Implementing the WHO recommendations on the marketing of food and nonalcoholic beverages to children in the Eastern Mediterranean Region

Implementing the WHO recommendations on the marketing of food and non-alcoholic beverages to children in the Eastern Mediterranean Region

Implementing the WHO recommendations on the marketing of food and non- alcoholic beverages to children in the Eastern Mediterranean Region

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Implementing the WHO recommendations on the marketing of food and non-alcoholic beverages to children in the Eastern Mediterranean Region / World Health Organization. Regional Office for the Eastern Mediterranean p. ISBN: 978-92-9274-527-1 ISBN: 978-92-9274-528-8 (online) 1. Legislation, Food 2. Food – adverse effects 3. Beverages - adverse effects 4. Marketing - legislation & jurisprudence 5. Child Nutrition Disorders 6. Pediatric Obesity - prevention & control 7. Chronic Disease - prevention & control 8. Nutrition Policy 9. World Health Organization I. Title II. Regional Office for the Eastern Mediterranean (NLM Classification: WS 130) This publication was originally published under ISBN: 978-92-9022-224-8, 978-92-9022-227-9

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Contents

Acknowledgements ........................................................................................................... 5

Executive summary ............................................................................................................ 7

1. Increase in childhood obesity and related noncommunicable diseases in the Eastern Mediterranean Region ................................................................................. 9

1.1 Increasing prevalence of overweight, obesity and diabetes in the Region ... 9

1.2 Dietary factors responsible for the increase in overweight, obesity and diabetes in the Region......................................................................................... 11

1.3 Commitment of countries of the Region to tackle marketing of food to children ................................................................................................................. 14

1.4 Purpose, structure and scope of this report ..................................................... 21

2. Harmful effect of food marketing on children ................................................... 25

2.1 International evidence supporting the regulation of marketing of unhealthy food to children ............................................................................ 25

2.2 Food marketing trends in the Region ............................................................... 34 2.3 Recommendations ............................................................................................... 40

3. Designing effective regulation on food marketing to children ....................... 41

3.1 Multisectoral approach to the regulation of food marketing to children ... 41 3.2 Adoption of comprehensive restrictions on the marketing of unhealthy

food to children ................................................................................................... 45 3.3 From national to regional restrictions on unhealthy food marketing to

children ................................................................................................................. 53 3.4 From policy development to policy implementation .................................... 55 3.5 Recommendations ............................................................................................... 56

4. Protecting the public interest from real, perceived or potential conflicts of interest ......................................................................................................................... 57 4.1 Limited value of industry pledges .................................................................... 58 4.2 Children’s rights approach to the implementation of the

Recommendations ............................................................................................... 62 4.3 Recommendations ............................................................................................... 65

References ......................................................................................................................... 67

Annex 1: Rapid questionnaire on implementation of the Recommendations .... 76

Acknowledgements

This work was coordinated by Dr Ayoub Al Jawaldeh, Regional Adviser in Nutrition, WHO Regional Office for the Eastern Mediterranean, with direct support from Professor Amandine Garde, Director of the Law & Non-Communicable Diseases Unit at the University of Liverpool, United Kingdom, who designed the study, analysed the data and wrote the report. The first draft of the report was written in 2013 with the financial support of the United Kingdom Economic and Social Research Council (grant number: ES/J020761/1).

The Regional Office would like to acknowledge the contribution to this work of Dr Faten Ben Abdelaziz and the nutrition focal points in all countries of the Region.

Executive summary

Over the past 15 years, evidence has accumulated which shows that the marketing of nutritiously poor food high in saturated fats, trans-fatty acids, free sugars or salt (unhealthy food) influences children’s preferences, purchase requests and consumption patterns. Consequently, the Sixty-third World Health Assembly in 2010 adopted a set of recommendations which calls on Member States to adopt policies restricting the marketing of unhealthy food to children (Set of recommendations on the marketing of foods and non-alcoholic beverages to children). However, despite growing rates of childhood overweight and obesity and the extensive marketing to children of unhealthy food in the Eastern Mediterranean Region, Member States have been relatively slow in implementing the WHO Recommendations. This report provides a situational analysis of the progress made in the Region in implementing the WHO Recommendations and identifies issues Member States need to consider when adopting policies intended to restrict the marketing of unhealthy food to children.

The first section of the report highlights the alarming increase in overweight and obesity in the Region and the commitment Member States have made to ensure that they implement the WHO recommendations and restrict the marketing of unhealthy food to children.

Section 2 focuses on the extent to which unhealthy food is marketed to children in the Region, and highlights some of the media and techniques most frequently used to do so. The evidence linking unhealthy food marketing and children’s food preferences, purchase requests and consumption patterns, and ultimately childhood obesity, is reviewed and the complexity of the current media environment and its effect on children is discussed.

After making the case that Member States should implement the Recommendations as part of effective overweight and obesity prevention strategies, the report describes the actions taken in the Region to date to implement them. It highlights the achievements and identifies areas where further progress is required to ensure that the Recommendations are fully implemented.

The third section of the report emphasizes the importance of building consensus across and beyond government in order to facilitate the adoption of as comprehensive a policy as possible, which tackles the two main components of marketing: exposure (reach and frequency) and power (content, design and execution). This requires that Member States consider the key policy parameters and set clear definitions for “marketing to children” and “unhealthy food”. The more comprehensive a policy is, the less easy it will be for the food industry to shift its investment from one medium to another or from one marketing technique to another. The fewer loopholes a policy

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contains, the more effective it will be. Nevertheless, the Recommendations also acknowledge that if a comprehensive approach is not feasible, Member States should develop a stepwise approach. Thus, any steps Member States take to restrict the marketing of unhealthy food to children – even if they cannot do so comprehensively – is preferable to no intervention at all. In light of the current media environment in the Region, Member States who are not in a position to adopt a comprehensive approach to regulating unhealthy food marketing to children should consider at least television and in-school marketing as two priority areas for regulatory intervention. Section 3 concludes by highlighting the need for the Region to adopt cross-border marketing standards as Arabic is widely spoken as a common language and a broad range of media readily cross national borders.

The final section of the Report discusses the need for policy-makers to act in the public interest and avoid all conflicts of interest, as specifically mentioned in the Recommendations. The main stakeholders responsible for the implementation of the Recommendations are competent public authorities. Member States have a duty to ensure that the Recommendations are effectively implemented so that they comply with their duty to protect the child’s right to health and other related rights under the United Nations Convention on the Rights of the Child and other international human rights treaties they have ratified. A human rights approach to childhood obesity and noncommunicable disease prevention requires that the Recommendations are read in light of the Convention on the Rights of the Child and other human rights treaties. In practice, this means that Member States should not delegate their responsibility to define the policy parameters to private stakeholders such as the food or the advertising industries.

There is no time for complacency. Despite rapidly growing childhood overweight and obesity rates and the extensive marketing of unhealthy food to children in the Region, Member States have been slow to implement the Recommendations. The Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013–2020 and the regional resolution EM/RC61/R.3 explicitly call on Member States to urgently implement the Recommendations as part of effective obesity prevention strategies. This report is intended to help countries do so. In particular, it draws on the main lessons learnt over the past few years from countries within and outside the Region that have taken some steps to implement the Recommendations. The recent adoption of Agenda 2030 and the Sustainable Development Goals, particularly Goals 2 and 3, make it even more urgent for Member States to ensure that robust policies are in place, including effective restrictions on the marketing of unhealthy food to children.

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1. Increase in childhood obesity and related noncommunicable diseases in the Eastern Mediterranean Region

In the Eastern Mediterranean Region of the World Health Organization (WHO), noncommunicable diseases (NCDs) are responsible for over 50% of mortality and more than 60% of disease burden. Most of the deaths from NCDs are caused by cardiovascular diseases, diabetes, cancers and chronic lung disease. The four groups of diseases largely share the same risk factors, namely tobacco use, physical inactivity and unhealthy diets (1, p. 2).

This report focuses on unhealthy diets and, more specifically, on the need to regulate the marketing of food and non-alcoholic beverages to children in order to promote healthier diets as part of effective obesity prevention and nutrition strategies. This introductory section is intended to give the context of the issue. It describes the fast rising prevalence of overweight, obesity and diabetes (section 1.1) and the dietary risk factors responsible for this in the Region (section 1.2), and highlights the importance of regulating the marketing of food and non-alcoholic beverages to children as part of the multisectoral, coordinated strategies needed to stop the increase of obesity and diabetes and reduce diet-related NCDs (section 1.3). It concludes by explaining the purpose, methodology and structure of the rest of the report (section 1.4).

