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.     

The quality of dietary intake methodology and reporting in child and adolescent obesity intervention trials: a systematic review

Assessing dietary intake is important in evaluating childhood obesity intervention effectiveness. The purpose of this review was to evaluate the dietary intake methods and reporting in intervention studies that included a dietary component to treat overweight or obese children. A systematic review of studies published in the English language, between 1985 and August 2010 in health databases. The search identified 2,295 papers, of which 335 were retrieved and 31 met the inclusion criteria. Twenty‐three studies reported energy intake as an outcome measure, 20 reported macronutrient intakes and 10 studies reported food intake outcomes. The most common dietary method employed was the food diary (n = 13), followed by 24‐h recall (n = 5), food frequency questionnaire (FFQ) (n = 4) and dietary questionnaire (n = 4). The quality of the dietary intake methods reporting was rated as ‘poor’ in 15 studies (52%) and only 3 were rated as ‘excellent’. The reporting quality of FFQs tended to be higher than food diaries/recalls. Deficiencies in the quality of dietary intake methods reporting in child obesity studies were identified. Use of a dietary intake methods reporting checklist is recommended. This will enable the quality of dietary intake results to be evaluated, and an increased ability to replicate study methodology by other researchers.     

Associations of maternal stress with children's weight‐related behaviours: a systematic literature review

Low adherence to guidelines for weight‐related behaviours (e.g. dietary intake and physical activity) among US children underscores the need to better understand how parental factors may influence children's obesity risk. In addition to most often acting as primary caregiver to their children, women are also known to experience greater levels of stress than men. This study systematically reviewed associations between maternal stress and children's weight‐related behaviours. Our search returned 14 eligible articles, representing 25 unique associations of maternal stress with a distinct child weight‐related behaviour (i.e. healthy diet [n = 3], unhealthy diet [n = 6], physical activity [n = 7] and sedentary behaviour [n = 9]). Overall, findings for the relationship between maternal stress and children's weight‐related behaviours were mixed, with no evidence for an association with children's healthy or unhealthy dietary intake, but fairly consistent evidence for the association of maternal stress with children's lower physical activity and higher sedentary behaviour. Recommendations for future research include prioritizing prospective designs, identifying moderators, and use of high‐resolution, real‐time data collection techniques to elucidate potential mechanisms.     

Mediators of socioeconomic inequalities in dietary behaviours among youth: A systematic review

Children and adolescents with a lower socioeconomic position have poorer dietary behaviours compared to their counterparts with a higher socioeconomic position. A better understanding of the mechanisms behind such socioeconomic inequalities is vital to identify targets for interventions aimed at tackling these inequalities. This systematic review aimed to summarize existing evidence regarding the mediators of socioeconomic differences in dietary behaviours among youth. A systematic literature search of MEDLINE, Embase, PsycINFO, and Web of Science databases yielded 20 eligible studies. The dietary behaviours included in the reviewed studies were the intake of fruit and vegetables, sugar‐sweetened beverages, unhealthy snacks/fast food and breakfast. The consistent mediators of the effects of socioeconomic position on dietary behaviours among youth were: self‐efficacy, food preferences and knowledge at the intrapersonal level; and availability and accessibility of food items at home, food rules and parental modelling at the interpersonal level. Few studies including mediators at the organisational, community or policy levels were found. Our review found several modifiable factors at the intrapersonal and interpersonal levels that could be targeted in interventions aimed at combating inequalities in dietary behaviours among youth. Rigorous studies exploring organisational, community and policy level mediators are warranted.     

