reviews do not involve the statistical synthesis of a set of studies, the technique of meta-analyses, but rather attempt to reduce the inevitable bias from narrative reviews by developing explicit and systematic criteria for study inclusion and for assessing the level of evidentiary support provided by each study. As a result, systematic evidence reviews sometimes include far fewer studies than traditional narrative reviews, but they also typically include more than just randomized controlled trials. For example, this review includes not only many controlled experimental studies, but also many observational studies—both cross-sectional and longitudinal—on the influence of food and beverage marketing on the diets and diet-related health of children and youth.

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Food Marketing to Children and Youth: Threat or Opportunity? In addition to supporting a rigorous assessment of a comparatively large body of research, a systematic evidence review is well suited for finding and describing any major gaps in the existing evidence base. The influence of television advertising intended for children, for example, has been studied fairly extensively by academic researchers. However, the influence of Internet marketing techniques, such as advergaming—developed specifically for older children and growing rapidly, unlike television advertising—has not been the subject of a single peer-reviewed, published academic study. A section at the end of the chapter presents recommended research directions derived largely from the committee’s systematic evidence review process. The Analytic Framework A five-element causal framework (Figure 5-1) was used in assessing the research evidence that related marketing to the diets and diet-related health of children and youth. These elements relate to the marketing-associated elements of the overall ecological schematic presented in Chapter 1. The arrows in this framework are meant to represent potential causal mechanisms by which marketing might affect diet and diet-related health.1 At the outset, the framework was created from the committee’s identification of likely variables, relationships, and processes if food and beverage marketing were to have an effect on young people’s diet and diet-related health. For each of the major elements in the framework, multiple variables were identified to support the widest possible search for relevant research. As research was identified and reviewed, the framework was revised to better reflect what has been studied. In the resulting framework, the initiating or exogenous factors are marketing variables. Marketing variables involve the product, such as differences in product formulation, packaging, or portion size; place, such as placement of items at eye level on supermarket shelves or availability in vending machines, convenience stores, or quick serve restaurants; price, such as the price of healthful food in a school vending machine versus the price for less healthful options; and promotion, such as television or billboard advertising. The systematic evidence review focused on marketing intended for young people ages 18 years and younger rather than on the parents of these young people. At the same time, research was included when it addressed marketing techniques that could engage either or both 1   The problems of causal inference are discussed in the section on Causal Inference Validity below.

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Food Marketing to Children and Youth: Threat or Opportunity? FIGURE 5-1 The five-element causal framework used to organize the systematic evidence review.

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Food Marketing to Children and Youth: Threat or Opportunity? young people and their parents (e.g., product placement in a popular movie that both young people and parents would watch) if the research reported results for young people. Marketing might affect diet through a variety of mediators or precursors of diet. In general, a mediator/precursor is a factor through which causal influence passes. For example, if watching television increases obesity, this influence might be mediated by decreasing physical activity, or it might be mediated by increasing calorie intake, or by both. In the causal framework in Figure 5-1, mediators/precursors of diet are intended to capture the factors that could be directly affected by marketing and that in turn might have a direct effect on diet, but which themselves do not involve directly obtaining or consuming food. For example, television advertisements for sweetened cereals aimed at young children are effective when they cause the child to make a request to the person who purchases food for the family. Thus a common mediator to consuming food or beverage products at home is food purchase requests. Other marketing approaches aim to change purchasing behavior through influencing beliefs about what is “cool” to drink, what provides energy, or what constitutes a balanced breakfast. Still other marketing efforts seek to influence a child’s preferences for a product through its association with a well-known character, such as Darth Vader or Tony the Tiger®. Of the studies the committee reviewed on the relationship between a specific marketing factor and a precursor to diet, the great bulk involved food or beverage preferences, beliefs, or purchase requests. Thus the second element in the causal framework consists of a family of factors identified as precursors of diet. Those factors primarily include food and beverage preferences, beliefs, or purchase requests. The third element in the causal framework is diet. For the committee’s task, diet refers to the distribution and amount of food consumed on a regular basis. Unfortunately, not all studies measured diet comprehensively in this way. Many measured some short-term dietary behavior, such as the number of pieces of fruit or candy consumed in a child-care setting during an afternoon following an exposure to television advertising for fruit or candy that morning. Short-term effects on consumption may or may not translate into longer term effects on a young person’s dietary patterns. Thus, it is important to distinguish studies that considered short-term dietary effects from those that attempted to relate marketing to a more comprehensive measure of diet. Experimental studies tended to focus on short-term consumption following some controlled exposure; cross-sectional and longitudinal studies employed broader measures of usual dietary intake, though they rarely assessed diet comprehensively. The fourth element in the framework is diet-related health such as obesity, the metabolic syndrome, or type 2 diabetes. Nearly all the empiri-

