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

      Context

      The IOM released an expert committee report in 2005 that assessed the nature, extent, and influence of food and beverage marketing practices on the diets and health of American children and adolescents. The report concluded that prevailing marketing practices did not support a healthful diet and offered recommendations for diverse stakeholders to promote a healthful diet. The investigators evaluated progress made by food, beverage, and restaurant companies; trade associations; entertainment companies; and the media to achieve the IOM report recommendations over 5 years.

      Evidence acquisition

      A literature review was conducted of electronic databases and relevant government, industry, and media websites between December 1, 2005, and January 31, 2011. Evidence selection was guided by the IOM LEAD principles (i.e., locate, evaluate, and assemble evidence to inform decisions) and five qualitative-research criteria, and it was validated by data and investigator triangulation. The investigators selected and categorized 117 data sources into two evidence tables used to evaluate industry progress (i.e., no, limited, moderate, and extensive).

      Evidence synthesis

      Food and beverage companies made moderate progress; however, limited progress was made by other industry subsectors. Industry stakeholders used integrated marketing communications (IMC) to promote primarily unhealthy products, which threaten children's and adolescents' health and miss opportunities to promote a healthy eating environment.

      Conclusions

      Diverse industry stakeholders have several untapped opportunities to advance progress by promoting IMC to support a healthful diet; substantially strengthening self-regulatory programs; supporting truthful and non-misleading product labeling and health claims; engaging in partnerships; and funding independent evaluations of collective efforts.

      Context

      Food and beverage marketing to children and adolescents is a complex, contentious, and rapidly evolving issue linked to the U.S. overweight and obesity crisis that affects one third (32%) of American children and adolescents, aged 2–19 years.
      • Ogden C.L.
      • Carroll M.D.
      • Curtin L.R.
      • Lamb M.M.
      • Flegal K.M.
      Prevalence of high body mass index in U.S. children and adolescents, 2007–2008.
      • Ogden C.L.
      • Carroll M.D.
      • Flegal K.M.
      High body mass index for age among U.S. children and adolescents, 2003–2006.
      In 2004, Congress directed the IOM of the National Academies to convene an expert committee to review the evidence for food and beverage marketing practices that influence the diets of children and adolescents and recommend strategies to promote a healthful diet. In December 2005, the IOM released an expert committee report, Food Marketing to Children and Youth: Threat or Opportunity?
      • McGinnis J.M.
      • Gootman J.A.
      • Kraak VI,
      Committee on Food Marketing and the Diets of Children and Youth; Institute of Medicine
      Food marketing to children and youth: threat or opportunity?.
      which assessed the nature, extent, and influence of food and beverage marketing on the diets and health of American children and adolescents.
      See related Commentary by McGinnis in this issue.
      The IOM committee documented that most American children and adolescents have inadequate intakes of nutrient-dense food groups (i.e., fruits, vegetables, whole grains, and low-fat dairy) and consume lower than recommended levels of shortfall nutrients (i.e., potassium, fiber, and calcium).
      • McGinnis J.M.
      • Gootman J.A.
      • Kraak VI,
      Committee on Food Marketing and the Diets of Children and Youth; Institute of Medicine
      Food marketing to children and youth: threat or opportunity?.
      Young people also have excessive intakes of energy-dense foods and beverages and consume higher than recommended levels of nutrients of concern (i.e., sodium, added sugars, total calories, total fat, and saturated fat). Recent analyses have confirmed these troubling dietary trends.
      • Spear B.A.
      • Barlow S.E.
      • Ervin C.
      • et al.
      Recommendations for treatment of child and adolescent overweight and obesity.
      Committee on Nutrition Standards for National School Lunch and Breakfast Programs; National Research Council
      Nutrition standards and meal requirements for national school lunch and breakfast programs: phase I.
      DHHS, U.S.Department of Agriculture
      Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines for Americans, 2010.
      • Siega-Riz A.M.
      • Deming D.M.
      • Reidy K.C.
      • Fox M.K.
      • Condon E.
      • Briefel R.R.
      Food consumption patterns of infants and toddlers: where are we now?.
      • Piernas C.
      • Popkin B.M.
      Trends in snacking among U.S. children
      • Reedy J.
      • Krebs-Smith S.M.
      Dietary sources of energy, solid fats, and added sugars among children and adolescents in the U.S.
      The IOM committee conducted a systematic literature review and found that TV advertising influenced children's preferences and purchase requests, diets, and health. The committee's findings were limited to TV advertising because of knowledge gaps and lack of access to proprietary information about newer forms of integrated marketing communications (IMC), whereby companies combine advertising, public relations, sales promotion, direct marketing, sponsorships, and point-of-purchase with many communication techniques to provide clarity, consistency, and maximum impact to reach customers.
      American Association of Advertising Agencies
      Integrated marketing communications (IMC) Business Dictionary.com.
      • Kitchen P.J.
      • Brignell J.
      • Li T.
      • Jones G.S.
      The emergence of IMC: a theoretical perspective.
      The IOM committee
      • McGinnis J.M.
      • Gootman J.A.
      • Kraak VI,
      Committee on Food Marketing and the Diets of Children and Youth; Institute of Medicine
      Food marketing to children and youth: threat or opportunity?.
      also found that leading food and beverage companies spent substantial resources to market branded food and beverage products to young people that do not support a healthful diet. These findings were confirmed by the Federal Trade Commission (FTC).
      • Kovacic W.
      • Harbour P.
      • Leibowitz J.
      • Rosch J.
      Marketing food to children & adolescents: a review of industry expenditures, activities, and self-regulation.
      According to the 2006 marketing expenditures of 44 food, beverage, and restaurant companies, more than $1.6 billion were spent to market primarily unhealthy products to children and adolescents, of which $870 million were spent to market to children aged <12 years and more than $1 billion were spent to market to adolescents.
      • Kovacic W.
      • Harbour P.
      • Leibowitz J.
      • Rosch J.
      Marketing food to children & adolescents: a review of industry expenditures, activities, and self-regulation.
      The IOM committee concluded that food and beverage marketing influences the diets and health of children and adolescents; current marketing practices are out of balance with a healthful diet and create an environment that puts young people's health at risk; companies and marketers have underutilized their potential to apply resources and creativity to market a healthful diet; achieving a healthful diet will require industry leadership and sustained, multisectoral, and integrated efforts; and current public policy lacks support or authority to address emerging marketing practices that influence diets.
      The IOM report offered 10 recommendations to guide diverse private- and public-sector stakeholders to promote a healthful diet to children and adolescents. The first five recommendations focus on industry stakeholders including food, beverage, and restaurant companies; industry trade associations; food retailers; entertainment companies; and the media.
      A companion paper will address public-sector stakeholder progress. This paper reviews the available evidence between December 1, 2005, and January 31, 2011, to evaluate industry stakeholders' progress to market a healthful diet to children and adolescents. The results are discussed within the context of potential opportunities and actions industry stakeholders might pursue to advance progress toward the IOM food marketing report recommendations.

