An accountability evaluation for the industry's responsible use of brand mascots and licensed media characters to market a healthy diet to American children

Corporate strategies that target children are controversial given the link between food marketing and childhood obesity. This case study explored diverse stakeholders' accountability expectations and actions for industry policies and practices that used popular cartoon brand mascots and media characters to promote food products to American children. We reviewed five electronic databases and Internet sources between January 2000 and January 2015. Evidence (n = 90) was selected based upon the Institute of Medicine's LEAD principles (i.e. locate, evaluate, assemble evidence to inform decisions) and organized into two tables: peer‐reviewed articles, books and grey‐literature reports (n = 34); and media stories, news releases and public testimony (n = 56). A four‐step accountability framework was used to evaluate accountability structures. The results showed that moderate progress was achieved by stakeholders to take and share the account, limited progress to hold industry and government to account, and limited progress to strengthen accountability structures. Between 2006 and 2015, the U.S. Children's Food and Beverage Advertising Initiative lacked clear policies for companies to use brand mascots and media characters on food packages, in merchandising, and as toy giveaways and premiums. Government, industry and civil society can substantially strengthen their accountability for these food marketing practices to ensure healthy food environments for children.     

Associations between social media,adolescent mental health,and diet: A systematic review

Social media use is integral to many adolescents' lives. It brings benefits but can also have detrimental effects on both physical and mental health. We conducted a systematic review examining associations between social media use, adolescent mental health (including body image, self-esteem, stress, interpersonal relationships and loneliness, anxiety, and depressive symptoms), and dietary outcomes. Quantitative studies published between 2019 and 2023 investigating both mental health and diet were searched in 11 databases. The risk of bias was appraised using ROBINS-E. Data were narratively synthesized by type of association, PROGRESS-Plus health equity characteristics, and related to social media influencers. Twenty-one studies were included, of which only one focused on influencers. Sex/gender was the only equity characteristic assessed (n = 8), with mixed results. The findings suggest significant positive correlations between social media use and both depressive and disordered eating symptoms, body dissatisfaction, and anxiety. Four studies identified body image, self-esteem, or anxiety as moderators acting between social media exposure and dietary outcomes. Policy interventions mitigating the impact of social media on adolescents—particularly body image and disordered eating—are needed, alongside follow-up studies on causal pathways, the role of influencers, equity impacts, dietary intake, and the best measurement tools to use.     

Behavioral science in video games for children's diet and physical activity change: key research needs

Innovative intervention programs are needed to overcome the limitations in previous programs that promoted change in diabetes risk behaviors in children. Serious video games show promise of changing dietary and physical activity behaviors, but research is needed on the optimal design of behavior-change procedures in video games, the mechanisms that account for changes obtained, and the groups in which these interventions work best. Such research will permit the optimal design of serious video games for diabetes and obesity prevention in the future.     

Prevalence of healthy and unhealthy food and beverage price promotions and their potential influence on shopper purchasing behaviour: A systematic review of the literature

Policies to restrict unhealthy food and beverage price promotions have been recommended, as part of a broader strategy to reduce obesity, but little evidence underpins such recommendations. We aimed to synthesize the literature on the prevalence of healthy and unhealthy food and beverage price promotions and their potential influence on purchasing behaviour. Eight scientific databases (covering health, business, and marketing) and grey literature were systematically searched using search terms related to “food and beverage price promotions” up until July 2019. Articles were included if they examined prevalence of, and/or consumer response to, food and non‐alcoholic beverage price promotions, from a nutritional perspective. Of the 16 included studies, eight examined the prevalence of price promotions and eight examined the potential influence of price promotions on purchasing behaviour. Seven of the “prevalence” studies found that price promotions were more common for unhealthy foods and beverages. Seven “influence” studies found a greater proportion of price‐promoted purchases were for unhealthy compared with healthy products. Policies that reduce the prevalence and/or influence of price promotions on unhealthy foods and beverages may shift consumer purchasing away from unhealthy foods and beverages. Empirical studies are required to better understand how consumers and industry may respond to such policies.     