A systematic review of fast food access studies

The frequent consumption of energy‐dense fast food is associated with increased body mass index. This systematic review aims to examine the methodology and current evidence on fast food access and its associations with outcomes. Six databases were searched using terms relating to fast food. Only peer‐reviewed studies published in English during a 10‐year period, with data collection and analysis regarding fast food access were included. Forty articles met the aforementioned criteria. Nearly half of the studies (n = 16) used their own set of features to define fast food. Studies predominantly examined the relationship between fast food access and socioeconomic factors (n = 21) and 76% indicated fast food restaurants were more prevalent in low‐income areas compared with middle‐ to higher‐income areas. Ten of 12 studies found fast food restaurants were more prevalent in areas with higher concentrations of ethnic minority groups in comparison with Caucasians. Six adult studies found higher body mass index was associated with living in areas with increased exposure to fast food; four studies, however, did not find associations. Further work is needed to understand if and how fast food access impacts dietary intake and health outcomes; and if fast food access has disparate socioeconomic, race/ethnicity and age associations.     

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.     

Influence of food companies' brand mascots and entertainment companies' cartoon media characters on children's diet and health: a systematic review and research needs

Reducing the extent and persuasive power of marketing unhealthy foods to children worldwide are important obesity prevention goals. Research is limited to understand how brand mascots and cartoon media characters influence children's diet. We conducted a systematic review of five electronic databases (2000–2014) to identify experimental studies that measured how food companies' mascots and entertainment companies' media characters influence up to 12 diet‐related cognitive, behavioural and health outcomes for children under 12 years. Eleven studies met the inclusion criteria. Studies used 21 unique popular media characters, but no brand mascots. Results suggest that cartoon media character branding can positively increase children's fruit or vegetable intake compared with no character branding. However, familiar media character branding is a more powerful influence on children's food preferences, choices and intake, especially for energy‐dense and nutrient‐poor foods (e.g. cookies, candy or chocolate) compared with fruits or vegetables. Future research should use a theoretically grounded conceptual model and larger and more diverse samples across settings to produce stronger findings for mediating and moderating factors. Future research can be used to inform the deliberations of policymakers, practitioners and advocates regarding how media character marketing should be used to support healthy food environments for children.     

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     

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 of the influence of the retail food environment around schools on obesity‐related outcomes

The high prevalence of childhood obesity has led to questions about the influence of ‘obesogenic’ environments on children's health. Public health interventions targeting the retail food environment around schools have been proposed, but it is unclear if they are evidence based. This systematic review investigates associations between food outlets near schools and children's food purchases, consumption and body weight. We conducted a keyword search in 10 databases. Inclusion criteria required papers to be peer reviewed, to measure retailing around schools and to measure obesity‐related outcomes among schoolchildren. Thirty papers were included. This review found very little evidence for an effect of the retail food environment surrounding schools on food purchases and consumption, but some evidence of an effect on body weight. Given the general lack of evidence for association with the mediating variables of food purchases and consumption, and the observational nature of the included studies, it is possible that the effect on body weight is a result of residual confounding. Most of the included studies did not consider individual children's journeys through the food environment, suggesting that predominant exposure measures may not account for what individual children actually experience. These findings suggest that future interventions targeting the food environment around schools need careful evaluation.     

A systematic review of neighbourhood economic context on child obesity and obesity‐related behaviours

Childhood obesity is of great importance given a third of children in the USA are overweight or obese. Previous research has examined neighbourhood economic context in relation to children's obesity and obesity‐rated behaviours. However, different definitions and measures of neighbourhood context make it difficult to compare findings and make definitive conclusions. This review is to synthesize studies assessing the associations between neighbourhood economic context and children's obesity or obesity‐related behaviours. The review included 39 studies investigating the relationship between residential neighbourhood economic context and children's obesity, dietary habits or physical activity after controlling for family‐level economic status. Studies reported mixed results in the relationship between neighbourhood economic indicators and child obesity outcomes. Of reviewed studies, 60% showed an inverse association between higher neighbourhood economic status and obesity, and 33% and 14% showed positive associations between higher neighbourhood economic status and healthy dietary habits or physical activity. Several studies suggested gender, age, race/ethnicity, individual‐level economic status, rurality and social connectedness as moderators in the neighbourhood‐obesity association. Findings suggest that, in order to move towards causal inferences and inform interventions, future research should examine neighbourhood impacts longitudinally and test theory‐driven mediators and moderators to clarify the mechanisms by which neighbourhoods influence child obesity.     