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Food Marketing to Children and Youth: Threat or Opportunity? cal research relating some marketing factor to diet-related health considered some version of the relationship between direct or indirect measures of body fat (adiposity) and television viewing. For simplicity, the term adiposity is used in this chapter to encompass the range of measures in the research reviewed. The fifth element in the framework is moderators, variables that might alter the cause and effect relationships described in the path from marketing to diet-related health. In this domain, the committee identified age, gender, race/ethnicity, socioeconomic status, as well as whether a young person has the opportunity to make independent food purchases, can understand the persuasive intent of advertising, and has accurate nutritional knowledge as a potential moderator. In general, a moderator is a factor that changes the nature of the causal relationship between two other factors. In the most extreme and simple case, the state of a flashlight’s batteries moderates the influence of the switch on the state of the light. When the batteries are charged, the state of the switch fully determines the state of the light. When the batteries are dead, the switch has no effect whatsoever on the light. In another example, genetic or congenital factors moderate the influence of certain drugs on their intended outcome. For example, the effect of penicillin is quite different among those not allergic. Similarly, certain factors might moderate the effect of marketing on precursors, diet, or diet-related health. For example, the influence of television advertisements on food and beverage preferences might be moderated by cognitive development, as indexed by age. Children under about age 8 generally do not understand the persuasive intent of advertising or the implications of persuasive intent for the nature of the advertising they encounter (Blosser and Roberts, 1985; Donohue et al., 1978; Robertson and Rossiter, 1974; Ward et al., 1977). Presumably, they are more readily influenced by advertising and other forms of marketing than are children older than about 8 years. Income or socioeconomic status might also moderate the effects of marketing on diet. For those in a low-income family, for example, the effect of price might be much stronger than it is for those in a high-income family. Because foods such as fruits and vegetables cost more per calorie than do French fries or cheeseburgers, socioeconomic status may be an important moderator of the influence of fruit and vegetable marketing strategies. In another example, gender may moderate teens’ reactions to marketing for sweet or high-fat foods and beverages. By early adolescence, many girls are concerned about their weight (Story et al., 1995) and, assuming that teens know that consuming sweets and high-fat foods leads to weight gain, they might be more resistant to the marketing of those foods than adolescent boys. The arrows in the framework are not meant to reflect quantitative

