Characterising Parent-Appeal Marketing on Foods for Children: A Scoping Review.

PURPOSE OF REVIEW: This scoping review examines current evidence on parent-appeal marketing on the front-of-pack of food products for children and the impacts on parents' perceptions, intentions, and behaviours. RECENT FINDINGS: Thirteen relevant studies were identified. Marketing features on packages of foods for children that appealed to parents include health claims, nutrition claims, non-nutrient claims such as 'natural', healthy-looking product images, images of healthy ingredients, and celebrity endorsements. At the same time, parents were wary of front-of-pack marketing and find it confusing, deceptive, and misleading. Child-appeal marketing features such as cartoon characters and bright colours gave parents the perception that products were unhealthy. Overall, this scoping review offers important insights into the types of front-of-pack marketing that appeal to parents and offers an inventory of parent-appeal marketing features. These findings support the design and implementation of policies that aim to reduce commercial influences on children's diets through stronger regulation of marketing of foods for children.

The rise and fall of the Queensland Government policy to restrict unhealthy food and alcohol advertising on publicly owned assets.

OBJECTIVE: To examine the strategies employed by opponents of the Queensland Government's policy to restrict unhealthy food and alcohol advertising on publicly owned assets and identify which of the opposing arguments appeared to influence the policy outcomes. METHODS: Retrospective qualitative policy analysis case study informed by the Policy Dystopia Model of corporate political activity. We used qualitative content analysis to examine data from stakeholder submissions to the 'Advertising content on Queensland Government advertising spaces' policies (v1 and 2), and Minister for Health's diaries. RESULTS: Stakeholders from the food, beverage, alcohol and advertising industries and several not-for-profit health organisations opposed the policy. Industry actors used discursive strategies, coalition management (including co-option of not-for-profit health organisations), information management and direct involvement with policy makers to communicate their arguments against the policy. The second version of the policy was weaker regarding scope and key policy provisions, reflecting the arguments of industry actors. CONCLUSIONS: Influence from industries with a clear conflict of interest should be minimised throughout policy development to ensure public health is prioritised over corporate gain. IMPLICATIONS FOR PUBLIC HEALTH: Our findings can support other jurisdictions to prepare for industry opposition when designing policies to restrict unhealthy food and alcohol marketing.

Collaborating with end-users in evidence synthesis: case studies for prevention in the first 2000 days.

BACKGROUND: Evidence synthesis is an important tool to inform decision-making in public health policy and practice. Collaborative approaches to evidence synthesis involving researchers and the end-users of their research can enhance the relevance of the evidence for policy and practice and overcome the limitations of traditional evidence synthesis methods. Despite its benefits, collaboration is not consistently integrated into evidence-synthesis methods. Type of program or service: Collaborative evidence synthesis for public health policy and practice. METHODS: Reflecting on our experiences of undertaking collaborative evidence syntheses with end-users to inform policy and practice around preventive health in the first 2000 days of life, we have collated our key learnings to inform future collaborations in public health research. RESULTS: Key themes generated from our reflections were: 1) establish genuine partnerships early on with stakeholders, leveraging existing trusted relationships; 2) identify common goals; 3) prioritise evidence synthesis aims and objectives to ensure they are policy and practice relevant; and 4) maintain transparent, two-way communication. LESSONS LEARNT: Collaboration involving researchers and end-users enhances knowledge synthesis methodologies, increases relevance and accessibility of the evidence for end-users, and strengthens research-policy relationships.

Front-of-pack marketing on infant and toddler foods: Targeting children and their caregivers.