Evidence of a possible link between obesogenic food advertising and child overweight

A recent review of the literature concluded that advertising of foods on television may influence children's food choices and encourage unhealthy diets, but the review acknowledged there was a lack of clear evidence in coming to this conclusion. The present paper examines ecological evidence for a link between advertising to children and the risk of overweight using data from surveys of advertising on children's television and estimates of the prevalence of overweight among children, in the USA, Australia and eight European countries. A significant association was found between the proportion of children overweight and the numbers of advertisements per hour on children's television, especially those advertisements that encourage the consumption of energy‐dense, micronutrient‐poor foods (r = 0.81, P < 0.005). A weaker, negative association was found between the proportion of children overweight and the number of advertisements encouraging healthier diets (r = ?0.56, P < 0.10). The quantity of advertising on children's television appears to be related to the prevalence of excess body weight among children. Furthermore, the content of the advertising appears to have a specific effect. The findings justify the need for taking precautionary measures to reduce children's exposure to obesogenic marketing practices.     

Systematic review of the relationship between childcare educators' practices and preschoolers' physical activity and eating behaviours

The role of childcare educators is important given that 81% of preschoolers living in developed countries receive childcare outside their home. Since children learn by observing and imitating others, childcare educators may play a role in promoting healthy eating behaviours and physical activity in young children. Six databases were searched for quantitative peer‐reviewed, English or French primary studies reporting the correlates, predictors or effectiveness of childcare educators' practices on preschoolers' healthy eating and physical activity behaviours. Risk of bias was assessed using the Quality Assessment Tool for Quantitative Studies. Fifteen articles were included in this review: 10 measured physical activity levels and five assessed eating behaviours. The quality score was rated as low for eight of these articles, and as moderate for the remaining seven. Two of four cross‐sectional studies reported a positive relationship between educators and children's behaviours. Eleven intervention studies reported significant favourable effects of interventions. Educators may play a positive role in promoting healthy behaviours in children, but this is mainly based on a small number of intervention type studies of low or moderate quality. The influence of specific components of educators' practices on children's healthy eating and physical activity behaviours remains inconclusive.     

Effectiveness of school‐based interventions to prevent obesity among children aged 4 to 12 years old in middle‐income countries: A systematic review and meta‐analysis

Economic and accompanying nutrition transition in middle‐income countries is resulting in rapidly increasing childhood obesity prevalence, exceeding acceleration rates in the West. Previous school‐based obesity prevention reviews have mainly included studies from high‐income countries. This review aimed to summarize the evidence from randomized controlled trials evaluating the effectiveness of school‐based interventions in preventing childhood obesity in middle‐income countries. Six electronic databases were searched: MEDLINE, EMBASE, CINAHL Plus, LILACS, IBECS and WPRIM. Eligibility criteria included middle‐income country setting, randomized/cluster‐randomized controlled trials, children aged 4–12 years and school‐based interventions targeting dietary intake and/or physical activity. Twenty‐one cluster‐randomized controlled trials, conducted in Asia (n = 10), South America (n = 4), North America (n = 4) and the Middle East (n = 3), were included. Fifteen studies reported a significant intervention effect on at least one adiposity‐related outcome. Characteristics of effective interventions included combined diet and PA interventions, school teacher‐delivery, duration of >8 months, parental involvement, education sessions and school food modifications. The risk of bias in these trials was mixed. The pooled estimate of the odds ratio for obesity in intervention versus control schools (nine studies) was 0.77; 95% CI, 0.63 to 0.94; p = 0.009. In conclusion, there is some evidence to support school‐based interventions in preventing childhood obesity in middle‐income countries.     

