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Factors Shaping Food and Beverage Consumption of Children and Youth

INTRODUCTION

Eating behaviors cannot be understood, explained, or changed without considering the context in which an individual lives (e.g., individual characteristics, home, and family). This context is nested within a broader community context, such as the neighborhood and schools, and societal factors (e.g., marketing, economics, culture). Interactions within and among these contexts affect behavior. A multidimensional approach to understanding the processes and context of the influences shaping children’s and youths’ eating behaviors can help explain relationships among factors in different domains.

This chapter presents an ecological perspective for understanding factors that influence child and adolescent eating behaviors and food and beverage choices. From this perspective, child and adolescent eating behaviors are conceptualized as a function of individual and environmental influences, or spheres of influence. These include biological factors, familial and social relationships, neighborhood, community, and institutional settings, culture and values, and broader social and economic trends. This chapter describes the following spheres of influence:

  • Individual and developmental factors (e.g., developmental, biological, psychological/psychosocial);

  • Family and social influences;

  • Institutional, neighborhood, and community environments; and

  • Macrosystem influences (e.g., marketing, culture and values, food systems).



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Food Marketing to Children and Youth: Threat or Opportunity? 3 Factors Shaping Food and Beverage Consumption of Children and Youth INTRODUCTION Eating behaviors cannot be understood, explained, or changed without considering the context in which an individual lives (e.g., individual characteristics, home, and family). This context is nested within a broader community context, such as the neighborhood and schools, and societal factors (e.g., marketing, economics, culture). Interactions within and among these contexts affect behavior. A multidimensional approach to understanding the processes and context of the influences shaping children’s and youths’ eating behaviors can help explain relationships among factors in different domains. This chapter presents an ecological perspective for understanding factors that influence child and adolescent eating behaviors and food and beverage choices. From this perspective, child and adolescent eating behaviors are conceptualized as a function of individual and environmental influences, or spheres of influence. These include biological factors, familial and social relationships, neighborhood, community, and institutional settings, culture and values, and broader social and economic trends. This chapter describes the following spheres of influence: Individual and developmental factors (e.g., developmental, biological, psychological/psychosocial); Family and social influences; Institutional, neighborhood, and community environments; and Macrosystem influences (e.g., marketing, culture and values, food systems).

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Food Marketing to Children and Youth: Threat or Opportunity? All of these factors may directly or indirectly influence eating behaviors. If the diets of children and youth are to improve, attention must be given not only to the behavior of individuals but also to the environmental context and conditions in which people live and eat. Current studies are inadequate to explain with certainty how individual and environmental influences interact to influence dietary behaviors and health outcomes of children and youth. Simultaneous analyses of sociodemographic, psychological, developmental, and environmental factors and their interactions with food choices are rare in the literature. The few cases that do exist are often focused on a specific age group or a single food group, such as fruits and vegetables. The following sections present both empirical evidence and theoretical links to eating behaviors. INDIVIDUAL AND DEVELOPMENTAL FACTORS Individual influences on children’s eating behaviors include biological and genetic factors, sensory characteristics, psychological and psychosocial factors, developmental stages, consumer socialization, and lifestyle factors. Biological and Genetic Factors Biological Factors Eating is a behavior influenced by physiological factors. It involves many organs and the central nervous system. Hunger, appetite, and satiety are all under neural regulatory control. Physiological factors influence food intake through sensory stimulation (e.g., smell, sight, taste of food), gastrointestinal signals, and circulating factors and chemical signals (e.g., glucose, insulin, peptides). Environmental and cognitive factors can interfere with or override physiological controls of eating and calorie intake. In fact, food intake in humans may depend more on external factors rather than physiological factors (Bell and Rolls, 2001). Recent advances in the field of behavioral neuroscience have begun to increase the scientific understanding of the neurobiology of eating and food intake, including when and how much food is consumed and when eating is terminated. Gut–brain signals appear to be a critical neural network in the regulation of calorie intake and meal size. The discovery of bioactive food-stimulated gut peptides, adipocyte hormones, and hypothalamic neuropeptides all appear to affect food intake (Schwartz, 2004). It has been suggested that central regulatory mechanisms may contribute to the preference of sugars and fats over other macronutrients and tastes (Drewnowski and Levine, 2003). Much of the neurobiological mechanism research has been done in animal models, or human neuroimaging studies with patterns of

