Food Marketing to Children and Youth

Threat or Opportunity?

Committee on Food Marketing and the Diets of Children and Youth

J. Michael McGinnis, Jennifer Appleton Gootman, Vivica I. Kraak, Editors

Food and Nutrition Board

Board on Children, Youth, and Families

INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS
Washington, D.C.
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Food Marketing to Children and Youth: Threat or Opportunity? Food Marketing to Children and Youth Threat or Opportunity? Committee on Food Marketing and the Diets of Children and Youth J. Michael McGinnis, Jennifer Appleton Gootman, Vivica I. Kraak, Editors Food and Nutrition Board Board on Children, Youth, and Families INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES THE NATIONAL ACADEMIES PRESS Washington, D.C. www.nap.edu

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Food Marketing to Children and Youth: Threat or Opportunity? THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. The study was supported by Contract No. 200-2000-00629, Task Order No. 27 between the National Academy of Sciences and the Centers for Disease Control and Prevention. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the authors and do not necessarily reflect the views of the organizations or agencies that provided support for the project. Library of Congress Cataloging-in-Publication Data Institute of Medicine (U.S.). Committee on Food Marketing and the Diets of Children and Youth. Food marketing to children and youth : threat or opportunity? / Committee on Food Marketing and the Diets of Children and Youth, Food and Nutrition Board, Board on Children, Youth, and Families ; J. Michael McGinnis, Jennifer Appleton Gootman, Vivica I. Kraak, editors. p. ; cm. Includes bibliographical references and index. ISBN 0-309-09713-4 (hardback) 1. Children—Nutrition. 2. Youth—Nutrition. 3. Food industry and trade. 4. Target marketing. 5. Health promotion. 6. Nutrition policy. 7. Child consumers. [DNLM: 1. Food. 2. Adolescent. 3. Advertising. 4. Child. 5. Diet. 6. Food Habits. 7. Public Policy. WS 115 I59f 2006] I. McGinnis, J. Michael. II. Gootman, Jennifer Appleton. III. Kraak, Vivica I. IV. Title. RJ206.F66 2006 618.92’39—dc22 2005037404 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Box 285, Washington, DC 20055. Call (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area), Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2006 by the National Academy of Sciences. All rights reserved. Cover design by Spectrum Science Communications. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

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Food Marketing to Children and Youth: Threat or Opportunity? “Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES Advising the Nation. Improving Health.

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Food Marketing to Children and Youth: Threat or Opportunity? THE NATIONAL ACADEMIES Advisers to the Nation on Science, Engineering, and Medicine The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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Food Marketing to Children and Youth: Threat or Opportunity? COMMITTEE ON FOOD MARKETING AND THE DIETS OF CHILDREN AND YOUTH J. MICHAEL MCGINNIS (Chair), Institute of Medicine, Washington, DC DANIEL R. ANDERSON, Department of Psychology, University of Massachusetts, Amherst J. HOWARD BEALES III, School of Business, George Washington University, Washington, DC DAVID V. B. BRITT, Sesame Workshop (emeritus), Amelia Island, FL SANDRA L. CALVERT, Children’s Digital Media Center, Georgetown University, Washington, DC KEITH T. DARCY, Ethics Officer Association, Waltham, MA AIMÉ DORR, Graduate School of Education and Information Studies, University of California, Los Angeles LLOYD J. KOLBE, Department of Applied Health Science, Indiana University, Bloomington DALE L. KUNKEL, Department of Communication, University of Arizona, Tucson PAUL KURNIT, KidShop, Kurnit Communications, and Lubin School of Business at Pace University, Chappaqua, New York ROBERT C. POST, Yale Law School, New Haven, CT RICHARD SCHEINES, Department of Philosophy, Carnegie Mellon University, Pittsburgh, PA FRANCES H. SELIGSON, Nutrition Consultant, Hershey, PA MARY STORY, Division of Epidemiology, School of Public Health, University of Minnesota, Minneapolis ELLEN A. WARTELLA, Office of the Executive Vice Chancellor and Provost, University of California, Riverside JEROME D. WILLIAMS, Department of Advertising, University of Texas, Austin Liaison from the Food and Nutrition Board NANCY F. KREBS, Department of Pediatrics, University of Colorado Health Sciences Center, Denver

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Food Marketing to Children and Youth: Threat or Opportunity? Staff JENNIFER APPLETON GOOTMAN, Study Director VIVICA I. KRAAK, Study Director LESLIE J. SIM, Research Associate SHANNON L. WISHAM, Research Associate AMIEE M. ADASCZIK, Health Science Intern (January 2005 through May 2005) KELLY D. HORTON, Christine Mirzyan Science and Technology Policy Fellow (June 2005 through August 2005)

