industry progress to market a healthful diet to american children and adolescents

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Industry Progress to Market a Healthful Dietto American Children and Adolescents

Vivica I Kraak MS RD Mary Story PhD RD Ellen A Wartella PhD Jaya Ginter MPH

This activity is available for CME credit See page A4 for information

Context The IOM released an expert committee report in 2005 that assessed the nature extent andinfluence of food and beveragemarketing practices on the diets and health of American children andadolescents The report concluded that prevailing marketing practices did not support a healthfuldiet and offered recommendations for diverse stakeholders to promote a healthful diet Theinvestigators evaluated progress made by food beverage and restaurant companies tradeassociations entertainment companies and the media to achieve the IOM report recommenda-tions over 5 years

Evidence acquisition A literature review was conducted of electronic databases and relevantgovernment industry and media websites between December 1 2005 and January 31 2011Evidence selection was guided by the IOM LEAD principles (ie locate evaluate and assembleevidence to inform decisions) and fıve qualitative-research criteria and it was validated by dataand investigator triangulation The investigators selected and categorized 117 data sources intotwo evidence tables used to evaluate industry progress (ie no limited moderate andextensive)

Evidence synthesis Food and beverage companies made moderate progress however limitedprogress was made by other industry subsectors Industry stakeholders used integrated marketingcommunications (IMC) to promote primarily unhealthy products which threaten childrenrsquos andadolescentsrsquo health and miss opportunities to promote a healthy eating environment

Conclusions Diverse industry stakeholders have several untapped opportunities to advance prog-ress by promoting IMC to support a healthful diet substantially strengthening self-regulatoryprograms supporting truthful and non-misleading product labeling and health claims engaging inpartnerships and funding independent evaluations of collective efforts(Am J Prev Med 201141(3)322ndash333) copy 2011 American Journal of Preventive Medicine

Context

Food and beverage marketing to children and ado-lescents is a complex contentious and rapidlyevolving issue linked to the US overweight and

besity crisis that affects one third (32) of Americanhildren and adolescents aged 2ndash19 years12 In 2004Congress directed the IOM of the National Academies toconvene an expert committee to review the evidence for

From the Deakin Population Health Strategic Research Centre School ofHealth and Social Development Deakin University (Kraak) MelbourneAustralia Division of Epidemiology and Community Health School ofPublic Health University of Minnesota (Story Ginter) Minneapolis Min-nesota and School of Communication Northwestern University (Wart-ella) Evanston Illinois

Address correspondence toVivica I KraakMSRDDeakinPopulationHealth Strategic Research Centre School of Health and Social Develop-ment Deakin University 221 Burwood Highway Melbourne Victoria3125 Australia E-mail vivicakraakdeakineduau

0749-3797$1700doi 101016jamepre201105029

322 Am J Prev Med 201141(3)322ndash333 copy 2011 Amer

food and beverage marketing practices that influence thediets of children and adolescents and recommend strate-gies to promote a healthful diet In December 2005 theIOM released an expert committee report Food Market-ing to Children andYouth Threat orOpportunity3 whichassessed the nature extent and influence of food andbeverage marketing on the diets and health of Americanchildren and adolescentsThe IOM committee documented that most Ameri-

can children and adolescents have inadequate intakesof nutrient-dense food groups (ie fruits vegetableswhole grains and low-fat dairy) and consume lowerthan recommended levels of shortfall nutrients (iepotassium fıber and calcium)3 Young people alsohave excessive intakes of energy-dense foods and bev-erages and consume higher than recommended levelsof nutrients of concern (ie sodium added sugars

total calories total fat and saturated fat) Recent

ican Journal of Preventive Medicine bull Published by Elsevier Inc

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Kraak et al Am J Prev Med 201141(3)322ndash333 323

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analyses have confırmed these troubling dietarytrends4ndash9

The IOM committee conducted a systematic literaturereview and found that TV advertising influenced chil-drenrsquos preferences and purchase requests diets andhealth The committeersquos fındings were limited to TV ad-vertising because of knowledge gaps and lack of access toproprietary information about newer forms of inte-grated marketing communications (IMC) wherebycompanies combine advertising public relations salespromotion direct marketing sponsorships and point-of-purchase with many communication techniques toprovide clarity consistency and maximum impact toreach customers1011

The IOM committee3 also found that leading food andeverage companies spent substantial resources to mar-et branded food and beverage products to young peoplehat do not support a healthful diet These fındings wereonfırmed by the Federal Trade Com-ission (FTC)12 According to the 2006arketing expenditures of 44 food bev-rage and restaurant companies morehan $16 billion were spent to marketrimarily unhealthy products to chil-ren and adolescents of which $870illion were spent to market to chil-ren aged 12 years and more than $1illion were spent to market to adolescents12

The IOMcommittee concluded that food and beveragemarketing influences the diets and health of children andadolescents current marketing practices are out of bal-ance with a healthful diet and create an environment thatputs young peoplersquos health at risk companies and mar-keters have underutilized their potential to apply re-sources and creativity to market a healthful diet achiev-ing a healthful diet will require industry leadership andsustained multisectoral and integrated efforts and cur-rent public policy lacks support or authority to addressemerging marketing practices that influence dietsThe IOM report offered 10 recommendations to guide

diverse private- and public-sector stakeholders to pro-mote a healthful diet to children and adolescents Thefırst fıve recommendations focus on industry stakehold-ers including food beverage and restaurant companiesindustry trade associations food retailers entertainmentcompanies and the mediaA companion paper will address public-sector stake-

holder progress This paper reviews the available evi-dence between December 1 2005 and January 31 2011to evaluate industry stakeholdersrsquo progress to market ahealthful diet to children and adolescents The results are

Srela

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discussed within the context of potential opportunities

eptember 2011

and actions industry stakeholders might pursue to ad-vance progress toward the IOM food marketing reportrecommendations

Evidence AcquisitionTable 1 summarizes the methods used to evaluate indus-try progress The investigators (1) established the evi-dence selection approach criteria and search strategyincluding search terms (2) conducted a literature reviewbetween December 1 2005 and January 31 2011 ofelectronic databases federal government agency web-sites company and industry websites gray-literaturestudies and reports and media stories or news releases(3) selected and categorized 117 evidence sources (n47published articles and reports and n70 media stories ornews releases) into two evidence tables (4) indepen-dently reviewed the evidence for the major IOM recom-mendations and subrecommendations before assigning

an evaluation category and reached con-sensus on the progress evaluation category(ie no limited moderate and extensive)for stakeholder groups in a specifıc sectorpertinent to each recommendation and(5) identifıed opportunities and potentialactions that industry stakeholders couldtake to accelerate progress toward the IOMfoodmarketing recommendations based on

the evidence table other expert committee reports andgrounded in the evolving policy developments for eacharea exploredTo guide the evidence selection and interpretation the

investigators used principles developed by a separateIOM expert committee in 201013 based on an obesity-prevention decision-making framework to locate evalu-te and assemble evidence to inform decisions (LEAD)he LEAD principles were developed for decisionmakerso use a systems perspective to identify the type of evi-ence required to answer specifıc public health questionshen evidence is limited but actions must be taken TheEAD approach combines available evidence with the-ry professional experience and local wisdom to informecision making and integrates scientifıc evidence intoroader factors that influence obesity-prevention poli-ies13 The investigators selected the LEAD approach be-cause it was appropriate to the research task to use allavailable evidence to inform policy Food marketing toyoung people is a complex issue requiring diverse evi-dence from broad areas to evaluate overall progress overtimemade bymultiple stakeholders to market a healthfuldiet to children and adolescentsThe investigators used fıve accepted qualitative-

ry byin

e

eetedntanis

research criteria14 (ie data relevance research-design

epor

324 Kraak et al Am J Prev Med 201141(3)322ndash333

quality professional judgment contextual analysis andcredibility by data verifıcation) and data and investigatortriangulation to validate evidence convergence1516 Thesearch terms were selected after reviewing the existingfood and beverage marketing literature (Table 1) Theinitial search yielded hundreds of documents The inves-tigators repeated and refıned subsequent searches ac-cording to specifıc evaluations that pertained to the IOMrecommendations for each industry sector examinedAppendix A (available online at wwwajpmonlineorg)

summarizes the study designs report descriptions andfındings for 47 evidence sources Appendix B (availableonline at wwwajpmonlineorg) lists 70 media storiespress or news releases used for the evaluationFigure 1 provides the recommendations for industry

stakeholders specifıc action domains and a progressevaluation for each industry sector The investigators