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Food Marketing to Children and Youth: Threat or Opportunity? brain activation produced by the thought, sight, smell, or taste of food. Thus, the effect of the neurobiology of eating and food intake on human behavior has not been fully elucidated. Some universal biological food predispositions may exist, including preferences for sweetness and fat texture, avoidance of irritation, avoidance of bitter and strong tastes, a tendency to be suspicious of new foods, and a set of genetic learning predispositions (Rozin, 2002). These predispositions may have served an adaptive function in human history when food was relatively scarce, modest in fat or sugar content, and limited in variety (Rozin, 2002). However, food today is abundant and widely available and thousands of new food products are introduced every year, including those high in sugar, fat, and salt, which appeal to our taste predispositions (Chapter 4). In today’s food environment, children’s predispositions and adults’ responses to them can promote food preferences and intake patterns that foster less healthful eating patterns that can contribute to the development of obesity (Birch, 1999). Genetic Factors Although the influences of genes on weight status and obesity are well documented, genetic influences on eating patterns and behaviors have received much less attention. While there is strong support from animal models for a genetic basis to food intake, a limited number of human studies suggest that food selection and intake, specifically for macronutrients (e.g., fats, carbohydrates) and total calories, may be genetically influenced to some extent (Keller et al., 2002). Research from family and twin studies suggests a modest to moderate genetic contribution to eating behaviors (de Castro and Plunkett, 2002; Keller et al., 2002; Klump et al., 2000; Reed et al., 1997). Selected adult twin studies show that heredity accounts for 11–65 percent of the variance in the average overall calorie intake (Keller et al., 2002). These studies also show the importance of nongenetic environmental effects. Studies among family members suggest that genetic influences on nutrient intake among first degree relatives is weak and that nongenetic effects associated with a shared environment are the major contributors to energy intake (Perusse et al., 1988). Studies assessing food preferences in both families and twins have found that the heritable component for individual foods is very low (Reed et al., 1997; Rozin and Millman, 1987). This suggests the important influential role of the environment on dietary patterns. Reported heritability of macronutrient intakes (e.g., fats, carbohydrates) tends to be somewhat stronger. A better understanding is needed to elucidate the complex interplay between human genes and the environment. Individual variation in taste and food preferences may be genetically

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Food Marketing to Children and Youth: Threat or Opportunity? influenced (Birch, 1999; Keller and Tepper, 2004). Sensitivity to bitter taste is a heritable trait. Compounds such as 6-n-propylthiouracil (PROP) taste bitter to some people and are tasteless to others. Some, but not all studies have shown that PROP tasters show lower acceptance of cruciferous and other bitter vegetables (e.g., broccoli, cabbage, brussel sprouts), have more food dislikes, and are more sensitive to sweet tastes and the texture of fat (Birch, 1999; Keller and Tepper, 2004). These studies suggest that genetic taste factors may play an important role in the development of food preferences and dietary intake in children (Keller et al., 2002). A better understanding of the genetic basis of taste may lead to the design of better dietary prevention strategies for children (Keller et al., 2002). More research is needed to identify genetic markers that will facilitate our understanding of genetic predispositions and how they interact with feeding and dietary experiences and social and environmental contexts. Sensory Characteristics and Taste Sensory Characteristics Perceptions and responses to the sensory properties of food—taste, smell, and texture—affect food preferences and eating habits (Drewnowski, 1997). Sensory responses are influenced by genetic, physiological, and metabolic variables. Preferences for sweet tastes, saltiness, and fatty textures may be an innate human trait or acquired early in life. By about 4 months, for example, infants begin to show a preference for salt (Birch, 1999). On the other hand, bitter and strong tasting foods are often rejected early in life. From an evolutionary basis, these responses may have served biological functions needed for survival. In nature, sweetness is associated with readily available calories from carbohydrates, and salt is needed for survival. However, bitterness may be associated with natural toxins signaling dietary danger (Mennella et al., 2004, 2005; Rozin, 2002). The tendency to learn to prefer calorie-dense foods may have been adaptive at times in our history when food was scarce (Rozin, 2002). Innate taste responses are observed immediately after birth. Facial expressions on human newborns show a positive hedonic response to sweet tastes and a negative response to bitter and sour tastes (Drewnowski, 1997). The sensory pleasure response to sweetness and dietary fat may be mediated by the brain through neurotransmitters or endogenous opiate peptides (Benton, 2004). Studies of young children have shown that their food preferences are influenced primarily by two factors: sweetness and familiarity (Birch, 1999; Drewnowski, 1997). Preferences for fat also may be acquired in early life, as children learn to prefer those flavors of foods that are associated with

