Reducing Student Exposure to Digital Food and Beverage Marketing: Policy and Practice Recommendations.

Digital marketing of unhealthy foods and beverages to children and adolescents is pervasive, highly effective, undermines healthy eating, and contributes to health inequities. Expanded use of electronic devices and remote learning during the COVID-19 pandemic has increased the urgency for policy interventions to limit digital food marketing in schools and on school-issued devices. The US Department of Agriculture provides little guidance to schools for how to address digital food marketing. Federal and state privacy protections for children are inadequate. Considering these policy gaps, state and local education authorities can incorporate strategies to reduce digital food marketing into school policies for: content filtering on school networks and on school-issued devices; digital instructional materials; student-owned device use during lunch; and school use of social media to communicate with parents and students. Model policy language is provided. These policy approaches can leverage existing policy mechanisms to address digital food marketing from a variety of sources.

The role of chain pharmacies to promote healthy food retail: Current trends, legal limits, and policy opportunities.

Chain drug stores have increased their health care role through expanded pharmacy services and retail health clinics. They also are major food retailers. This creates a tension between health promotion and sales of unhealthy foods and beverages to pharmacy customers. This article explores opportunities to improve the nutritional quality of foods sold at chain drug stores that differ from general healthy food retail approaches. It considers the legal limits on marketing to pharmacy customers; the potential roles of health insurers, pharmacy benefit managers and retail health clinics to voluntarily improve food offerings; and formal policymaking legal considerations and approaches.

Community-Based Policies and Support for Free Drinking Water Access in Outdoor Areas and Building Standards in U.S. Municipalities.

We examined community-level characteristics associated with free drinking water access policies in U.S. municipalities using data from a nationally representative survey of city managers/officials from 2,029 local governments in 2014. Outcomes were 4 free drinking water access policies. Explanatory measures were population size, rural/urban status, census region, poverty prevalence, education, and racial/ethnic composition. We used multivariable logistic regression to test differences and presented only significant findings. Many (56.3%) local governments had at least one community plan with a written objective to provide free drinking water in outdoor areas; municipalities in the Northeast and South regions and municipalities with ≤ 50% of non-Hispanic whites were less likely and municipalities with larger population size were more likely to have a plan. About 59% had polices/budget provisions for free drinking water in parks/outdoor recreation areas; municipalities in the Northeast and South regions were less likely and municipalities with larger population size were more likely to have it. Only 9.3% provided development incentives for placing drinking fountains in outdoor, publicly accessible areas; municipalities with larger population size were more likely to have it. Only 7.7% had a municipal plumbing code with a drinking fountain standard that differed from the statewide plumbing code; municipalities with a lower proportion of non-Hispanic whites were more likely to have it. In conclusion, over half of municipalities had written plans or a provision for providing free drinking water in parks, but providing development incentives or having a local plumbing code provision were rare.

Public Perception of Quality and Support for Required Access to Drinking Water in Schools and Parks.

PURPOSE: We assessed public support for required water access in schools and parks and perceived safety and taste of water in these settings to inform efforts to increase access to and consumption of tap water. DESIGN: Cross-sectional survey of the US public collected from August to November 2011. SETTING: Random digit-dialed telephone survey. PARTICIPANTS: Participants (n = 1218) aged 17 and older from 1055 US counties in 46 states. MEASURES: Perceived safety and taste of water in schools and parks as well as support for required access to water in these settings. ANALYSIS: Survey-adjusted perceived safety and taste as well as support for required access were estimated. RESULTS: There was broad support for required access to water throughout the day in schools (96%) and parks (89%). Few participants believed water was unsafe in schools (10%) or parks (18%). CONCLUSION: This study provides evidence of public support for efforts to increase access to drinking water in schools and parks and documents overall high levels of perceived taste and safety of water provided in these settings.

"We're Part of the Solution": Evolution of the Food and Beverage Industry's Framing of Obesity Concerns Between 2000 and 2012.

We investigated how industry claim-makers countered concerns about obesity and other nutrition-related diseases in newspaper coverage from 2000, the year before the US Surgeon General's Call to Action on obesity, through 2012. We found that the food and beverage industry evolved in its response. The defense arguments were made by trade associations, industry-funded nonprofit groups, and individual companies representing the packaged food industry, restaurants, and the nonalcoholic beverage industry. Individual companies used the news primarily to promote voluntary self-regulation, whereas trade associations and industry-supported nonprofit groups directly attacked potential government regulations. There was, however, a shift away from framing obesity as a personal issue toward an overall message that the food and beverage industry wants to be "part of the solution" to the public health crisis.

Children's recall of fast food television advertising-testing the adequacy of food marketing regulation.