Influence of unhealthy food and beverage marketing on children's dietary intake and preference: a systematic review and meta‐analysis of randomized trials

Marketing of foods and beverages high in fat, sugar and salt are suggested to contribute to poor dietary behaviours in children and diet‐related diseases later in life. This systematic review and meta‐analysis of randomized trials aimed to assess the effects of unhealthy food and beverage marketing on dietary intake (grams or kilocalories) and dietary preference (preference score or percentage of participants who selected specific foods/beverages) among children 2 to 18 years of age. We searched MEDLINE, EMBASE and PsycINFO up to January 2015 for terms related to advertising, unhealthy foods or beverages among children. Randomized trials that assessed the effects of unhealthy food and beverage marketing compared with non‐dietary advertisement or no advertisement in children were considered eligible. Two authors independently extracted information on study characteristics and outcomes of interest and assessed risk of bias and the overall quality of evidence using grade methodology. Meta‐analysis was conducted separately for dietary intake and preference using a random‐effects model. We identified 29 eligible studies, of which 17 studies were included for meta‐analysis of dietary preference and nine for meta‐analysis of dietary intake. Almost half of the studies were at high risk of bias. Our meta‐analysis showed that in children exposed to unhealthy dietary marketing, dietary intake significantly increased (mean difference [MD] = 30.4 kcal, 95% confidence interval [CI] 2.9 to 57.9, and MD = 4.8 g, 95%CI 0.8 to 8.8) during or shortly after exposure to advertisements. Similarly, children exposed to the unhealthy dietary marketing had a higher risk of selecting the advertised foods or beverages (relative risk = 1.1, 95%CI 1.0 to 1.2; P = 0.052). The evidence indicates that unhealthy food and beverage marketing increases dietary intake (moderate quality evidence) and preference (moderate to low quality evidence) for energy‐dense, low‐nutrition food and beverage. Unhealthy food and beverage marketing increased dietary intake and influenced dietary preference in children during or shortly after exposure to advertisements. © 2016 World Obesity     

Effect of changes to the school food environment on eating behaviours and/or body weight in children: a systematic review

Previous school obesity‐prevention reviews have included multi‐component interventions. Here, we aimed to review the evidence for the effect of isolated food environment interventions on both eating behaviours (including food purchasing) and/or body weight. Five electronic databases were searched (last updated 30 November 2013). Of the 1,002 unique papers identified, 55 reported on school food environment changes, based on a review of titles and abstracts. Thirty‐seven further papers were excluded, for not meeting the inclusion criteria. The final selection consisted of 18 papers (14 United States, 4 United Kingdom). Two studies had a body mass index (BMI) outcome, 14 assessed purchasing or eating behaviours and two studies assessed both weight and behaviour. Seventeen of 18 papers reported a positive outcome on either BMI (or change in BMI) or the healthfulness of food sold or consumed. Two studies were rated as strong quality and 11 as weak. Only three studies included a control group. A school environment supportive of healthy eating is essential to combat heavy marketing of unhealthy food. Modification of the school food environment (including high‐level policy changes at state or national level) can have a positive impact on eating behaviours. A need exists, however, for further high‐quality studies.     

The impact of initiatives to limit the advertising of food and beverage products to children: a systematic review

In response to increasing evidence that advertising of foods and beverages affects children's food choices and food intake, several national governments and many of the world's larger food and beverage manufacturers have acted to restrict the marketing of their products to children or to advertise only ‘better for you’ products or ‘healthier dietary choices’ to children. Independent assessment of the impact of these pledges has been difficult due to the different criteria being used in regulatory and self‐regulatory regimes. In this paper, we undertook a systematic review to examine the data available on levels of exposure of children to the advertising of less healthy foods since the introduction of the statutory and voluntary codes. The results indicate a sharp division in the evidence, with scientific, peer‐reviewed papers showing that high levels of such advertising of less healthy foods continue to be found in several different countries worldwide. In contrast, the evidence provided in industry‐sponsored reports indicates a remarkably high adherence to voluntary codes. We conclude that adherence to voluntary codes may not sufficiently reduce the advertising of foods which undermine healthy diets, or reduce children's exposure to this advertising.     

