Effects of marketing claims on toddler food products on parents' product preferences, perceptions and purchasing intentions: an online experiment.

BACKGROUND: The retail market for toddler-specific packaged foods is growing. Many of these products are ultra-processed and high in nutrients of concern for health, yet marketed in ways that may make them appear wholesome. This study aims to assess parents' responses to claims on unhealthy, ultra-processed toddler food products and test whether removing such claims promotes more accurate product perceptions and healthier product preferences. METHODS: Parents of toddlers aged 12 to < 36 months (N = 838) were recruited for an online experiment testing four on-pack claim conditions: control (no claim); 'contains "good" ingredient'; 'free from "bad" ingredient'; and unregulated 'child-related' claim. Participants were randomly assigned to one condition, then viewed images of toddler food products that varied in nutrition content and the claims displayed. Participants completed tasks assessing product preferences (unhealthy product displaying claim vs. a healthier option with no claim, across four food categories (banana bars, strawberry snacks, blueberry yogurt snacks and veggie snacks)), purchase intentions and product perceptions. Poisson regression (count variable) and linear regression (continuous outcomes) analyses were employed to test for mean differences by marketing claim conditions. RESULTS: For the overall sample, brief exposure to 'free from "bad" ingredient' claims increased participant's intentions to purchase unhealthy food products for their toddlers, but there was no clear evidence that 'contains "good" ingredient' claims and 'child-related' claims significantly impacted parent's preferences, purchase intentions and perceptions of toddler foods. However, certain claims influenced particular parent subgroups. Notably, parents with three or more children chose more unhealthy products when these products displayed 'contains "good" ingredient' or 'free from "bad" ingredient' claims; the latter claims also promoted stronger purchase intentions and enhanced product perceptions among this subgroup. CONCLUSIONS: Findings indicate that 'free from "bad" ingredient' claims on unhealthy toddler foods are of most concern, as they boost the appeal of these products to parents. 'Contains "good" ingredient' claims and 'child-related' claims showed limited effects in this study. Considering available evidence, we recommend claims should not be permitted on child-oriented foods, as they may promote inaccurate product perceptions and unhealthy product choices by parents, that can detract from their children's diets and health.

Commercially available foods for young children (<36 months) in Australia: An assessment of how they compare to a proposed nutrient profile model.

ISSUE ADDRESSED: To assess the nutritional composition of commercially available foods (CAFs) for infants and toddlers sold in Australia to determine whether they meet World Health Organization (WHO) Europe's proposed standards for nutritionally appropriate foods for children <36 months. METHODS: A cross-sectional retail audit of infant (n = 177) and toddler (n = 73) foods found in-store and online at three major Victorian supermarkets was conducted in August/September 2019. Products were grouped according to WHO Europe's food categories and their nutrient content assessed against specific composition standards applicable to their category. The presence of added sugar in each product was also recorded. RESULTS: Most infant products (71%) were soft-wet spoon-able, ready-to-eat foods whereas the most prevalent category for toddler products was dry finger foods and snacks (71%). Overall, just one-third of CAFs met all the nutrient recommendations for their category, with infant foods more likely to be compliant than toddler foods (43% vs. 10%; P < .001). Around 9 in 10 infant (93%) and toddler (89%) CAFs contained added sugar according to the Public Health England definition of 'free' sugars. CONCLUSIONS: There is considerable scope to improve the nutritional composition of Australian CAFs for both infants and toddlers, to reduce harmful sugars in these foods and to improve the energy density of them. For CAFs marketed as suitable for toddlers there is also considerable scope to reduce the sodium content. SO WHAT?: These findings support the need for stronger regulation of CAFs for infants and toddlers to better promote healthy eating patterns and taste preferences in young children.

Food purchasing practices in various retail settings and dietary intake: A cross-sectional survey of Australian adolescents.

BACKGROUND/AIMS: Discretionary, energy-dense, nutrient-poor food and drinks are heavily marketed and readily available in retail settings frequented by adolescents. This study examines associations between food purchasing practices in various retail settings and dietary intake among Australian adolescents. METHODS: Participants were students in years 8 to 11 (ages 12-17 years) who completed the 2009-10 (n = 13 790), 2012-13 (n = 10 309) or 2018 (n = 9102) National Secondary Students' Diet and Activity (NaSSDA) cross-sectional survey. Multistage stratified random sampling was used. An online survey completed at school assessed self-reported frequency of food purchasing practices in various retail settings and consumption of discretionary food, sugary drinks, fruit and vegetables. Generalised linear regression models examined associations between food purchasing practices and dietary behaviour. RESULTS: Relative to students who brought lunch from home, those who purchased lunch from school or nearby outlets reported higher intake of discretionary food and sugary drinks and lower fruit intake. Buying lunch from school was also associated with lower vegetable intake. Buying food or drinks on the school commute, outside school grounds during school hours, from supermarket checkouts, and using mobile phone apps were each associated with higher discretionary food and sugary drink intake (all P < .01). CONCLUSIONS: Purchasing food or drink in various retail settings is associated with higher intake of discretionary food and drink among Australian adolescents, and some purchasing practices appeared to displace fruit and vegetable intake. SO WHAT?: These findings highlight a need to improve the accessibility and promotion of healthier food and drink options in schools and other retail settings.