      Evidence Acquisition

      Table 1 summarizes the methods used to evaluate industry progress. The investigators (1) established the evidence selection approach, criteria, and search strategy, including search terms; (2) conducted a literature review between December 1, 2005, and January 31, 2011, of electronic databases, federal government agency websites, company and industry websites, gray-literature studies and reports, and media stories or news releases; (3) selected and categorized 117 evidence sources (n=47 published articles and reports and n=70 media stories or news releases) into two evidence tables; (4) independently reviewed the evidence for the major IOM recommendations and subrecommendations before assigning an evaluation category, and reached consensus on the progress evaluation category (i.e., no, limited, moderate, and extensive) for stakeholder groups in a specific sector pertinent to each recommendation; and (5) identified opportunities and potential actions that industry stakeholders could take to accelerate progress toward the IOM food marketing recommendations based on the evidence table, other expert committee reports, and grounded in the evolving policy developments for each area explored.
      Table 1Methodologic approach used to evaluate industry progress
      I. Investigators used the IOM LEAD principles (i.e., locate, evaluate, and assemble evidence to inform decisions) to establish evidence selection approach, criteria, and search strategy
        Five qualitative-research criteria (i.e., data relevance, research-design quality, professional judgment, contextual analysis, and credibility by data verification)
        Search terms (i.e., child, children, adolescents, food advertising, food marketing, beverage advertising, health, wellness, obesity, overweight, food retail, restaurant, fast food, media, entertainment, product reformulation, labeling, nutrient profiling, health claim, nutrient claim, advertising, marketing, industry self-regulation, licensed character, and partnership)
        Triangulation (i.e., data and investigator) to identify convergence of evidence
      II. LOCATE: Investigators conducted a literature review between December 1, 2005, and January 31, 2011
        Electronic databases (i.e., MEDLINE, Science Direct, LexisNexis, Library of Congress, Business Source Premier and Mergent)
        U.S. federal government agency websites (i.e., DHHS, CDC, Department of Education, Federal Communications Commission, Food and Drug Administration, Federal Trade Commission, NIH, U.S. Department of Agriculture, and the Office of the White House Press Secretary)
        Websites of food, beverage, restaurant, and entertainment companies and industry trade associations
        Studies and reports released by industry, government, nonprofit organization, foundations, and academic institutions
        Media stories, press and news releases
      III. EVALUATE and ASSEMBLE: Investigators selected and categorized 117 evidence sources (n=47 published articles or reports and n=70 media stories, press or news releases) into two evidence tables that contained the following information:
        Primary author, year, and reference number
        Study design or report description (i.e., government, industry, foundation, nongovernment organization, peer-reviewed journal article, and expert committee report), or media story, press or news release description
        Major findings
      All of the available evidence was considered before one of four evaluation categories was selected (i.e., no, limited, moderate, and extensive) for stakeholders within a specific sector pertinent to each IOM recommendation, drawing from these criteria:
        Stakeholder transparency, accountability, cooperation, and collaboration within and across sectors with other groups (e.g., government and public health advocates), consistency of actions, establishing and implementing meaningful goals and benchmarks, and voluntary reporting on progress to promote a healthful diet to children and adolescents
      IV. INFORM DECISIONS: Investigators identified opportunities and potential actions that industry stakeholders could take to advance progress toward the IOM food marketing recommendations
        Proposed actions are grounded in the evidence tables, the evolving policy developments for each relevant area, and supported by other expert committee and advisory group reports
      To guide the evidence selection and interpretation, the investigators used principles developed by a separate IOM expert committee in 2010,
      Committee on an Evidence Framework for Obesity Prevention Decision Making; Institute of Medicine
      based on an obesity-prevention decision-making framework to locate, evaluate, and assemble evidence to inform decisions (LEAD). The LEAD principles were developed for decisionmakers to use a systems perspective to identify the type of evidence required to answer specific public health questions when evidence is limited but actions must be taken. The LEAD approach combines available evidence with theory, professional experience, and local wisdom to inform decision making and integrates scientific evidence into broader factors that influence obesity-prevention policies.
      Committee on an Evidence Framework for Obesity Prevention Decision Making; Institute of Medicine
      The investigators selected the LEAD approach because it was appropriate to the research task to use all available evidence to inform policy. Food marketing to young people is a complex issue requiring diverse evidence from broad areas to evaluate overall progress over time made by multiple stakeholders to market a healthful diet to children and adolescents.
      The investigators used five accepted qualitative-research criteria
      • Cohen D.J.
      • Crabtree B.F.
      Evaluative criteria for qualitative research in health care: controversies and recommendations.
      (i.e., data relevance, research-design quality, professional judgment, contextual analysis, and credibility by data verification) and data and investigator triangulation to validate evidence convergence.
      • Mays N.
      • Pope C.
      Qualitative research in health care: assessing quality in qualitative research.
      • Mays N.
      • Pope C.
      • Popay J.
      Systematically reviewing qualitative and quantitative evidence to inform management and policy-making in the health field.
      The search terms were selected after reviewing the existing food and beverage marketing literature (Table 1). The initial search yielded hundreds of documents. The investigators repeated and refined subsequent searches according to specific evaluations that pertained to the IOM recommendations for each industry sector examined.
      Appendix A (available online at www.ajpmonline.org) summarizes the study designs, report descriptions, and findings for 47 evidence sources. Appendix B (available online at www.ajpmonline.org) lists 70 media stories, press, or news releases used for the evaluation.
      Figure 1 provides the recommendations for industry stakeholders, specific action domains, and a progress evaluation for each industry sector. The investigators convened to discuss opportunities and actions that industry decision makers might take to accelerate progress toward the IOM committee's recommendations. Figure 1 highlights potential opportunities and actions that are grounded in the evidence tables, the evolving policy developments for each area, and supported by other expert committee and advisory group reports. The results are presented in a narrative summary.
      Figure thumbnail gr1
      Figure 1Potential opportunities and actions for industry stakeholders to promote a healthful diet to American children and adolescents
      Note: Based on the IOM private-sector recommendations
      ABA, American Beverage Association; CARU, Children's Advertising Review Unit; CBBB, Council of the Better Business Bureaus, Inc.; CFBAI, Children's Food and Beverage Advertising Initiative; FMI, Food Marketing Institute; FDA, Food and Drug Administration; FTC, Federal Trade Commission; GMA, Grocery Manufacturers Association; IMC, Integrated Marketing Communications; IWG, Federal Interagency Working Group on Marketing to Children (i.e., CDC, FDA, FTC, USDA); NRA, Natonal Restaurant Association; SFA, Snack Food Association

      Evidence Synthesis

      The evaluation showed that extensive progress was not made by any industry stakeholder to achieve the IOM recommendations (Figure 1). Moderate progress was made by food and beverage companies and industry, in cooperation with public-sector groups, to improve marketing practice standards; and limited progress was made by restaurants, industry trade associations, entertainment companies, and the media over the 5-year period reviewed.