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Food Marketing to Children and Youth: Threat or Opportunity? high-calorie and fat content (Drewnowski, 1997). However, the predisposition to prefer a sweet taste is readily modified by experiences with food and eating (Birch, 1999). One study showed that at birth all infants preferred sweet solutions to water, but by 6 months, preference for sweetened water was linked to the infant’s food experience; those infants routinely given sweetened water by their mothers showed a greater preference for it than infants who had been given water that was not sweetened (Beauchamp and Moran, 1982). Substantial evidence shows that predispositions to prefer sweet, fatty, and salty foods and reject bitter ones can be readily altered through experience with food and eating (Birch, 1999). Flavor is another primary dimension by which young children determine food acceptance (Mennella et al., 2005). Some relatively new evidence has hypothesized that experience with a flavor in amniotic fluid or breast milk may modify an infant’s acceptance and enjoyment of similarly flavored foods at weaning, and that this may underlie individual differences in food acceptability and possibly serve as the foundation for lifelong food habits (Mennella et al., 2004). Mennella et al. (2001) found that weaning infants who had exposure to the flavor of carrots in either amniotic fluid or breast milk were perceived to respond more positively to that flavor in a food base than did nonexposed infants. Thus, preliminary research suggests that prenatal and early postnatal exposure to flavors may predispose the young infant to have a favorable response to those flavors in foods. Taste One of the most important individual influences on food choice is taste, which also is influenced by the aroma and texture of food. Research has consistently shown that children, adolescents, and adults all report that taste is the most important influence on their food choices (Barr, 1994; French et al., 1999; Glanz et al., 1998; Horacek and Betts, 1998; Neumark-Sztainer et al., 1999). Taste preference has also been found to be directly related to children’s fruit and vegetable consumption (Neumark-Sztainer et al., 2003), calcium intake (Barr, 1994), and carbonated soft drink consumption (Grimm et al., 2004). In studies assessing motivation for vending snack choices and food choices at school, adolescents rated taste as the most important factor to consider, followed by hunger and price (French et al., 1999; Shannon et al., 2002). Those who placed greater emphasis on snack taste were less likely to report low-fat vending snacks as current or intended choices. “Healthfulness” and “tastiness” tend to be seen as opposites by children (Wardle and Huon, 2000). There appears to be widespread belief among children and adolescents that “if a food tastes good, it must not be good for me” and “if a food tastes bad, it is probably good for me” (Baranowski et al., 1993). In one study of

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Food Marketing to Children and Youth: Threat or Opportunity? teenagers, only one-fourth thought low-fat foods taste good (Shannon et al., 2002). In an experimental study with 9- to 11-year-old children, Wardle and Huon (2000) tested the idea that a “healthy” label would reduce the appeal of a novel drink. Children were asked to taste and rate one or two drinks—one was described and labeled as “a new health drink” and the other as a “new drink.” The results showed children rated the drink labeled healthful as tasting less pleasant and said they would be less likely to ask their parents to buy it than the same drink presented just as a “new drink” (Wardle and Huon, 2000). Developmental Stages Early childhood lays the foundation for food behaviors and food preferences. The developmental stage1 of a child has a central influence on eating behaviors. During infancy (ages 0–12 months), feeding is central to the parent–child relationship and for the infant developing a sense of security and trust. Early childhood (ages 1–5 years) is characterized by rapid growth and change in the child’s physical, cognitive, communicative, and social development (NRC and IOM, 2000). Eating behaviors move from complete dependence on the caregiver to more self-directed control. During early childhood, parents and primary caretakers largely determine what foods are provided and when eating occurs. Developmental characteristics of young children influence their eating behavior and include dislike for new foods (neophobia), food jags (favoring only one or two foods), and picky eating (e.g., refusal to eat certain foods and not wanting foods to touch each other on the plate) (Story et al., 2002a). These are normative behaviors in young children (Birch, 1999). Middle childhood (ages 6–11 years) is a time of major cognitive development and mastery of cognitive, physical, and social skills. Children in this age group progress from dependence on their parents to increasing independence, with a growing interest on the development of friendships and the world around them. Their eating behaviors reflect these changes and become more influenced by outside sources. The dramatic physical, developmental, and social changes that occur during adolescence (ages 12–19 years) can markedly affect eating behaviors and dietary intake. Growing independence and eating away from home, concern with appearance and body weight, the need for peer acceptance, and busy schedules all can impact eating patterns and food choices. 1   In this report, the committee characterized infants and toddlers as under age 2 years, younger children as ages 2–5 years, older children as ages 6–11 years, and teens as ages 12–18 (Chapter 1). These age categories and terms differ slightly from what is presented from the research described in this chapter.