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Food Marketing to Children and Youth: Threat or Opportunity? strength, only the possibility of a causal element, and are primarily meant to provide a guide with which to review the relevant research. Nor is the framework meant to be exhaustive. The causal relationships flow only in one direction: from marketing through precursors and so on to diet and diet-related health. Clearly, however, the variables included in the framework might also relate bidirectionally. For example, consumer preferences for sweets or high-fat foods can clearly influence marketing strategies, among other things, influencing product formulation or the product qualities emphasized in advertising. Or, as another example, public concern about diet-related health outcomes such as nutritional inadequacies or obesity can impact product formulation and advertising claims, such as emphasizing fortified, low-fat, or whole-grain products. Such bidirectional relationships require more academic research, and their existence underlines the dynamic complexities noted in ecological perspective presented in Chapter 1. The framework, then, provides both a causal perspective for the committee’s examination of evidence on the influence of marketing on young people’s diet and diet-related health, and a structure for organizing the empirical research on this topic. Many studies have examined the relationship between a marketing factor and a mediator/precursor. Many others ignored mediators/precursors and examined the relationship between a marketing factor and a measure of diet, and still others ignored precursors and diet, but examined the relationship between a marketing factor and some aspect of diet-related health. The analysis of the evidence presented later in this chapter is organized along these lines: evidence for a causal connection between marketing and mediator/precursor factors first, then evidence for a causal connection between marketing and diet, and finally, evidence for a causal connection between marketing and diet-related health. Identification of Research for the Review Unlike narrative reviews, a systematic evidence review includes explicit criteria for which studies to include and which to exclude. In establishing these criteria, the committee sought to create a body of evidence that would be both extensive and directly relevant to its charge of assessing the effects of food and beverage marketing on the diets and diet-related health of children and youth. The committee identified four distinct foci of existing research: industry and marketing sources and peer-reviewed literature; marketing and television advertising; television advertising and media use; and marketing of products other than foods and beverages. These had implications for the criteria used to determine what research was included in the systematic evidence review.

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Food Marketing to Children and Youth: Threat or Opportunity? Industry and Marketing Sources and Peer-Reviewed Literature Marketing research is carried out by many different people and organizations for many different purposes. For ease of discussion, the committee characterized them broadly into two categories: industry and marketing information and peer-reviewed literature. There are some notable differences between them. A large amount of industry and marketing information related to foods and beverages promotion to children and youth is not publicly available, but peer-reviewed literature is in the public domain. Additionally, industry and marketing sources usually focus on specific products or brands, often in comparison to other product categories or brands, whereas peer-reviewed literature is usually directed at understanding the marketing process and related effects across a wide range of product categories. Marketing and Television Advertising A large amount of the research about the effect of marketing on young people’s diet and diet-related health examines food and beverage advertising on television. This might be explained by three realities: Advertising is the most visible and measurable component of promotion, one of the classic four marketing practices, the others being product, place, and price; Advertising consumes a substantial and specific portion of a firm’s marketing budget; and Of all food and beverage advertising encountered by children and adolescents, the majority occurs when they are viewing broadcast television and cable television programs. Understanding the effects of televised advertising in today’s food and beverage marketing on young people’s diets and diet-related health contributes substantially to understanding the effects of broader marketing. Fuller understanding would come with research on other types of promotion in addition to advertising, other venues for advertising in addition to television and cable television, and other types of marketing in addition to promotion (i.e., product, place, and price). The marketing arena is complex and ever changing (see Chapter 4). Considerable work is still needed to develop a full understanding of marketing’s current role, its likely future role, and important options for enhancing its positive role in influencing young people’s diet and diet-related health. For the systematic evidence review, the committee established criteria that included all forms of market-

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Food Marketing to Children and Youth: Threat or Opportunity? ing in all venues and vigorously searched for research about marketing other than television advertising. Television Advertising and Media Use A number of research studies deliberately use overall amount of television viewing time (primarily at home) as a measure of overall exposure to television advertising, on the assumption that advertising is a part of virtually all television viewing. Measuring home viewing assesses naturally occurring behavior and aggregates it over the many hours a day every day that most young people are watching television. Along with these benefits of measuring overall viewing come various measurement and inference challenges. In assessing the evidence on marketing’s effects, attention was given to the extent to which the measurement and inference problems were addressed when overall television viewing was used intentionally to assess overall exposure to television advertising. A number of other studies consider overall amount of television viewing per se as an independent variable, particularly in relationship to adiposity. Many are not explicit about the exact mechanisms by which television viewing relates to adiposity or they discuss several different possibilities, often but not always including exposure to advertising for foods and beverages. For example, some of the studies specify that a measure of television viewing is meant to reflect absence of physical activity. The committee established criteria by which all such studies could be included in the evidence base. In these studies, if a relationship was found between television viewing and the outcome of interest, such as adiposity, the reason for the relationship had several plausible explanations for it. Exposure to advertising is one. The committee’s task was to determine for each study of this type whether there was good support for arguing that the relationship of television viewing to the outcome was, indeed, attributable in some degree to exposure to advertising during viewing. Marketing of Products Other Than Foods and Beverages There is a substantial body of research on the effect of marketing products other than foods and beverages to children and youth. In general, this research indicates that marketing can influence young people’s beliefs, actions, and preferences. Much of the research has focused on television advertising for toys, but it has also included work on advertising for cigarettes and alcohol, as well as other products and services. A discussion of some of this body of research is included elsewhere in the report, but it was not formally evaluated by the committee for the systematic