      Food and Beverage Companies—Moderate Progress Achieved

      Industry reports suggest that progress was made to reformulate and expand healthier products
      Federal Trade Commission and DHHS
      Perspective on marketing, self-regulation, & childhood obesity: a report on a joint workshop of the Federal Trade Commission and DHHS, 2006.
      General Mills
      General Mills achieves further sugar reductions in cereals [press release].
      Pepsi to cut salt, sugar and saturated fats
      Reuters [news release].
      Kraft Foods Inc
      Kraft Foods plans to reduce sodium in North American products an average of 10 percent by 2012 [news release].
      • Kolish E.D.
      • Peeler C.L.
      Changing the landscape of food & beverage advertising: the Children's Food and Beverage Advertising Initiative in action A progress report on the first six months of implementation: July–December 2007.
      • Peeler C.L.
      • Kolish E.D.
      • Enright M.
      The Children's Food & Beverage Advertising Initiative in action A report on compliance and implementation during 2008.
      • Peeler C.L.
      • Kolish E.D.
      • Enright M.
      • Burke C.
      The Children's Food & Beverage Advertising Initiative in action A report on compliance and implementation during 2009.
      Healthy Weight Commitment Foundation
      Food and beverage manufacturers pledging to reduce annual calories by 1.5 trillion by 2015.
      ; reduce TV advertising for unhealthy products (i.e., sweet snacks and sugar-sweetened beverages [SSBs])
      • Kolish E.D.
      • Peeler C.L.
      Changing the landscape of food & beverage advertising: the Children's Food and Beverage Advertising Initiative in action A progress report on the first six months of implementation: July–December 2007.
      • Peeler C.L.
      • Kolish E.D.
      • Enright M.
      The Children's Food & Beverage Advertising Initiative in action A report on compliance and implementation during 2008.
      • Peeler C.L.
      • Kolish E.D.
      • Enright M.
      • Burke C.
      The Children's Food & Beverage Advertising Initiative in action A report on compliance and implementation during 2009.
      Grocery Manufacturers Association
      GMA: More than two-thirds of the advertisements seen by children and teens today promote more nutritious foods and healthy lifestyles [news release].
      that was supported by two independent evaluations
      • Powell L.M.
      • Szczpka G.
      • Chaloupka F.J.
      Trends in exposure to television food advertisements among children and adolescents in the U.S..
      • Harris J.L.
      • Weinberg M.E.
      • Schwartz M.B.
      • Ross C.
      • Ostroff J.
      • Brownell K.D.
      Trends in television food advertising
      Progress in reducing unhealthy marketing to young people?.
      ; develop front-of-package (FOP) labeling for consumers to identify healthy products
      Committee on Examination of Front-of-Package Nutrition Ratings Systems and Symbols; Institute of Medicine
      Smart Choices Program helps shoppers identify better food and beverage choices [media release].
      ; and initiate partnerships to promote a healthful diet and healthy lifestyles.
      Healthy Weight Commitment Foundation
      Healthy Weight Commitment Foundation introduced [media release].
      The White House Office of the First Lady
      Remarks by the First Lady at Healthy Weight Announcement press conference.
      In 2006, the Council of the Better Business Bureaus (CBBB) and National Advertising Review Council announced revisions to strengthen the Children's Advertising Review Unit's (CARU's) self-regulatory guidelines and released the Children's Food and Beverage Advertising Initiative (CFBAI).
      Council of the Better Business Bureaus
      New food, beverage initiative to focus kids' ads on healthy choices; revised guidelines strengthen CARU's guidance to food advertisers [news release].
      The CFBAI became operational with ten food companies in July 2007.
      • Kolish E.D.
      • Peeler C.L.
      Changing the landscape of food & beverage advertising: the Children's Food and Beverage Advertising Initiative in action A progress report on the first six months of implementation: July–December 2007.
      By September 2010, 17 companies (15 food and beverage companies and two restaurant companies) participated in the CFBAI and voluntarily pledged to shift the child-directed advertising messages to encourage healthier dietary choices and healthy lifestyles.
      Council of the Better Business Bureaus
      Sara Lee Corporation joins industry initiative to promote healthier foods to kids [news release].
      Three CFBAI monitoring reports were released at 6, 12, and 24 months (2008–2010)
      • Kolish E.D.
      • Peeler C.L.
      Changing the landscape of food & beverage advertising: the Children's Food and Beverage Advertising Initiative in action A progress report on the first six months of implementation: July–December 2007.
      • Peeler C.L.
      • Kolish E.D.
      • Enright M.
      The Children's Food & Beverage Advertising Initiative in action A report on compliance and implementation during 2008.
      • Peeler C.L.
      • Kolish E.D.
      • Enright M.
      • Burke C.
      The Children's Food & Beverage Advertising Initiative in action A report on compliance and implementation during 2009.
      that documented high compliance with company pledges for child-directed advertising. The CFBAI guidelines were strengthened and revised in 2009 and 2010.
      Council of the Better Business Bureaus
      Self-regulatory program for children's advertising.
      • Lukovitz K.
      CFBAI tightens nutrition standards in kid ads MediaPost News.
      Council of the Better Business Bureaus
      BBB Children's Food and Beverage Advertising Initiative: participant definitions of advertising primarily directed to children under 12 and policies for not advertising to children under six.
      Several food and beverage companies promote healthy lifestyles through public–private partnerships with industry coalitions, such as the Healthy Weight Commitment Foundation (HWCF),
      Healthy Weight Commitment Foundation
      Healthy Weight Commitment Foundation introduced [media release].
      Healthy Weight Commitment Foundation
      2010 annual review.
      and the Partnership for a Healthier America (PHA).
      The White House Office of the First Lady
      Remarks by the First Lady at Healthy Weight Announcement press conference.
      The investigators' progress evaluation found that despite positive actions reported, product reformulations showed only incremental changes to meet healthier nutrient profiles
      • Langlois A.
      • Crossley R.
      The proof of the pudding…benchmarking ten of the world's largest food companies' response to obesity and related health concerns.
      • Harris J.L.
      • Schwartz M.B.
      • Brownell K.
      • et al.
      Cereal FACTS: evaluating the nutrition quality and marketing of children's cereals.
      • Schwartz M.B.
      • Ross C.
      • Harris J.L.
      • et al.
      Breakfast cereal industry pledges to self-regulate advertising to youth: will they improve the marketing landscape?.
      ; companies continued to advertise and market unhealthy foods and beverages to young people
      • Kovacic W.
      • Harbour P.
      • Leibowitz J.
      • Rosch J.
      Marketing food to children & adolescents: a review of industry expenditures, activities, and self-regulation.
      • Henry A.
      • Story M.
      Food and beverage brands that market to children and adolescents on the Internet: a content analysis of branded websites.
      • Harris J.L.
      • Bargh J.A.
      • Brownell K.D.
      Priming effects of television food advertising on eating behavior.
      • Lingas E.O.
      • Dorfman L.
      • Bukofzer E.
      Nutrition content of food and beverage products on Web sites popular with children.
      compared to pre-December 2005 marketing trends
      • Alvy L.
      • Calvert S.L.
      Food marketing on popular children's web sites: a content analysis.
      • Batada A.
      • Seitz M.D.
      • Wootan M.G.
      • Story M.
      Nine out of 10 food advertisements shown during Saturday morning children's television programming are for foods high in fat, sodium, or added sugars, or low in nutrients.
      • Gantz W.
      • Schwartz N.
      • Angelini J.R.
      • Rideout V.
      Food for thought: television food advertisements to children in the U.S..
      • Lee M.
      • Yoonhyeung C.
      • Qilliam E.T.
      • Cole R.T.
      Playing with food: content analysis of food advergames.
      • Moore E.
      It's child's play: advergaming and the online marketing of food to children.
      • Powell L.H.
      • Szczypka G.
      • Chaloupka F.J.
      • Braunschweig C.L.
      Nutritional content of television food advertisements seen by children and adolescents in the U.S..
      • Weber K.
      • Story M.
      • Harnack L.
      Internet food marketing strategies aimed at children and adolescents: a content analysis of food and beverage brand websites.
      ; companies used misleading advertising and health claims to promote children's products
      • Mikkelsen L.
      • Merlo C.
      • Lee V.
      • Chao C.
      Where's the fruit? Fruit content of the most highly-advertised children's food and beverages.
      • Colby S.E.
      • Johnson L.
      • Scheett A.
      • Hoverson B.
      Nutrition marketing on food labels.
      • Sims J.
      • Mikkelsen L.
      • Gibson P.
      • Warming E.
      Claiming health: front-of-package labeling of children's food Prevention Institute.
      and the FTC and CARU investigated certain claims
      Federal Trade Commission
      FTC investigation of ad claims that Rice Krispies benefits children's immunity leads to stronger order against Kellogg [media release].
      Children's Advertising Review Unit
      CARU recommends Kellogg discontinue certain claims on “Pop-Tarts” packaging.
      Federal Trade Commission
      Nestlé subsidiary to settle FTC false advertising charges; Will drop deceptive health claims for BOOST Kid Essentials [media release].
      ; and FOP labeling symbols and nutrient-profiling systems were based on different criteria that hindered consumers' selection of healthy products in grocery stores.
      Committee on Examination of Front-of-Package Nutrition Ratings Systems and Symbols; Institute of Medicine
      • Neuman W.
      Food label program to suspend operations The New York Times.
      Company pledges failed to protect children aged <12 years and adolescents, aged 12–17 years, from all types of marketing practices promoting unhealthy products
      • Batada A.
      • Wootan M.G.
      Better-for-who? Revisiting company promises on food marketing to children.
      • Macmullan J.
      Left wanting more: food company policies on marketing to children.
      • Kunkel D.
      • McKinley C.
      • Wright P.
      The impact of industry self-regulation on the nutritional quality of foods advertised on television to children.
      • Wootan M.G.
      • Batada A.
      • Balkus O.
      Food marketing report card: an analysis of food and entertainment company policies to self-regulate food and beverage marketing to children.
      ; nonparticipating CFBAI companies were more likely to market unhealthy products
      • Kunkel D.
      • McKinley C.
      • Wright P.
      The impact of industry self-regulation on the nutritional quality of foods advertised on television to children.
      ; and public–private partnerships should be evaluated for effectiveness.
      • Kraak V.I.
      • Story M.
      A public health perspective on the concept of healthy lifestyles and public-private partnerships for global obesity prevention.