A systematic review and meta-analysis of the effect of digital game-based or influencer food and non-alcoholic beverage marketing on children and adolescents: Exploring hierarchy of effects outcomes

Videogame livestreaming platforms are an emerging form of digital media, popular with young people, where users watch gaming influencers play videogames. Food and non-alcoholic beverage (hereafter: food) brands have a substantial presence on these platforms, yet no studies have examined the impact of this food marketing on young people. This systematic review and meta-analysis examined the evidence (quantitative or mixed-method) for a relationship between exposure to digital game-based or influencer food marketing, and food-related (brand awareness, attitudes, preferences, purchase, and consumption), and post-consumption (weight, body mass index [BMI], and dental caries) outcomes in young people (≤18 years). Twenty-three databases were searched in March 2021. Twenty-two studies met the inclusion criteria, of which 20 were included in the quantitative synthesis. Meta-analyses indicated food marketing was associated with more positive attitudes and greater preferences (OR = 1.74, p < 0.001 [95%CI: 1.355, 2.232]), and increased consumption (SMD = 0.37, p < 0.001 [95%CI: 0.219, 0.529]). Narrative synthesis indicated that food marketing may increase brand awareness but not pester intent, although data were limited. Evidence suggests that there is a relationship between exposure to food marketing via influencers and digital gaming media, and several food-related outcomes. This is the first quantitative synthesis to demonstrate these relationships; this work has implications for food marketing policy.     

Obesity and the Mediterranean diet: a systematic review of observational and intervention studies

World Health Organization projections estimate that worldwide approximately one‐third of adults are overweight and one‐tenth are obese. There is accumulating research into the Mediterranean diet and whether it could prevent or treat obesity. Therefore, the purpose of this paper was to systematically review and analyse the epidemiological evidence on the Mediterranean diet and overweight/obesity. We identified 21 epidemiological studies that explored the relationship between the Mediterranean diet and weight. These included seven cross‐sectional, three cohort and 11 intervention studies. Of these, 13 studies reported that Mediterranean diet adherence was significantly related to less overweight/obesity or more weight loss. Eight studies found no evidence of this association. Exploring the relationship between the Mediterranean diet and overweight/obesity is complex, and there are important methodological differences and limitations in the studies that make it difficult to compare results. Although the results are inconsistent, the evidence points towards a possible role of the Mediterranean diet in preventing overweight/obesity, and physiological mechanisms can explain this protective effect. Despite this, more research is needed to substantiate this association. Epidemiological studies should use a consistent universal definition of the Mediterranean diet, and address common methodological limitations to strengthen the quality of research in this area.     

Children's and parents' opinions on the sport‐related food environment: a systematic review

Sport is a key setting for interventions to address child obesity given its obesogenic nature. Understanding children's and parents' opinions on the sport‐related food environment is critical in developing effective programmes and policies to improve children's health. This systematic review synthesizes quantitative and qualitative research examining children's and parents' opinions on the sport‐related food environment. During July 2016, a range of electronic databases of academic and grey literature were searched. Thirty‐two publications (11 including children, 17 parents and 4 both) were included for review. The publications were assessed using the Analysis Grid for Environments Linked to Obesity framework to categorize the sport‐related food environment into the physical, sociocultural, economic and political environments. The literature available investigating children's and parents' opinions of the sport‐related food environment suggests that many children and parents consider the environment neither conducive to nor supportive of children's healthy food behaviours or wider health and well‐being. Both groups would likely support actions to change and improve it. This systematic review found that original research specifically investigating children's and parents' perspectives on almost all aspects of the sport‐related food environment is limited. Thus, there is scope for further investigation into this important part of children's food environments.     

Impact of food labelling systems on food choices and eating behaviours: a systematic review and meta‐analysis of randomized studies

Food labels are considered a crucial component of strategies tackling unhealthy diets and obesity. This study aims at assessing the effectiveness of food labelling in increasing the selection of healthier products and in reducing calorie intake. In addition, this study compares the relative effectiveness of traffic light schemes, Guideline Daily Amount and other food labelling schemes. A comprehensive set of databases were searched to identify randomized studies. Studies reporting homogeneous outcomes were pooled together and analysed through meta‐analyses. Publication bias was evaluated with a funnel plot. Food labelling would increase the amount of people selecting a healthier food product by about 17.95% (confidence interval: +11.24% to +24.66%). Food labelling would also decrease calorie intake/choice by about 3.59% (confidence interval: ?8.90% to +1.72%), but results are not statistically significant. Traffic light schemes are marginally more effective in increasing the selection of healthier options. Other food labels and Guideline Daily Amount follow. The available evidence did not allow studying the effects of single labelling schemes on calorie intake/choice. Findings of this study suggest that nutrition labelling may be an effective approach to empowering consumers in choosing healthier products. Interpretive labels, as traffic light labels, may be more effective.     