1.1 Increasing prevalence of overweight, obesity and diabetes in

the Region

The prevalence of obesity and overweight is worryingly high in the Region – at 46.8% it is well above the global average (39%) among adults1. In 2014, half the Region’s adult women (50.1%) and more than two in five men (43.8%) were overweight or obese (2). These figures rise to over two thirds in some countries, whilst other countries, in an earlier stage of the nutrition transition that often accompanies economic development, have moderate levels of overweight or obesity, or have emerging overweight or obesity only in certain socioeconomic groups (3) (Figs 1 and 2).

1 World Health Organization. Obesity and overweight. Fact sheet. Reviewed February 2018

(http://www.who.int/mediacentre/factsheets/fs311/en/).

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Fig. 1 Age standardized prevalence of overweight (BMI 25–29.9 kg/m2) and obesity (BMI ≥ 30 kg/m2) in males in countries of the Eastern Mediterranean Region, 2014

(Source: Data from NCD Risk Factor Collaboration. Trends in adult body-mass index in 200 countries from 1975 to 2014: a

pooled analysis of 1698 population-based measurement studies with 19.2 million participants Lancet 2016;387:1377–96)

Fig. 2 Age standardized prevalence of overweight (BMI 25–29.9 kg/m2) and obesity (BMI ≥ 30 kg/m2) in females in countries of the Eastern Mediterranean Region, 2014

(Source: Data from NCD Risk Factor Collaboration. Trends in adult body-mass index in 200 countries from 1975 to 2014: a

pooled analysis of 1698 population-based measurement studies with 19.2 million participants Lancet 2016;387:1377–96).

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High rates of childhood overweight give particular cause for concern2. On average, 6.9% of children under five years are already overweight in the Region – higher than the global average of 6.2% – and in some countries more than 15% are affected. In many countries of the Region, more than half of adolescents aged between 13 and 18 years are overweight or obese (4). As childhood obesity tends to persist during adulthood3 , the development of obesity prevention strategies specifically targeting children is therefore all the more necessary.

The Eastern Mediterranean Region has the highest prevalence of diabetes in the world. Around 43 million people in the Region live with this chronic disease – an increase from 6% in 1980 to 14% in 2014. It affects more than 20% of adults in some countries4. If not properly controlled, diabetes puts people affected at increased risk of serious complications, such as cardiovascular disease, vision loss, nerve damage, leg amputation and kidney failure, and of early death. More than 10% of deaths in adult women and 9% of deaths in adult men in the Region are attributable to high blood glucose (2). In addition, there are many millions more with pre-diabetes, who are increased risk of developing clinically evident diabetes within the next 5–10 years and who already have a greater risk of heart disease (3, p. 10).

Children born to women who are overweight or obese before pregnancy are immediately disadvantaged for life as they are at greater risk of later health problems, including obesity (5). Diabetes during pregnancy not only exposes a mother to much greater risk, but also markedly increases her child’s chances of ill health in the future (6).

1.2 Dietary factors responsible for the increase in overweight,

obesity and diabetes in the Region

Children become overweight if they consume more calories than they use over a period of time. The main drivers of child overweight and obesity therefore include unhealthy diet and physical inactivity. A multitude of factors explain why a population consumes more calories or expends fewer than it did before. The difficulty comes from the fact that no single factor can, on its own, explain this evolution. Unravelling the complex combination of factors is key to tackling the problem

2 Childhood overweight and obesity refers to children and youth between the ages of 2 and 18 years who suffer an excess of

body fat.

3 Approximately one third (26% male, 41% female) of obese Arabic-speaking preschool children and half (42% male, 63%

female) of obese school-aged children were also obese at adulthood according to a survey of data collected between 1970 and

1992 (Serdula MK, Ivery D, Coates RJ, Freedman DS, Williamson DF, Byers T. Do obese children become obese adults? A

review of the literature. Prev Med. 1993 Mar;22(2):167–77).

4 The risk of diabetes is known to increase as children and adults in particular gain weight. Thus, the longer an adult has been

obese and the more extreme their obesity, the greater the risk of diabetes. Yet in the Region, the prevalence of diabetes is about

twice the rates found for equivalent prevalence rates of obesity in, for example, European Union countries; this potentially

indicates a greater sensitivity of the population in the Region to diabetes if they gain weight (3, pp 10,11).

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effectively5. Therefore, as the Commission on Ending Childhood Obesity (ECHO) has noted, “it is only by taking a multisectoral approach through a comprehensive, integrated package of interventions that address the obesogenic environment, the life- course dimension and the education sector, that sustained progress can be made” (7, p. 40).

Once regarded only as a problem for high-income countries, overweight and obesity have also risen sharply over the past several decades in low- and middle-income countries. Consequently, some countries are now facing a “double burden” of disease. While they continue to deal with the problems of infectious diseases and undernutrition, at the same time they are experiencing a rapid upsurge in chronic disease risk factors such as overweight and obesity, particularly in urban settings. It is not uncommon to find undernutrition and obesity existing side by side within the same country, the same community and even within the same household. This double burden may reflect the effect of inadequate prenatal and infant nutrition predisposing individuals to weight gain and metabolic risks from later exposure to unhealthy food and lack of physical activity. It also reflects the documented consequences of the “nutrition transition”. Most countries in Asia, Latin America, northern Africa, the Middle East and the urban areas of sub-Saharan Africa have all experienced a shift in the overall structure of their dietary patterns and an increase in associated disease patterns over the past few decades. Major dietary changes include a large increase in the consumption of fat and added sugar and often animal food products, and a fall in total cereal and fibre intake, with a large proportion of the population consuming over 30% of energy from fat. This, coupled with equally rapid changes in physical activity levels with the shift from a preindustrial agrarian economy to industrialization, has led to the inexorable rise in obesity6 (8).

This report does not focus on physical inactivity – it merely notes that the Eastern Mediterranean Region has some of the highest rates of physical inactivity in the world (1, p. 2). It focuses instead on the dietary risk factors which explain the growing prevalence of overweight, obesity and diabetes in the Region.

Dietary risk factors causing weight gain and diabetes include high intakes of total fat and free sugars, excessive saturated fatty acid consumption and an inadequate intake of fibre-rich foods. In addition, high intake of sugary drinks, not just overall sugar intake, increases the likelihood of being overweight or obese, particularly among children, and is also associated with an increased risk of type 2 diabetes (2).

5 For a very striking map of the causal web of obesity, see Fig. 5.2 “The full obesity system map with thematic clusters” in the

Foresight Project Report, Tackling obesities: future choices (London: Government Office for Science, October 2007:84).

6 It should not be assumed that underweight and overweight are opposing public health concerns. As the UN Special Rapporteur

pointed out, “the increased reliance on food imports is a major cause of ‘nutrition transition’ in the developing world, by which

nutritionists mean the shift to processed foods richer in salt, sugar and saturated fats – foods that have a long shelf life and are

attractive to urban populations and younger generations, but are often less nutritious and less healthy” (De Schutter O. Final

report to the UN General Assembly. The transformative potential of the right to food. A/HRC/25/57, at page 7).

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Remarkable increases in total energy, fat and sugar intake in countries throughout the Region in recent decades mean that diets in the Region have gone in the opposite direction to all national and WHO recommendations (3, p. 11). In particular, while women should, on average, consume less than 25 g of free sugars per day and men less than 35 g per day7, average intakes in many countries already exceed 80 g per person daily.

The types of food and drinks consumed by children in the Region tend to be extremely high in sugar, including breakfast cereals and soft drinks of poor nutritional value. On average 50% of adolescents drink one or more soft drink daily8. The highest prevalence is in Kuwait (74.3%), followed by Qatar (62.5%), Lebanon (60.2%) and Palestine (58.2%)9. Data on the types of food consumed in the Region are limited. However, according to a review by Badran and Laher, adolescents tend to eat ready- made food more often than home-made food (9).

Many factors have contributed to the change in eating habits in the Region. In Saudi Arabia and Kuwait, the increase in food intake is part of the socialization process, which is usually based on large gatherings where traditional meals, consisting of rice (high carbohydrates) and meat (high fat), are shared. Food intake outside the home has also increased, thus increasing the risk of obesity10. In Lebanon, the diet style has changed to a fast-food style diet. The fat consumption in Lebanese children has increased from 24% to 34% during the period 1963–1998. In Bahrain, although a good percentage of children consume fresh fruits three or more times a week, a large majority eat fast food at least once a week and eat whilst watching television (10). Finally, a high proportion of schoolchildren in the Region skip breakfast, increasing their risk of snacking on the way to school or during school breaks, having unhealthier diets more generally and becoming obese11.

7 This is based on the WHO-recommended daily intake of less than 5% from free sugars – Guideline: sugars intake for adults

and children. Geneva: World Health Organization; 2015 (http://apps.who.int/iris/bitstream/10665/149782/

1/9789241549028_eng.pdf).