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Food Marketing to Children and Youth: Threat or Opportunity? evidence review because it does not directly assess the effects of food and beverage marketing. Final Criteria for Research Included in the Systematic Evidence Review Based on considerations such as these, the committee’s review was limited to publicly available, scientific studies involving quantitative data on the relationship between (1) a variable involving marketing relevant to young people ages 18 years and younger, and (2) either a variable involving a mediator/precursor, or a variable involving diet, or a variable involving diet-related health.2 Studies that only considered the effect of a moderator variable and had no data pertinent to the relationship between a marketing variable and a precursor, diet, or diet-related health variable were not included. For example, if a study examined the effect of income on attitudes toward fruit and vegetables and had no measure of a marketing variable such as price or placement, then it was not included. Any study that met the inclusion criteria and employed measures that could be interpreted as assessing a marketing variable was included, whether or not the researchers intended the measure to represent that variable. For example, studies were included that used amount of television exposure as the independent variable, or that used attending a high school with Channel One programs (a specially produced high school news program that includes food and beverage advertisements) and examined precursors, diet, or diet-related health. The criteria for a study to be included in the committee’s systematic evidence review were therefore as follows: Only peer-reviewed, published research that included a full description of methods and results or that directed the reader to another publicly available report that provided the full description of methods. This research could have appeared in print books and journals or e-books and e-journals. Only research reports written entirely in English. Any country as the location for the research. Any publication date. Only original research, no review articles. Only research that reported a quantitative relationship between a variable involving marketing relevant to young people (as opposed to parents only) and a variable involving a mediator/precursor, or diet, or diet-related physical health outcome for young people (as opposed to parents). 2   Diet-related health was defined as physical health not psychosocial health.

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Food Marketing to Children and Youth: Threat or Opportunity? Any research that used an independent variable that could be interpreted as a measure for some aspect of marketing. Only published, peer-reviewed research literature was used in this review. There are certain constraints in this respect that apply to any literature review of this sort. It is possible, for example, that investigators have not submitted for publication the results of studies in which the relationship between food and beverage marketing and a pertinent outcome was not statistically significant. In addition, peer reviewers and journal editors may have had a bias to favorably review only those studies in which the results are statistically significant. If so, then the published studies represent only a sample of all studies that have been done, and this sample is biased in the direction of statistically significant relationships between food and beverage marketing and the outcome of interest. However, if such a bias does exist, the direction of that bias should not be assumed as either an increase or decrease in the influence of marketing on the measured precursors, diet, or diet-related health. Although a publication bias is possible in the research reviewed below, the committee considered the bias, if it exists, to be small. As will be displayed, nonsignificant results have been published in numerous and diverse sources. Moreover, an early examination of unpublished theses, dissertations, and conference papers revealed relatively few nonsignificant findings. Given the importance of the issues, the committee considered it unlikely that well-conceived and well-executed studies were not submitted or were rejected on the grounds that the results were not statistically significant. Finding the Research Using the guidelines described above and the many possible variables identified with the initial proposed causal framework, extensive and iterative searches for relevant literature were conducted. Briefly, the quest included an online bibliographic search of several databases, outreach to experts in relevant fields, examining published literature reviews, recourse to committee members’ personal and university libraries, and pursuing references cited in articles that were being coded for the systematic evidence review. A two-stage process determined whether each item was included in the final systematic evidence review. One or more committee members read the titles and abstracts of more than 200 items and removed any that clearly did not meet one or more of the inclusion criteria. Many review articles, opinion pieces, studies involving adults only, and studies that did not in-