A systematic review of the Australian food retail environment: Characteristics,variation by geographic area,socioeconomic position and associations with diet and obesity

There is strong support across multiple sectors for the implementation of policies to create healthier food environments as part of comprehensive strategies to address obesity and improve population diets. The existing evidence base describing food retail environments and their relationship with health outcomes is limited in several respects. This systematic review examines the current evidence regarding food retail environments in Australia, including associations with diet and people with obesity, and socioeconomic and geographic disparities. Three databases were searched and independently screened. Studies were included if they were undertaken in Australia and objectively measured the food retail environment. Sixty papers were included. The broad range of methodological approaches used across studies limited the ability to synthesize the evidence and draw conclusions. Results indicated that there is some evidence that disparities exist in food retail environments across measures of socioeconomic position and geographic area in parts of Australia. Overall, there were inconsistent findings regarding the association between the healthiness of food retail environments and diet or people with obesity. Findings support previous calls for standardized tools and measures for monitoring the healthiness of food retail environments. This is imperative to inform evidence‐based policy and evaluation in this critical component of recommended obesity prevention strategies.     

Assessing the potential effectiveness of food and beverage taxes and subsidies for improving public health: a systematic review of prices,demand and body weight outcomes

Taxes and subsidies are increasingly being considered as potential policy instruments to incentivize consumers to improve their food and beverage consumption patterns and related health outcomes. This study provided a systematic review of recent U.S. studies on the price elasticity of demand for sugar‐sweetened beverages (SSBs), fast food, and fruits and vegetables, as well as the direct associations of prices/taxes with body weight outcomes. Based on the recent literature, the price elasticity of demand for SSBs, fast food, fruits and vegetables was estimated to be ?1.21, ?0.52, ?0.49 and ?0.48, respectively. The studies that linked soda taxes to weight outcomes showed minimal impacts on weight; however, they were based on existing state‐level sales taxes that were relatively low. Higher fast‐food prices were associated with lower weight outcomes particularly among adolescents, suggesting that raising prices would potentially impact weight outcomes. Lower fruit and vegetable prices were generally found to be associated with lower body weight outcomes among both low‐income children and adults, suggesting that subsidies that would reduce the cost of fruits and vegetables for lower‐socioeconomic populations may be effective in reducing obesity. Pricing instruments should continue to be considered and evaluated as potential policy instruments to address public health risks.     

Efficacy of very low‐energy diet programs for weight loss: A systematic review with meta‐analysis of intervention studies in children and adolescents with obesity

The objective of this review was to evaluate the efficacy and safety of very low‐energy diet (VLED) programs for weight loss in children and adolescents with obesity. Six electronic databases were searched identifying 24 eligible studies (16 pre‐post studies, four nonrandomized trials, two randomized controlled trials [RCTs], and two chart reviews) published up to October 2018. Studies were in English, implemented a VLED (≤3360 kJF/day [≤800 kcal/day] or <50% estimated energy requirements) in 5‐ to 18‐year‐olds with obesity, and reported at least one weight‐related outcome. Weight‐related outcomes significantly improved postintervention in all studies. Meta‐analysis of 20 studies indicated a mean 10.1 kg (95% confidence interval [CI], 8.7‐11.4 kg, P < 0.001; I² = 92.3%) weight loss following interventions lasting 3 to 20 weeks. Moderator analysis indicated greater weight loss in adolescent‐only studies (10‐18 years) and formulated meal replacement interventions and inpatient settings. Meta‐analysis of seven studies reporting weight at follow‐up (5‐14.5 months from baseline) indicated 5.3 kg mean weight loss (CI, 2.5‐8.0 kg, P < 0.001; I² = 50.6%). Details of adverse events were limited. VLED programs are effective for treating children and adolescents with obesity. However, conclusions on their safety cannot be drawn from the existing literature at this time. Future studies should include long‐term follow‐up with ongoing support and comprehensive monitoring of all adverse events.     