8 Global school-based Student Health Survey data, 2011 (http://www.who.int/ncds/surveillance/gshs/en/). This survey is a

collaborative surveillance project designed to help countries measure and assess the behavioural risk factors and protective

factors in 10 key areas among young people aged 13 to 17 years.

9Other countries also have extremely high consumption rates (e.g. Egypt with 60% of boys and 51% of girls aged 13–15 years

drinking one or more carbonated soft drink daily, or Pakistan with rates of 28% and 49% respectively).

10For example, in Saudi Arabia, the more food that primary-aged schoolchildren (aged 6–11 years) eat outside the home, the

higher the risk they will be obese: among those who did not eat outside the home, 9% were obese, while among those who ate

outside the home more than five times per week, 53% were obese (Amin TT, Al-Sultan AI, Ali A. Overweight and obesity

and their association with dietary habits, and sociodemographic characteristics among male primary school children in Al-

Hassa, Kingdom of Saudi Arabia. Indian J Community Med. 2008 Jul;33(3):172–81).

11 A study carried out in the Region showed that 32% of children aged 6 or 7 years in the United Arab Emirates, 50% of

children aged 10–15 years in Bahrain and 74% of girls aged 12–16 years in Saudi Arabia missed breakfast completely

(Musaiger A. Overweight and obesity in the Eastern Mediterranean Region: prevalence and possible causes. J Obes.

2011;2011:407237).

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Rapidly changing diets in the Region and their effect on the fast rising prevalence of overweight, obesity and diabetes call for an urgent response. Diet-related NCDs could largely be prevented if multisectoral, coordinated, population-based initiatives were adopted to reduce exposure to unhealthy diets and physical inactivity (7, p. 40). To this effect, and drawing on the body of existing, evidence-based policy recommendations, the Regional Office has produced a report identifying 10 priority areas for action for the population-wide prevention of obesity and diabetes in the Region. Under these 10 areas, 37 strategic interventions are proposed for Member States to consider. Priority area for action 6 focuses on the implementation of appropriate restrictions on marketing of unhealthy food (3).

1.3 Commitment of countries of the Region to tackle marketing of

food to children

1.3.1 From the Global Strategy on diet, physical activity and health to the Recommendations

on marketing of foods and non-alcoholic beverages to children

Recognizing the opportunity to reduce deaths and diseases worldwide by improving diets and increasing levels of physical activity, the 57th World Health Assembly adopted the WHO Global Strategy on Diet, Physical Activity and Health in 2004 (Resolution WHA 57.17). The Global Strategy has four main objectives:

- to reduce risk factors for chronic diseases that stem from unhealthy diets and

physical inactivity through public health actions;

- to increase awareness and understanding of the influences of diet and physical

activity on health and the positive impact of preventive interventions;

- to develop, strengthen and implement global, regional, national policies and

action plans to improve diets and increase physical activity that are sustainable,

comprehensive and actively engage all sectors; and

- to monitor science and promote research on diet and physical activity.

In particular, the Strategy called on governments to “work with consumer groups and the private sector (including advertising) to develop appropriate multisectoral approaches to deal with the marketing of food to children, and to deal with such issues as sponsorship, promotion and advertising” (11, para 40-3).

Subsequently, in light of growing evidence that food marketing influences children’s food preferences, purchase requests and consumption patterns, the WHO Director- General was requested at the 60th World Health Assembly in 2007 to “promote responsible marketing including the development of a set of recommendations on the marketing of foods and non-alcoholic beverages to children in order to reduce the impact of foods high in saturated fats, trans-fatty acids, free sugars, or salt (unhealthy

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food12), in dialogue with all relevant stakeholders, including private-sector parties, while ensuring avoidance of potential conflict of interest”. Later, at the 63rd World Health Assembly in 2010, WHO Member States endorsed a set of recommendations on the marketing of foods and non-alcoholic beverages to children (Resolution WHA 63.14): the Recommendations (12) (Box 1).

As part of its mandate, WHO has been working with Member States to support them implement the Recommendations. To this end, the Secretariat published a framework implementation report which provides guidance to Member States for implementing the Recommendations and monitoring and evaluating their policies (13). In particular, the report draws the attention of Member States to the key issues at the different stages of the policy cycle. WHO has also provided training to countries at both regional and national levels and support to countries in implementation of the Recommendations.

Box 1 Overview of the Recommendations

Four key points are highlighted here, which pertain to the development of effective policies on marketing of

unhealthy food to children and are particularly relevant for this report on the Eastern Mediterranean Region.

1 The Recommendations are evidence-based

The WHO commissioned an independent systematic literature review to establish whether, and if so the extent

to which, restrictions on unhealthy food marketing to children were warranted13. The review noted that food

marketing to children was primarily for unhealthy food, in contrast to dietary recommendations. It highlighted

that food marketing had become a global phenomenon and tended to be mixed and integrated, using multiple

messages in multiple channels. The review focused on the effect of unhealthy food marketing on children and

concluded that it had the following effects:

- it undermines food knowledge and confuses children as to what is healthy and unhealthy food;

- it stimulates a preference for unhealthy food;

- it encourages the purchase of, and pestering for, unhealthy food; and

- it makes children more likely to consume unhealthy food. This unhealthy eating is directly linked to the recent increases in childhood obesity and weight gain, and related health harms.

Several studies have since confirmed that food marketing contributes to childhood obesity. Section 2 provides

an overview of the research underpinning the Recommendations.

2 The Recommendations call for extensive marketing restrictions

12 The term “food” is used to refer to both food and non-alcoholic beverages.

13 The Recommendations specifically refer to the following studies: 1) Hastings G, Stead M, McDermott L, Forsyth A,

MacKintosh A, Rayner M et al. Review of research on the effects of food promotion to children. Final report, prepared for the

Food Standards Agency. Glasgow: University of Strathclyde; 22 September 2003; 2) Hastings G, McDermott L, Angus K,

Stead M, Thomson S. The extent, nature and effects of food promotion to children: a review of the evidence. Geneva: World

Health Organization; 2006; 3) McGinnis JM, Gootman JA, Kraak VI, editors. Food marketing to children and youth: threat

or opportunity? Washington DC: Institute of Medicine, National Academies Press; 2006; and 4) Cairns G, Angus K, Hastings

G. The extent, nature and effects of food promotion to children: a review of the evidence to December 2008. Geneva: World

Health Organization; 2009.

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The WHO Recommendations call for extensive restrictions on the marketing of unhealthy food to children. Not

only do they define the key concept of “marketing”, but they also urge countries to adopt as comprehensive an

approach as possible so that their policies tackle the many media and marketing techniques used to promote

unhealthy food to children and limit the opportunities for the food industry to shift its investment from regulated

to unregulated media or marketing techniques.

The concept of “marketing” is defined as “any form of commercial communication or message that is designed

to, or has the effect of, increasing the recognition, appeal and/or consumption of particular products and

services. It comprises anything that acts to advertise or otherwise promote a product or service” (12, p. 7). This

definition is intended to reduce the impact of unhealthy food marketing on children. Consequently, it includes

advertising as well as other forms of promotion, and is interpreted to cover all forms of direct or indirect promotion

in a marketing strategy (13, p. 9). Importantly, although the definition in the Recommendations does not refer to

“brands”, this should not be interpreted as suggesting that brand marketing should fall outside the scope. A

literal interpretation suggests that reference to “consumption of particular products and services” could refer to

the products and services constituting a particular brand portfolio. Furthermore, excluding brand marketing

would not be in the spirit of the Recommendations. As stated in the framework implementation report, “Insofar

as certain brands and organizations are clearly associated with products or services whose marketing could fall

within the scope of the Recommendations, it is necessary to consider how brands are marketed” (12, p.9).

Moreover, the broad definition of the Recommendations would also cover promotion through product labelling

or packaging – forms of promotion that are traditionally excluded by industry-wide pledges on food marketing,

as discussed in section 4.

Furthermore, to ensure that policies are effective, the Recommendations urge countries to develop policies that

tackle the two components of marketing: 1) “exposure”, or the reach and frequency of the marketing message;

and 2) “power”, the creative content, design and execution of the message. This covers the full range of media

and techniques used by companies to market food to children, including advertising, direct marketing, point-of-

sale, product placement, sponsorship, design and packaging. It is only then that policies on food marketing will

achieve their stated objective and effectively reduce the overall impact of unhealthy food marketing on children.