      Restaurants—Limited Progress Achieved

      Full-service and quick-serve chain restaurants (QSRs) made limited progress to expand and promote healthier meals and provide calories and other nutrition information at point of choice and consumption. A 2006 Keystone Center advisory committee (with industry representatives) reinforced the IOM food marketing report recommendations for restaurants to expand healthier options, reduce portion sizes, and promote menu labeling
      The Keystone Center
      Keystone Forum on away-from-home foods: opportunities for preventing weight gain and obesity.
      Food and Drug Administration
      FDA receives Keystone Forum report on away-from-home foods: improving consumers' ability to manage calorie intake key to anti-obesity efforts [news release].
      ; however, restaurants failed to act, as revealed by two studies in 2008–2009 that documented that less than 10% of children's restaurant meals met healthful criteria consistent with the Dietary Guidelines for Americans (DGA).
      • Wootan M.
      • Batada A.
      • Marchlewicz E.
      Kids' meals: obesity on the menu.
      • O'Donnell S.I.
      • Hoerr S.L.
      • Mendoza J.A.
      • Tsuei Goh E.
      Nutrient quality of fast food kids meals.
      In 2010, the Rudd Center released a study examining children's and adolescents' meal choices at 12 leading QSR chains.
      • Harris J.L.
      • Schwartz M.B.
      • Brownell K.D.
      • et al.
      Fast food FACTS: evaluating fast food nutrition and marketing to youth. Rudd Center for Food Policy and Obesity.
      The study documented that only 12 of 3039 children's meal combinations met established nutrition criteria for preschoolers; only 15 meals met nutrition criteria for older children; meals purchased by adolescents provided an average of 800–1100 calories/meal, representing half of their recommended daily calories; and meals sold to young people rarely offered healthy side dishes as the default choice.
      • Harris J.L.
      • Schwartz M.B.
      • Brownell K.D.
      • et al.
      Fast food FACTS: evaluating fast food nutrition and marketing to youth. Rudd Center for Food Policy and Obesity.
      Although some restaurants reported expanding healthier children's meal options,
      • Kolish E.D.
      • Peeler C.L.
      Changing the landscape of food & beverage advertising: the Children's Food and Beverage Advertising Initiative in action A progress report on the first six months of implementation: July–December 2007.
      • Peeler C.L.
      • Kolish E.D.
      • Enright M.
      The Children's Food & Beverage Advertising Initiative in action A report on compliance and implementation during 2008.
      • Peeler C.L.
      • Kolish E.D.
      • Enright M.
      • Burke C.
      The Children's Food & Beverage Advertising Initiative in action A report on compliance and implementation during 2009.
      changes made suggested an industry strategy to respond to negative public relations generated by advocacy groups disclosing that most restaurant meals exceeded young children's recommended daily calories (480 calories/meal, representing one third of the recommended 1300 calories/day for young children)
      • Nicklas T.A.
      • Hates D.
      American Dietetic Association
      Position of the American Dietetic Association: nutrition guidance for healthy children ages 2 to 11 years.
      and adolescents' recommended daily calories (733 calories/meal, representing one third of the recommended 2200 calories/meal for adolescents).
      • Gidding S.S.
      • Dennison B.A.
      • Birch L.L.
      • et al.
      American Heart Association
      Dietary recommendations for children and adolescents A guide for practitioners.
      Meals also exceeded recommendations for sodium, fat, and added sugars
      • Wootan M.
      • Batada A.
      • Marchlewicz E.
      Kids' meals: obesity on the menu.
      • O'Donnell S.I.
      • Hoerr S.L.
      • Mendoza J.A.
      • Tsuei Goh E.
      Nutrient quality of fast food kids meals.
      • Harris J.L.
      • Schwartz M.B.
      • Brownell K.D.
      • et al.
      Fast food FACTS: evaluating fast food nutrition and marketing to youth. Rudd Center for Food Policy and Obesity.
      that contributed to poor diet quality. Two studies suggested that mandatory menu labeling may help parents make healthier choices for their children.
      • Roberto C.A.
      • Larsen P.D.
      • Agnew H.
      • Baik J.
      • Brownell K.D.
      Evaluating the impact of menu labeling on food choices and intake.
      • Tandon P.S.
      • Wright J.
      • Zhou C.
      • Rogers C.B.
      • Christakis D.A.
      Nutrition menu labeling may lead to lower-calorie restaurant meal choices for children.
      Only Subway and Walt Disney restaurants have designated healthy default choices (i.e., fruits, nonstarchy vegetables, and low-fat or fat-free milk) as the preferred side dishes and beverages, respectively, accompanying children's meals instead of high-calorie, low-nutrient options (i.e., french fries and SSBs).
      • Wootan M.
      • Batada A.
      • Marchlewicz E.
      Kids' meals: obesity on the menu.
      • Harris J.L.
      • Schwartz M.B.
      • Brownell K.D.
      • et al.
      Fast food FACTS: evaluating fast food nutrition and marketing to youth. Rudd Center for Food Policy and Obesity.
      The Walt Disney Company introduces new food guidelines to promote healthier kids' diets
      New policy to associate Disney brands and characters with a more nutritionally balanced range of foods [news release].
      McDonald's and Burger King are the only two restaurants participating in the CFBAI.
      • Kolish E.D.
      • Peeler C.L.
      Changing the landscape of food & beverage advertising: the Children's Food and Beverage Advertising Initiative in action A progress report on the first six months of implementation: July–December 2007.
      • Peeler C.L.
      • Kolish E.D.
      • Enright M.
      The Children's Food & Beverage Advertising Initiative in action A report on compliance and implementation during 2008.
      • Peeler C.L.
      • Kolish E.D.
      • Enright M.
      • Burke C.
      The Children's Food & Beverage Advertising Initiative in action A report on compliance and implementation during 2009.
      Several other leading QSR restaurants, including YUM! Brands (the parent company for KFC, Taco Bell, and Pizza Hut) and Subway, have not joined the CFBAI.
      The QSR sector spent more than $4.2 billion in 2009 on marketing to young people and adults through TV, digital, mobile, and social media.
      • Harris J.L.
      • Schwartz M.B.
      • Brownell K.D.
      • et al.
      Fast food FACTS: evaluating fast food nutrition and marketing to youth. Rudd Center for Food Policy and Obesity.
      From 2003 through 2009, exposure to QSR chain TV advertisements increased by 21% for preschoolers; 34% for children (aged 2–11 years); and 39% for adolescents (aged 12–17 years).
      • Powell L.M.
      • Szczpka G.
      • Chaloupka F.J.
      Trends in exposure to television food advertisements among children and adolescents in the U.S..
      • Harris J.L.
      • Schwartz M.B.
      • Brownell K.D.
      • et al.
      Fast food FACTS: evaluating fast food nutrition and marketing to youth. Rudd Center for Food Policy and Obesity.
      African-American children and adolescents, who are disproportionately affected by higher overweight and obesity rates, were targeted more aggressively by QSR chain restaurant TV advertisements during this period.
      • Powell L.M.
      • Szczpka G.
      • Chaloupka F.J.
      Trends in exposure to television food advertisements among children and adolescents in the U.S..
      • Harris J.L.
      • Schwartz M.B.
      • Brownell K.D.
      • et al.
      Fast food FACTS: evaluating fast food nutrition and marketing to youth. Rudd Center for Food Policy and Obesity.
      • Grier S.A.
      • Kumanyika S.K.
      The context for choice: health implications of targeted food and beverage marketing to African Americans.
      A 2010 evaluation documented that only 24% of 42 restaurants had marketing policies for children and had complied with the FTC's recommendation to standardize nutrition criteria for marketing to children.
      • Wootan M.G.
      • Batada A.
      • Balkus O.
      Food marketing report card: an analysis of food and entertainment company policies to self-regulate food and beverage marketing to children.
      No evidence showed that restaurants had used competitive pricing to encourage healthy meals, and QSR restaurants failed to provide nutrition guidelines for meals when offering toys to children.
      National Policy and Legal Analysis Network to Prevent Childhood Obesity
      Model California ordinance regulating chain restaurant giveaways with children's meals.
      • Gordon R.
      S.F. proposal: healthier kids meals or no toys.
      McDonald's opposed health advocates in California's Santa Clara County
      An ordinance of the board of supervisors of the County of Santa Clara adding Chapter XXII of Division A18 to the County of Santa Clara ordinance code relating to toys and other incentives with restaurant food.
      and San Francisco
      • Gordon R.
      SF fast-food toy ban gets supervisors' first OK SFGate.
      to legally mandate specific nutrition standards when distributing toys or incentives with children's meals. Although McDonald's defended its Happy Meals,
      • Cancino A.
      McDonald's CEO stands up for Happy Meals
      The Chicago Tribune.
      the company reportedly reformulated children's meals and posted the updated information on a public website
      • Warner M.
      McDonald's magic: calories disappear from Happy Meals after chain is threatened with lawsuit CBS Business Network (BNET).
      after being threatened with a consumer advocacy-group lawsuit
      • Gardner S.
      Letter to McDonald's Corporation and McDonald's USA Center for Science in the Public Interest v. McDonald's USA, LLC.
      formally initiated in December 2010.
      Center for Science in the Public Interest
      Class action lawsuit targets McDonald's use of toys to market to children.
      Restaurants have not joined public–private partnerships such as the HWCF and the PHA to promote a healthful diet. The restaurant leadership inadequacies were noted by First Lady Michelle Obama, who encouraged the sector to substantially improve meals for American children and families and their involvement in the Let's Move! initiative.
      The White House Office of the First Lady
      Remarks by the First Lady in address to the National Restaurant Association meeting.