OBJECTIVE: To identify and quantify child- and caregiver-appeal on front-of-pack marketing on infant and toddler foods in the Australian food supply. METHODS: Content analysis of the presence and type of front-of-pack marketing techniques displayed on the front-of-pack of infant and toddler foods (for children aged up to 36 months) available in Australia's two major supermarkets' online stores. RESULTS: Infant and toddler foods are promoted by up to 15 unique marketing techniques on the front-of-pack with an average of eight unique features per pack. A majority of food packages included marketing techniques targeting children, and all food packages included marketing techniques targeting caregivers, most commonly promoting health and nutrition. CONCLUSIONS: Infant and toddler food packages are saturated with front-of-pack marketing features that target children and caregivers. To adequately protect young children's diets from the harmful influence of food marketing, and to promote the development of optimal feeding behaviours, government-led controls of all marketing intended to influence children's diets are required. In the context of marketing infant and toddler foods, this includes regulation of front-of-pack marketing techniques targeted to children and their caregivers. IMPLICATIONS FOR PUBLIC HEALTH: Comprehensive government-led food marketing controls are required to protect children's diets from the harmful influence of marketing. The scope of these controls must include all unhealthy food marketing that children are exposed to and all other forms of unhealthy food marketing intended to influence children's diets.

Combining public health evidence, policy experience and communications expertise to inform preventive health: reflections on a novel method of knowledge synthesis.

Knowledge synthesis methods help summarize evidence and utilize content expertise to draw out key messages to aid knowledge mobilization and translation. Systems thinking and coproduction can support this by facilitating a multiperspective view and ensuring that knowledge is mobilized and translated in a useful and meaningful way for policy-makers and practitioners. In this paper, we describe the development of a knowledge synthesis approach that utilizes coproduction with policy-makers to combine the findings of a programme of research with policy knowledge to support decision-makers working in chronic disease prevention. The process developed by The Australian Prevention Partnership Centre combined the expertise of research, policy and science communications experts. We reflect on how we used coproduction processes to embed policy-makers as partners in the evidence synthesis process via research-policy dialogues, and embedded science communication into the development and presentation of the findings. This differs from a more common approach of researchers generating evidence for policy with limited input from policy-makers themselves. By collaborating with policy-makers and using coproduction, we can better inform policy-relevant research and generate policy-relevant knowledge. We describe the development of our knowledge synthesis approach using two case studies: the first drawing on a body of work in public health law, and the second on a body of work focused on the first 2000 days of life. We consider how these case studies demonstrate the value of working with policy partners as part of a knowledge synthesis process, and discuss how this process could be adapted and used in future.

Evaluation of the introduction of a healthy food and drink policy in 13 community recreation centres on the healthiness and nutrient content of customer purchases and business outcomes: An observational study.

INTRODUCTION: This observational study assessed the introduction of a comprehensive healthy food and drink policy across 13 community organisation managed aquatic and recreation centres in Victoria, Australia, and the associated changes on business outcomes, and the healthiness of purchases. The policy, based on state government guidelines, mandated that food and drink availability be based on healthiness classification: 'red' (limit) <10%, and 'green' (best choice) >50%, and the remainder 'amber' (choose carefully). METHODS: Six years of monthly sales data were split into three periods, prior to (1/01/2013-31/12/2014), during (1/01/2015-31/12/2016) and post (1/1/2017-31/12/2018), policy implementation. Using point-of-sale data, food and drink nutrient content, and state guidelines, items were classified as 'red'/'amber'/'green'. Linear models with Newey West standard errors were fitted to compare the mean value of outcomes between post- to pre-policy implementation periods, for each outcome and centre; and were pooled using random effect meta-analyses. RESULTS: Comparing post- to pre-policy implementation periods, total food sales did not change (mean percentage difference: -3.2% (95% confidence interval (CI) -21% to 14%), though total drink sales declined -27% (CI -37% to -17%). The mean percentage of 'red' foods sold declined by -15% (CI -22% to -7.7%), 'amber' food sales increased 11% (CI 5.5% to 16%). 'Green' food sales did not change (3.3%, CI -1.4% to 8.0%). The mean percentage of 'red' drinks sold declined -37% (CI -43% to -31%), 'amber' and 'green' drink sales increased by 8.8% (CI 3.6% to 14%) and 28% (CI 23% to 33%), respectively. The energy density and sugar content (percentage of total weight/volume) of both food and drinks decreased. CONCLUSIONS: This study has shown that the implementation of a policy to improve the health of retail food environments can result in a shift towards healthier purchases. Sales revenue from foods did not decline, though revenue from drinks did, indicating future research needs to explore mitigation of this.