The Recommendations distinguish two different approaches: comprehensive and stepwise approaches. A

comprehensive approach tackles all forms of unhealthy food marketing to children, and deals with the two main

components of marketing, exposure and power. In contrast, a stepwise approach is more selective: it would

proceed in stages, prioritizing the regulation of some forms of marketing over others (13, p. 16). There are a

variety of stepwise approaches: some policies will tackle exposure rather than power; some will tackle power

rather than exposure; and some will tackle certain (but not all) aspects of exposure and power. For example, a

stepwise policy might target certain categories of unhealthy food (sugar-sweetened beverages); a particular type

of media and programming (children’s television programmes); or particular settings (schools) and/or marketing

techniques (celebrity endorsement). All stepwise approaches share a common feature in that some gaps in the

regulatory framework are left in place. In countries that have restricted the marketing of unhealthy food to

children using a stepwise approach, these gaps have allowed the food industry to shift their investment and use

loopholes, as discussed later. Therefore, the Recommendations advocate a comprehensive approach (12,

Recommendation 3, note 17). The importance of designing comprehensive policies for countries is discussed

more fully in section 3.

3 The Recommendations urge countries to avoid conflicts of interest

Implementing the WHO recommendations on the marketing of food and non-alcoholic beverages to children

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The Recommendations also urge governments to protect the public interest and avoid conflicts of interests

(Recommendation 6). In particular, they call on countries to set clear definitions so as to eliminate the loopholes

that have been identified in existing regulatory frameworks. The definitions should include: the age group for

which restrictions should apply; the communication channels, settings and marketing techniques to be covered;

what constitutes marketing to children including product, timing, viewing audience, placement and content of the

marketing message; and what food falls within the scope of marketing restrictions (i.e. what constitutes

unhealthy food). In particular, Member States are specifically requested to define settings where children gather

and ensure that they are free of all forms of unhealthy food marketing14. The question of conflicts of interests

and the role of the private sector in the prevention of childhood obesity (and NCDs more generally) continues to

be debated. This is discussed more fully in section 4 below.

4 The Recommendations recognize the importance of tackling cross-border marketing

The Recommendations recognize the importance of tackling cross-border marketing to ensure that the

effectiveness of national policies is not reduced15. Many countries, including those with restrictions in place, are

exposed to food marketing in their country from beyond their borders. This risk is exacerbated when countries

have close cultural ties and share a common language, such as Arabic (and, to a lesser extent, French) in the

Region. It is therefore important for countries to cooperate and tackle cross-border food marketing. This issue

is dealt with in more detail in section 3.

1.3.2 Repeated calls for countries to implement the WHO Recommendations

Following the unanimous adoption of the WHO Recommendations on the marketing of foods and non-alcoholic beverages to children by the 63rd World Health Assembly in May 2010, Member States have taken measures to reduce the impact of unhealthy food marketing on children. Nevertheless, the implementation of the Recommendations has been slow, particularly in the Region.

In September 2011, all Member States adopted the Political Declaration of the High- level Meeting of the General Assembly on the Prevention and Control of Non- communicable Diseases, and committed to promoting the implementation of the WHO Recommendations and discouraging the marketing of food that contributes to unhealthy diets (A/RES/66/2, para. 43). As part of the preparation for this meeting, WHO conducted research which established that the implementation of population- wide interventions could have a high return on investment, in light of the enormous

14 This issue was raised by many Member States during the consultation that led to the Recommendations. The special situation

of schools as a setting where children are a captive audience and the health-promoting role that schools should have were

identified as needing specific attention in the Recommendations.

15 Recommendation 8. 15 Member States raised cross-border marketing as an issue of particular concern.

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social and economic costs of NCDs, particularly for low- and middle-income countries16.

Subsequently, in May 2013, the 66th World Health Assembly unanimously adopted the WHO Global Action Plan for the Prevention and Control of NCDs 2013–2020 (14). This plan includes a monitoring framework with nine voluntary global targets to be reached by 2025, including: a 25% reduction in the overall mortality from cardiovascular diseases, cancer, diabetes or chronic respiratory diseases; a 30% relative reduction in mean population intake of salt/sodium; and a halt to the rise of diabetes and obesity (Resolution WHA 66.10). These targets are ambitious, and their achievement requires the development of effective multisectoral interventions and their coordination at global, regional and national levels. In particular, the Global Action Plan urges Member States and the international community to work towards implementation of the Recommendations as a major component of effective childhood obesity prevention strategies. In particular, Indicator 23 focuses on the importance of adopting policies to reduce the impact on children of unhealthy food marketing.

At the regional level more specifically, countries have also been explicitly called upon to implement the Recommendations and reduce the commercial pressure on children. In particular, the 61st Regional Committee for the Eastern Mediterranean in Tunis in 2014 adopted resolution EM/RC61/R.3, which identified the implementation of the Recommendations as a strategic area of intervention and urged Member States to “support the Regional Director’s initiative to protect public health and promote healthy lifestyles, with a special focus on countering the largely unopposed commercial practices that promote unhealthy products, particularly those targeting children”.

To facilitate the implementation of the WHO Global Action Plan on NCDs, several mechanisms and working groups have been set up. In particular, the month following the adoption of the plan, the United Nations (UN) Secretary-General established the UN Inter-Agency Task Force on NCDs, under the lead of WHO. The Task Force coordinates the activities of relevant UN organizations and other intergovernmental organizations and assists countries in their implementation of the WHO Action Plan

16 The economic consequences of NCDs are enormous. If intervention efforts remain static and rates of NCDs continue to

increase as populations grow and age, cumulative economic losses to low- and middle-income countries from the four main

NCDs (heart disease and stroke; diabetes; cancer; chronic lung disease) are estimated to exceed US$ 7 trillion over the period

2011–2025 (an average of nearly US$ 500 billion per year). This yearly loss is equivalent to approximately 4% of these

countries’ current annual output. On a per-person basis, the annual losses amount to an average of US$ 25 in low-income

countries, US$ 50 in lower middle-income countries and US$ 139 in upper middle-income countries. In contrast, findings from

the second study by the WHO indicate that the cost of scaled-up implementation of a core set of NCD “best buy” intervention

strategies is comparatively low. Population-based measures for reducing tobacco and harmful alcohol use, as well as unhealthy

diet and physical inactivity, are estimated to cost US$ 2 billion per year for all low- and middle-income countries – less than

US$ 0.40 per person. Individual-based NCD “best buy” interventions – such as counselling, drug therapy for cardiovascular

disease and measures to prevent cervical cancer – bring the total annual cost to US$ 11.4 billion. On a per-person basis, the

annual investment ranges from under US$ 1 in low-income countries to US$ 3 in upper middle-income countries. See WHO:

From burden to “best buys” (http://apps.who.int/medicinedocs/documents/s18804en/s18804en.pdf).

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and other high-level commitments to address NCDs worldwide17. Improved global monitoring and improved coordination is intended to provide the foundation for advocacy, policy development and global action, and help frame the concrete actions that countries should take between now and the next UN High-Level Meeting on NCDs in 201818.

Furthermore, in 2014, the WHO Director-General established the WHO Global Coordination Mechanism on NCDs whose scope and purpose is to enhance the coordination of activities, multi-stakeholder engagement and action across all sectors in order to implement the WHO Global Action Plan on NCDs. It is led by the Member States and other participants including UN organizations and non-State actors such as nongovernmental organizations and academic institutions. To date, integrated support has been provided directly to a number of Member States that are willing to take the lead, including the Islamic Republic of Iran and Oman (15).

After noting that progress in tackling childhood obesity had been “slow and inconsistent”, the WHO Director-General also established the ECHO Commission in June 2014. The Commission, made up of 15 commissioners, was entrusted with producing a report specifying which approaches and combinations of interventions were likely to be most effective in tackling childhood and adolescent obesity in different contexts around the world. Two ad hoc working groups were convened to provide the Director-General with guidance, firstly, on the science and evidence for ending childhood obesity and, secondly, on implementation, monitoring and accountability frameworks. One of the tasks of the working group on science and evidence was to provide expert advice to the Commission on the role of marketing of unhealthy food to children in the growing rates of overweight and obesity – highlighting the strength of evidence in relation to obesity (16, pp 69–79). The ECHO Commission submitted its final report to the WHO Director-General on 25 January 2016, including a comprehensive, integrated package of recommendations to address childhood obesity across six areas: promotion of the intake of healthy foods; promotion of physical activity; preconception and pregnancy care; early childhood diet and physical activity; health, nutrition and physical activity for school-age children; and weight management. In relation to food marketing, the report highlighted (7):

There is unequivocal evidence that the marketing of unhealthy foods and sugar-sweetened beverages is related to childhood obesity. Despite the increasing number of voluntary efforts by industry, exposure to the marketing of unhealthy foods remains a major issue demanding change that

17 World Health Organization. Noncommunicable diseases and their risk factors. UN Interagency Task Force on NCDs

(UNIATF) (www.who.int/nmh/ncd-task-force/en/).

18 For the ongoing preparations for the 2018 meeting, see: World Health Organization. Noncommunicable diseases and their

risk factors. Getting to 2018: Preparing for the third UN High-level Meeting on NCDs

(http://www.who.int/nmh/events/2015/getting-to-2018/en/)

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will protect all children equally. Any attempt to tackle childhood obesity should, therefore, include a reduction in exposure of children to, and the power of, marketing.