Table 1 Methodologic approach used to evaluate industr

I Investigators used the IOM LEAD principles (ie locate evaluaevidence selection approach criteria and search strategy

Five qualitative-research criteria (ie data relevance reseand credibility by data verification)

Search terms (ie child children adolescents food adveobesity overweight food retail restaurant fast food medprofiling health claim nutrient claim advertising marketi

Triangulation (ie data and investigator) to identify conve

II LOCATE Investigators conducted a literature review between

Electronic databases (ie MEDLINE Science Direct LexisNe

US federal government agency websites (ie DHHS CDCommission Food and Drug Administration Federal Tradeof the White House Press Secretary)

Websites of food beverage restaurant and entertainmen

Studies and reports released by industry government no

Media stories press and news releases

III EVALUATE and ASSEMBLE Investigators selected and categoand n70 media stories press or news releases) into two e

Primary author year and reference number

Study design or report description (ie government indusjournal article and expert committee report) or media sto

Major findings

All of the available evidence was considered before one of foand extensive) for stakeholders within a specific sector perti

Stakeholder transparency accountability cooperation angovernment and public health advocates) consistency ofbenchmarks and voluntary reporting on progress to prom

IV INFORM DECISIONS Investigators identified opportunities anadvance progress toward the IOM food marketing recomme

Proposed actions are grounded in the evidence tables thsupported by other expert committee and advisory group r

convened to discuss opportunities and actions that in-

dustry decision makers might take to accelerate progresstoward the IOMcommitteersquos recommendations Figure 1highlights potential opportunities and actions that aregrounded in the evidence tables the evolving policy de-velopments for each area and supported by other expertcommittee and advisory group reports The results arepresented in a narrative summary

Evidence SynthesisThe evaluation showed that extensive progress was notmade by any industry stakeholder to achieve the IOM rec-ommendations (Figure 1) Moderate progress wasmade byfood and beverage companies and industry in cooperationwith public-sector groups to improve marketing practicestandards and limited progress was made by restaurantsindustry trade associations entertainment companies and

gress

nd assemble evidence to inform decisions) to establish

-design quality professional judgment contextual analysis

g food marketing beverage advertising health wellnessntertainment product reformulation labeling nutrientdustry self-regulation licensed character and partnership)

e of evidence

mber 1 2005 and January 31 2011

Library of Congress Business Source Premier and Mergent)

partment of Education Federal Communicationsmission NIH US Department of Agriculture and the Office

panies and industry trade associations

t organization foundations and academic institutions

117 evidence sources (n47 published articles or reportsce tables that contained the following information

foundation nongovernment organization peer-reviewedress or news release description

valuation categories was selected (ie no limited moderateto each IOM recommendation drawing from these criteria

laboration within and across sectors with other groups (egns establishing and implementing meaningful goals andhealthful diet to children and adolescents

tential actions that industry stakeholders could take toons

lving policy developments for each relevant area andts

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the media over the 5-year period reviewed

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Figure 1 Potential opportunities and actions for industry stakeholders to promote a healthful diet to American childrenand adolescentsNote Based on the IOM private-sector recommendationsABA American Beverage Association CARU Childrenrsquos Advertising Review Unit CBBB Council of the Better Business Bureaus Inc CFBAIChildrenrsquos Food and Beverage Advertising Initiative FMI Food Marketing Institute FDA Food and Drug Administration FTC Federal TradeCommission GMA Grocery Manufacturers Association IMC Integrated Marketing Communications IWG Federal Interagency Working Group

on Marketing to Children (ie CDC FDA FTC USDA) NRA Natonal Restaurant Association SFA Snack Food Association

eptember 2011

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Food and Beverage CompaniesmdashModerateProgress AchievedIndustry reports suggest that progress was made toreformulate and expand healthier products17ndash24 re-uce TV advertising for unhealthy products (ie sweetnacks and sugar-sweetened beverages [SSBs])21ndash2325

that was supported by two independent evalua-tions2627 develop front-of-package (FOP) labeling foronsumers to identify healthy products2829 and initi-te partnerships to promote a healthful diet andealthy lifestyles3031

In 2006 the Council of the Better Business Bureaus(CBBB) and National Advertising Review Council an-nounced revisions to strengthen the Childrenrsquos Advertis-ing Review Unitrsquos (CARUrsquos) self-regulatory guidelinesand released the Childrenrsquos Food and Beverage Advertis-ing Initiative (CFBAI)32 The CFBAI became operationalith ten food companies in July 200721

By September 2010 17 companies (15 food and bever-age companies and two restaurant companies) partici-pated in the CFBAI and voluntarily pledged to shift thechild-directed advertising messages to encourage health-ier dietary choices and healthy lifestyles33

Three CFBAI monitoring reports were released at 612 and 24 months (2008ndash2010)21ndash23 that documentedhigh compliance with company pledges for child-directed advertising The CFBAI guidelines werestrengthened and revised in 2009 and 201034ndash36 Severalfood and beverage companies promote healthy lifestylesthrough publicndashprivate partnerships with industry coali-tions such as the HealthyWeight Commitment Founda-tion (HWCF)3037 and the Partnership for a Healthiermerica (PHA)38

The investigatorsrsquo progress evaluation found that de-spite positive actions reported product reformulationsshowed only incremental changes to meet healthier nu-trient profıles39ndash41 companies continued to advertiseandmarket unhealthy foods and beverages to young peo-ple1242ndash44 compared to pre-December 2005 marketingtrends45ndash51 companies used misleading advertisingnd health claims to promote childrenrsquos products52ndash54 andhe FTC and CARU investigated certain claims55ndash57 andFOP labeling symbols and nutrient-profıling systemswere based on different criteria that hindered consum-ersrsquo selection of healthy products in grocery stores2858

Company pledges failed to protect children aged 12years and adolescents aged 12ndash17 years from all typesof marketing practices promoting unhealthy prod-ucts59ndash62 nonparticipating CFBAI companies weremore likely to market unhealthy products61 and pub-licndashprivate partnerships should be evaluated for

effectiveness63 t

RestaurantsmdashLimited Progress AchievedFull-service and quick-serve chain restaurants (QSRs)made limited progress to expand and promote healthiermeals and provide calories and other nutrition informa-tion at point of choice and consumption A 2006 Key-stone Center advisory committee (with industry repre-sentatives) reinforced the IOM food marketing reportrecommendations for restaurants to expandhealthier op-tions reduce portion sizes and promote menu label-ing6465 however restaurants failed to act as revealed bywo studies in 2008ndash2009 that documented that less than0 of childrenrsquos restaurant meals met healthful criteriaonsistent with the Dietary Guidelines for AmericansDGA)6667

In 2010 the Rudd Center released a study examiningchildrenrsquos and adolescentsrsquo meal choices at 12 leadingQSRchains68 The studydocumented that only 12 of 3039childrenrsquosmeal combinationsmet establishednutrition cri-teria for preschoolers only 15 meals met nutrition criteriafor older children meals purchased by adolescents pro-vided an average of 800ndash1100 caloriesmeal representinghalf of their recommended daily calories and meals soldto young people rarely offered healthy side dishes as thedefault choice68

Although some restaurants reported expandinghealthier childrenrsquos meal options21ndash23 changes madesuggested an industry strategy to respond to negativepublic relations generated by advocacy groups disclosingthat most restaurant meals exceeded young childrenrsquosrecommended daily calories (480 caloriesmeal repre-senting one third of the recommended 1300 caloriesdayfor young children)69 and adolescentsrsquo recommendedaily calories (733 caloriesmeal representing one thirdf the recommended 2200 caloriesmeal for adoles-ents)70 Meals also exceeded recommendations for so-dium fat and added sugars66ndash68 that contributed to poordiet quality Two studies suggested thatmandatorymenulabelingmayhelp parentsmake healthier choices for theirchildren7172