Shifting the social determinants of food insecurity during the COVID-19 pandemic: the Australian experience.

We aimed to explore experiences of government-led actions on the social determinants of food insecurity during Australia's COVID-19 pandemic response (which included novel, yet temporary, social protection measures to support Australians facing hardship during state-wide lockdowns). During November-December 2020, we conducted in-depth interviews with 24 Victorians who received government income support (prior to COVID-19) and the temporary COVID-19 specific payments. Interviews were guided by a theoretical understanding of the social determinants of health and health inequities, which we aligned to the social policy context. Data were audio-recorded, transcribed, inductively coded, categorised and thematically analysed. Our sample included mostly women (n = 19) and single parents (n = 13). Interviews reflected four key themes. Firstly, participants described 'battles all around them' (i.e., competing financial, health and social stressors) that were not alleviated by temporary social policy changes and made healthy eating difficult to prioritise during the pandemic. Secondly, housing, income, job, and education priorities rendered food a lower and more flexible financial priority - even with 18 participants receiving temporary income increases from COVID-19 Supplements. Thirdly, given that food remained a lower and more flexible financial priority, families continued to purchase the cheapest and most affordable options (typically less healthful, more markedly price discounted). Finally, participants perceived the dominant public and policy rhetoric around income support policies and healthy eating to be inaccurate and shaming - often misrepresenting their lived experiences, both prior to and during COVID-19. Participants reported entrenched struggles with being able to afford basic living costs in a dignified manner during COVID-19, despite temporary social protection policy changes. To reduce inequities in population diets, a pre-requisite to health, all stakeholders must recognise an ongoing responsibility for adopting long-term food and social policies that genuinely improve lived experiences of food insecurity and poverty. Supplementary Information: The online version contains supplementary material available at 10.1007/s12571-022-01318-4.

Nurturing children's development through healthy eating and active living: Time for policies to support effective interventions in the context of responsive emotional support and early learning.

Fostering the growth, development, health, and wellbeing of children is a global priority. The early childhood period presents a critical window to influence lifelong trajectories, however urgent multisectoral action is needed to ensure that families are adequately supported to nurture their children's growth and development. With a shared vision to give every child the best start in life, thus helping them reach their full developmental potential, we have formed the International Healthy Eating Active Living Matters (HEALing Matters) Alliance. Together, we form a global network of academics and practitioners working across child health and development, and who are dedicated to improving health equity for children and their families. Our goal is to ensure that all families are free from structural inequality and oppression and are empowered to nurture their children's growth and development through healthy eating and physical activity within the context of responsive emotional support, safety and security, and opportunities for early learning. To date, there have been disparate approaches to promoting these objectives across the health, community service, and education sectors. The crucial importance of our collective work is to bring these priorities for early childhood together through multisectoral interventions, and in so doing tackle head on siloed approaches. In this Policy paper, we draw upon extensive research and call for collective action to promote equity and foster positive developmental trajectories for all children. We call for the delivery of evidence-based programs, policies, and services that are co-designed to meet the needs of all children and families and address structural and systemic inequalities. Moving beyond the "what" is needed to foster the best start to life for all children, we provide recommendations of "how" we can do this. Such collective impact will facilitate intergenerational progression that builds human capital in future generations.

A Critical Analysis of Representations of Inequalities in Childhood Obesity in Australian Health Policy Documents.