Settings where children and adolescents gather (such as schools and sports facilities or events) and the screen-based offerings they watch or participate in, should be free of marketing of unhealthy foods and sugar-sweetened beverages. The Commission notes with concern the failure of Member States to give significant attention to Resolution WHA 63.14 endorsed by the World Health Assembly in 20103 and requests that they address this issue.

On this basis, it called on Member States to implement the Recommendations (ECHO recommendation 1.3), and in particular to develop a nutrient profiling model (ECHO recommendation 1.4) and address the issue of cross-border marketing (ECHO recommendation 1.5).

In May 2016, the 69th World Health Assembly welcomed the Commission’s report (Resolution WHA 69.8) and asked the WHO to develop an action plan for the implementation of its recommendations. Following consultation with Member States and relevant stakeholders, an implementation plan was submitted to the 70th World Health Assembly in May 2017 (EB140/30). Work is now ongoing in advance of the review of the progress in the prevention and control of NCDs scheduled for the Third UN High Level Meeting on NCDs in 2018 (Resolution WHA 68.10).

Other major policy developments illustrate the increased attention being given to nutrition and obesity prevention globally. In particular, in the Rome Declaration on Nutrition in 2014, ministers and representatives of WHO Member States explicitly acknowledged that all forms of malnutrition – including undernutrition, micronutrient deficiencies, and overweight and obesity – not only affect people’s health and well-being, but have negative social and economic consequences to individuals, families, communities and countries (17). The UN General Assembly subsequently endorsed the Rome Declaration and proclaimed 2016–2025 the UN Decade of Action on Nutrition (A/RES/70/259). These developments led to the inclusion of malnutrition and NCDs as important elements of the 2030 Agenda and the Sustainable Development Goals (SDGs): SDG 2 urges “all countries and all stakeholders” to “end hunger, achieve food security and improved nutrition and promote sustainable agriculture”, while SDG 3 calls on them to “ensure healthy lives and promote well-being for all at all ages.” (A/RES/70/1). It is hoped that the inclusion of childhood obesity as a major development concern can help galvanize political will and lead, in particular, to the effective implementation of the WHO Recommendations throughout the world.

1.3.3 Poor implementation of the Recommendations

Despite these clear and repeated calls on Member States to implement the

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Recommendations, the extent to which they have been used as a tool for the development of policies at the national and regional level has varied from one country to the other. Overall, progress remains slow, and more than seven years after their adoption, several countries still have to implement them (18). This is particularly true in the Region where, despite very varied action and progress, overall far too little has been done to limit the marketing of unhealthy food, particularly to children. This is confirmed by the research underlying this report.

Only a relatively few countries in the world have adopted legally binding measures (as opposed to relying on self-regulatory commitments of the food and the advertising industries)19, and from their experiences we can distinguish two main approaches. On the one hand, a growing number of countries have specifically limited – or are considering limiting – the marketing of unhealthy food to children in order to promote a media environment that is more conducive to healthier diets. This is the approach a few countries have taken or are considering, as discussed in section 3. On the other hand, some countries have prohibited all advertising (including, but not limited to, food) to children in order to protect them – given their credulity and vulnerability – from its negative effects. This approach, which was pioneered by Quebec in 1979, has had as a “collateral benefit” of limiting the exposure of children to unhealthy food marketing, thus contributing to specific public health objectives, such as the prevention of childhood overweight and obesity20.

In the Region, the Islamic Republic of Iran has taken substantial steps to restrict the marketing of unhealthy food to children. Several others are in the process of adopting national plans to align their national regulations with the Recommendations. Other countries have not taken any serious measures. The regional situation is discussed more fully in section 3.

1.4 Purpose, structure and scope of this report

In its commitment to scale up technical support to Member States, the Regional Office has taken a number of actions to raise awareness and facilitate the implementation of the WHO Global Action Plan on NCDs across the Region, and more specifically to support the adoption of effective restrictions on the marketing of unhealthy food to children. Following a technical advisory meeting on NCDs in Kuwait in April 2013, the Regional Office organized in collaboration with the University of Liverpool which

19 The World Cancer Research Fund has developed the NOURISHING database, a tool supporting the work of policy-makers,

researchers and civil society organizations worldwide. It comprises a list of policies to promote healthy diets and reduce obesity

and NCDs, and, in particular, examples of implementation of the Recommendations

(http://www.wcrf.org/sites/default/files/4_Restrict_advertising_Oct2017.pdf)

20 While Quebec’s legislation does not apply exclusively to food marketing, it has had a positive impact on reducing children’s

exposure to unhealthy food marketing (see section 2.1.1).

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included:

- a consultation in Amman with an interdisciplinary group of experts on food

marketing to children (including lawyers, consumer and public health

organizations and journalists) and selected countries of the Region;

- a regional workshop in June 2015, also in Amman, to build capacity to help

countries to implement the Recommendations;

- personalized training for the Omani government on their implementation of the

Recommendations (May 2017).

This report is the outcome of the work carried out in the past four years. It is primarily intended to support Member States in their implementation of the Recommendations at national and regional levels. In particular, it attempts to map the regulatory scene. It identifies what action has already been taken in the Region to implement the Recommendations on the basis of three questionnaires circulated to all countries of the Region in April 2013, January 2015 and January 2017. The questionnaire circulated in January 2017 is available in Annex 1. The report also highlights what Member States need to consider when implementing the Recommendations, drawing on experiences both within and outside the Region.

Section 2 provides an overview of the media and marketing techniques used to promote unhealthy food to children in the Region and beyond. It looks both at the extent to which such food is marketed to children in the Region, as well as the effect that such marketing has on children’s food preferences, purchase requests and consumption patterns, and highlights the growing complexity of the current media environment.

Given that unhealthy food is bad for children and undermines their rights, the question arises of how Member States should best implement the Recommendations as part of effective overweight and obesity prevention strategies. Section 3 assesses what has been achieved to date in the Region following the endorsement of the WHO Recommendations and identifies opportunities for further progress at national and regional levels. It emphasizes the importance of building consensus across and beyond government in order to facilitate the adoption of a wide-ranging policy restricting unhealthy food marketing to children. Section 3 concludes by looking at the issue from a regional perspective, highlighting the importance for the Region as a whole to adopt cross-border standards to ensure that the efforts of individual Member States to restrict unhealthy food marketing to children are adequately supported.

Section 4 discusses the important need for policy-makers to act in the public interest, and avoid all real, perceived or potential conflicts of interest. In practice, this means that Member States should not delegate their responsibility to set the policy parameters to private stakeholders such as food or advertising industry operators. In particular, section 4 focuses on the limitations of relying on voluntary commitments, and the responsibility of the food industry to stop promoting unhealthy food

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marketing to children. It also emphasizes that countries in the Region have a legal obligation to regulate the harmful marketing strategies of the food industry under the UN Convention on the Rights of the Child and other international human rights instruments. A human rights approach to childhood obesity and NCD prevention requires that the Recommendations are read in light of this Convention and other human rights treaties.

It is worth highlighting from the outset that this report focuses exclusively on the implementation of the Recommendations. It does not discuss the implementation of the International Code of Marketing of Breast-milk Substitutes21 and other relevant instruments intended to protect, promote and support breastfeeding. This does not mean that measures to improve infant nutrition, including the imposition of restrictions on the marketing of breast-milk substitutes, do not have an important role to play in preventing childhood overweight and obesity. Quite the contrary, new scientific evidence highlights the need to focus on the life course, and the need to intervene even before conception and reduce the exposure of pregnant women, infants, children and adolescents to an obesogenic environment22. Similarly, this report does not discuss food labelling policies which are intended to help consumers make healthier food choices by providing them with clear, sufficient and non- misleading information. The focus is exclusively on the extent to which restrictions on the marketing of unhealthy food to children are justified. This report also does not discuss social marketing and education campaigns, and the role that marketing of healthy food could play in promoting healthier diets. Even though they fall outside the scope of this report, food labelling and nutrition education are nonetheless components of effective overweight and obesity prevention strategies23. It is important to point this out as the information gathered through the three questionnaires distributed to countries in 2013, 2015 and 2017 on implementation of the Recommendations suggests that the distinction between these intervention areas is still unclear.

Finally, because this report takes as its starting point the implementation of the Recommendations, it focuses on the marketing of unhealthy food to children. This does not mean that Member States should not consider adopting a whole population approach and restrict the marketing of unhealthy food to both children and adults. On the contrary, the Regional Office considers that “restricting all marketing of [unhealthy food] is a way to protect adult health and to protect adolescents and

21 Adopted at the 34th World Health Assembly in 1981, the Code bans the marketing to the general public of – among others –

breast-milk substitutes, including infant formula (Article 5) (www.who.int/nutrition/publications/infantfeeding/9241541601/en/).