Only Subway andWalt Disney restaurants have desig-nated healthy default choices (ie fruits nonstarchy veg-etables and low-fat or fat-free milk) as the preferred sidedishes and beverages respectively accompanying chil-drenrsquosmeals instead of high-calorie low-nutrient options(ie french fries and SSBs)666873 McDonaldrsquos andBurger King are the only two restaurants participating inthe CFBAI21ndash23 Several other leading QSR restaurantsncluding YUM Brands (the parent company for KFCaco Bell and Pizza Hut) and Subway have not joinedhe CFBAITheQSR sector spentmore than $42 billion in 2009 onarketing to young people and adults through TV digi-

al mobile and social media68 From 2003 through 2009

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exposure to QSR chain TV advertisements increased by21 for preschoolers 34 for children (aged 2ndash11 years)and 39 for adolescents (aged 12ndash17 years)2668 African-merican children and adolescents who are dispropor-ionately affected by higher overweight and obesity ratesere targeted more aggressively by QSR chain restaurantV advertisements during this period266874

A 2010 evaluation documented that only 24 of 42restaurants had marketing policies for children and hadcompliedwith the FTCrsquos recommendation to standardizenutrition criteria for marketing to children62 No evi-dence showed that restaurants had used competitive pric-ing to encourage healthy meals and QSR restaurantsfailed to provide nutrition guidelines for meals whenoffering toys to children7576McDonaldrsquos opposed healthadvocates in Californiarsquos Santa Clara County77 and SanFrancisco78 to legally mandate specifıc nutrition stan-ards when distributing toys or incentives with chil-renrsquos meals Although McDonaldrsquos defended itsappy Meals79 the company reportedly reformulatedhildrenrsquos meals and posted the updated informationn a public website80 after being threatened with aonsumer advocacy-group lawsuit81 formally initiatedn December 201082

Restaurants have not joined publicndashprivate partner-ships such as the HWCF and the PHA to promote ahealthful diet The restaurant leadership inadequacieswere noted by First Lady Michelle Obama who encour-aged the sector to substantially improve meals for Amer-ican children and families and their involvement in theLetrsquos Move initiative83

Industry Trade AssociationsmdashLimitedProgress AchievedIndustry trade associations collectively made limitedprogress to demonstrate leadership and harness industrycreativity support and resources to market a healthfuldiet Trade associations representing the food beveragefood retail and fresh produce industry demonstrated cer-tain positive actions during the period reviewed2584ndash90

Very limited progress was made by trade associationsrepresenting advertisers and marketers9192 restau-ants93 and the confection94 and snack-food95 sectorsNo evidence showed that the 2006 school snack-foodagreement96 had been evaluated Unhealthy food andbeverage products were widely available to childrenthrough food retailers9798 Nevertheless Wal-Mart an-ounced encouraging steps in early 2011 to expandealthier options99 Only three trade associations areembers or partners of the HWCF37

This evaluation accounted for delayed industry tradeactionsmdashwhich appeared to improve in February 2010

after Letrsquos Move was initiated100 and in May 2010 after

eptember 2011

the release of the White House Task Force Report onChildhoodObesity101mdashand lobbying actions that under-mined public health goals The National Restaurant As-sociation (NRA) neither publicly encouraged membersto join the CFBAI nor provided technical support topromote clear advertising policies to children thataligned with healthy criteria NRA also failed to supportmenu labeling until it became apparent that it would beenacted into law through healthcare reform legislation inMarch 2010102 Two advertising trade associations con-inue to defend their right to advertise to children9192

The National Confectioners Association viewed theChild Nutrition ProgramReauthorization legislation as athreat because of proposed limits on candy sales in schoolvending machines94 These trade associations did notake position papers or policies publicly available toupport marketing a healthful dietThe Grocery Manufacturers Associationrsquos (GMArsquos)ositive actions were evaluated within the context ofpending $16 million and the NRA spending $14 mil-ion respectively to lobby legislators to oppose an SSBax in 2009103 In late 2010 and early 2011 GMA and theFoodMarketing Institute (FMI) announced that they haddeveloped their ownFOPnutrition labeling system calledldquoNutrition Keysrdquo and pledged a $50 million educationcampaign to provide American consumers with an easy-to-use format providing calories saturated fat sodiumand added sugars104ndash106 This strategy was developedithout FDA input107 and preempted a forthcoming

IOM report based on consumersrsquo understanding ofFOP systems The industry initiative could confuseconsumers unless it is spearheaded by the Food andDrug Administration (FDA) and informed by IOMrecommendations28

Marketing Practice StandardsmdashModerateProgress AchievedIndustry stakeholders made moderate progress to workwith government and other groups to establish and en-force marketing standards for young people By 2010 atotal of 17 companies representing about two thirds ofthe industry marketing expenditures for children andadolescents voluntarily participated in the CFBAI andreported progress in revising applying and evaluatingtheir advertising standards233336108ndash110 Althoughany marketing practices and marketing to adolescentsere excluded from companiesrsquo pledgesGovernment made moderate progress to evaluate

ompaniesrsquo compliance The FTC released three reportsetween 2006 and 2008mdashone with the DHHS acknowl-dging some positive company actions17 an analysis ofyoung peoplersquos TV advertising exposure between 1977

and 2004 that showed a majority of advertisements pro-

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moted unhealthy foods to children aged 2ndash11 yearsthrough prime-time TV and other programming111 andreport documenting that more than $16 billion waspent in 2006 to market primarily unhealthy food andeverage products to young people12

A 2008 Senate hearing112 and the FTC12 urged compa-ies to adopt meaningful uniform nutrition standardsor all products marketed to children and developledges beyond child-directed advertising that would ap-ly to all forms of marketing including measured mediapending (representing media categories that companiesse to promote products systematically tracked by mediaesearch companies) and unmeasured media spending(representing sales promotions coupons and Internet-based marketing that are not systematically tracked)312

No company has yet complied fully with the FTCrecommendationsA 2006 Federal Communications Commission (FCC)

Task Force was unable to reach consensus on nutritionstandards andmediamarketing by 2008113 In 2009 con-ern about the limited effectiveness of industry self-egulation prompted Congress to direct the federal gov-rnment to convene an Interagency Working GroupIWG) on Marketing to Children with representativesrom the CDC FDA FTC and US Department of Agri-ulture (USDA) to conduct a study and develop re-ommendations to establish food marketing standardsor promotional practices targeting children anddolescents114

Congress requested the IWG to submit its report andrecommendations by July 15 2010 Although tentativedraft nutrition standards were released by the federalIWG at an FTC meeting in December 2009115 delays inposting to elicit public input prevented the IWG frommeeting the July 15 2010 congressional deadline116 Ineptember 2010 the FTC delivered subpoenas to 48 foodnd beverage manufacturers distributors and QSRs tobtain information to review changes in industry expen-itures andmarketing activities from 2006 to 2009 and tossess the effectiveness of industryrsquos voluntary actionsver this period117 for a follow-up report to be released in011118

This progress evaluation noted several industry inade-quacies to improve marketing practices that protect chil-dren and adolescents First most companies have notextended self-regulatory pledges to cover broader formsof child-directed marketing such as product packagingand in-store marketing The pledges of most companiesdo not cover all forms of spending on ldquonew mediardquo (iedigital mobile and interactive social media) that are lessexpensive and highly engaging to maximize youngpeoplersquos exposure to marketing messages for un-

healthy products more effectively when compared to p

traditional forms of advertising119 The pledges ofost companies also do not cover all school-basedarketing practices (ie fundraisers sponsorship in-chool celebrations label-redemption programs pro-ucts donated as contributions-in-kind and causearketing)120ndash123

Second companies have not extended pledges to coveradvertising and marketing practices that promote un-healthy food and beverage products targeted to adoles-cents119 Third each CFBAImemberrsquos pledge is based onits own selective nutrition standards rather than a univer-sal set of evidence-based nutrition standards62 Fourthlthough a reduction in third-party licensed characterssed to promote products to young children was ob-erved companies are using other forms of cross-romotion marketing123 Nearly half (494) of com-any advertisements use licensed characters to promotenhealthy products61 which is important because chil-ren prefer foods with licensed characters especially fornergy-dense foods (candy) compared to healthier op-ions (baby carrots)124