BACKGROUND: In Australia, childhood obesity follows a socioeconomic gradient whereby children with lower socioeconomic position are disproportionately burdened. To reduce these inequalities in childhood obesity requires a multi-component policy-driven response. Action to address health issues is underpinned by the ways in which they are represented as 'problems' in public policy. This study critically examines representations of inequalities in childhood obesity within Australian health policy documents published between 2000-2019. METHODS: Australia's federal, state and territory government health department websites were searched for health policy documents including healthy weight, obesity, healthy eating, food and nutrition strategies; child and youth health strategies; and broader health and wellbeing, prevention and health promotion policies that proposed objectives or strategies for childhood obesity prevention. Thematic analysis of eligible documents was guided by a theoretical framework informed by problematization theory, ecological systems theory, and theoretical principles for equity in health policy. RESULTS: Eighteen policy documents were eligible for inclusion. The dominant representation of inequalities in childhood obesity was one of individual responsibility. The social determinants of inequalities in childhood obesity were acknowledged, yet policy actions predominantly focused on individual determinants. Equity was positioned as a principle of policy documents but was seldom mentioned in policy actions. CONCLUSION: Current representations of inequalities in childhood obesity in Australian health policy documents do not adequately address the underlying causes of health inequities. In order to reduce inequalities in childhood obesity future policies will need greater focus on health equity and the social determinants of health (SDoH).

How are health, nutrition, and physical activity discussed in international guidelines and standards for children in care? A narrative review.

BACKGROUND: Children in care (CiC) have often experienced trauma and, as a result, are at high risk for poor health outcomes. It is imperative that human-service stakeholders provide trauma-informed health services and interventions. However, little is known about how health promotion is addressed in the standards and guidelines for CiC. For this scoping review, the aim was to examine and compare how nutrition and physical activity are discussed in: 1) federal standards for CiC across the United Kingdom, the United States, New Zealand, and Australia; and 2) state and territory guidance in Australia. METHOD: The grey literature was searched for documents outlining key child-welfare standards, guidelines, or policies for the provision of care across foster, kinship, or residential care. Documents were examined for the inclusion of recommendations and/or strategies focused on primary health and the promotion of nutrition and/or physical activity. RESULTS: A total of 52 documents were included in this review: 28 outlining international federal guidance and 24 Australian documents. In the United States, New Zealand, and Australia, references to physical activity were often broad, with minimal direction, and nutrition was often neglected; the United Kingdom provided more detailed guidance to promote nutrition and physical activity among CiC. CONCLUSION: There is a lack of consistency and specificity in guidelines supporting healthy lifestyle interventions for CiC both internationally and within Australia. It is recommended that 1) specific trauma-informed health promotion guidelines are developed for CiC; and 2) trauma-informed health promotion training is provided to carers. Doing so will ensure that care is provided in a manner in which stakeholders recognize the signs and consequences of trauma in order to determine the most appropriate health interventions to improve outcomes and prevent ongoing trauma for this population.

Policies to restrict unhealthy food and beverage advertising in outdoor spaces and on publicly owned assets: A scoping review of the literature.

Unhealthy food marketing influences attitudes, preferences, and consumption of unhealthy foods, leading to excess weight gain. Outdoor advertising is highly visible (often displayed on publicly owned assets), but the evidence supporting regulation is unclear. This systematic scoping review of academic and grey literature aimed to (1) describe potential health and economic impacts of implementing government-led policies that restrict unhealthy food advertising in outdoor spaces or on public assets (including studies examining prevalence of advertising, associations with health outcomes and interventional studies); (2) identify and describe existing policies; and (3) identify factors perceived to have influenced policy implementation. Thirty-six academic studies were eligible for inclusion. Most reported on prevalence of unhealthy food advertising, demonstrating high prevalence around schools and in areas of lower socioeconomic position. None examined health and economic impacts of implemented policies. Four jurisdictions were identified with existing regulations; five had broader marketing or consumer protection policies that captured outdoor food marketing. Facilitators of policy implementation included collaboration, effective partnerships, and strong political leadership. Barriers included lobbying by food, media, and advertising industries. Implementation of food marketing policies in outdoor spaces and on public assets is feasible and warranted. Strong coalitions and leadership will be important to drive the policy agenda forward.

Weight stigma and obesity-related policies: A systematic review of the state of the literature.