Diet and blood lipids in 1–4 year-old children

Background and aimEarly nutrition may programme blood lipid levels and thereby later cardiovascular health of children. The objective here was to evaluate the effects of maternal dietary counselling during pregnancy and breastfeeding on dietary intakes and blood lipid values in 1–4 year-old children. Further, the nutritional determinants of children's lipid profiles were assessed.Methods and resultsMothers were randomised into dietary counselling or control groups at the first trimester of pregnancy. Their children were followed up clinically at 1, 2 and 4 years of age, by three-day food records and analyses of total cholesterol, HDL cholesterol and apolipoproteins A-I and B as well as lipoprotein (a). In general, the mean intake of saturated fatty acids as a proportion of total energy intake (E%) was higher than the recommended, while the mean intake of polyunsaturated fatty acids was low in children's diet. Over the first years, girls had higher concentration of non-HDL cholesterol than boys; 2.64 mmol/l (95% CI 2.54–2.74) vs. 2.49 (2.38–2.60); p = 0.038. Maternal dietary counselling was not reflected in the children's lipid values. Children's monounsaturated fatty acid intake (E%) correlated with apoA-I (p = 0.048) and, furthermore, there was a negative correlation between polyunsaturated fatty acid intake (E%) and apoB (p = 0.046).ConclusionChildren's dietary fatty acid intake, but not maternal dietary counselling was shown to be related to blood apolipoproteins in children.     

Changes in consumption of added sugars from age 13 to 30 years: a systematic review and meta‐analysis of longitudinal studies

Added sugar intake during adolescence has been associated with weight gain and cardiometabolic risk factors. Moreover, dietary habits may persist into adulthood, increasing chronic disease risk in later life. This systematic review investigated changes in intake of added sugars between the ages of 13 and 30 years. Literature databases were searched for longitudinal studies of diet during adolescence or early adulthood. Retrieved articles were screened for studies including multiple measures of intake of sugars or sugary foods from cohort participants between the ages of 13 and 30. Data were analysed using random‐effects meta‐analysis, by the three main nutrient and food group categories identified (PROSPERO: CRD42015030126). Twenty‐four papers reported longitudinal data on intake of added sugar or sucrose (n = 6), sugar‐sweetened beverages (SSBs) (n = 20) and/or confectionery (n = 9). Meta‐analysis showed a non‐significant per year of age decrease in added sugar or sucrose intake (?0.15% total energy intake (95%CI ?0.41; 0.12)), a decrease in confectionery consumption (?0.20 servings/week (95%CI ?0.41; ?0.001)) and a non‐significant decrease in SSB consumption (?0.15 servings/week (95%CI ?0.32; 0.02)). Taken together, the overall decrease in added sugar intake observed from adolescence to early adulthood may suggest opportunities for intervention to further improve dietary choices within this age range.     

Associations between socioeconomic position and correlates of sedentary behaviour among youth: a systematic review

Existing research evidence indicates that children and adolescents of parents with a low socioeconomic position spend more time on sedentary behaviour than their counterparts. However, the mechanisms driving these differences remain poorly understood. The main aim of this systematic review was to summarize the evidence regarding the association between socioeconomic position and correlates of sedentary behaviour among youth (0–18 years) from developed countries. The literature search was conducted using MEDLINE, Embase, CINAHL and PsycINFO. A total of 37 studies were included. All but three studies examined screen‐based sedentary behaviours only. Methodological quality ranged from low to moderate. Education was the most commonly used indicator of socioeconomic position, followed by income. Socioeconomic position was inversely related to the presence of a TV in the child's bedroom, parental modelling for TV viewing, parental co‐viewing and eating meals in front of the TV. We found no/indeterminate evidence for an association between socioeconomic position and rules and regulations about screen time. The findings suggest possible factors that could be targeted in future intervention studies to decrease screen‐based sedentary behaviour in lower socioeconomic groups in particular.     