Media and EntertainmentCompaniesmdashLimited Progress AchievedThe media and entertainment industry made limitedprogress during the period reviewed At a 2008 Senatehearing113 the FCC Chairman expressed concern thatfew media companies had voluntarily limited advertise-ments targeting children124 A 2010 evaluation showedhat only one quarter of entertainment companies had alear policy on food marketing to children Existing pol-cies addressed third-party licensed characters but wereeaker for products marketed through broadcast printnd digital media and product placement62 Only WaltDisney and Sesame Workshop reported limiting child-directedmarketing to productsmeeting specifıc nutritionstandards The Cartoon Network developed policies forlicensed characters but lacked policies for other promo-tional activities Nickelodeon neither had nutrition stan-dards nor a clear policy about food marketing to chil-dren62125126 despite earlier public commitments toimplement policies17127

One evaluation found that the percentage of advertise-ments for high-calorie and low-nutrient foods aired byentertainment companies decreased only slightly be-tween 2005 and 2009 (before and after the CFBAI wasimplemented) from about nine in ten (88) to eight inten (79) food advertisements61 No childrenrsquos enter-ainment companies currently participate in the CFBAIrHWCF Entertainment companiesrsquo brand-equity char-cters are exempted from the updated 2010 CFBAI prin-iples that encouragedmember companies to limit third-

arty licensed characters to advertise only products that

wwwajpmonlineorg

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promote a healthful diet or healthy lifestyles CFBAIpledges exclude licensed characters on product packag-ing becausemost companies do not consider this promo-tion activity to represent advertising40

The media shape the publicrsquos opinions about obesitydiet and health by emphasizing feature stories and arti-cles about the causes of unhealthy diets affected groupsand stakeholders responsible for an effective responseTrends in media coverage of obesity-related storiesshowed a steady increase during the period reviewed128

but the specifıc content and accuracy of these stories areunknown In 2009 a report examining US healthcarejournalism found that fınancial pressures on the mediaindustry and competition to break news on innovativeand expanding Internet-basedmedia platforms influenceand affect the quality of health reporting These chal-lenges have caused journalists specializing in healthcarecoverage to be concerned about the lack of in-depthdetailed reporting and the influence of public relationsand advertising on news content and consumersrsquo percep-tions of media stories129

DiscussionEating behaviors of children and adolescents are highlycomplex because they are influenced by the interplay ofmany factors across different contexts to potentially cre-ate healthy food and eating environments130 Marketingo young people is equally complicated because it in-olves diverse stakeholders with different motivationsnd priorities that interact over time The IOM commit-ee identifıed foodmarketing to children and adolescentss a current threat to young peoplersquos diets and health butlso viewed marketing as potentially providing opportu-ities to improve young peoplersquos future diet and health3

A subsequent 2007 IOM obesity prevention progressreport131 acknowledged the tensions among private- andpublic-sector stakeholders to promote a healthful diet tochildren and adolescents with special consideration forthe following issues conveying consistent and appealingmessages ensuring transparency by sharing relevantmarketing data obtaining company-wide commitmentsunderstanding the interactions among companies mar-keting practices and consumer demand balancing free-market system goals with protecting young peoplersquoshealth and committing to monitor and evaluate allefforts

Industry decision makers and policymakers havemany opportunities to accelerate progress toward theIOM foodmarketing committeersquos recommendations andto create healthy eating environments by using a newinfrastructure that has evolved since the 2006 IOM food

marketing report release The infrastructure includes in-

eptember 2011

dustry self-regulatory mechanisms (ie CBBB CARUand CFBAI) publicndashprivate partnerships independentmonitoring and evaluations undertaken by academic andadvocacy groups and federal government initiatives in-cluding the IWGon FoodMarketing to Children132 FTCstudies116117 FDA leadership on FOP labeling133 andthe HHS and USDA release of the DGA 2010134

This evaluation found that moderate progress wasmade by food and beverage companies and diversegroups to strengthenmarketing practice standardsHow-ever restaurants industry trade associations entertain-ment companies and the media made limited progressIndustry stakeholders used IMC to market primarily un-healthy products that threaten childrenrsquos and adoles-centsrsquo health and miss opportunities to promote healthyeating environments In July 2011 the CBBB and CFBAIannounced a promising agreement reached with partici-pating companies to follow uniform nutrition criteria forfoods advertised to children The new criteria will en-courage companies to reformulate and develop newproducts with less sodium saturated fat and sugars andfewer calories otherwise they will not advertise themafter December 31 2013135 There aremany other oppor-tunities and actions that industry stakeholders could taketo accelerate progress Proposed actions are grounded inthe evidence reviewed for this progress evaluation andrecommended by other expert committees and advisorygroups (Figure 1)61217272864101117131ndash134

ConclusionThe IOM recommendations provide a coherent frame-work to ensure that a nexus of coordinated actions areimplemented to promote a healthful diet to youngpeopleThis paper used the IOM LEAD approach to evaluateprogress made by industry stakeholders to achieve theIOM food marketing report recommendations for mar-keting a healthful diet to children and adolescents Theresults can inform potential actions that decision makersmight take to promote healthy products a healthful dietand healthy food and eating environmentsA companion paper will address public-sector stake-

holder progress Moderate progress was made by foodand beverage companies and diverse private- and public-sector stakeholders to improve marketing practice stan-dards Limited progress was made by restaurants indus-try trade associations and entertainment companies andthe media to market a healthful diet Diverse industrystakeholders have many untapped opportunities to ad-vance progress by collectively promoting IMC for healthyfood beverages and meals substantially strengtheningself-regulatory programs supporting clear truthful and

non-misleading product labeling and health claims en-


gaging in publicndashprivate partnerships and funding inde-pendent evaluations of collective efforts

This paper was supported by a grant provided by the RobertWood Johnson Foundationrsquos Healthy Eating ResearchProgramThe authors are grateful for the insightful comments pro-

vided by the anonymous reviewers We thank Juan Quirarte ofQDesign for creating Figure 1

No fınancial disclosures were reported by the authors of thispaper

References1 OgdenCL CarrollMDCurtin LR LambMM Flegal KM Prevalence

of high bodymass index inUS children and adolescents 2007ndash2008J Am Med Assoc 2010303(3)242ndash49 jamaama-assnorgcgireprint3033242

2 Ogden CL Carroll MD Flegal KM High body mass index for ageamong US children and adolescents 2003ndash2006 J Am Med Assoc2008299(20)2401ndash5 jamaama-assnorgcgireprint299202401

3 McGinnis JM Gootman JA Kraak VI editors Committee on FoodMarketing and the Diets of Children and Youth Institute of Medi-cine Food marketing to children and youth threat or opportunityWashington DC The National Academies Press 2006

4 Spear BA Barlow SE Ervin C et al Recommendations for treatmentof child and adolescent overweight and obesity Pediatrics 2007120(4S)S254ndash88 Pediatricsaappublicationsorgcgireprint120Supplement_4S254

5 Stallings VA Taylor CL editors Committee on Nutrition Standardsfor National School Lunch and Breakfast Programs National Re-search Council Nutrition standards and meal requirements for na-tional school lunch and breakfast programs phase I Proposed ap-proach for recommending revisions Washington DC The NationalAcademies Press 2008

6 DHHS USDepartment of Agriculture Report of the Dietary Guide-lines Advisory Committee on the Dietary Guidelines for Americans2010 Washington DC Agricultural Research Service USDA 2010wwwcnppusdagovDGAs2010-DGACReporthtm

7 Siega-Riz AM Deming DM Reidy KC Fox MK Condon E BriefelRR Food consumption patterns of infants and toddlers where are wenow J Am Diet Assoc 2010110(12S)S38ndash51

8 Piernas C Popkin BM Trends in snacking among US childrenHealth Aff (Millwood) 201029(3)398ndash04 wwwncbinlmnihgovpmcarticlesPMC2837536pdfnihms174260pdf