BACKGROUND AND AIM: In the United States, the fast food companies McDonald's and Burger King participate in marketing self-regulation programs that aim to limit emphasis on premiums and promote emphasis of healthy food choices. We determine what children recall from fast food television advertisements aired by these companies. METHODS: One hundred children aged 3-7 years were shown McDonald's and Burger King children's (MDC & BKC) and adult (MDA & BKA) meal ads, randomly drawn from ads that aired on national US television from 2010-11. Immediately after seeing the ad, children were asked to recall what they had seen and transcripts evaluated for descriptors of food, healthy food (apples or milk), and premiums/tie-ins. RESULTS: Premiums/tie-ins were common in children's but rarely appeared in adult ads, and all children's ads contained images of healthy foods (apples and milk). Participants were significantly less likely to recall any food after viewing the children's vs. the adult ad (MDC 32% [95% confidence interval 23, 41] vs. MDA 68% [59, 77]) p <0.001; BKC 46% [39, 56] vs. BKA 67% [58, 76] respectively, p = 0.002). For children's ads alone and for both restaurants, recall frequency for all food was not significantly different from premium/tie-ins, and participants were significantly more likely to recall other food items than apples or milk. Moreover, premiums/tie-ins were recalled much more frequently than healthy food (MDC 45% [35, 55] vs. 9% [3, 15] p<0.001; BKC 54% [44, 64] vs. 2% [0, 5] respectively, p<0.001). CONCLUSIONS: Children's net impressions of television fast food advertising indicate that industry self-regulation failed to achieve a de-emphasis on toy premiums and tie-ins and did not adequately communicate healthy menu choices. The methods devised for this study could be used to monitor and better regulate advertising patterns of practice.

Children's reaction to depictions of healthy foods in fast-food television advertisements.

IMPORTANCE: Since 2009, quick-service restaurant chains, or fast-food companies, have agreed to depict healthy foods in their advertising targeted at children. OBJECTIVE: To determine how children interpreted depictions of milk and apples in television advertisements for children's meals by McDonald's and Burger King (BK) restaurants. DESIGN, SETTING, AND PARTICIPANTS: Descriptive qualitative study in a rural pediatric practice setting in Northern New England. A convenience sample of 99 children (age range, 3-7 years) was shown depictions of healthy foods in fast-food advertisements that aired from July 1, 2010, through June 30, 2011. The images from McDonald's and BK showed milk and apples. Children were asked what they saw and not prompted to respond specifically to any aspect of the images. EXPOSURE: Two still images drawn from advertisements for healthy meals at McDonald's and BK. MAIN OUTCOMES AND MEASURES: Children's responses were independently content coded to food category by 2 researchers. RESULTS: Among the 99 children participating, only 51 (52%) and 69 (70%) correctly identified milk from the McDonald's and BK images, respectively, with a significantly greater percentage correct (P = .02 for both) among older children. The children's recall of apples was significantly different by restaurant, with 79 (80%) mentioning apples when describing the McDonald's image and only 10 (10%) for the BK image (P < .001). The percentage correct was not associated with age in either case. Conversely, although french fries were not featured in either image, 80 children (81%) recalled french fries after viewing the BK advertisement. CONCLUSIONS AND RELEVANCE: Of the 4 healthy food images, only depiction of apples by McDonald's was communicated adequately to the target audience. Representations of milk were inadequately communicated to preliterate children. Televised depictions of apple slices by BK misled the children in this study, although no action was taken by government or self-regulatory bodies.

Student-reported school drinking fountain availability by youth characteristics and state plumbing codes.

INTRODUCTION: Caloric intake among children could be reduced if sugar-sweetened beverages were replaced by plain water. School drinking water infrastructure is dictated in part by state plumbing codes, which generally require a minimum ratio of drinking fountains to students. Actual availability of drinking fountains in schools and how availability differs according to plumbing codes is unknown. METHODS: We abstracted state plumbing code data and used the 2010 YouthStyles survey data from 1,196 youth aged 9 through 18 years from 47 states. We assessed youth-reported school drinking fountain or dispenser availability and differences in availability according to state plumbing codes, sociodemographic characteristics, and area-level characteristics. RESULTS: Overall, 57.3% of youth reported that drinking fountains or dispensers in their schools were widely available, 40.1% reported there were only a few, and 2.6% reported that there were no working fountains. Reported fountain availability differed significantly (P < .01) by race/ethnicity, census region, the fountain to student ratio specified in plumbing codes, and whether plumbing codes allowed substitution of nonplumbed water sources for plumbed fountains. "Widely available" fountain access ranged from 45.7% in the West to 65.4% in the Midwest and was less common where state plumbing codes required 1 fountain per more than 100 students (45.4%) compared with 1 fountain per 100 students (60.1%) or 1 fountain per fewer than 100 students (57.6%). CONCLUSION: Interventions designed to increase consumption of water may want to consider the role of plumbing codes in availability of school drinking fountains.