Obesity prevention and related public health advertising versus competing commercial advertising expenditure in Australia.

Mass media campaigns can change attitudes and behaviours to improve population health. However, a key challenge is achieving share of voice in a complex and cluttered media environment. The aim of this study was to compare advertising expenditure on public health campaigns for obesity prevention (and related healthy eating and physical activity campaigns) with competing commercial categories of (a) sugary drinks, (b) artificially sweetened drinks and (c) diet/weight loss products and programmes. These commercial products may either undermine or dilute public health messages by directly contributing to poor health or confusing the public about the best ways to sustain a healthy lifestyle. Monthly estimates of advertising expenditure in Australian media (television, outdoor, cinema, radio, newspapers, magazines and digital) were obtained from Nielsen Media for 2016-18. Eligible public health advertising expenditure for the entire period (total AUD$27M) was vastly outweighed by the commercial categories of sugary drinks (AUD$129M) and diet/weight loss products and services (AUD$122M). Artificially sweetened drinks accounted for an additional AUD$23M of expenditure. These results highlight the need to rebalance the ratio of advertising to support public health in Australia through increased funding for obesity prevention and related campaigns, and critically, through government regulation to limit competing commercial advertising.

Differences in healthiness perceptions of food and dietary patterns among the general public and nutrition experts: A cross-sectional online survey.

ISSUES ADDRESSED: Diet quality plays a vital role in the prevention of prevalent non-communicable diseases; however, misperceptions of healthiness of common foods and beverages may be undermining Australians' attempts to maintain a healthy diet. The current study aimed to assess the extent and nature of differences in public and expert opinion in the foods, beverages and dietary patterns that are considered healthy. METHODS: A cross-sectional online survey of 1,097 Victorian adults aged 18-64 and 134 professional dietitians and nutritionists assessed healthiness perceptions of foods, beverages and dietary patterns, self-reported dietary patterns, and factors considered when making healthy choices. Differences in perceptions and dietary patterns between samples and by sex, socio-economic area and level of education were assessed using multivariable logistic regression. RESULTS: There were large discrepancies in which items the public and expert samples considered healthy. Females and those in high socio-economic areas tended to report healthiness perceptions that aligned with the expert sample to a greater degree than their counterparts. Personal judgement of products was important to both samples when making decisions about healthy choices. CONCLUSIONS: The public and expert samples differed greatly in healthiness perceptions with significant variation by demographics. SO WHAT?: Well-funded, sustained public health campaigns are needed to provide the public with evidence-based health and nutrition information and combat persuasive, misleading messaging from popular media and marketing.

Brief Report: A Latent Class Analysis of Guideline Compliance Across Nine Health Behaviors.

BACKGROUND: Prevalence figures for health-related behaviors disguise the existence of behavioral clusters. A growing body of work indicates the potential effectiveness of using simultaneous (versus sequential) approaches to targeting health-related behaviors to make deeper inroads into addressing non-communicable diseases. To inform future interventions designed to simultaneously address multiple risk factors, the aim of the present study was to identify behavioral clusters including nine behaviors relating to smoking, alcohol consumption, nutrition, physical activity, and sleep. METHOD: A latent class analysis was applied to a nationally representative sample of 1849 adult Australians. RESULTS: Of the four identified segments, one was characterized by a relatively healthy behavioral profile and another demonstrated poor results across multiple lifestyle domains. The other two groups comprised individuals who demonstrated healthy behaviors in some domains (e.g., substance use) but not in others (primarily physical inactivity and junk food consumption, respectively). CONCLUSIONS: Results suggest the opportunity to encourage individuals in the latter two groups to build on existing positive behaviors to achieve greater overall compliance with health recommendations. Particularly intensive interventions are likely needed for those in the unhealthiest group to address the potentially reinforcing effects of their multiple unhealthy behaviors.

Sugary drink advertising expenditure across Australian media channels 2016-2018.