      Industry Trade Associations—Limited Progress Achieved

      Industry trade associations collectively made limited progress to demonstrate leadership and harness industry creativity, support, and resources to market a healthful diet. Trade associations representing the food, beverage, food retail, and fresh produce industry demonstrated certain positive actions during the period reviewed.
      Grocery Manufacturers Association
      GMA: More than two-thirds of the advertisements seen by children and teens today promote more nutritious foods and healthy lifestyles [news release].
      American Beverage Association
      School Beverage Guidelines Progress Report 2006-2007.
      American Beverage Association
      School beverage guidelines progress report 2007-2008.
      American Beverage Association
      Alliance School Beverage Guidelines Final Progress Report.
      American Beverage Association
      Beverage industry will make calories more clear and useable for consumers [news release].
      Food Marketing Institute
      Health & wellness.
      Food Marketing Institute
      Obesity strategy Approved by the FMI Board of Directors.
      United Fresh Produce Association
      News and issues.
      Very limited progress was made by trade associations representing advertisers and marketers,
      Association of National Advertising
      ANA mission.
      American Association of Advertising Agencies
      About the Association.
      restaurants,
      National Restaurant Association
      About Us.
      and the confection
      National Confectioners Association
      Year in review: 2008.
      and snack-food
      Snack Food Association
      Introduction.
      sectors. No evidence showed that the 2006 school snack-food agreement
      Alliance for a Healthier Generation
      President Clinton and AHA announce joint agreement between Alliance for a Healthier Generation and food industry leaders to set healthy standards for snacking in school.
      had been evaluated. Unhealthy food and beverage products were widely available to children through food retailers.
      • Borradaile K.E.
      • Sherman S.
      • Vander Veur S.S.
      • et al.
      Snacking in children: the role of urban corner stores.
      • Farley T.A.
      • Baker E.T.
      • Futrell L.
      • Rice J.C.
      The ubiquity of energy-dense snack foods: a national multicity study.
      Nevertheless, Wal-Mart announced encouraging steps in early 2011 to expand healthier options.
      • Wilgoren D.
      • Mui Y.Q.
      With praise from Michelle Obama, Wal-Mart announces healthy food campaign The Washington Post.
      Only three trade associations are members or partners of the HWCF.
      Healthy Weight Commitment Foundation
      2010 annual review.
      This evaluation accounted for delayed industry trade actions—which appeared to improve in February 2010 after Let's Move! was initiated
      The White House Office of the First Lady
      First Lady Michelle Obama launches Let's Move: America's move to raise a healthier generation of kids.
      and in May 2010 after the release of the White House Task Force Report on Childhood Obesity
      White House Task Force on Childhood Obesity
      Solving the problem of childhood obesity within a generation: White House Task Force on Childhood Obesity report to the president.
      —and lobbying actions that undermined public health goals. The National Restaurant Association (NRA) neither publicly encouraged members to join the CFBAI nor provided technical support to promote clear advertising policies to children that aligned with healthy criteria. NRA also failed to support menu labeling until it became apparent that it would be enacted into law through healthcare reform legislation in March 2010.
      National Restaurant Association says nutrition information provision is win for consumers and restaurants
      Two advertising trade associations continue to defend their right to advertise to children.
      Association of National Advertising
      ANA mission.
      American Association of Advertising Agencies
      About the Association.
      The National Confectioners Association viewed the Child Nutrition Program Reauthorization legislation as a threat because of proposed limits on candy sales in school vending machines.
      National Confectioners Association
      Year in review: 2008.
      These trade associations did not make position papers or policies publicly available to support marketing a healthful diet.
      The Grocery Manufacturers Association's (GMA's) positive actions were evaluated within the context of spending $1.6 million and the NRA spending $1.4 million, respectively, to lobby legislators to oppose an SSB tax in 2009.
      • Spolar C.
      • Eaton J.
      Food lobby mobilizes, as soda tax bubbles up.
      In late 2010 and early 2011, GMA and the Food Marketing Institute (FMI) announced that they had developed their own FOP nutrition labeling system called “Nutrition Keys” and pledged a $50 million education campaign to provide American consumers with an easy-to-use format providing calories, saturated fat, sodium, and added sugars.
      Food Marketing Institute and the Grocery Manufacturers Association
      Food & beverage industry announces front-of-pack nutrition labeling initiative to inform consumers and combat obesity [media release].
      Grocery Manufacturers Association
      Food and beverage industry launches nutrition keys front-of-pack nutrition labeling initiative to inform consumers and combat obesity [press release].
      Food Marketing Institute
      Food and beverage industry launches Nutrition Keys Front-of-Pack Nutrition Labeling Initiative to inform consumers and combat obesity; nutrition icon to be supported by $50 million industry-funded consumer education campaign [news release].
      This strategy was developed without FDA input
      • Neuman W.
      Food makers devise own label plan The New York Times.
      and preempted a forthcoming IOM report based on consumers' understanding of FOP systems. The industry initiative could confuse consumers unless it is spearheaded by the Food and Drug Administration (FDA) and informed by IOM recommendations.
      Committee on Examination of Front-of-Package Nutrition Ratings Systems and Symbols; Institute of Medicine

      Marketing Practice Standards—Moderate Progress Achieved

      Industry stakeholders made moderate progress to work with government and other groups to establish and enforce marketing standards for young people. By 2010, a total of 17 companies, representing about two thirds of the industry marketing expenditures for children and adolescents, voluntarily participated in the CFBAI and reported progress in revising, applying, and evaluating their advertising standards.
      • Peeler C.L.
      • Kolish E.D.
      • Enright M.
      • Burke C.
      The Children's Food & Beverage Advertising Initiative in action A report on compliance and implementation during 2009.
      Council of the Better Business Bureaus
      Sara Lee Corporation joins industry initiative to promote healthier foods to kids [news release].
      Council of the Better Business Bureaus
      BBB Children's Food and Beverage Advertising Initiative: participant definitions of advertising primarily directed to children under 12 and policies for not advertising to children under six.
      Council of the Better Business Bureaus
      Children's Food and Beverage Advertising Initiative program and core principles statement.
      Council of the Better Business Bureaus
      3rd annual report on the Children’s Food and Beverage Advertising Initiative shows excellent compliance [news release].