Feasibility,acceptability, and effectiveness of a multidisciplinary intervention in childhood obesity from primary care: Nutrition,physical activity,emotional regulation,and family

Childhood obesity is a growing problem with a complex aetiology, for which multidisciplinary interventions are required. Our programme describes a novel structured psychosocial family‐based intervention targeting the emotional regulation in childhood obesity, using a train trip metaphor aimed at improving healthy lifestyles for the family. The aims were (a) to describe the feasibility and acceptability of this psychosocial family‐based intervention among children with overweight or obesity in primary care and (b) to examine the effectiveness of the “ENTREN‐F” programme (with family intervention) compared with the “ENTREN” programme (without family intervention) among Spanish children regarding anthropometric variables, physical activity, emotional well‐being, and family functioning. Children were randomly allocated to either ENTREN‐F programme (n = 30) or psychological intervention for children (ENTREN, n = 40), and assessments were carried out over time (T₀ baseline vs. T₁ post/6‐month vs. T₂ 6‐month follow‐up). Both parent groups expressed high levels of satisfaction with the interventions. ENTREN‐F resulted in higher adherence to treatment and was more effective in improving z–body mass index, reducing children's anxiety, and increasing family adaptability than the ENTREN programme. There were no significant changes in parents' emotional well‐being and expressed emotion. Both groups improved in the children's emotional well‐being and light physical activity. In summary, this multidisciplinary psychosocial family‐based intervention was succesful.     

An examination of comorbid asthma and obesity: assessing differences in physical activity,sleep duration,health-related quality of life and parental distress

Objective: Compare youth with comorbid asthma and obesity to youth with obesity only to determine if differences exist in body mass index, dietary intake, levels of physical activity, sleep duration and health-related quality of life. Levels of parent distress were also compared. Methods: Participants included 248 children (n?=?175 in Obesity group; n?=?73 in Asthma?+?Obesity group) with a BMI?≥?85th percentile for age and gender, and their participating parent(s) or legal guardian(s). Measures of child height and weight were obtained by study personnel and Z-scores for child body mass index were calculated using age- and gender-specific norms. Child physical activity and sleep duration were measured via accelerometers. Dietary intake, health-related quality of life and parent distress were assessed via self-report. Results: The Asthma?+?Obesity group evidenced significantly higher body mass index scores, and had lower sleep duration. There was a non-statistically significant trend for lower levels of physical activity among children in the Asthma?+?Obesity group. Dietary intake, health-related quality of life and parent distress did not differ between groups. Conclusions: Youth with comorbid asthma and obesity are at increased risk for negative health and psychosocial difficulties compared to youth who are overweight or obese only. Professionals providing treatment for youth with asthma are encouraged to assess the implications of weight status on health behaviors and family psychosocial adjustment.     

Determinants of sugar‐sweetened beverage consumption in young children: a systematic review

Sugar‐sweetened beverage (SSB) consumption is associated with adverse health outcomes. Improved understanding of the determinants will inform effective interventions to reduce SSB consumption. A total of 46,876 papers were identified through searching eight electronic databases. Evidence from intervention (n = 13), prospective (n = 6) and cross‐sectional (n = 25) studies on correlates/determinants of SSB consumption was quality assessed and synthesized. Twelve correlates/determinants were associated with higher SSB consumption (child's preference for SSBs, TV viewing/screen time and snack consumption; parents' lower socioeconomic status, lower age, SSB consumption, formula milk feeding, early introduction of solids, using food as rewards, parental‐perceived barriers, attending out‐of‐home care and living near a fast food/convenience store). Five correlates/determinants were associated with lower SSB consumption (parental positive modelling, parents' married/co‐habiting, school nutrition policy, staff skills and supermarket nearby). There was equivocal evidence for child's age and knowledge, parental knowledge, skills, rules/restrictions and home SSB availability. Eight intervention studies targeted multi‐level (child, parents, childcare/preschool setting) determinants; four were effective. Four intervention studies targeted parental determinants; two were effective. One (effective) intervention targeted the preschool environment. There is consistent evidence to support potentially modifiable correlates/determinants of SSB consumption in young children acting at parental (modelling), child (TV viewing) and environmental (school policy) levels.