22 The final report of the ECHO Commission is unequivocal in this respect with its focus on the importance of adopting a life-

course approach and the importance of breastfeeding as “core to optimizing infant development, growth and nutrition”. In

particular, the Commission urges States to enforce the International Code of Marketing of Breast-milk Substitutes and

subsequent World Health Assembly resolutions (ECHO Recommendation 4.1) (7).

23 See the final report of the ECHO Commission, Recommendations 1.6 and 1.7 on food labelling and Recommendations 1.7,

4.3, 4.10 and 5.4 on nutrition education (7). On social marketing, see: Hastings G, Domegan C. Social marketing: rebels with

a cause, 3rd edition. Oxford: Routledge; 2017.

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children from exposure to marketing that is supposedly targeted only at adults. Given that no country has completely eliminated children’s exposure to marketing of [unhealthy food] by defining child audiences, a whole population approach might well be particularly relevant to the Region, where children and adolescents comprise more than half of the population” (3, p. 20).

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2. Harmful effect of food marketing on children

In the past 20 years, a direct link between unhealthy food marketing and childhood obesity has been established as stated in the ECHO Commission’s final report: “There is unequivocal evidence that the marketing of unhealthy foods and sugar-sweetened beverages is related to childhood obesity.” (7, p. 18).

Little systematic research has been done in the Region to evaluate the extent of unhealthy food marketing and its effect on children. However, it is clear that unhealthy food is promoted extensively in the Region, as discussed in section 2.2. More research would help provide a more complete picture of the extent, nature and impact of unhealthy food marketing in Member States. This in turn could better inform national and regional policies to implement the Recommendations. Nevertheless, the knowledge gathered in a growing number of countries worldwide demonstrates that there are clear trends in the extent, nature and impact of unhealthy food marketing on children. Countries of the Region should use this to introduce restrictions on unhealthy food marketing in their countries without further delay.

This section reviews the evidence base underpinning the Recommendations (section 2.1), and presents data more specifically on the marketing of unhealthy food in the Region (section 2.2).

2.1 International evidence supporting the regulation of marketing

of unhealthy food to children

One of the first studies was published in 2003 after the United Kingdom (UK) Food Standards Agency commissioned a systematic literature review of all sound studies that had been carried out on food marketing to children in order to establish whether, and if so the extent to which, restrictions on unhealthy food marketing to children were warranted (19, p. 3). After noting that food marketing to children was primarily for unhealthy food, the review highlighted that food marketing had become a global phenomenon and tended to be varied and integrated, using multiple messages in multiple channels. It concluded that unhealthy food marketing had the following effects on children:

- it undermines food knowledge and confuses children as to what is healthy and

unhealthy food;

- it stimulates a preference for unhealthy food;

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- it encourages the purchase of, and pestering for, unhealthy food; and

- it makes children more likely to consume unhealthy food. This unhealthy eating

is directly linked to the recent increases in childhood obesity and weight gain,

and related health harms (19,20, pp 378–80).

Importantly, the report found that advertising led to an increase in consumption not only of the product of a given brand, but also of all the products of the category in question (19). In other words, not only will children prefer one brand of fizzy sugary drink to another if they are exposed to the marketing of the advertised product, but they will also increase their consumption of fizzy sugary drinks to the detriment of other healthier drinks, such as water and milk.

This review has been regularly updated since it was first published in 2003. The latest update was commissioned by WHO (21) and provides the evidence supporting the Recommendations, which state (12, paras 12,13):

“Evidence from systematic reviews on the extent, nature and effects of food marketing to children concludes that advertising is extensive and other forms of food marketing to children are widespread across the world. Most of this marketing is for foods with a high content of fat, sugar or salt. Evidence also shows that television advertising influences children’s food preferences, purchase requests and consumption patterns.

The systematic reviews show that, although television remains an important medium, it is gradually being complemented by an increasingly multifaceted mix of marketing communications that focuses on branding and building relationships with consumers. […] Food marketing to children is now a global phenomenon and tends to be pluralistic and integrated, using multiple messages in multiple channels.”

Subsequent studies have confirmed these findings. For example, a review published in 2012 concluded that, “current marketing practice predominantly promotes low- nutrition foods and beverages” and that “food promotions have a direct effect on children’s nutrition knowledge, preferences, purchase behaviour, consumption patterns and diet-related health” (22).

Evidence about the relationship between unhealthy food marketing and children’s food preferences and purchase requests comes from a range of sources, including systematic literature reviews, experimental studies and studies evaluating the effectiveness of restrictions on food marketing to children. It is likely that this evidence provides a conservative assessment of the effect of unhealthy food on children’s health, given that beyond the direct effect of unhealthy food marketing on children, there is a range of indirect effects that are more difficult to measure (16, pp 72–5).

Seven years after the adoption of the Recommendations, television is still a frequently

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used medium to market unhealthy food to children (section 2.1.1). However, other media are being used more and more to promote unhealthy food to children, particularly the Internet and other forms of digital marketing (section 2.1.2). Furthermore, bearing in mind that the effectiveness of marketing is a function of both exposure and power (Recommendation 2), section 2.1.3 discusses the marketing techniques that have been used to promote unhealthy food to children and their effect. The medium in which the communication message appears relates to the reach, frequency and impact of the message (or exposure, as discussed in sections 2.1.1and 2.1.2), whereas its creative content, design and execution relate to its power (as discussed in section 2.1.3). This section does not provide a comprehensive account of research on unhealthy food marketing to children. It is intended to give a snapshot of the research which supports the existence of the relationship between unhealthy food marketing and obesity, which could be replicated in the Region, and which therefore supports the implementation of the Recommendations.

2.1.1 Television advertising

A 2010 global study of television food advertising on the commercial channels most watched by children included several European countries (UK, Germany, Italy, Greece, Sweden and Spain). The results showed that food advertisements comprised 11–29% of all advertisements broadcast, and of those, between 53% and 87% were for unhealthy food. Although this study speaks to children’s potential rather than actual exposure, it was found that non-core food advertisements were more prevalent at times when higher numbers of children would be watching television (“peak times” based on typical viewing patterns for each country) (23).

In 2004, the Office of Communications (Ofcom), an independent regulator for the UK communication industries, commissioned research into the role played by television advertising in influencing children’s consumption of unhealthy food. The report concluded that advertising had a modest, direct effect on children’s food choices and a larger but unquantifiable indirect effect on children’s food preferences, consumption and behaviour24. On this basis, while noting the multiple factors responsible for childhood overweight and obesity, Ofcom acknowledged that there was a case for regulating food advertising to children on television to address this public health issue. This research was the basis for a ban on all unhealthy food marketing in and around children’s television programmes in the UK, as discussed in section 3.

Studies also show that children are often exposed to a high volume of television advertising for unhealthy food on commercial television at times when the largest numbers of children are watching (during children’s programmes and family shows which are designed for a mixed audience including children) (24–26), and that this

24 Sonia Livingstone produced three reports for Ofcom on the effects of food advertising (February 2004, May 2004

and January 2006). They are all available at http://www.ofcom.org.uk. Her findings are summarized in: Livingstone S. Does

TV advertising make children fat: what the evidence tells us? Public Policy Research. 2006;13(1):54–61.

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marketing influences their food preferences, purchase requests and consumption patterns (27). In the Region, a review by Nassar and Al Zien supports the conclusion that the negative effects of television commercials are particularly noticeable, including on nutrition and childhood obesity (28).

Evaluation of the existing restrictions on television advertising to children further supports the argument that there is a relationship between unhealthy food marketing and children’s food preferences, purchase requests and consumption patterns. For example, a study in Quebec, where advertising to children of up to 13 years of age is prohibited (including unhealthy food marketing), estimated that the ban led to an 11% decrease in the probability of purchasing fast food and that it had reduced fast food consumption by US$ 88 million per year (29).

These findings are important in light of the fact that television is still one of the most popular media for promoting unhealthy food to children (30). It is also important to note that, even though the Internet and other forms of digital marketing have grown rapidly and are expected to become even more significant worldwide, reduced spending on television advertising does not necessarily mean reduced exposure to such marketing25.

2.1.2 Other media used to promote unhealthy food to children

As mentioned in section 1, the Recommendations define the notion of marketing broadly as “any form of commercial communication or message that is designed to, or has the effect of, increasing the recognition, appeal and/or consumption of particular products and services. It comprises anything that acts to advertise or otherwise promote a product or service.” This broad definition is necessary because food marketing is everywhere. Even though the main food and beverage companies are allocating an increasing part of their marketing budgets to digital media26, they also continue to use more traditional ways to promote unhealthy food to children, including advertising through television, radio, print and billboards, as well as sponsorship, point-of-sale advertising and packaging design.