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Food Marketing to Children and Youth: Threat or Opportunity? FOOD AND NUTRITION BOARD ROBERT M. RUSSELL (Chair), U.S. Department of Agriculture Jean Mayer Human Nutrition Research Center on Aging, Tufts University, Boston, MA LARRY R. BEUCHAT, Center for Food Safety, University of Georgia, Griffin MICHAEL P. DOYLE, Center for Food Safety, University of Georgia, Griffin SUSAN FERENC, SAF* Risk, LC, Madison, WI NANCY F. KREBS, Department of Pediatrics, University of Colorado Health Sciences Center, Denver SHIRIKI K. KUMANYIKA, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia REYNALDO MARTORELL, Rollins School of Public Health, Emory University, Atlanta, GA J. GLENN MORRIS, University of Maryland, School of Medicine, Baltimore SUZANNE P. MURPHY, Cancer Research Center of Hawaii, University of Hawaii, Honolulu JOSE M. ORDOVAS, Nutrition and Genomics Laboratory, Tufts University, Boston, MA LYNN PARKER, Child Nutrition Programs and Nutrition Policy, Food Research and Action Center, Washington, DC NICHOLAS J. SCHORK, Department of Psychiatry, Polymorphism Research Laboratory, University of California, San Diego REBECCA J. STOLTZFUS, Division of Nutritional Sciences, Cornell University, Ithaca, NY JOHN W. SUTTIE, Department of Biochemistry, University of Wisconsin, Madison WALTER C. WILLETT, Department of Nutrition, Harvard School of Public Health, Harvard University, Boston, MA CATHERINE E. WOTEKI, Global Director of Scientific Affairs, Mars, Incorporated, McLean, VA BARRY L. ZOUMAS, Department of Agricultural Economics and Rural Sociology, Pennsylvania State University, University Park

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Food Marketing to Children and Youth: Threat or Opportunity? Staff LINDA D. MEYERS, Director GERALDINE KENNEDO, Administrative Assistant ANTON BANDY, Financial Associate ELISABETH RIMAUD, Financial Associate (through May 2005) IOM boards do not review or approve individual reports and are not asked to endorse conclusions and recommendations. The responsibility for the content of the reports rests with the authoring committee and the institution.

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Food Marketing to Children and Youth: Threat or Opportunity? BOARD ON CHILDREN, YOUTH, AND FAMILIES MICHAEL I. COHEN (Chair), Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY BARBARA L. WOLFE (Vice-chair), Departments of Economics and Population Health Sciences, University of Wisconsin, Madison JAMES A. BANKS, Center for Multicultural Education, University of Washington, Seattle WILLIAM R. BEARDSLEE, Department of Psychiatry, Children’s Hospital, Boston, MA P. LINDSAY CHASE-LANSDALE, School of Education and Social Policy, Northwestern University, Evanston, IL THOMAS DEWITT, Children’s Hospital Medical Center of Cincinnati, OH MARY JANE ENGLAND, Regis College, Weston, MA BRENDA ESKENAZI, School of Public Health, University of California, Berkeley CHRISTINE FERGUSON, Children’s Investment Project, Alexandria, VA PATRICIA GREENFIELD, Department of Psychology, University of California, Los Angeles NEAL HALFON, School of Public Health, University of California, Los Angeles HARRIET KITZMAN, School of Nursing, University of Rochester, NY SUSAN MILLSTEIN, Division of Adolescent Medicine, University of California, San Francisco ELENA NIGHTINGALE, The National Academies/Institute of Medicine, Washington, DC GARY D. SANDEFUR, College of Letters and Science, University of Wisconsin, Madison RUTH STEIN, Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY LAURENCE D. STEINBERG, Department of Psychology, Temple University, Philadelphia, PA ELLEN A. WARTELLA, Office of the Executive Vice Chancellor and Provost, University of California, Riverside

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Food Marketing to Children and Youth: Threat or Opportunity? Staff ROSEMARY CHALK, Director WENDY KEENAN, Senior Program Assistant (through April 2005) DEBORAH JOHNSON, Senior Program Assistant IOM boards do not review or approve individual reports and are not asked to endorse conclusions and recommendations. The responsibility for the content of the reports rests with the authoring committee and the institution.

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Food Marketing to Children and Youth: Threat or Opportunity? Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: MARK P. BECKER, Office of the Executive Vice President and Provost, University of South Carolina, Columbia ODILIA BERMUDEZ, Friedman School of Nutrition Science and Policy, Tufts University, Boston, MA RONETTE BRIEFEL, Mathematica Policy Research, Inc., Washington, DC KATE CLANCY, Union of Concerned Scientists, Washington, DC JANICE DODDS, School of Public Health, University of North Carolina, Chapel Hill ADAM DREWNOWSKI, Department of Epidemiology, University of Washington, Seattle RACHEL GELLER, The Geppetto Group, New York, NY