9 Reedy J Krebs-Smith SM Dietary sources of energy solid fats andadded sugars among children and adolescents in the USJ Am DietAssoc 2010110(10)1477ndash84

10 American Association of Advertising Agencies Integrated marketingcommunications (IMC) Business Dictionarycom wwwbusinessdictionarycomdefınitionintegrated-marketing-communications-IMChtml

11 Kitchen PJ Brignell J Li T Jones GS The emergence of IMC atheoretical perspective J Advertising Res 200444(1)19ndash30

12 Kovacic W Harbour P Leibowitz J Rosch J Marketing food tochildren amp adolescents a review of industry expenditures activitiesand self-regulation Washington DC Federal Trade Commission2008 wwwftcgovos200807P064504foodmktingreportpdf

13 Kumanyika SK Parker L Sim LJ editors Committee on an EvidenceFramework for Obesity Prevention Decision Making Institute of

Medicine Bridging the evidence gap in obesity prevention a frame-

work to inform decision making Washington DC The NationalAcademies Press 2010

14 Cohen DJ Crabtree BF Evaluative criteria for qualitative research inhealth care controversies and recommendations Ann Fam Med20086(4)331ndash9 wannfammedorgcgireprint6433

15 Mays N Pope C Qualitative research in health care assessing qualityin qualitative research BMJ 200032050ndash2

16 Mays N Pope C Popay J Systematically reviewing qualitative andquantitative evidence to inform management and policy-making inthe health fıeld J Health Serv Res Policy 200510(1S)S6ndash20

17 Federal Trade Commission and DHHS Perspective on marketingself-regulation amp childhood obesity a report on a joint workshop of theFederal Trade Commission and DHHS 2006 wwwftcgovos200605PerspectivesOnMarketingSelfRegulationampChildhoodObesityFTCandHHSReportonJointWorkshoppdf

18 General Mills General Mills achieves further sugar reductions in cereals[press release] December 9 2010 wwwgeneralmillscomenMediaNewsReleasesLibrary2010DecemberBigGaspx

19 Pepsi to cut salt sugar and saturated fats Reuters [news release]March 212010wwwreuterscomarticleidUSTRE62K25220100321

20 Kraft Foods Inc Kraft Foods plans to reduce sodium in North Americanproducts an average of 10 percent by 2012 [news release] March 17 2010phxcorporate-irnetphoenixzhtmlc129070amppirol-newsArticleampID1403344

21 KolishEDPeelerCLChangingthelandscapeoffoodampbeverageadvertisingtheChildrenrsquosFoodandBeverageAdvertising Initiative inactionAprogressreport on the fırst sixmonths of implementation JulyndashDecember 2007 Ar-lingtonVACouncilof theBetterBusinessBureaus Inc2008wwwbbborgusstorage16documentsCFBAIChildrenFampBInit_Sept21pdf

22 PeelerCLKolishEDEnrightMTheChildrenrsquosFoodampBeverageAdvertis-ing Initiative in actionA report on compliance and implementationduring2008 Arlington VA Council of the Better Business Bureaus Inc 2009wwwbbborgusstorage0Shared20DocumentsCFBAI20Reportpdf

23 PeelerCLKolishEDEnrightMBurkeCTheChildrenrsquos FoodampBeverageAdvertisingInitiative inactionAreportoncomplianceandimplementationduring 2009 Arlington VA Council of the Better Business Bureaus Inc2010 wwwbbborgusstorage0Shared20DocumentsBBBwithlinkspdf

24 HealthyWeightCommitmentFoundationFoodandbeveragemanufactur-ers pledging to reduce annual calories by 15 trillion by 2015 May 17 2010[press release] wwwhealthyweightcommitorgnews1-5-trillion-calories-by-2015

25 Grocery Manufacturers Association GMA More than two-thirds of theadvertisements seen by children and teens today promote more nutritiousfoods and healthy lifestyles [news release] March 9 2010 httpwwwgmaonlineorgnews-eventsnewsroomgma-more-than-two-thirds-of-the-advertisements-seen-by-children-and-teens-t

26 Powell LM SzczpkaGChaloupka FJ Trends in exposure to televisionfood advertisements among children and adolescents in theUS ArchPediatr Adolesc Med 2010164(9)878ndash9 archpediama-assnorgcgireprint1649794

27 Harris JL Weinberg ME Schwartz MB Ross C Ostroff J Brownell KDTrends in television food advertising Progress in reducing unhealthy mar-keting to young people New Haven CT Rudd Center for Food Policyamp Obesity 2010 wwwyaleruddcenterorgresourcesuploaddocswhatreportsRuddReport_TVFoodAdvertising_210pdf

28 Wartella EA Lichtenstein AH Boon CS editors Committee on Examina-tionofFront-of-PackageNutritionRatingsSystemsandSymbolsInstituteofMedicine Examination of front-of-package nutrition rating systems andsymbols phase I report Washington DC The National Academies Press2010

29 Smart Choices Program helps shoppers identify better food and beveragechoices [media release] August 5 2009 httpwwweurekalertorg

pub_releases2009-08asfn-scp080509php

wwwajpmonlineorg


S

30 HealthyWeight Commitment Foundation HealthyWeight CommitmentFoundation introduced [media release] October 5 2009 wwwhealthyweightcommitorgnewsFoundation_Introduced

31 The White House Offıce of the First Lady Remarks by the First Lady atHealthyWeight Announcement press conference May 17 2010 [press re-lease] wwwwhitehousegovthe-press-offıceremarks-fırst-lady-healthy-weight-announcement-press-conference

32 CounciloftheBetterBusinessBureausNewfoodbeverageinitiativetofocuskidsrsquo adsonhealthychoices revisedguidelines strengthenCARUrsquosguidanceto food advertisers [news release] November 14 2006 wwwbbborgalertsarticleaspID728

33 Council of the Better Business Bureaus Sara Lee Corporationjoins industry initiative to promote healthier foods to kids[news release] September 23 2010 wwwsaraleecommediaED121A9453FE4EBC8FC152A89482F32Bashx

34 Council of the Better Business Bureaus Self-regulatory program for chil-drenrsquosadvertising9theditionNewYorkNYChildrenrsquosAdvertisingReviewUnit 2009wwwcaruorgguidelinesguidelinespdf

35 LukovitzKCFBAItightensnutritionstandards inkidadsMediaPostNewsDecember 17 2009 wwwmediapostcompublicationsfaArticlesshowArticleampart_aid119309

36 Council of the Better Business Bureaus BBBChildrenrsquos Food and BeverageAdvertising Initiative participant defınitions of advertising primarily di-rected to children under 12 and policies for not advertising to childrenunder six wwwbbborgusstorage0Shared20Documentsaudience20defınitions20for20under201220and20under20age20six-fınalpdf

37 Healthy Weight Commitment Foundation 2010 annual review January28 2011 wwwhealthyweightcommitorgHWCF_AnnualReportHWCF_2010_ARpdf


39 LangloisACrossleyRTheproofof thepudding benchmarking tenof theworldrsquos largest food companiesrsquo response to obesity and related health con-cerns United Kingdom JPMorgan and Insight Investment 2008 wwwinsight-investmentcoukglobaldocumentsriliterature367922proof_of_the_pudding_prespdf

40 Harris JL Schwartz MB Brownell K et al Cereal FACTS evaluating thenutrition quality and marketing of childrenrsquos cereals 2009 wwwcerealfactsorgmediaCereal_FACTS_Reportpdf

41 Schwartz MB Ross C Harris JL et al Breakfast cereal industry pledges toself-regulate advertising to youth will they improve the marketinglandscapeJPublicHealthPolicy201031(1)59ndash73wwwpalgrave-journalscomjphpjournalv31n1pdfjphp200950apdf

42 Henry A Story M Food and beverage brands that market to children andadolescents on the Internet a content analysis of branded websites J NutrEducBehav 200941(5)353ndash59

43 Harris JL Bargh JA Brownell KD Priming effects of television food adver-tising on eating behaviorHealthPsychol 200928(4)404ndash13

44 Lingas EODorfmanL Bukofzer ENutrition content of food andbeverageproducts on Web sites popular with children Am J Public Health200999(3S)S587ndash92

