Better Health For All

By Jennifer Mindell, Reader in Public Health, Research Department of Epidemiology and Public Health, University College London

Today nearly a third of children aged two to 15 are overweight or obese (1, 2), and younger generations are becoming obese at earlier ages and staying obese for longer. Given the evidence that children and adults’ diet is influenced by advertising, summarised by Adams and colleagues (3), the World Health Organization (WHO) made 12 recommendations in 2010 about marketing food and non-alcoholic drinks to children (4).

However, industry spends 500 times as much on promoting high fat, salt or sugar (HFSS) foods as the WHO spends on promoting healthy diets. For example, food companies in the UK spend one billion pounds on marketing. Not surprisingly to a public health audience, there are marked differences in proportions between constituents of a healthy diet and food advertising (Figure). The ways that marketing can influence behaviour, as well as some examples, were available in the presentation given at the FPH 2017 annual conference session organised by the FPH Health Improvement Committee.

Adapted from: www.foodcomm.org.uk/pdfs/Broadcasting_bad_health.pdf

In the UK, legal restrictions on television advertising of HFSS foods to children under 16 focused on preventing screening of such advertisements on children’s channels, and around or during programmes on general channels of particular appeal to children aged 4-15 years. As the Health Improvement Committee had predicted, this had no effect on children’s exposure overall (despite adherence to the restrictions) because of increased HFSS advertising around programmes aimed at a general audience, not covered by these regulations, screened before 9pm (4): larger numbers of children watch these general programmes than watch ‘children’s TV’. Similar restrictions were introduced on 1 July 2017 on advertising HFSS foods to children under 16 via non-broadcast media, including on children’s media and on media where children form more than 25% of the audience. However, the exclusions are many (see examples).

Discussions by about 25 people at the FPH conference session produced the following policy suggestions:
A. Gold standard: Ban advertising of all HFSS products (regardless of to whom, when, where).
B. Banning marketing aimed at or influencing children is a good place to start, if (A) isn’t (yet) politically acceptable. This should be a part safeguarding children.
C. We need to keep reiterating our point that the proportion of the audience who are children is irrelevant:

• Far more children may watch a generally popular show (eg. X Factor) than children’s TV or TV programmes where children are 25%+ of the audience, so restrictions need to apply based on the number of children exposed as well as the percentage.
• Advertising aimed overtly at adults also influences children through what adults buy for them, what adults do, and what adults see as the norm.

D. Online material is now more important than TV; even TV is mostly watched on-demand, so the timing of programmes is now largely irrelevant: Should we ignore the watershed?
E. Ban anything aimed at children or young people, eg. toys, cartoon characters, celebrities, that can increase desirability of the associated HFSS products or influence behaviour adversely. The Olympics should not be associated with MacDonalds, Coca Cola, etc.
F. Ban HFSS product displays and marketing at point of sale (PoS) eg. supermarket checkouts, newsagents.
G. Ban displays of HFSS products at children’s height (put on top shelves only?)
H. Ban HFSS displays or marketing posters in shop windows (seen by children as they pass).
I. Ban marketing that displays people eating except when sitting at a table for a meal The benefit of the Mediterranean diet may be partly because of eating slowly at a family meal while talking, etc, instead of eating ‘on the go’, as well as the actual diet itself.
J. Harness the opportunity of controlled environments to change the accepted norms (eg. rules for schools, workplaces, hospitals, prisons).
K. Recognise the time it takes to change social norms and to make regulation socially acceptable; balance this with the size of impact of HFSS products on health and health inequalities.
L. Need for a clear iteration of the harms of HFSS with agreement amongst influential public health bodies, to start influencing the debate.

Other ideas suggested were to ban price-based promotions of HFSS, given that fruit is often more expensive to buy than crisps or chocolate bars. Chile introduced health warnings and standardised packages for HFSS last year; we need to monitor what effects these have. Brexit may yield an opportunity to influence front-of-packaging labelling, for example by portion size rather than per 100g, if EU rules no longer apply. Given most children’s incessant exposure to marketing, schools should be encouraged to teach advertising literacy.

The main conclusions by those attending as that this is a societal responsibility, rather than individuals or their parents being to blame. Population-level initiatives are needed to control commercial activities that are costly to the country both in terms of poor health and regarding healthcare, social care, and economic costs of ill health.

References:

1. Fuller E, Mindell J, Prior G (Eds). Health Survey for England trend tables 2015. Leeds: NHS Digital, 2016.
2. Childhood obesity: a plan for action. London, 2017. https://www.gov.uk/government/publications/childhood-obesity-a-plan-for-action/childhood-obesity-a-plan-for-action
3. Adams J, Tyrrell R, Adamson AJ, White M. Effects of restrictions on television food advertising to children on exposure to advertisements for ‘less healthy’ foods: repeat cross-sectional study. Plos One. 2012;7(2):e31578.
4. World Health Organization. Set of recommendations on the foods and non-alcoholic beverages to children. Geneva: WHO, 2010.