Despite the fact that there is less evidence to draw on about the effect of unhealthy food marketing in media other than television, evidence is growing rapidly and confirms that there is indeed a direct link between unhealthy food marketing and

25 The proliferation of television channels and expanding new media has reduced average costs and therefore increased

opportunities significantly. For example, the number of television impacts in the UK (one person seeing one advertisement)

rose by 21% from 790 billion impacts in 2006 to 956 billion impacts in 2010, despite the fact that expenditure on television

advertising across major categories was reported to have fallen by nearly 60% (Marketing of foods high in fat, salt and sugar

to children: Update 2012–2013. Copenhagen: WHO Regional Office for Europe; 2013:2).

26 By 2018, Internet advertising is likely to become the most invested media type for advertising globally; advertising

expenditure on social networks in 2017 reached US$ 35.98 billion (www.emarketer.com/Article/Social-Network-Ad-

Spending-Hit-2368-Billion-Worldwide-2015/1012357#sthash.tjwLObVZ.dpuf).

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children’s food preferences, purchase requests and consumption patterns.

In November 2016, the WHO Regional Office for Europe published an important report that provided a comprehensive analysis of digital marketing of unhealthy food to children in the WHO European Region (31). It noted with concern that:

- children are exposed to countless numbers of hidden digital marketing

techniques promoting unhealthy food;

- parents might be unaware of or underestimate the harmful impact of digital

marketing, despite the effect of such marketing on children;

- in the absence of effective regulation of digital media in many countries, children

are increasingly exposed to persuasive, individually tailored marketing

techniques through, for example, social media sites and “advergames” (i.e.

computer-based and online games which include brand advertising and product

placement);

- using sophisticated techniques, digital platforms are able to collect extensive

personal data from Internet users, including children, in order to deliver

behavioural advertising, targeting audiences with precision. For example:

 geolocation data from mobile devices enable marketers to deliver

advertisements and special offers in real time when users are in an area

in which specific products are sold, encouraging them to “walk in and

buy”;

 some food chains partner with gaming companies in order to, for

example, make the chain’s restaurants important game locations;

 digital marketing can be pursued on numerous platforms, such as

advergames, social media and animated movies, or through powerful

peer influencers such as video bloggers, known as “vloggers”;

- assessing the extent of digital unhealthy marketing viewed by children of all ages

is a major challenge for researchers external to digital platforms because

proprietary data are not published, and other currently available methods do not

readily allow access to these data.

Social networking sites such as Facebook and message services such as Twitter are particularly popular with children and young people as well as with advertisers27. Early indications are that substantial advertising of food high in fat, salt or sugar reaches children in digital media. For example, the five food and beverage Facebook brand pages in Australia most popular with users aged 13–17 years featured sugar- sweetened drinks, ice-creams, chocolate and fast food (32). Similarly, in Ireland, of the 113 most popular retail and Facebook food and soft drink brands, the 18 that Facebook

27 In China, for example, advertising spending on social networks was expected to increase to US$ 6.11 billion in 2017, or

12.5% of all digital advertising dollars in the country. eMarketer, 15 April 2015 (https://www.emarketer.com/Article/Social-

Network-Ad-Spending-Hit-2368-Billion-Worldwide-2015/1012357?ecid=PR1020).

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estimated had the greatest “reach” among users aged 13 or 14 years all featured sugar- sweetened carbonated drinks, fast foods, savoury snacks, sweets, chocolate and ice- cream (33). Social media marketing can increase advertisement recall, awareness of the product or brand and intent to purchase. Even if children are required to declare they are over a certain age to register on networking sites and message services, they often declare a false age and access them at a much younger age. This raises concern about the effectiveness of age-verification and whether enough is being done to prevent children from accessing age-restricted content on social media sites28 (34).

The report of the WHO Regional Office for Europe also noted that mobile digital marketing was developing at a fast pace (31, p. 4). In particular, it referred to the net children go mobile study in six European countries (Belgium, Denmark, Ireland, Italy, Portugal, Romania and the UK) which reported a “post-desktop media ecology” among children aged 9–16 years (35), with smartphones being the devices most frequently used daily. Mobile device ownership is rapidly increasing: 67% of British children own a tablet (36), and tablet ownership is increasing very rapidly in Central and Eastern Europe and Turkey (37). Companies collect mobile phone numbers from their interactive websites and customize their messages on the basis of users’ interests. Smartphone applications further increase the opportunities for unhealthy food marketing, allowing food operators to communicate information about products (38).

Box 2 illustrates the strategies food companies can use with digital online marketing to extend their reach to children.

28 Combined exposure to television and Internet social networking is also increasing: over 50% of X Factor viewers in the UK

reportedly used the Facebook site whilst they were watching the television show (Marketing of foods high in fat, salt and sugar

to children: Update 2012–2013. Copenhagen: WHO Regional Office for Europe; 2013:6). For a more complete discussion,

see: (31).

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Box 2 Digital online marketing29

Children access the Internet from an early age30, and often without parental or any adult supervision. Furthermore, as is the case for television advertising, the food marketed to children online or via other new media tends to be unhealthy. However, the Internet and other forms of digital marketing allow food companies to develop marketing strategies which are far more immersive, interactive and integrated than they have ever been able to do on television or other more traditional media.

Immersive: the online environment often portrays marketing opportunities as entertainment, making it particularly difficult for children to distinguish marketing from content, to the point that marketing sometimes becomes content. For example, major food companies have internet sites offering a range of games promoting their goods, services and brands (“advergames”). These games, which are often intended for children without always referring explicitly to the goods, services and brands thus promoted, are highly immersive. They are designed to be entertaining and rely on children playing for long periods of time, sometimes with several repeat visits. They are a particular cause for concern as they tend to operate “under the cognitive radar”, i.e. without children being aware that they are the targets of unhealthy food marketing. A systematic review of the impact of advergames on children was carried out in 2012, highlighting their influence on children’s dietary choices (39). Moreover, it also emphasizes that “research that tests the effects of advergames on children rather than their understanding of commercial intent concurs that older and more experienced children are just as affected by advergames as younger children” (emphasis in the original)31. Several studies have since confirmed the poor nutritional value of the foods marketed to children via advergames (40–44).

Interactive: media such as the Internet and smartphones enable companies to gather information and adapt their marketing strategies to target each potential customer as individually and effectively as possible. In particular, the increasing use of “behavioural marketing” (coupled with geolocalization technology) personalizes the connection between a brand and its customers. This trend is compounded by the rapid development of social networking sites which allow food manufacturers to ensure that their brands are referred to, “liked” and promoted by children themselves without them always realizing that they have been recruited as “brand ambassadors”. This form of “viral marketing” in turn enables the brands to create a mix of social impressions which incorporate both “paid” and “earned” media. However, social media marketing increases advertisement recall, awareness of the product or brand and intent to purchase (45). Even though children may have to declare that they are over a certain age to register on networking sites and message services, evidence suggests that they often register under false ages and access them at a much younger age which, in turn, raises questions around the effectiveness of age- verification (34), and gives rise to both public health and data protection concerns.

Integrated: the Internet has significantly increased the opportunities available to food operators to ensure that their strategies are always more integrated. For example, in the United States, a survey reviewed 130 food company websites: 48% had designated children’s areas featuring a variety of marketing techniques including advergaming, interactive programmes, branded spokes-characters and tie-ins to other products. Of the companies with child- oriented sites, 87% promoted unhealthy food (46). Beyond their own websites, major food operators have created powerful alliances with companies such as Google in order to increase their presence on search engines and emails, as well as Facebook, Twitter and YouTube and other user-generated content sites.

Digital online marketing has become an integral component of the “marketing mix” of food brands: it has not replaced other forms of more traditional food marketing; rather, it has been added to them to increase brand presence across a larger, more diverse range of media. With digital opportunities, food marketing has become more ubiquitous and multifaceted than ever.

Even if advertisers spend an increasing part of their marketing budget on new media, they also continue to use more traditional settings to promote unhealthy food to

29 Box 2 is reproduced from box E in the report of the ad hoc working group on science and evidence for ending childhood

obesity (16, pp 72–5).

30 For example, in 2011, 65% of UK children aged 5–7 years and 85% of children aged 8–11 accessed the Internet through

home computers. Several of them also own a smartphone: 1 in 50 children aged 5–7 years and 1 in 8 children aged 8–11 years

(Children and parents: media use and attitudes. London: Ofcom; 2011).

31 A study by Harris and others also found that children playing advergames with energy-dense food consumed more energy-

dense snacks and fewer fruits and vegetables than children who played advergames with fruit or those in the control group

(Harris JL, Speers SE, Schwartz MB, Brownell KD. US food company branded advergames on the Internet: children’s

exposure and effects on snack consumption. Journal of Child Media. 2012;6:51–68).