45 AlvyLCalvertSLFoodmarketingonpopularchildrenrsquoswebsitesacontentanalysis JAmDietAssoc 2008108(4)710ndash3

46 Batada A Seitz MDWootanMG StoryM Nine out of 10 food advertise-ments shown during Saturdaymorning childrenrsquos television programmingare for foods high in fat sodium or added sugars or low in nutrients J AmDietAssoc 2008108(4)673ndash8

47 GantzW Schwartz N Angelini JR Rideout V Food for thought televisionfood advertisements to children in the US Menlo Park CA The Henry JKaiser Family Foundation 2007wwwkfforgentmediaupload7618pdf

48 Lee M Yoonhyeung C Qilliam ET Cole RT Playing with food contentanalysis of food advergames J Consum Aff 200943(1)129ndash54

www3intersciencewileycomcgi-binfulltext122207659PDFSTART

eptember 2011

49 Moore E Itrsquos childrsquos play advergaming and the onlinemarketing of food tochildren Menlo Park CA The Henry J Kaiser Family Foundation 2006wwwkfforgentmediaupload7536pdf

50 Powell LH Szczypka G Chaloupka FJ Braunschweig CL Nutritional con-tentof televisionfoodadvertisementsseenbychildrenandadolescents intheUS Pediatrics 2007120(3)576ndash83 pediatricsaappublicationsorgcgireprint1203576

51 Weber K StoryM Harnack L Internet foodmarketing strategies aimed atchildren and adolescents a content analysis of food and beverage brandwebsites JAmDietAssoc 2006106(9)1463ndash6

52 MikkelsenLMerloCLeeVChaoCWherersquos the fruitFruit contentof themosthighly-advertisedchildrenrsquos foodandbeveragesOaklandCAPreven-tion Institute 2007 wwwpreventioninstituteorgsafruitwheresthefruitpdf

53 Colby SE Johnson L Scheett A Hoverson B Nutritionmarketing on foodlabels JNutr EducBehav 201042(2)92ndash8

54 Sims J Mikkelsen L Gibson P Warming E Claiming health front-of-package labeling of childrenrsquos food Prevention Institute 2011wwwpreventioninstituteorgcomponentjlibraryarticleid-293127html

55 FederalTradeCommissionFTCinvestigationofadclaimsthatRiceKrispiesbenefıts childrenrsquos immunity leads to stronger order against Kellogg [mediarelease] June 3 2010wwwftcgovopa201006kelloggshtm

56 Childrenrsquos Advertising Review Unit CARU recommends Kellogg discon-tinue certain claimson ldquoPop-Tartsrdquo packagingMay24 2010 [news release]wwwcaruorgnews20105165PRpdf

57 Federal TradeCommissionNestleacute subsidiary to settle FTC false advertisingchargesWilldropdeceptivehealthclaims forBOOSTKidEssentials [mediarelease] July 14 2010wwwftcgovopa201007nestleshtm

58 Neuman W Food label program to suspend operations The New YorkTimes 2009Oct 23wwwnytimescom20091024business24foodhtml

59 Batada A Wootan MG Better-for-who Revisiting company promises onfoodmarketingtochildrenWashingtonDCCenterforScienceinthePublicInterest 2009 cspinetorgnewpdfpledgereportpdf

60 Macmullan J Leftwantingmore food companypolicies onmarketing tochildren London UK Consumers International 2010 wwwjunkfoodgenerationorgdocumentsLeft_wanting_morepdf

61 KunkelDMcKinleyCWrightPThe impact of industry self-regulationonthenutritional quality of foods advertisedon television to childrenOaklandCA Children Now December 2009 wwwchildrennoworguploadsdocumentsadstudy_2009pdf

62 WootanMGBatadaABalkusOFoodmarketingreportcardananalysisoffoodandentertainmentcompanypolicies to self-regulate foodandbeveragemarketing to children Washington DC Center for Science in the PublicInterest 2010 cspinetorgnewpdfmarketingreportcardpdf

63 Kraak VI Story M A public health perspective on the concept of healthylifestyles and public-private partnerships for global obesity prevention AmDietAssoc 2010110(2)192ndash200

64 TheKeystone Center Keystone Forumon away-from-home foods oppor-tunities for preventing weight gain and obesity Washington DC KeystoneCenter 2006 keystoneorgfılesfıleaboutpublicationsForum_Report_FINAL_5-30-06pdf

65 Food and Drug Administration FDA receives Keystone Forum report onaway-from-home foods improving consumersrsquo ability to manage calorieintake key to anti-obesity efforts [news release] June 2 2006 wwwfdagovNewsEventsNewsroomPressAnnouncements2006ucm108661htm

66 Wootan M Batada A Marchlewicz E Kidsrsquo meals obesity on the menuWashington DC Center for Science in Public Interest 2008 wwwcspinetorgkidsmeals

67 OrsquoDonnell SI Hoerr SLMendoza JA Tsuei Goh E Nutrient quality of fastfoodkidsmealsAmJClinNutr 200888(5)1388ndash95

68 Harris JLSchwartzMBBrownellKDetalFast foodFACTSevaluatingfastfood nutrition and marketing to youth Rudd Center for Food Policy and

Obesity 2010wwwrwjforgfılesresearch20101108fffactsreportpdf

1

1

1

1

1

1

1

1

1


69 Nicklas TAHatesDAmericanDieteticAssociationPosition of theAmeri-canDieteticAssociationnutritionguidance forhealthychildrenages2 to11years JAmDietAssoc 2008108(6)1038ndash44 1046ndash7

70 Gidding SS Dennison BA Birch LL et al American Heart AssociationDietary recommendations for children and adolescents A guide for practi-tioners Pediatrics 2006117(2)544ndash59 pediatricsaappublicationsorgcgireprint1172544

71 Roberto CA Larsen PD Agnew H Baik J Brownell KD Evaluating theimpact of menu labeling on food choices and intake Am J Public Health2010100(2)312ndash8

72 Tandon PSWright J Zhou C Rogers CB Christakis DA Nutritionmenulabelingmay leadto lower-calorie restaurantmealchoices forchildrenPedi-atrics 2010125(2)244ndash8 pediatricsaappublicationsorgcgireprint1252244

73 The Walt Disney Company introduces new food guidelines to promotehealthier kidsrsquo diets New policy to associate Disney brands and characterswithamorenutritionallybalancedrangeof foods[newsrelease]October162006 corporatedisneygocomnewscorporate20062006_1016_food_guidelineshtml

74 Grier SA Kumanyika SK The context for choice health implications oftargeted food and beverage marketing to African Americans Am J PublicHealth 200898(9)1616ndash29

75 National Policy and Legal AnalysisNetwork to PreventChildhoodObesityModelCaliforniaordinanceregulatingchainrestaurantgiveawayswithchil-drenrsquos meals 2009 wwwnplanonlineorgchildhood-obesityproductsmodel-ord-healthy-toy-giveaway

76 GordonR SF proposal healthier kidsmeals or no toys The San FranciscoChronicle August 11 2010 wwwsfgatecomcgi-binarticlecgifıleca20100811MNJG1ES4M2DTL

77 OrdinanceNoNS-300-820Anordinanceof theboardof supervisorsof theCountyofSantaClaraaddingChapterXXIIofDivisionA18totheCountyofSantaClaraordinancecode relating to toys andother incentiveswith restau-rant food April 26 2010 wwwsccgovorgkeyboardattachmentsBOS20Agenda2010April2027202010202926863TMPKeyboard203046978pdf

78 GordonRSFfast-foodtoybangetssupervisorsrsquo fırstOKSFGateNovember3 2010 wwwsfgatecomcgi-binarticlecgifca20101102MN111G5PCNDTL

79 Cancino A McDonaldrsquos CEO stands up for Happy Meals The ChicagoTribune July 8 2010 chicagobreakingbusinesscom201007mcdonalds-ceo-stands-up-for-happy-meal-toyshtml

80 WarnerMMcDonaldrsquos magic calories disappear fromHappyMeals afterchain is threatened with lawsuit CBS Business Network (BNET) July 132010 industrybnetcomfood10002721mcdonalds-magic-calories-disappear-from-happy-meals-after-chain-is-threatned-with-lawsuittagcontenttop-activecomments