OBJECTIVE: The aim of this study was to describe advertising expenditure for sugary drinks compared with alternative cold non-alcoholic beverages (artificially sweetened beverages, plain water, plain milk) between 2016 and 2018 across Australian media channels. METHODS: Monthly estimates of advertising expenditure for non-alcoholic beverages were obtained from Nielsen Media and aggregated by product type and media. RESULTS: Total sugary drink advertising expenditure between 2016 and 2018 ($129.5M) significantly exceeded expenditure on artificially sweetened drinks ($23.26M), plain water ($14.27M), and plain milk ($31.30M). Television and out-of-home advertising accounted for the largest share of sugary drink advertising (45%, 35%). Expenditure on out-of-home advertising was more heavily dominated by sugary drinks (75%) than advertising in all media combined (65%). Sugary drink advertising peaked in warmer months and was lowest in August. Soft drinks (26%), flavoured milks (24%) and energy drinks (21%) accounted for the majority of sugary drink advertising. CONCLUSIONS: Cold non-alcoholic beverage advertising in Australian media is dominated by the advertising of sugary drinks. Implications for public health: Restricting unhealthy beverage advertising on television and out-of-home media may be most effective initially. However, comprehensive restrictions capturing a broader range of media and settings would be optimal to prevent displacement and limit advertising reach and exposure.

Factors associated with ordering food via online meal ordering services.

OBJECTIVE: Online meal ordering services are increasing in popularity in Australia and globally. Meals ordered online for home delivery are typically less healthy than home-made meals, potentially contributing to weight gain. The aim of the present study was to identify the types of consumers who are most likely to engage in online meal ordering. DESIGN: A cross-sectional survey including items relating to demographic and lifestyle factors was disseminated via a web panel provider. SETTING: Australia. PARTICIPANTS: A total of 2010 Australian adults aged 18+ years. RESULTS: More than a quarter of respondents (28 %) engaged in online meal ordering at least once in the previous month. Younger respondents, those with a higher BMI, and those with higher education and income levels were more likely to have done so. Consuming higher levels of sugary drinks and fast-food restaurant patronage were significantly associated with ordering meals online for home delivery. CONCLUSIONS: The outcomes of this study suggest that the use of online meal ordering services is becoming a common practice in Australia, and it is therefore important to implement evidence-based strategies and policies to encourage individuals to make healthy food choices when using these services.

Latent Class Trajectory Modeling of Adult Body Mass Index and Risk of Obesity-Related Cancer: Findings from the Melbourne Collaborative Cohort Study.

BACKGROUND: Obesity increases the risk of 13 cancer types. Given the long process of carcinogenesis, it is important to determine the impact of patterns of body mass over time. METHODS: Using data from 30,377 participants in the Melbourne Collaborative Cohort Study, we identified body mass index (BMI) trajectories across adulthood and examined their association with the risk of obesity-related cancer. Participants completed interviews and questionnaires at baseline (1990-1994, age 40-69 years), follow-up 1 (1995-1998), and follow-up 2 (2003-2005). Body mass was recalled for age 18 to 21 years, measured at baseline, self-reported at follow-up 1, and measured at follow-up 2. Height was measured at baseline. Cancer diagnoses were ascertained from the Victorian Cancer Registry and the Australian Cancer Database. A latent class trajectory model was used to identify BMI trajectories that were not defined a priori. Cox regression was used to estimate HRs and 95% confidence intervals (CI) of obesity-related cancer risks by BMI trajectory. RESULTS: Six distinct BMI trajectories were identified. Compared with people who maintained lower normal BMI, higher risks of developing obesity-related cancer were observed for participants who transitioned from normal to overweight (HR, 1.29; 95% CI, 1.13-1.47), normal to class I obesity (HR, 1.50; 95% CI, 1.28-1.75), or from overweight to class II obesity (HR, 1.66; 95% CI, 1.32-2.08). CONCLUSIONS: Our findings suggest that maintaining a healthy BMI across the adult lifespan is important for cancer prevention. IMPACT: Categorization of BMI by trajectory allowed us to identify specific risk groups to target with public health interventions.

Secondary school canteens in Australia: analysis of canteen menus from a repeated cross-sectional national survey.

OBJECTIVE: The current study aimed to assess the nutritional quality of Australian secondary school canteen menus. DESIGN: Stratified national samples of schools provided canteen menus in 2012-2013 and 2018, which were systematically assessed against a 'traffic light' classification system according to the National Healthy School Canteen Guidelines. Items were classified as green (healthiest and recommended to dominate canteen menus), amber (select carefully) or red (low nutritional quality, should not appear on canteen menus), and pricing and promotional strategies were recorded. SETTING: Australia. PARTICIPANTS: Canteen menus from 244 secondary schools (2012-2013 n 148, 2018 n 96). RESULTS: A total of 21 501 menu items were classified. Forty-nine percent of canteen menus contained at least 50 % green items; however, nearly all (98·5 %) offered at least one red item and therefore did not comply with national recommendations. Snacks and drinks had the least healthy profile of all product sectors, and a large proportion of schools supplied products typically of poor nutritional quality (meat pies and savoury pastries 91·8 %, sugary drinks 89·5 %, sweet baked goods 71·5 %, ice creams 64·1 % and potato chips 44·0 %). Red items were significantly cheaper than green items on average, and many schools promoted the purchase of red items on canteen menus (52·8 %). There were few differences between survey waves. CONCLUSIONS: There is considerable room for improvement in the nutritional quality of canteen menus in Australian secondary schools, including in the availability, pricing and promotion of healthier options. Additional resources and services to support implementation of national guidelines would be beneficial.