      • Lukovitz K.
      CFBAI reports on kids’ marketing compliance MediaPost News.
      Although, many marketing practices and marketing to adolescents were excluded from companies' pledges.
      Government made moderate progress to evaluate companies' compliance. The FTC released three reports between 2006 and 2008—one with the DHHS acknowledging some positive company actions
      Federal Trade Commission and DHHS
      Perspective on marketing, self-regulation, & childhood obesity: a report on a joint workshop of the Federal Trade Commission and DHHS, 2006.
      ; an analysis of young people's TV advertising exposure between 1977 and 2004 that showed a majority of advertisements promoted unhealthy foods to children aged 2–11 years through prime-time TV and other programming
      • Holt D.J.
      • Ippolito P.M.
      • Desrochers D.M.
      • Kelley C.R.
      Children's exposure to TV advertising in 1977 and 2004zcn>Federal Trade Commission Bureau of Economics Staff Report.
      ; and a report documenting that more than $1.6 billion was spent in 2006 to market primarily unhealthy food and beverage products to young people.
      • Kovacic W.
      • Harbour P.
      • Leibowitz J.
      • Rosch J.
      Marketing food to children & adolescents: a review of industry expenditures, activities, and self-regulation.
      A 2008 Senate hearing
      Office of U.S. Senator Dick Durbin
      Durbin co-chairs hearing on childhood obesity [news release].
      and the FTC
      • Kovacic W.
      • Harbour P.
      • Leibowitz J.
      • Rosch J.
      Marketing food to children & adolescents: a review of industry expenditures, activities, and self-regulation.
      urged companies to adopt meaningful, uniform nutrition standards for all products marketed to children, and develop pledges beyond child-directed advertising that would apply to all forms of marketing, including measured media spending (representing media categories that companies use to promote products systematically tracked by media research companies) and unmeasured media spending (representing sales promotions, coupons, and Internet-based marketing that are not systematically tracked).
      • McGinnis J.M.
      • Gootman J.A.
      • Kraak VI,
      Committee on Food Marketing and the Diets of Children and Youth; Institute of Medicine
      Food marketing to children and youth: threat or opportunity?.
      • Kovacic W.
      • Harbour P.
      • Leibowitz J.
      • Rosch J.
      Marketing food to children & adolescents: a review of industry expenditures, activities, and self-regulation.
      No company has yet complied fully with the FTC recommendations.
      A 2006 Federal Communications Commission (FCC) Task Force was unable to reach consensus on nutrition standards and media marketing by 2008.
      • Carugati A.
      FCC dissatisfied with media's reluctance to fight childhood obesity.
      In 2009, concern about the limited effectiveness of industry self-regulation prompted Congress to direct the federal government to convene an Interagency Working Group (IWG) on Marketing to Children with representatives from the CDC, FDA, FTC, and U.S. Department of Agriculture (USDA) to conduct a study and develop recommendations to establish food marketing standards for promotional practices targeting children and adolescents.
      Congress requested the IWG to submit its report and recommendations by July 15, 2010. Although tentative draft nutrition standards were released by the federal IWG at an FTC meeting in December 2009,
      Interagency Working Group on Food Marketed to Children
      Tentative proposed nutrition standards.
      delays in posting to elicit public input prevented the IWG from meeting the July 15, 2010, congressional deadline.
      • Neuman W.
      Ad rules stall, keeping cereal a carton staple The New York Times.
      In September 2010, the FTC delivered subpoenas to 48 food and beverage manufacturers, distributors, and QSRs to obtain information to review changes in industry expenditures and marketing activities from 2006 to 2009 and to assess the effectiveness of industry's voluntary actions over this period
      • Thomaselli R.
      FTC subpoenas 48 food companies regarding marketing to kids Advertising Age.
      for a follow-up report to be released in 2011.
      Federal Trade Commission
      Food industry marketing to children and adolescents study: paperwork comment; project no. P094511.
      This progress evaluation noted several industry inadequacies to improve marketing practices that protect children and adolescents. First, most companies have not extended self-regulatory pledges to cover broader forms of child-directed marketing, such as product packaging and in-store marketing. The pledges of most companies do not cover all forms of spending on “new media” (i.e., digital, mobile, and interactive social media) that are less expensive and highly engaging to maximize young people's exposure to marketing messages for unhealthy products more effectively when compared to traditional forms of advertising.
      • Montgomery K.C.
      • Chester J.
      Interactive food and beverage marketing: targeting adolescents in the digital age.
      The pledges of most companies also do not cover all school-based marketing practices (i.e., fundraisers, sponsorship, in-school celebrations, label-redemption programs, products donated as contributions-in-kind, and cause marketing).
      Council of the Better Business Bureaus
      Fact Sheet on the Elementary School Advertising Principles.
      • Wootan M.G.
      Center for Science in the Public Interest letter to Ms. Elaine Kolish, Children's Food and Beverage Advertising Initiative.
      • Kolish E.D.
      Council of the Better Business Bureaus letter to Ms. Margo Wootan, Center for Science in the Public Interest.
      • Harris J.L.
      • Schwatz M.B.
      • Brownell K.D.
      Marketing foods to children and adolescents: licensed characters and other promotions on packaged foods in the supermarket.
      Second, companies have not extended pledges to cover advertising and marketing practices that promote unhealthy food and beverage products targeted to adolescents.
      • Montgomery K.C.
      • Chester J.
      Interactive food and beverage marketing: targeting adolescents in the digital age.
      Third, each CFBAI member's pledge is based on its own selective nutrition standards rather than a universal set of evidence-based nutrition standards.
      • Wootan M.G.
      • Batada A.
      • Balkus O.
      Food marketing report card: an analysis of food and entertainment company policies to self-regulate food and beverage marketing to children.
      Fourth, although a reduction in third-party licensed characters used to promote products to young children was observed, companies are using other forms of cross-promotion marketing.
      • Harris J.L.
      • Schwatz M.B.
      • Brownell K.D.
      Marketing foods to children and adolescents: licensed characters and other promotions on packaged foods in the supermarket.
      Nearly half (49.4%) of company advertisements use licensed characters to promote unhealthy products,
      • Kunkel D.
      • McKinley C.
      • Wright P.
      The impact of industry self-regulation on the nutritional quality of foods advertised on television to children.
      which is important because children prefer foods with licensed characters, especially for energy-dense foods (candy) compared to healthier options (baby carrots).
      • Roberto C.A.
      • Baik J.
      • Harris J.L.
      • Brownell K.D.
      Influence of licensed characters on children's taste and snack preferences.