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Food Marketing to Children and Youth: Threat or Opportunity? With respect to the specific influence of food and beverage marketing on young people’s diets, a systematic evidence review supported the following findings: There is strong evidence that television advertising influences the short-term consumption of children ages 2–11 years. There is insufficient evidence about its influence on the short-term consumption of teens ages 12–18 years. There is moderate evidence that television advertising influences the usual dietary intake of younger children ages 2–5 years and weak evidence that it influences the usual dietary intake of older children ages 6–11 years. There is also weak evidence that it does not influence the usual dietary intake of teens ages 12–18 years. With respect to the specific influence of food and beverage marketing on young people’s diet-related health, a systematic evidence review relied on research investigating the relation between amount of television viewing, among other variables, and diet-related health. Amount of television viewing is highly correlated with amount of exposure to television advertising and is frequently used as a measure of advertising exposure. The committee’s purposes are served by reviewing research about television viewing and diet-related health, but findings about advertising effects are difficult because of measurement quality, alternative explanations of findings, and other factors. With these caveats noted, the systematic evidence review supported the following findings: Statistically, there is strong evidence that exposure to television advertising is associated with adiposity in children ages 2–11 years and teens ages 12–18 years. The association between adiposity and exposure to television advertising remains after taking alternative explanations into account, but the research does not convincingly rule out other possible explanations for the association; therefore, current evidence is not sufficient to arrive at any finding about a causal relationship from television advertising to adiposity. It is important to note that even a small influence, aggregated over the entire population of American children and youth, would be consequential in impact. In addition to conducting a systematic evidence review of the research examining the relationships of marketing to the precursors of diet, to diet, and to diet-related health, the committee conducted a narrative review of this research and other relevant research in order to understand the role of

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Food Marketing to Children and Youth: Threat or Opportunity? moderators in altering the marketing relationships. The committee found the literature too small altogether and too varied in topic to support any conclusions about the ways in which differences in age, gender, race/ ethnicity (including home language), and socioeconomic status may alter (moderate) the influence of marketing on these precursors. However, with respect to age, the committee found that: Most children ages 8 years and under do not effectively comprehend the persuasive intent of marketing messages, and most children ages 4 years and under cannot consistently discriminate between television advertising and programming. The evidence is currently insufficient to determine whether or not this meaningfully alters the ways in which food and beverage marketing messages influence children. Finally, both the systematic evidence review and the narrative review revealed areas in which new research is needed, as well as the characteristics of research that is most likely to be helpful to committees addressing charges such as ours. Specific recommendations for future research are offered in a preceding section. The committee’s overall finding is as follows: New research is needed on food and beverage marketing and its impact on diet and diet-related health and on improving measurement strategies for factors involved centrally in this research. Much of this research must be interdisciplinary and fairly large-scale in nature, although some highly-focused small-scale research is also desirable. Among the specific research needed are studies of newer promotion techniques, newer venues, and healthier products and portion sizes. REFERENCES *Andersen RE, Crespo CJ, Bartlett SJ, Cheskin LJ, Pratt M. 1998. Relationship of physical activity and television watching with body weight and level of fatness among children: Results from the Third National Health and Nutrition Examination Survey. J Am Med Assoc 279(12):938–942. *Anderson DR, Huston AC, Schmitt KL, Linebarger DL, Wright JC. 2001. Early childhood television viewing and adolescent behavior: The recontact study. Mon Soc Res Child Dev 66(1):I–VIII, 1–147. *Armstrong CA, Sallis JF, Alcaraz JE, Kolody B, McKenzie TL, Hovell MF. 1998. Children’s television viewing, body fat, and physical fitness. Am J Health Promot 12(6):363–368. ATSDR (Agency for Toxic Substances and Disease Registry). 2002. Analytical Methods. [Online]. Available at: http://www.atsdr.cdc.gov/toxprofiles/tp13-c6.pdf [accessed October 14, 2005]. *These references are studies included in the systematic evidence review.

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