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Food Marketing to Children and Youth: Threat or Opportunity? Age-associated declines in diet quality are evident as children move from childhood through adolescence. For example, a recent longitudinal study with girls found that dietary quality declined between ages 5 and 9 years (Mannino et al., 2004). Girls at 9 years of age tended to have inadequate intakes of dairy foods, fruits and vegetables, and several nutrients more often than the younger girls. Other longitudinal studies have shown that dietary decline continues during middle childhood into adolescence; intakes of fruits, vegetables, and milk decreases, and carbonated soft drinks increase (Lytle et al., 2000). Psychological and Psychosocial Factors Food Preferences The complex interactions of many factors shape food preferences, including a child’s early experiences with food and eating, positive or negative conditioning, exposure, and genetics (Birch, 1999). Self-reported food preferences are one of the strongest predictors of food choices and dietary intake (Baranowski et al., 2002; Birch and Fisher, 1998; Drewnowski and Hann, 1999; Woodward et al., 1996). Repeated exposures increase children’s preference for a food or flavor (Birch, 1999). A longitudinal study of children from ages 2–3 years to 8 years reported that a high percentage of children’s food preferences are formed as early as ages 2–3 years, and few changes in preferences occurred over the 5-year period (Skinner et al., 2002). The strongest predictors of the number of foods liked at age 8 years were the number of foods liked at age 4 years (Skinner et al., 2002). When food is plentiful, food likes and dislikes play an important role in influencing food choices. Among children, sweet foods and high-fat foods tend to be the most preferred foods (Drewnowski, 1997; Rozin, 2002), while vegetables are the least preferred foods (Skinner et al., 2002). Parents often cite dislike as the primary reason for children’s low vegetable intakes (Wardle et al., 2003a). It is not clear why vegetables are disliked by children, but it may be because of the sensitivity to the bitter taste of cruciferous vegetables, bland preparation of vegetables, the negative context in which vegetables may be presented—if you want dessert, you have to eat your peas, poor parental modeling, or low exposure. Skinner et al. (2002) found that foods disliked by mothers tended not to be offered to children. A growing body of research suggests that a dislike of foods can be transformed into liking with experience of repeated tasting or exposures (Wardle et al., 2003a). In one study with children, 10 daily exposures to the taste of an unfamiliar vegetable (e.g., raw red pepper) significantly increased children’s liking and consumption of the vegetable (Wardle et al., 2003b). Another recent study found that daily exposure for 14 days to the taste of a