      Media and Entertainment Companies—Limited Progress Achieved

      The media and entertainment industry made limited progress during the period reviewed. At a 2008 Senate hearing,
      • Carugati A.
      FCC dissatisfied with media's reluctance to fight childhood obesity.
      the FCC Chairman expressed concern that few media companies had voluntarily limited advertisements targeting children.
      • Roberto C.A.
      • Baik J.
      • Harris J.L.
      • Brownell K.D.
      Influence of licensed characters on children's taste and snack preferences.
      A 2010 evaluation showed that only one quarter of entertainment companies had a clear policy on food marketing to children. Existing policies addressed third-party licensed characters but were weaker for products marketed through broadcast, print, and digital media and product placement.
      • Wootan M.G.
      • Batada A.
      • Balkus O.
      Food marketing report card: an analysis of food and entertainment company policies to self-regulate food and beverage marketing to children.
      Only Walt Disney and Sesame Workshop reported limiting child-directed marketing to products meeting specific nutrition standards. The Cartoon Network developed policies for licensed characters but lacked policies for other promotional activities. Nickelodeon neither had nutrition standards nor a clear policy about food marketing to children
      • Wootan M.G.
      • Batada A.
      • Balkus O.
      Food marketing report card: an analysis of food and entertainment company policies to self-regulate food and beverage marketing to children.
      • Batada A.
      • Wootan M.G.
      Nickelodeon markets nutrition-poor foods to children.
      Center for Science in the Public Interest
      Nickelodeon: food marketing little improved between 2005 & 2008.
      despite earlier public commitments to implement policies.
      Federal Trade Commission and DHHS
      Perspective on marketing, self-regulation, & childhood obesity: a report on a joint workshop of the Federal Trade Commission and DHHS, 2006.
      • Martin A.
      Nickelodeon to limit use of characters on junk foods The New York Times.
      One evaluation found that the percentage of advertisements for high-calorie and low-nutrient foods aired by entertainment companies decreased only slightly between 2005 and 2009 (before and after the CFBAI was implemented) from about nine in ten (88%) to eight in ten (79%) food advertisements.
      • Kunkel D.
      • McKinley C.
      • Wright P.
      The impact of industry self-regulation on the nutritional quality of foods advertised on television to children.
      No children's entertainment companies currently participate in the CFBAI or HWCF. Entertainment companies' brand-equity characters are exempted from the updated 2010 CFBAI principles that encouraged member companies to limit third-party licensed characters to advertise only products that promote a healthful diet or healthy lifestyles. CFBAI pledges exclude licensed characters on product packaging because most companies do not consider this promotion activity to represent advertising.
      • Harris J.L.
      • Schwartz M.B.
      • Brownell K.
      • et al.
      Cereal FACTS: evaluating the nutrition quality and marketing of children's cereals.
      The media shape the public's opinions about obesity, diet, and health by emphasizing feature stories and articles about the causes of unhealthy diets, affected groups, and stakeholders responsible for an effective response. Trends in media coverage of obesity-related stories showed a steady increase during the period reviewed
      International Food Information Council Foundation
      Trends in Obesity-Related Media Coverage.
      but the specific content and accuracy of these stories are unknown. In 2009, a report examining U.S. healthcare journalism found that financial pressures on the media industry and competition to break news on innovative and expanding Internet-based media platforms influence and affect the quality of health reporting. These challenges have caused journalists specializing in healthcare coverage to be concerned about the lack of in-depth, detailed reporting and the influence of public relations and advertising on news content and consumers' perceptions of media stories.
      • Schwitzer G.
      The state of health journalism in the U.S..