You wouldn't eat 16 teaspoons of sugar-so why drink it? Aboriginal and Torres Strait Islander responses to the LiveLighter sugary drink campaign.

ISSUE ADDRESSED: The reach and impact of the LiveLighter and Aboriginal sugar-sweetened beverage (SSB) advertisements among Aboriginal and Torres Strait Islander adults. METHODS: The Aboriginal SSB advertisement launched online in January 2015 and aired on NITV in October/November 2015 as part of the Government-funded LiveLighter campaign. The advertisement was developed in Victoria and featured members of the Victorian Aboriginal community. Another LiveLighter advertisement targeting the general population was broadcast over the same period. Online surveys were completed by 150 Aboriginal and/or Torres Strait Islander adults in November/December 2015. RESULTS: Around half of respondents reported seeing either the Aboriginal (47%) or the LiveLighter (56%) SSB advertisement, and the proportion was significantly greater in Victoria (Aboriginal: 60%, LiveLighter: 66%) than other states/territories (Aboriginal: 29%, LiveLighter: 43%). Compared to the LiveLighter advertisement, the Aboriginal campaign was seen to be more believable, to be more relevant and to have an important message for the Aboriginal community (P < 0.001). Participants from Victoria were significantly more likely to identify the sugar content of regular soft drink, compared with those from other states/territories (68% vs 40%, P < 0.001). Sixty per cent of participants who had seen the Aboriginal SSB advertisement reported they drank less SSBs compared with 48% of those not exposed, though the difference was not statistically significant (P > 0.05). CONCLUSIONS: Results suggest the Aboriginal advertisement resonated with Aboriginal and Torres Strait Islander people and impacted knowledge about the sugar content of SSBs, particularly in Victoria where the campaign originated. SO WHAT?: This study highlights the importance of Aboriginal and Torres Strait Islander-led health promotion campaigns and tailoring health messages to the local Aboriginal and/or Torres Strait Islander community.

Controlled cohort evaluation of the LiveLighter mass media campaign's impact on adults' reported consumption of sugar-sweetened beverages.

OBJECTIVE: To evaluate the LiveLighter 'Sugary Drinks' campaign impact on awareness, knowledge and sugar-sweetened beverage (SSB) consumption. DESIGN: Cohort study with population surveys undertaken in intervention and comparison states at baseline (n=900 each), with 78% retention at follow-up (intervention: n=673; comparison: n=730). Analyses tested interactions by state (intervention, comparison) and time (baseline, follow-up). SETTING AND PARTICIPANTS: Adults aged 25-49 years residing in the Australian states of Victoria and South Australia. INTERVENTION: The 6-week mass media campaign ran in Victoria in October/November 2015. It focused on the contribution of SSBs to the development of visceral 'toxic fat', graphically depicted around vital organs, and ultimately serious disease. Paid television advertising was complemented by radio, cinema, online and social media advertising, and stakeholder and community engagement. PRIMARY OUTCOME MEASURE: Self-reported consumption of SSBs, artificially sweetened drinks and water. SECONDARY OUTCOME MEASURES: Campaign recall and recognition; knowledge of the health effects of overweight and SSB consumption; perceived impact of SSB consumption on body weight and of reduced consumption on health. RESULTS: A significant reduction in frequent SSB consumption was observed in the intervention state (intervention: 31% compared with 22%, comparison: 30% compared with 29%; interaction p<0.01). This was accompanied by evidence of increased water consumption (intervention: 66% compared with 73%; comparison: 68% compared with 67%; interaction p=0.09) among overweight/obese SSB consumers. This group also showed increased knowledge of the health effects of SSB consumption (intervention: 60% compared with 71%, comparison: 63% compared with 59%; interaction p<0.05) and some evidence of increased prevalence of self-referent thoughts about SSB's relationship to weight gain (intervention: 39% compared with 45%, comparison: 43% compared with 38%; interaction p=0.06). CONCLUSIONS: The findings provide evidence of reduced SSB consumption among adults in the target age range following the LiveLighter campaign. This is notable in a context where public health campaigns occur against a backdrop of heavy commercial product advertising promoting increased SSB consumption.