Effect of DASH diet on oxidative stress parameters: A systematic review and meta-analysis of randomized clinical trials

Background and aimsOxidative stress (OS) is one of the main risk factors for several chronic diseases. The Dietary Approaches to Stop Hypertension (DASH) contain many antioxidants and may contribute to managing OS.ObjectiveTo perform a systematic review and meta-analysis to examine the impacts of the DASH diet on OS parameters.MethodsA comprehensive electronic search in MEDLINE, Scopus, EMBASE, and the Cochrane Central Register of Controlled Trials was performed through September 2020 to find related studies evaluating the impact of the DASH diet on OS parameters. Standardized mean differences were pooled using random-effects meta-analysis.ResultsEight studies with a total of 317 subjects met our inclusion criteria. Four studies included in meta-analysis model with 200 participants (100 in treatment and 100 in control group). The DASH diet was associated with a statistically significant decrease in malondialdehyde (MDA) (SMD: −0.53; 95% CI: −0.89, −0.16; I² = 42.1%), and a significant increase in glutathione (GSH) (SMD: 0.83; 95% CI: 0.36, 1.03; I² = 42.1%). Meta-analysis found no statistically significant effect of DASH diet on nitric oxide (NO) (SMD: −1.40; 95% CI: −0.12, 1.93; I² = 92.6%) or total antioxidant capacity (TAC) levels (SMD: 0.95; 95% CI: −0.10, 1.99; I² = 87.6%).ConclusionOur results demonstrated that a DASH diet could significantly increase GSH and decrease MDA levels. Furthermore, there is a trend to improve TAC, NO, and f2-isoprostanes by the adherence to the DASH diet. However, long-term, large sample size and well-designed randomized clinical trials are still needed to draw concrete conclusions about DASH diet’s effects on OS parameters.     

The effect of screen advertising on children's dietary intake: A systematic review and meta‐analysis

Evidence indicates that screen advertising for unhealthy food results in significant increases in dietary intake among children. This review was undertaken with the main aim of estimating the quantitative effect of screen advertising in experimental and nonexperimental conditions on children's dietary intake. Systematic searches were undertaken of interdisciplinary databases. Studies from 1980 to April 2018, all geography and languages, were included; participants were children and adolescents aged between 2 and 18 years; the intervention was screen advertising; and the outcome was dietary intake. Meta‐analyses were conducted for measured and nonmeasured outcomes. Food advertising was found to increase dietary intake among children (age range 2‐14, mean 8.8 years) in experimental conditions for television (TV) advertising and advergames. Meta‐analysis revealed that children exposed to food advertising on TV (11 studies) and advergames (five studies) respectively consumed an average 60.0 kcal (95% confidence interval [CI], 3.1‐116.9) and 53.2 kcal (95% CI, 31.5‐74.9) more than children exposed to nonfood advertising. There was also an effect by body mass index (BMI). Findings from nonexperimental studies revealed that exposure to TV food advertising was positively associated with and predictive of dietary intake in children. Short‐term exposure to unhealthy food advertising on TV and advergames increases immediate calorie consumption in children.     

Fast food consumption and increased caloric intake: a systematic review of a trajectory towards weight gain and obesity risk

Consumption of fast food, which have high energy densities and glycemic loads, and expose customers to excessive portion sizes, may be greatly contributing to and escalating the rates of overweight and obesity in the USA. Whether an association exists between fast food consumption and weight gain is unclear. Sixteen studies (six cross sectional, seven prospective cohort, three experimental) meeting methodological and relevance criteria were selected for inclusion in this systematic review. While more research needs to be conducted specifically in regard to effects of fast food consumption among subpopulations such as children and adolescents, sufficient evidence exists for public health recommendations to limit fast food consumption and facilitate healthier menu selection. As the fast food industry continues to increase both domestically and abroad, the scientific findings and corresponding public health implications of the association between fast food consumption and weight are critical.