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Food Marketing to Children and Youth: Threat or Opportunity? previously disliked vegetable increased children’s (ages 2–6 years) liking and consumption of that vegetable (Wardle et al., 2003a). These results suggest that repeated exposure through frequent tasting may be effective in increasing children’s acceptance of vegetables and other healthful, but not necessarily well-liked foods (e.g., whole grains, unsweetened cereals). In homes, schools, and child-care settings, repeated exposure to initially disliked foods in an emotionally positive atmosphere could increase preference and consumption of those foods. Social factors and the context in which the food is offered are important in shaping children’s preferences. Preschool children’s preferences for and consumption of disliked vegetables increased when children observed peers choosing and eating the vegetables that the target child disliked (Birch, 1999). Child feeding practices may also impact children’s preferences and intake patterns. When children are given foods as rewards for approved behaviors, enhanced preference for those foods results (Birch, 1999). In contrast, when children are rewarded for eating a disliked food such as vegetables, this leads to a decline in the preference for that food (Birch, 1999). Finding: Food preferences develop as early as 2–3 years of age and are shaped by a child’s early experiences, positive or negative conditioning, exposure to foods, and a biological predisposition to prefer sweet, high-fat, and salty foods. Gender Gender differences in food choices and dietary intakes emerge as children move into adolescence. During childhood food intakes are similar between girls and boys. U.S. Department of Agriculture (USDA) data from the 1989–1991 Continuing Surveys of Food Intakes by Individuals (CSFII) showed little differences in mean daily intakes of the Food Guide Pyramid groups for grains, vegetables, fruit, dairy, and meat among boys and girls ages 2–5 years and ages 6–11 years (Munoz et al., 1997). Among adolescents, boys ate more servings of grains, more vegetables (including french fries), dairy, and meat servings compared to girls (Chapter 2). Studies have shown that as a group, adolescent girls are more likely than adolescent boys to have lower intakes of essential vitamins and minerals, and fewer servings of fruits, vegetables, and dairy foods (Gleason and Suitor, 2001; Story et al., 2002b). Boys are more likely to have diets higher in total fat and saturated fat compared to girls (Gleason and Suitor, 2001; Troiano et al., 2000) and to consume larger amounts of carbonated soft drinks (French et al., 2003a). On average, adolescent boys eat larger quantities of food than adolescent girls, so they are more likely to meet daily

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Food Marketing to Children and Youth: Threat or Opportunity? recommended intakes for vitamins and minerals. Adolescent girls are also more likely to skip meals, especially breakfast, than are adolescent males (Gleason and Suitor, 2001; Chapter 2). Gender differences in attitudes towards food are also evident during adolescence. Adolescent girls are more likely than adolescent boys to be concerned about health and weight, and this concern is associated with more positive attitudes and behaviors regarding healthful foods. In one study of 1,083 adolescent high school students, girls were more likely than boys to report that low-fat foods are beneficial for future health and maintaining weight (Fulkerson et al., 2004a). Boys were more likely than girls to report that healthful eating is not important to them. Girls’ weight concerns may predispose them to have more favorable attitudes toward healthful eating. These results suggest the importance of segmented nutrition education interventions for adolescents. Concern About Health and Nutrition Health and nutrition are not a primary influence on the food choices among the majority of children, adolescents, and adults. In a study of 289 adolescents, while nearly two-thirds (61 percent) of the students reported that eating healthful foods was important to them, only 27 percent were motivated by health in making food choices (Shannon et al., 2002). Gender differences are also evident; one-third (36 percent) of girls report being motivated by health concerns compared to only 18 percent of adolescent boys (Shannon et al., 2002). Studies have also shown that students with higher health concerns have lower intakes of fat and higher nutrient intakes compared to those less concerned about health (Horacek and Betts, 1998). Conversely, those least motivated by health concerns had the highest fat intakes. Other studies have shown that children who value health for the foods they choose have better dietary quality (Gibson et al., 1998). Research has demonstrated that age positively predicts the perceived importance of nutrition and the health effects of food; it becomes more important as people age and is most valued by older adults (Glanz et al., 1998). From a developmental perspective, it is not surprising that health and nutrition are low-priority concerns for adolescents, that adolescents are the most inclined toward eating behaviors that are incompatible with a healthful diet, and that they are less concerned about nutrition compared to their parents or grandparents (Rozin, 2002). Qualitative research has shown that many adolescents do not perceive a need or urgency to change their eating behavior when the future seems so far away (Neumark-Sztainer et al., 1999; Story and Resnick, 1986). For many, the long-term benefits of good health may not outweigh the short-term advantages of convenience and immediate gratification.