81 GardnerSLetter toMcDonaldrsquosCorporationandMcDonaldrsquosUSACenterfor Science in the Public Interest v McDonaldrsquos USA LLC June 22 2010cspinetorgnewpdfmcdonalds-demand-062210pdf

82 Center for Science in the Public Interest Class action lawsuit targetsMcDonaldrsquos use of toys tomarket to children December 15 2010 [pressrelease] wwwcspinetorgnew201012151html

83 The White House Offıce of the First Lady Remarks by the First Lady inaddress to theNationalRestaurantAssociationmeetingSeptember132010[press release] wwwwhitehousegovthe-press-offıce20100913remarks-fırst-lady-address-national-restaurant-association-meeting

84 American Beverage Association School Beverage Guidelines Progress Re-port 2006-2007 September 2007 wwwameribevorgfıles240_progress_report_fullpdf

85 AmericanBeverageAssociation School beverage guidelines progress report2007-2008 September 2008 wwwhealthiergenerationorguploadedFilesAbout_The_AllianceSchoolBeverageReportpdf

86 American Beverage Association Alliance School BeverageGuidelines FinalProgress Report 2010 wwwameribevorgfıles240_School20Beverage

20Guidelines20Final20Progress20Reportpdf

87 AmericanBeverageAssociation Beverage industrywillmake caloriesmoreclear and useable for consumers [news release] February 9 2010wwwameribevorgnewsmedianews-releasesstatementsmore180

88 FoodMarketingInstituteHealthampwellnesswwwfmiorghealth-wellness89 FoodMarketing Institute Obesity strategy Approved by the FMI Board of

Directors January 10 2004 wwwfmiorgdocshealthObesityStrategy_2004pdf

90 United Fresh Produce Association News and issues wwwunitedfreshorgnewsviewsproject_fresh_start

91 Association of National Advertising ANA mission wwwananetaboutcontentmission

92 American Association of Advertising Agencies About the AssociationhttpwwwaaaaorgaboutassociationPagesdefaultaspx

93 National Restaurant Association About Us httpwwwrestaurantorgaboutus

94 National Confectioners Association Year in review 2008 ncafılescms-pluscomYear_In_Review_2008pdf

95 SnackFoodAssociationIntroductionwwwsfaorgwhointroductionaspx96 Alliance for aHealthierGeneration President Clinton andAHAannounce

jointagreementbetweenAllianceforaHealthierGenerationandfoodindus-try leaders to set healthy standards for snacking in school October 6 2006[press release] wwwhealthiergenerationorguploadedFilesFor_Schoolssnack-press-releasepdf

97 Borradaile KE Sherman S Vander Veur SS et al Snacking in children therole of urban corner stores Pediatrics 2009124(5)1293ndash8 pediatricsaappublicationsorgcgireprint12451293

98 Farley TA Baker ET Futrell L Rice JC The ubiquity of energy-dense snackfoods a nationalmulticity studyAmJPublicHealth 2010100(2)306ndash11

99 Wilgoren D Mui YQ With praise from Michelle Obama Wal-Martannounces healthy food campaign The Washington Post June 202011 wwwwashingtonpostcomwp-dyncontentarticle20110120AR2011012001581html

00 The White House Offıce of the First Lady First Lady Michelle Obamalaunches LetrsquosMove Americarsquosmove to raise a healthier generation of kidsFebruary 9 2010 [press release] wwwwhitehousegovthe-press-offıcefırst-lady-michelle-obama-launches-lets-move-americas-move-raise-a-healthier-genera

01 White House Task Force on Childhood Obesity Solving the problem ofchildhood obesity within a generationWhite House Task Force on Child-hood Obesity report to the president May 2010 wwwletsmovegovpdfTaskForce_on_Childhood_Obesity_May2010_FullReportpdf

02 NationalRestaurantAssociation saysnutrition informationprovision iswinfor consumers and restaurants March 22 2010 [news release] wwwrestaurantorgpressroompressreleaseID1910

03 Spolar C Eaton J Food lobbymobilizes as soda tax bubbles up The Huff-ington Post November 4 2009 huffpostfundorgstories200911soda-tax-bubbles-food-lobby-mobilizes

04 FoodMarketing InstituteandtheGroceryManufacturersAssociationFoodampbeverage industry announces front-of-pack nutrition labeling initiative toinform consumers and combat obesity [media release] October 27 2010wwwgmaonlineorgnewsdocsNewsReleasecfmDocID2015amp

05 Grocery Manufacturers Association Food and beverage industry launchesnutritionkeysfront-of-packnutritionlabelinginitiativetoinformconsumersand combat obesity [press release] January 24 2011 wwwgmaonlineorgnews-eventsnewsroomfood-and-beverage-industry-launches-nutrition-keys-front-of-pack-nutrition-

06 Food Marketing Institute Food and beverage industry launches NutritionKeys Front-of-Pack Nutrition Labeling Initiative to inform consumers andcombat obesity nutrition icon to be supported by $50 million industry-funded consumer education campaign [news release] January 24 2011wwwfmiorgnews_releasesindexcfmfuseactionmediatextampid1207

07 Neuman W Food makers devise own label plan The New YorkTimes January 24 2011 wwwnytimescom20110125business25labelhtml_r2

08 Council of the Better Business Bureaus Childrenrsquos Food and Beverage Ad-

vertising Initiative program and core principles statement Arlington

wwwajpmonlineorg


VA CBBB Revised Nov 2009 wwwbbborgusstorage0Shared20DocumentsCore20Principles20Final20Letterhead2012-2-09pdf

109 Council of the Better Business Bureaus 3rd annual report on theChildrenrsquosFood and Beverage Advertising Initiative shows excellent compliance[news release] December 15 2010 httpwwwbbborgusarticle3rd-annual-report-on-the-childrens-food-and-beverage-advertising-initiative-shows-excellent-compliance-24271

110 Lukovitz K CFBAI reports on kidsrsquo marketing compliance MediaPostNews December 15 2010 httpwwwmediapostcompublicationsindexcfmfaArticlesshowArticleampart_aid141429

111 HoltDJIppolitoPMDesrochersDMKelleyCRChildrenrsquosexposuretoTVadvertising in 1977 and 2004 zcnFederal Trade Commission Bureau ofEconomics Staff Report 2007wwwftcgovos200706cabecolorpdf

112 Offıce of US Senator Dick Durbin Durbin co-chairs hearing on child-hood obesity [news release] September 23 2008 durbinsenategovshowReleasecfmreleaseId303513

113 CarugatiA FCCdissatisfıedwithmediarsquos reluctance to fıght childhoodobe-sity Worldscreencom September 24 2008 wwwcommercialalertorgissueshealthchildhood-obesityfcc-dissatisfıed-with-medias-reluctance-to-fıght-childhood-obesity

114 Omnibus Appropriations Act of 2009 (HR 1105) rpcsenategovpublic_fılesL6OmnibusAppropriations03022009pdf

115 InteragencyWorkingGrouponFoodMarketed toChildrenTentativepro-posed nutrition standards Washington DC December 15 2009ftcgovbcpworkshopssizingupSNAC_PACpdf

116 Neuman W Ad rules stall keeping cereal a carton staple The New YorkTimes 2010 Jul 24wwwnytimescom20100724businessmedia24foodhtml_r2amphp

117 Thomaselli R FTC subpoenas 48 food companies regarding marketing tokids Advertising Age September 12010 adagecomarticlearticle_id145675

118 Federal Trade Commission Food industrymarketing to children andadolescents study paperwork comment project no P094511 FederalRegister 200974(181)48072ndash5 wwwftcgovos200909090921foodmarketingnoticepdf

119 MontgomeryKCChesterJ Interactivefoodandbeveragemarketing target-ing adolescents in the digital age J Adolesc Health 200945(3S)S18ndash29wwwdigitaladsorgdocumentsPIIS1054139X09001499pdf

120 Council of theBetterBusinessBureausFact Sheeton theElementarySchoolAdvertising Principles Arlington VA CBBB 2009 wwwbbborgusstorage0Shared20DocumentsESFactSheetFinalWordpdf