Weight stigma is an important issue colliding with obesity-related policies; both have population health and social impacts. Our aim was to conduct a systematic review of the peer-reviewed literature that combined the concepts of stigma, obesity, and policy. We searched PsycINFO, Medline, Scopus, and Google Scholar for peer-reviewed articles amalgamating terms relevant to stigma, obesity, and policy. Of 3219 records identified, 47 were included in the narrative synthesis. Two key types of studies emerged: studies investigating factors associated with support for obesity-related policies and those exploring policy implementation and evaluation. We found that support for nonstigmatizing obesity-related policies was higher when obesity was attributed as an environmental rather than individual problem. An undercurrent theme suggested that views that blame individuals for their obesity were associated with support for punitive policies for people living in larger bodies. Real-world policies often implicitly condoned stigma through poor language choice and conflicting discourse. Our findings inform recommendations for policy makers that broader socioecological stigma-reduction approaches are needed to fully address the issue of weight stigma in obesity-related policies. Efforts are needed in the research and policy sectors to understand how to improve the design and support of nonstigmatizing obesity-related policies.

Evaluating the implementation and customer acceptability of a sugar-sweetened beverage reduction initiative in thirty Australian aquatic and recreation centres.

OBJECTIVE: To assess the feasibility of implementation and customer perspectives of a sugar-sweetened beverage (SSB) reduction initiative across YMCA Victoria aquatic and recreation centres. DESIGN: Two data sources were used to assess implementation and customer acceptability. Photo audits were used to assess the type of drinks available for purchase 6 months prior to initiative implementation and 6 months after, in thirty centres. Change in the range of SSB targeted for removal, non-targeted SSB, as well as drinks classified as 'red' (limit), 'amber' (choose carefully) and 'green' (best choice), was reported. Customer surveys were conducted in three centres to assess acceptability and awareness of the initiative. Inductive and deductive thematic analysis was used to analyse customers' perspectives of the initiative. SETTING: 30 aquatic and recreation centres in Victoria, Australia. PARTICIPANTS: 806 customers. RESULTS: At post-implementation, 87 % of centres had removed targeted SSB. 'Red' drinks reduced by an average of 4·4 drink varieties compared to pre-implementation (11·9 varieties) and 'green' drinks increased by 1·4 varieties (3·2 varieties pre-implementation). Customers were largely unaware of the SSB-reduction initiative (90 %) but supported YMCA Victoria in continuing the initiative (89 %), with many believing it would support children in making healthier choices. CONCLUSIONS: Implementation of an initiative that limited SSB availability across a large number of aquatic and recreation centres was feasible and considered acceptable by customers. Customers frequently mentioned the importance of protecting children from consuming SSB.

A state-wide audit of unhealthy sponsorship within junior sporting clubs in Victoria, Australia.

OBJECTIVE: To systematically audit the extent of unhealthy sponsorship within junior community sporting clubs and ascertain whether differences exist across geographical areas and sport types. DESIGN: Club sponsorship data were assessed to determine the extent of unhealthy food/beverage, alcohol and gambling sponsorship using a cross-sectional design. Differences across geographical areas were assessed using logistic regressions. SETTING: A stratified random sampling procedure was used to select thirty communities across the state of Victoria, Australia. Within each community, local clubs across the top eight participating junior sports were selected for audit. PARTICIPANTS: Sponsorship data were collected from 191 club websites and Facebook pages in September-November 2019. RESULTS: Unhealthy sponsorships represented 8·9 % of all identified sponsorship arrangements. A quarter of all clubs accepted alcohol (25·6 %) and unhealthy food sponsors (25·9 %), and one-fifth of all clubs accepted high-risk food (unhealthy brands with large market share) (18·1 %) and gambling sponsors (20·4 %). Acceptance of unhealthy sponsorship differed across sport types with football, netball, cricket and soccer clubs having the greatest numbers. Compared with metro areas, a significantly greater proportion of sporting clubs in regional areas were affiliated with unhealthy food (32·7 % v. 19·6 %) and high-risk food sponsors (26·9 % v. 9·8 %). A higher proportion of clubs in low socio-economic status (SES), compared with the high SES areas, were affiliated with alcohol (33·9 % v. 16·5 %) and gambling sponsors (27·4 % v. 12·6 %). CONCLUSION: Victorian children participating in community junior sports are being exposed to marketing of unhealthy brands and products. Public health intervention is necessary to protect children from this exposure.