      Discussion

      Eating behaviors of children and adolescents are highly complex because they are influenced by the interplay of many factors across different contexts to potentially create healthy food and eating environments.
      • Story M.
      • Kaphingst K.M.
      • Robinson-O'Brien R.
      • Glanz K.
      Creating healthy food and eating environments: policy and environmental approaches.
      Marketing to young people is equally complicated because it involves diverse stakeholders with different motivations and priorities that interact over time. The IOM committee identified food marketing to children and adolescents as a current threat to young people's diets and health but also viewed marketing as potentially providing opportunities to improve young people's future diet and health.
      • McGinnis J.M.
      • Gootman J.A.
      • Kraak VI,
      Committee on Food Marketing and the Diets of Children and Youth; Institute of Medicine
      Food marketing to children and youth: threat or opportunity?.
      A subsequent 2007 IOM obesity prevention progress report
      acknowledged the tensions among private- and public-sector stakeholders to promote a healthful diet to children and adolescents, with special consideration for the following issues: conveying consistent and appealing messages; ensuring transparency by sharing relevant marketing data; obtaining company-wide commitments; understanding the interactions among companies, marketing practices, and consumer demand; balancing free-market system goals with protecting young people's health; and committing to monitor and evaluate all efforts.
      Industry decision makers and policymakers have many opportunities to accelerate progress toward the IOM food marketing committee's recommendations and to create healthy eating environments by using a new infrastructure that has evolved since the 2006 IOM food marketing report release. The infrastructure includes industry self-regulatory mechanisms (i.e., CBBB, CARU, and CFBAI); public–private partnerships; independent monitoring and evaluations undertaken by academic and advocacy groups; and federal government initiatives, including the IWG on Food Marketing to Children,
      Interagency Working Group on Food Marketed to Children
      Preliminary Proposed Nutrition Principles to Guide Industry Self-Regulatory Efforts Request for Comments. FCC, CDC, FDA and USDA.
      FTC studies,
      • Neuman W.
      Ad rules stall, keeping cereal a carton staple The New York Times.
      • Thomaselli R.
      FTC subpoenas 48 food companies regarding marketing to kids Advertising Age.
      FDA leadership on FOP labeling,
      Food and Drug Administration
      New front-of-package labeling initiative.
      and the HHS and USDA release of the DGA 2010.
      U.S. Department of Agriculture and DHHS
      Dietary guidelines for Americans, 2010.
      This evaluation found that moderate progress was made by food and beverage companies and diverse groups to strengthen marketing practice standards. However, restaurants, industry trade associations, entertainment companies, and the media made limited progress. Industry stakeholders used IMC to market primarily unhealthy products that threaten children's and adolescents' health and miss opportunities to promote healthy eating environments. In July 2011, the CBBB and CFBAI announced a promising agreement reached with participating companies to follow uniform nutrition criteria for foods advertised to children. The new criteria will encourage companies to reformulate and develop new products with less sodium, saturated fat and sugars, and fewer calories; otherwise they will not advertise them after December 31, 2013.
      Council of Better Business Bureaus announces groundbreaking agreement on child-directed food advertising [news release].
      There are many other opportunities and actions that industry stakeholders could take to accelerate progress. Proposed actions are grounded in the evidence reviewed for this progress evaluation, and recommended by other expert committees and advisory groups (Figure 1).
      DHHS, U.S.Department of Agriculture
      Report of the Dietary Guidelines Advisory Committee on the Dietary Guidelines for Americans, 2010.
      • Kovacic W.
      • Harbour P.
      • Leibowitz J.
      • Rosch J.
      Marketing food to children & adolescents: a review of industry expenditures, activities, and self-regulation.
      Federal Trade Commission and DHHS
      Perspective on marketing, self-regulation, & childhood obesity: a report on a joint workshop of the Federal Trade Commission and DHHS, 2006.
      • Harris J.L.
      • Weinberg M.E.
      • Schwartz M.B.
      • Ross C.
      • Ostroff J.
      • Brownell K.D.
      Trends in television food advertising
      Progress in reducing unhealthy marketing to young people?.
      Committee on Examination of Front-of-Package Nutrition Ratings Systems and Symbols; Institute of Medicine
      The Keystone Center
      Keystone Forum on away-from-home foods: opportunities for preventing weight gain and obesity.
      White House Task Force on Childhood Obesity
      Solving the problem of childhood obesity within a generation: White House Task Force on Childhood Obesity report to the president.
      • Thomaselli R.
      FTC subpoenas 48 food companies regarding marketing to kids Advertising Age.
      Interagency Working Group on Food Marketed to Children
      Preliminary Proposed Nutrition Principles to Guide Industry Self-Regulatory Efforts Request for Comments. FCC, CDC, FDA and USDA.
      Food and Drug Administration
      New front-of-package labeling initiative.
      U.S. Department of Agriculture and DHHS
      Dietary guidelines for Americans, 2010.

      Conclusion

      The IOM recommendations provide a coherent framework to ensure that a nexus of coordinated actions are implemented to promote a healthful diet to young people. This paper used the IOM LEAD approach to evaluate progress made by industry stakeholders to achieve the IOM food marketing report recommendations for marketing a healthful diet to children and adolescents. The results can inform potential actions that decision makers might take to promote healthy products, a healthful diet, and healthy food and eating environments.
      A companion paper will address public-sector stakeholder progress. Moderate progress was made by food and beverage companies and diverse private- and public-sector stakeholders to improve marketing practice standards. Limited progress was made by restaurants, industry trade associations, and entertainment companies and the media to market a healthful diet. Diverse industry stakeholders have many untapped opportunities to advance progress by collectively promoting IMC for healthy food, beverages, and meals; substantially strengthening self-regulatory programs; supporting clear, truthful, and non-misleading product labeling and health claims; engaging in public–private partnerships; and funding independent evaluations of collective efforts.
      This paper was supported by a grant provided by the Robert Wood Johnson Foundation's Healthy Eating Research Program .
      The authors are grateful for the insightful comments provided by the anonymous reviewers. We thank Juan Quirarte of QDesign for creating Figure 1.
      No financial disclosures were reported by the authors of this paper.

      Supplementary data

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      Linked Article

      • Societal Resolve and the Health of Children
        American Journal of Preventive MedicineVol. 41Issue 3
        • Preview
          If the true measure of society's progress is the attention devoted to the condition of its children, the nation may need a better compass to right its course. Six years ago, the IOM's Committee on Food Marketing to Children and Youth found, in effect, when it comes to health as arguably the key component of the human condition, 21st-century American culture has not measured up well in tending to its children's futures. Where do we stand today?
        • Full-Text
        • PDF
      • Front-of-Package Nutrition Labeling and Obesity Implications
        American Journal of Preventive MedicineVol. 42Issue 1
        • Preview
          Several studies convincingly suggest that obesity rates and all-cause related mortality are increasing.1 Dietary and lifestyle interventions such as weight loss and physical activity are effective to prevent obesity.2,3 In an elegant manuscript, Kraak et al.4 have evaluated the efforts made by the food industry to encourage a healthier food supply to American children and adolescents and thus prevent obesity. One of the criteria pointed out and evaluated by the authors was the development of the front-of-package (FOP) labeling for consumers to identify healthy products.
        • Full-Text
        • PDF