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Food Marketing to Children and Youth: Threat or Opportunity? Nutrition Knowledge Although knowing how and why to eat healthfully is important, nutrition knowledge alone does not ensure that children or adolescents will adopt healthful eating behaviors. A meta-analysis of the literature with adults, adolescents, and children found the association of nutrition knowledge with dietary behavior to be very weak (r = 0.10) (Axelson et al., 1985). Another more recent study with adults using CSFII data found that adults with more nutrition knowledge consumed more fruit and vegetables (Guthrie et al., 2005). Another study with mothers and children ages 9–11 years found that mothers’ nutrition knowledge was strongly correlated to their children’s fruit intake, but not to their intake of vegetables or sweets (Gibson et al., 1998). Children’s own nutrition knowledge did not correlate with their fruit or vegetable intake (Gibson et al., 1998). Clearly, nutrition knowledge alone is not sufficient to change dietary behaviors. Stress and Depression Stress and depression can affect appetite through either an increase or decrease in eating. However, relatively little research has been done with children or adolescents. Cartwright et al. (2003) examined associations between psychological stress and dietary practices in a socioeconomically and ethnically diverse sample of 4,320 children ages 11–12 years. Children completed a Perceived Stress Scale and food frequency questionnaires. Greater stress was associated with eating higher-fat foods, less fruit and vegetable intake, more frequent snacking, and skipping breakfast. These effects were independent of gender, weight, socioeconomic status, and ethnicity. An extensive body of research supports a strong relationship between depression and eating disorders among adolescents, as well as depression and weight dissatisfaction, negative body image, and disordered eating behaviors (Fulkerson et al., 2004b). Less is known about childhood depression and dietary practices. In a survey of 4,734 ethnically diverse middle and high school students, Fulkerson et al. (2004b) found that depressive symptoms were positively associated with perceived barriers to healthful eating and weight concerns. Adolescents who reported more depressive symptoms were less likely to eat breakfast, lunch, and dinner. No association was seen between depressive symptoms and calorie or nutrient intakes. Dieting Dieting is a widespread practice among preadolescents and adolescents, especially girls. Nationwide in 2003, 59 percent of high school girls

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Food Marketing to Children and Youth: Threat or Opportunity? and 29 percent of high school boys reported trying to lose weight during the 30 days preceding a survey conducted by Grunbaum et al. (2004). Nearly 20 percent of girls had gone without eating for 24 hours or more to lose weight, 11 percent had taken diet pills to lose weight, and 8 percent had vomited or taken laxatives to lose weight during the past 30 days (Grunbaum et al., 2004). The few studies that have examined adolescent weight control behaviors and associations with dietary intakes have had inconsistent results (Barr, 1995; French et al., 1995; Neumark-Sztainer et al., 2000; Story et al., 1998). Studies have shown that adolescents who engage in less healthful weight control behaviors (e.g., vomiting, laxatives, or diet pills) are at increased risk for dietary inadequacy and weight gain (Neumark-Sztainer et al., 2004; Story et al., 1998). Among 4,144 adolescents, girls using less healthful weight control behaviors had significantly lower intakes of fruits and vegetables, grains, calcium, iron, and other micronutrients compared to girls using healthy weight control methods or not dieting (Neumark-Sztainer et al., 2004). No such relationship was found among boys. Portion Size Several controlled laboratory and naturalistic studies show that in the short-term, older children and adults eat more with increasing portion sizes and larger package sizes (Rolls, 2003). In a laboratory study (Rolls et al., 2000), 5-year-old children varied their intake at meals directly with changes in portion sizes. When offered larger portions, children ate substantially more. In the same study, young children (about 3.5 years old) did not vary intake in relation to changes in portion size, suggesting that the ability to respond to internal cues of hunger is stronger at younger ages and diminishes with age as external factors become increasingly influential. Food packaging and portion sizes have increased steadily over the past 30 years (Wansink, 2004; Young and Nestle, 2002). Data suggest that the trend toward larger portion sizes began in the 1970s, increased sharply in the 1980s, and has continued to increase (Young and Nestle, 2002). Package size influences the volume of food consumed. When food packages are doubled in size, consumption in adults generally increases by 18–25 percent for meal-related foods and 30–45 percent for snack-related foods (Wansink, 2004). Data indicate that away-from-home portions sizes have increased over time (Nielsen and Popkin, 2003; Young and Nestle, 2002; Chapter 2). Larger portions not only contain more calories but also encourage people to eat more. Research suggests that individuals tend to overconsume high energy-dense foods beyond physiological satiety (Kral et al., 2004), especially when they are unaware that the portion sizes served to them have been substantially increased (Rolls et al., 2004). Satiety signals are not