National nutrition policy in high-income countries: is health equity on the agenda?

OBJECTIVE: Equity-oriented policy actions are a key public health principle. In this study, how equity and socioeconomic inequalities are represented in policy problematizations of population nutrition were examined. DATA SOURCES: We retrieved a purposive sample of government nutrition-policy documents (n = 18) from high-income nations. DATA SYNTHESIS: Thematic analysis of policy documents was informed by a multitheoretical understanding of equitable policies and Bacchi's "What's the Problem Represented to be?' analysis framework. Despite common rhetorical concerns about the existence of health inequalities, these concerns were often overshadowed by greater emphasis on lifestyle "problems" and reductionist policy actions. The notion that policy actions should be for all and reach everyone were seldom backed by specific actions. Rhetorical acknowledgements of the upstream drivers of health inequalities were also rarely problematized, as were government responsibilities for health equity and the role of policy and governance in reducing socioeconomic inequalities in nutrition. CONCLUSION: To positively influence health equity outcomes, national nutrition policy will need to transition toward the prioritization of actions that uphold social justice and comprehensively address the upstream determinants of health.

Differential exposure to, and potential impact of, unhealthy advertising to children by socio-economic and ethnic groups: A systematic review of the evidence.

Children's exposure to advertising of unhealthy food and nonalcoholic beverages that are high in saturated fats, salt and/or sugar is extensive and increases children's preferences for, and intake of, targeted products. This systematic review examines the differential potential exposure and impact of unhealthy food advertising to children according to socio-economic position (SEP) and/or ethnicity. Nine databases (health, business, marketing) and grey literature were searched in November 2019 using terms relating to 'food or drink', 'advertising' and 'socioeconomic position or ethnicity'. Studies published since 2007 were included. Article screening and data extraction were conducted by two independent reviewers. Quality of studies was assessed using the Newcastle-Ottawa quality scale. Of the 25 articles included, 14 focused on exposure to unhealthy food advertising via television, nine via outdoor mediums and two via multiple mediums. Most studies (n = 19) revealed a higher potential exposure or a greater potential impact of unhealthy food advertising among ethnic minority or lower SEP children. Few studies reported no difference (n = 3) or mixed findings (n = 3). Children from minority and socio-economically disadvantaged backgrounds are disproportionately exposed to unhealthy food advertising. Regulations to restrict unhealthy food advertising to children should be implemented to improve children's diets and reduce inequities in dietary intake.

Factors influencing sweet drink consumption among preschool-age children: A qualitative analysis.

ISSUE ADDRESSED: Consumption of high sugar foods and drinks are key risk factors for childhood obesity and dental decay. Sweet drinks are the single greatest contributor to the free sugars consumed by Australian children. Little is known about the factors influencing consumption of sweet drinks, particularly among preschool-age children. METHODS: Focus groups and semi-structured interviews conducted with parents and grandparents (n = 25) residing in different socio-economic areas across metropolitan and regional Victoria, Australia. Thematic analysis identified the factors influencing sweet drink consumption, which were then aligned with the socio-ecological model. RESULTS: At an individual level, health knowledge, health beliefs, and parenting skills and confidence influenced drink choices. At the social level, peer and family influence, and social and cultural norms emerged as influential. At the environmental level, sweet drink availability, targeted marketing, drink prices and settings-based policies influenced drink choices. Strategies identified by participants to support healthier drink choices included health education at the individual level; positive role modelling at the social level; and restricting unhealthy marketing, improved access to water, decreased availability of sweet drinks and price modification at the environmental level. CONCLUSION: Sweet drink consumption among preschool-age children is influenced by multiple factors across all domains of the socio-ecological model. Parents and grandparents are calling for education, healthy environments and supportive policies. SO WHAT?: In contrast to common rhetoric, children's sweet drink consumption is often influenced by factors beyond parental control. A multi-component strategy is required to support parents and grandparents in their efforts to make healthy choices for their children.