How television fast food marketing aimed at children compares with adult advertisements.

OBJECTIVES: Quick service restaurant (QSR) television advertisements for children's meals were compared with adult advertisements from the same companies to assess whether self-regulatory pledges for food advertisements to children had been implemented. METHODS: All nationally televised advertisements for the top 25 US QSR restaurants from July 1, 2009 to June 30, 2010 were obtained and viewed to identify those advertising meals for children and these advertisements were compared with adult advertisements from the same companies. Content coding included visual and audio assessment of branding, toy premiums, movie tie-ins, and depictions of food. For image size comparisons, the diagonal length of the advertisement was compared with the diagonal length of salient food and drink images. RESULTS: Almost all of the 92 QSR children's meal advertisements that aired during the study period were attributable to McDonald's (70%) or Burger King (29%); 79% of 25,000 television placements aired on just four channels (Cartoon Network, Nickelodeon, Disney XD, and Nicktoons). Visual branding was more common in children's advertisements vs. adult advertisements, with food packaging present in 88% vs. 23%, and street view of the QSR restaurant present in 41% vs. 12%. Toy premiums or giveaways were present in 69% vs. 1%, and movie tie-ins present in 55% vs. 14% of children's vs. adult advertisements. Median food image diagonal length was 20% of the advertisement diagonal for children's and 45% for adult advertisements. The audio script for children's advertisements emphasized giveaways and movie tie-ins whereas adult advertisements emphasized food taste, price and portion size. CONCLUSIONS: Children's QSR advertisements emphasized toy giveaways and movie tie-ins rather than food products. Self-regulatory pledges to focus on actual food products instead of toy premiums were not supported by this analysis.

Beyond cheeseburgers: the impact of commonsense consumption acts on future obesity-related lawsuits.

Since 2004, 25 states have passed Commonsense Consumption Acts (CCAs) to shield the food industry from civil liability for claims arising from obesity-related health harms. These laws continue to be introduced. CCAs have generally been discussed in terms of "tort reform." For this article, we conducted a systematic analysis of the content of all 25 state laws and found that the potential impact of CCAs goes well beyond obesity-related tort reform to limits on state Attorney General (AGs) authority and significant reforms to future statutory consumer protection claims by AGs, individuals and classes of consumers. Moreover, every CCA state had pre-existing legal protections against frivolous litigation-greatly undercutting arguments made by CCA proponents.

Getting back on tap: the policy context and cost of ensuring access to low-cost drinking water in Massachusetts schools.

BACKGROUND: Adequate water intake may have important health benefits for schoolchildren. Layers of federal, state, and local policy are relevant to provision of water within schools. Recently passed state and federal laws require free drinking-water access for students during mealtimes. PURPOSE: To review Massachusetts local district wellness policies related to water access, provide estimates of costs for three water-provision strategies, and discuss implications for policy relevant to adequate drinking-water access. METHODS: Legal research was conducted using the LexisNexis legal database and government websites. Local wellness policies were double-coded using existing research tools. Costs of three water-delivery options were estimated using a 10-year school-district perspective. RESULTS: Prior to 2010, most Massachusetts public school district wellness policies (92%-94%) did not address access to free drinking water. Ten-year costs per school for providing water during mealtimes to students, including dispenser unit, installation, water testing, water, cups, and labor, range between $12,544 and $27,922 (depending on water-delivery option) assuming the average Massachusetts school enrollment. Water-provision strategies relying on tap water are more economical than bottled water in the long term. CONCLUSIONS: Policy recommendations and cost considerations deserve attention at the local, state, and federal levels. Recommendations are discussed to ensure access to safe, free drinking water for all students.

Private enforcement: litigation as a tool to prevent obesity.

Private enforcement, or litigation, has played a historic role in protecting public health in the United States. Litigation is often employed as a means to protect public health when government regulation is absent or ineffectual. Litigation has been successfully employed to control both asbestos and tobacco and is poised for success in combating the obesity epidemic. Litigation is effective because it makes public industry practices and increases industry self-policing. Litigation related to obesity would likely employ theories of "unfair and deceptive trade practice" or general "personal injury" or tort claims. While opponents to the use of litigation often cite personal responsibility and the individual as the true locus of liability, these arguments fail to take into account the context of an individual's choice. While litigation can be effective, media attention and current political discourse on "tort reform" has engendered a set of legislative actions that would foreclose litigation as a public health strategy.