121 Wootan MG Center for Science in the Public Interest letter to Ms ElaineKolish Childrenrsquos Food and Beverage Advertising Initiative September 222009wwwcspinetorgnewpdfcbbletterpdf

122 Kolish ED Council of the Better Business Bureaus letter to Ms MargoWootan Center for Science in the Public Interest December 14 2009wwwbbborgusstorage0Shared20DocumentsCSPI20response

2012-14-09pdf

September 2011

123 Harris JL Schwatz MB Brownell KD Marketing foods to children andadolescents licensedcharactersandotherpromotionsonpackaged foodsin the supermarket Pub Health Nutr 201013(3)409ndash17 wwwyaleruddcenterorgresourcesuploaddocswhatadvertisingLicensedCharacters_PHN_310pdf

124 RobertoCABaik JHarris JLBrownellKD Influenceof licensed characterson childrenrsquos taste and snack preferences Pediatrics 2010126(1)88ndash93pediatricsaappublicationsorgcgireprint126188

125 Batada AWootanMGNickelodeonmarkets nutrition-poor foods to chil-drenAmJPrevMed200733(1)48ndash50

126 Center for Science in the Public Interest Nickelodeon foodmarketing littleimproved between 2005 amp 2008 October 2008 cspinetorgnewpdfnickelodeon_fact_sheet_2008pdf

127 Martin A Nickelodeon to limit use of characters on junk foods The NewYork Times August 16 2007 httpwwwnytimescom20070816business16kidshtml_r1

128 International Food Information Council Foundation Trends in Obesity-RelatedMediaCoverage September 2009

129 Schwitzer G The state of health journalism in the US The Henry J KaiserFamily Foundation 2009wwwkfforgentmediaupload7858pdf

130 Story M Kaphingst KM Robinson-OrsquoBrien R Glanz K Creating healthyfoodandeatingenvironmentspolicyandenvironmental approachesAnnuRevPublicHealth 200829253ndash72

131 Koplan JP Liverman CT Kraak VI Wisham SL editors Committee onProgress inPreventingObesity inChildrenandYouth InstituteofMedicineProgress inpreventingchildhoodobesityhowdowemeasureupWashing-tonDCTheNationalAcademies Press 2007

132 Interagency Working Group on Food Marketed to Children PreliminaryProposed Nutrition Principles to Guide Industry Self-Regulatory EffortsRequest for Comments FCC CDC FDA and USDA April 2011httpwwwftcgovos201104110428foodmarketproposedguidepdf

133 Food and Drug Administration New front-of-package labeling initiative2009wwwfdagovFoodLabelingNutritionucm202726htm

134 US Department of Agriculture and DHHS Dietary guidelines for Ameri-cans 2010 7th editionWashingtonDC US Government PrintingOffıceDecember 2010wwwcnppusdagovDGAs2010-PolicyDocumenthtm

135 Council of Better Business Bureaus announces groundbreaking agreementon child-directed food advertising [news release] July 14 2011 httpwwwbbborgusarticleCouncil-of-Better-Business-Bureaus-Announces-Groundbreaking-Agreement-on-Ch-28325

Appendix

Supplementary data

Supplementary data associatedwith this article can be found in theonline version at doi101016jamepre201105029

A pubcast created by the authors of this paper can be viewed at

httpwwwajpmonlineorgcontentvideo_pubcasts_collection

Industry Progress to Market a Healthful Diet to American Children and Adolescents

Context

Evidence Acquisition

Evidence Synthesis

Food and Beverage CompaniesmdashModerate Progress Achieved

RestaurantsmdashLimited Progress Achieved

Industry Trade AssociationsmdashLimited Progress Achieved

Marketing Practice StandardsmdashModerate Progress Achieved

Media and Entertainment CompaniesmdashLimited Progress Achieved

Discussion

Conclusion

References

Appendix

Supplementary data

bktcmmetpdmdb

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analyses have confırmed these troubling dietarytrends4ndash9

The IOM committee conducted a systematic literaturereview and found that TV advertising influenced chil-drenrsquos preferences and purchase requests diets andhealth The committeersquos fındings were limited to TV ad-vertising because of knowledge gaps and lack of access toproprietary information about newer forms of inte-grated marketing communications (IMC) wherebycompanies combine advertising public relations salespromotion direct marketing sponsorships and point-of-purchase with many communication techniques toprovide clarity consistency and maximum impact toreach customers1011

The IOM committee3 also found that leading food andeverage companies spent substantial resources to mar-et branded food and beverage products to young peoplehat do not support a healthful diet These fındings wereonfırmed by the Federal Trade Com-ission (FTC)12 According to the 2006arketing expenditures of 44 food bev-rage and restaurant companies morehan $16 billion were spent to marketrimarily unhealthy products to chil-ren and adolescents of which $870illion were spent to market to chil-ren aged 12 years and more than $1illion were spent to market to adolescents12

The IOMcommittee concluded that food and beveragemarketing influences the diets and health of children andadolescents current marketing practices are out of bal-ance with a healthful diet and create an environment thatputs young peoplersquos health at risk companies and mar-keters have underutilized their potential to apply re-sources and creativity to market a healthful diet achiev-ing a healthful diet will require industry leadership andsustained multisectoral and integrated efforts and cur-rent public policy lacks support or authority to addressemerging marketing practices that influence dietsThe IOM report offered 10 recommendations to guide

diverse private- and public-sector stakeholders to pro-mote a healthful diet to children and adolescents Thefırst fıve recommendations focus on industry stakehold-ers including food beverage and restaurant companiesindustry trade associations food retailers entertainmentcompanies and the mediaA companion paper will address public-sector stake-

holder progress This paper reviews the available evi-dence between December 1 2005 and January 31 2011to evaluate industry stakeholdersrsquo progress to market ahealthful diet to children and adolescents The results are

Srela

CommeMcGinthis i

discussed within the context of potential opportunities

eptember 2011

and actions industry stakeholders might pursue to ad-vance progress toward the IOM food marketing reportrecommendations

Evidence AcquisitionTable 1 summarizes the methods used to evaluate indus-try progress The investigators (1) established the evi-dence selection approach criteria and search strategyincluding search terms (2) conducted a literature reviewbetween December 1 2005 and January 31 2011 ofelectronic databases federal government agency web-sites company and industry websites gray-literaturestudies and reports and media stories or news releases(3) selected and categorized 117 evidence sources (n47published articles and reports and n70 media stories ornews releases) into two evidence tables (4) indepen-dently reviewed the evidence for the major IOM recom-mendations and subrecommendations before assigning

an evaluation category and reached con-sensus on the progress evaluation category(ie no limited moderate and extensive)for stakeholder groups in a specifıc sectorpertinent to each recommendation and(5) identifıed opportunities and potentialactions that industry stakeholders couldtake to accelerate progress toward the IOMfoodmarketing recommendations based on

the evidence table other expert committee reports andgrounded in the evolving policy developments for eacharea exploredTo guide the evidence selection and interpretation the

investigators used principles developed by a separateIOM expert committee in 201013 based on an obesity-prevention decision-making framework to locate evalu-te and assemble evidence to inform decisions (LEAD)he LEAD principles were developed for decisionmakerso use a systems perspective to identify the type of evi-ence required to answer specifıc public health questionshen evidence is limited but actions must be taken TheEAD approach combines available evidence with the-ry professional experience and local wisdom to informecision making and integrates scientifıc evidence intoroader factors that influence obesity-prevention poli-ies13 The investigators selected the LEAD approach be-cause it was appropriate to the research task to use allavailable evidence to inform policy Food marketing toyoung people is a complex issue requiring diverse evi-dence from broad areas to evaluate overall progress overtimemade bymultiple stakeholders to market a healthfuldiet to children and adolescentsThe investigators used fıve accepted qualitative-

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Context


Evidence Synthesis






Discussion

Conclusion

References

Appendix

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2012-14-09pdf

September 2011














Appendix

Supplementary data





Context


Evidence Synthesis






Discussion

Conclusion

References

Appendix

Supplementary data