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children32. For example, a recent study carried out in New Zealand showed that magazines specifically targeted to children and adolescents contained a significantly higher proportion of unhealthy branded food references compared with the most popular magazines, most of which were targeted to women (47). Packages are also used extensively to promote unhealthy food to children (48).

Marketing in schools is particularly worrying as it allows for the promotion of food brands in educational settings where children and parents trust that action is taken in the best interest of children. In the United States of America, the Federal Trade Commission reported that food companies spent US$ 186 million on in-school advertising in 2008, 90% of which was spent on soft drink promotion (49, p. 23). In- school marketing includes advertising or promotional activities in or around a preschool, elementary school, middle or junior high school, and high school, including cafeterias, vending machines, school events, athletic events or fields, school buses, and closed circuit television channels (49, p. 24). WHO has specifically urged countries to ensure that children are not exposed to unhealthy food marketing in settings where they gather, not least schools. This is discussed further in section 3.

Similarly, sponsorship provides the food industry with unique business opportunities to target a captive audience of new, young consumers – particularly when the arrangements relate to sports events of wide appeal. For example, the Olympic Partners benefit from exclusive marketing rights worldwide within a designated product or service category. Thus, Coca-Cola is the Olympic Games exclusive non-alcoholic beverages supplier and McDonald’s the exclusive retail food services supplier – until 2020, when its sponsorship terminates (50). At the Beijing Olympic Games, Coca-Cola was the largest spender, with an investment of US$ 125 million in advertising three months prior to and including the Olympics. McDonald’s followed with an advertising spend of US$ 87 million. However, there was also a marketing frenzy among competitor companies not involved as sponsors. PepsiCo spent almost US$ 100 million on advertising over the same period, while KFC trumped McDonald’s by spending US$ 238 million on advertising33 (51). Similarly, Coca-Cola sponsors the football World Cup, and it will sponsor the championship which is due to take place in Qatar in 202234. The food industry not only has a direct commercial interest in investing in sports sponsorship with the expectation of

32 “Traditional” settings for advertising are discussed in: Marketing food to children and adolescents: a review of industry

expenditures, activities, and self-regulation. (49); and A review of food marketing to children and adolescents: follow-up

report. Washington (DC): Federal Trade Commission; December 2012.

33 For a criticism of the commercialization of the Olympic Games, see in particular: Tomlinson A. The commercialization of

the Olympics: Cities, corporations, and the Olympic commodity. In: Young K, Wamsley KB, editors. Global Olympics:

Historical and Sociological Studies of the Modern Games (Research in the Sociology of Sport). UK: Emerald Group

Publishing; 2005:179.

34 The FIFA site itself states: “The FIFA World Cup™ is the most effective international marketing platform, reaching millions

of people in over 200 countries throughout the world” (http://www.fifa.com/about-fifa/marketing/sponsorship/partners/).

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significant returns on investment, but it also helps its overall image as a key stakeholder in the prevention and control of NCDs35.

2.1.3 Beyond exposure: power

Food operators also use a broad range of marketing techniques, known to be particularly effective with children, to promote their products, services and brands. A systematic literature review in 2014 identified 38 articles examining persuasive marketing techniques to promote unhealthy food to children (52). The most frequently reported techniques were: premium offers, promotional characters, nutritional and health claims, the theme of “taste” and the emotional appeal of “fun”. Similarly, a study published in 2011 in the UK found that the television food advertising likely to be seen by children made widespread use of promotional characters, celebrity endorsers and premium offers, and that these techniques were used more frequently to promote unhealthy rather than healthy food, even on dedicated children’s channels (53).

More specifically, some studies have shown that food packaging which displays familiar cartoon characters can increase children’s liking of the food (54,55). In one of these studies, children aged 4 to 6 years differentiated identical food on the basis of their packaging and consistently stated that they preferred the taste of those foods with a popular cartoon character on the packaging. The effect was seen most strongly for unhealthy food (56,57).

Similarly, evidence suggests that “gifts” distributed with children’s meals are a widespread and effective fast-food marketing tool targeting children, and are seen by parents in the UK as the marketing technique most likely to encourage children to pester their parents for unhealthy food (13, p. 25, box 4). According to a report from the U.S. Federal Trade Commission, 10 leading fast food restaurant chains spent US$ 360 million in 2006 on toys distributed with children’s meals in the United States alone (49, p. 23). The Commission also reported that in 2006, fast food restaurants sold more than 1.2 billion meals with toys to children under 12 years, accounting for 20% of food sold for children. Recognizing the potential power of “free toys”, the city of San Francisco has legislated to restrict “free toys” promotion in fast food outlets, specifying that toys can only be offered if the food sold is less than 600 kcal per meal or portion and does not exceed certain thresholds in salt, fat, saturated fat and sugar content36.

35 For a more detailed discussion of the sponsorship of sports events by food industry operators, see: Garde A, Rigby N. Going

for gold – should responsible governments raise the bar on sponsorship of the Olympic Games and other sporting events by

food and beverage companies? Communications Law. 2012;17:42; and the Sustain Report. The obesity games – junk food

sponsorship of the Olympic Games, London, 2012 (http://www.sustainweb.org/publications/?id=237).

36 Ordinance 290-10 amended Article 8 of the San Francisco Health Code by adding Sections 471.1 to 471.9 to set nutritional

standards for restaurant food sold accompanied by toys or other youth focused incentive item.

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Research suggests that children are also influenced by celebrity endorsement and that the influence of a celebrity endorser on food intake in children extends beyond his or her role in the specific endorsed food commercial, prompting increased consumption of the endorsed brand even when the endorser has been viewed in a non-food context. The ubiquitous nature of celebrity media may reinforce unhealthy eating practices in children, although further research is needed to confirm these findings (58,59). This is why Ireland, for example, has prohibited the use of celebrities to promote unhealthy food to children up to 18 years of age37.

Overall, the power of food marketing remains under-researched and the use of specific techniques promoting unhealthy food to children is rarely regulated – a few exceptions aside (60).

The pervasiveness of unhealthy food marketing combined with the use of powerful marketing techniques exacerbates children’s “pester power”. Food companies target children not only because they often have their own money to spend but they influence the overall purchasing decisions of their families (61). They also use children as a bridge into low- and middle-income countries where adults may be more resistant to westernized diets (62). Children should not be used as surrogate salespeople to pester their parents to buy heavily promoted unhealthy food. This is particularly so if children in lower-income households pester their parents when they have seen images of products their parents cannot afford (63), and in light of recent evidence that pestering is modestly related to diet and weight38.

This section, which has briefly reviewed the evidence on the nature, extent and effect of food marketing to children, confirms that it can no longer be argued that unhealthy food marketing does not contribute to childhood obesity. This should not, of course, be read as suggesting that obesity is not multifactorial in nature. Rather, it is intended to establish that – among the many areas of intervention required to address childhood obesity – unhealthy food marketing is one of them. The next section (2.2) looks more specifically at the situation in the Region.

2.2 Food marketing trends in the Region

As the Recommendations noted in 2010, “most of the available evidence to date comes from high-income countries” (12, para. 35). This remains largely true seven and half

37 Celebrities in this instance are defined as persons who are widely acclaimed, or honoured and/or known to children. It does

not include those persons or characters that become known to children solely as a result of their participation in commercial

communications. See section 11(9) of the Irish Children’s Commercial Communications Code

(http://www.bai.ie/?page_id=1929).

38 Asking for items seen on television has the most robust relationships across 23 child outcomes and over time (Huang CY,

Reisch LA, Gwozdz W, Molnár D, Konstabel K, Michels N, et al. Pester power and its consequences: do European children's

food purchasing requests relate to diet and weight outcomes? Public Health Nutr. 2016 Sep;19(13):2393–403).

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years after the Recommendations were adopted with few studies coming from low/middle-income countries (28,64–66).

In order to address this gap, the Regional Office commissioned the Pan Arab Research

Center (PARC39) to provide new data with a view to assessing the nature and extent of the marketing of unhealthy food, particularly children, in the Region and therefore support evidence-based policies40. These data, collected in 2012 and 2015, supplement the data which some countries have started to gather and analyse as a first step towards the implementation of the Recommendations. This also follows from the regional strategy on nutrition 2010–2019 and plan of action which specifically calls for “monitoring the characteristics of the food environment, including nutritional quality, food prices and marketing practices” (67).

The data that PARC gathered focuses on multinational and regional food and beverage companies, and primarily companies with a presence in most of the countries. The media focused on were mainstream broadcast, print and outdoor media. They did not include the Internet and other digital media, nor did they include packaging, point-of-sale advertising and sponsorship arrangements. The power of specific marketing techniques was also not evaluated –the focus was on the exposure of children to unhealthy food marketing in the media mentioned above. Despite these gaps, the data provide interesting insights into the nature of the food advertised to children in the Region and the extent of this advertising, p