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Food Marketing to Children and Youth: Threat or Opportunity? yogurt, soymilk, and tofu; and expanding culturally acceptable food options (IOM, 2005b). The Child Nutrition Programs, which include the NSLP, SBP, CACFP, and the Summer Food Programs, target children enrolled in public and nonprofit private schools, child-care institutions, and summer recreation programs. The NSLP discussed earlier is the largest of these programs, serving almost 29 million children every school day. Nearly half (49 percent) of the school lunches served are provided free to students and another 10 percent are provided at a reduced price (USDA, 2005). In recent years, there has been an increased emphasis on providing more nutritious food through these programs (Levedahl and Oliveira, 1999). Concern has centered on improving the quality of foods served in these programs, increasing the availability of fruits and vegetables, and improving the nutritional quality of commodity foods. Recently, efforts have been made to pilot programs to promote fresh fruits and vegetables in schools. The 2002 Farm Bill provided funds for the Fruit and Vegetable Pilot Program (FVPP) in 25 schools in four states and one Indian reservation (ERS, 2002). The recent Child Nutrition and WIC Reauthorization Act expanded the program to four more states and two more Indian reservations (Committee on Education and the Workforce, 2004). Although the USDA’s nutrition assistance programs vary greatly in size, target populations, and delivery mechanisms, they all provide children of low-income households with food, the means to purchase food, and nutrition education. Although the food assistance programs have been shown to increase the quantity of food consumed by participants, the effect of these programs on improving the quality of their diets has been more difficult to ascertain (Levedahl and Oliveira, 1999). Although a number of studies have attempted to quantify the effects of the nutrition assistance programs, there has been no comprehensive assessment of the effects of the programs on the diet and health outcomes of participants. A recent USDA-funded study reviewed research on the impact of the USDA’s nutrition assistance programs on participants’ health and diet outcomes. The main conclusion is that findings must be interpreted with caution due to the limitations of the studies (Fox et al., 2004). For targeted programs such as WIC, the NSLP, and SBP, nutrient intake is generally increased. The FSP increases household food intake, although whether nutritional quality is higher is unclear (Fox et al., 2004). There is a need for a well-designed comprehensive study on how nutrition and health status are impacted by participation in nutrition assistance programs. Nutrition assistance programs serve a large proportion of low-income children who need these programs to meet their daily calorie and nutritional needs. These children should have access to nutrient-rich foods that are ethnically and culturally appropriate. The USDA could explore innova-

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Food Marketing to Children and Youth: Threat or Opportunity? tive pilot programs to increase access to healthful foods or provide incentives for the purchase of these items. Examples include further expanding the FVPP to more schools; supporting farm-to-school programs, school gardens, and WIC gardens, ensuring that food stamp recipients have access to supermarkets, farmers’ markets, and other venues to provide fresh, high-quality, and affordable produce, and other healthful foods, fruit and vegetable vouchers, or bonus coupons for food stamp users (IOM, 2005a; Chapter 6). Government Regulations and Policies Government policies and regulations related to food and agriculture can directly and indirectly affect the supply or prices of food, the nutritional composition of foods, food safety, the information consumers receive about food, and consumer confidence in the food supply, all of which can influence consumer food choices (Ralston, 1999). As discussed in more depth in Chapter 6, the effects of policies and regulations, such as subsidies and taxation, on food choices depends on how the policy affects the cost of producing commodities, how those costs relate to final retail prices, how responsive consumers are to price changes, and how the policy directly influences consumer preference for the product (Ralston, 1999). A highly productive and efficient agriculture production system contributes to an ample supply of food in the United States. However, there has been little examination of how agricultural and economic public policies and the resulting food and agricultural environment affect food choice or obesity (Tillotson, 2004), including how the types and quantities of foods available through the federal food and nutrition assistance programs influence healthy diets for children and youth. SUMMARY The committee’s review of the elements shaping the food and beverage consumption of children and adolescents underscores the importance of using an ecological perspective to understand the interactions among factors that influence food preferences and eating behaviors. Multiple influences—individual and developmental factors, family and social elements, institutions, communities, and macrosystems—interact to shape the food and beverage consumption patterns of children and youth. This ecological perspective can be used to develop more effective strategies and programs to improve dietary behaviors. Nutrition knowledge of children and youth by itself does not necessarily motivate their food choices and dietary behaviors. Food preferences develop as early as ages 2–3 years and are shaped by a child’s early experi-

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