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Food Marketing to Children and Youth: Threat or Opportunity? JAMES O. HILL, Center for Human Nutrition, University of Colorado, Denver DONNA JOHNSON, Center for Public Health Nutrition, University of Washington, Seattle MILTON KOTELCHUCK, Department of Maternal and Child Health, Boston University School of Public Health, MA SHIRIKI K. KUMANYIKA, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia MICHAEL MUDD, Kraft Foods (emeritus), Chicago, IL JOHN C. PETERS, Food and Beverage Technology, Procter & Gamble Company, Cincinnati, OH BARRY M. POPKIN, School of Public Health, University of North Carolina, Chapel Hill JULIET SCHOR, Department of Sociology, Boston College, MA STEPHEN D. SUGARMAN, School of Law, University of California, Berkeley JANET TENNEY, Alexandria, VA LARRY WALLACK, School of Community Health, College of Urban and Public Affairs, Portland State University, OR Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by JOHANNA DWYER, Office of Disease Prevention, National Institutes of Health, and ELENA NIGHTINGALE, Institute of Medicine, the National Academies. Appointed by the National Research Council, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution.

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Food Marketing to Children and Youth: Threat or Opportunity? Preface Marketing works. It is a primary engine of our economy and its content can sometimes give us a glimpse of the forces shaping our futures. How marketing affects the perspectives and behaviors of our children and youth, including their diets, has been a subject of active discussion and debate for more than three decades, beginning in a time when marketing could generally be characterized in terms of the advertising done through the traditional media—television, radio, print. Times have changed markedly. Marketing is now a regular feature of virtually all the venues and communication vehicles we encounter in our daily lives. Television advertising remains the dominant form of marketing reaching children and youth that is formally tracked, but the expansion of alternative advertising and marketing strategies is evolving rapidly. Against the backdrop of pressing public concern over the rapid and widespread increase in the prevalence of childhood obesity, Congress, through the FY2004 Health, Labor, and Education Committee appropriation, directed the Centers for Disease Control and Prevention (CDC) to undertake a study of the role that marketing of food and beverages may play as a determinant of the nutritional status of children and youth, and how marketing approaches might be marshaled as a remedy. The CDC turned to the Institute of Medicine (IOM) of the National Academies to conduct this study, a natural corollary to the IOM report released in 2004, Preventing Childhood Obesity: Health in the Balance. The IOM Committee on Food Marketing and the Diets of Children and Youth is pleased to present this report, Food Marketing to Children and

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Food Marketing to Children and Youth: Threat or Opportunity? Youth: Threat or Opportunity? The report represents the most comprehensive review to date of the scientific studies designed to assess the influence of marketing on the nutritional beliefs, choices, practices, and outcomes for children and youth. In conducting our study, the committee not only developed and applied a rigorous analytic framework to the assessment of the relevant scientific literature but also undertook an extensive review of the nutritional status and trends for children and youth, what is known about the full range of factors that influence their dietary patterns, the broad and evolving food and beverage marketing environment, and the relevant policy levers that might be brought to bear to improve our children’s nutritional status. Important and relevant findings from our committee’s review are distributed throughout the body of the text. A summary list of the findings is provided in the final chapter, along with the committee’s overall conclusions and recommendations. This report notes that the prevailing pattern of food and beverage products marketed to children and youth has been high in total calories, sugar, salt, fat, and low in nutrients. A dietary profile that mirrors the products marketed would put our children and youth at risk for the types of nutritional problems that we see occurring today—increasing rates of obesity, and inadequacies of certain important micronutrients—and for the development of various serious chronic diseases later in life. Dietary choices are made in the midst of myriad social, cultural, and economic environmental influences. The focus of the committee was on the role of food and beverage marketing as one of these intersecting influences. In our review, the committee faced certain challenges related to the nature of the available research material. First, virtually all of the published scientific research has focused on advertising—and television advertising in particular. While television maintains an important place in food and beverage marketing, industry strategies have moved far beyond television advertising. Second, much of the research underpinning the development and implementation of food and beverage marketing activities is proprietary and unpublished, and, given the National Academies’ requirement that information used be in the public domain, a large amount of marketing research was unavailable for the committee’s use. Nonetheless, ample information and studies were available for the committee to draw certain key conclusions, including that television advertising influences the food preferences, purchase requests, and diets, at least of children under the age of 12 years, and is associated with the increased rates of obesity among children and youth. The committee could not state the relationship in quantitative terms, but it is clear that even a small effect across the entire population would represent an important impact. Although we could not draw conclusions about the impact of the broader marketing environment, it is highly likely that the influences reinforce those

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Food Marketing to Children and Youth: Threat or Opportunity? seen from advertising. Moreover, the committee found that, for an issue of this potential magnitude, there was both a need and an opportunity for substantially more industry and government attention and action—and cooperation—on an agenda to turn food and beverage marketing forces toward better diets for American children and youth. These recommendations are detailed in Chapter 7. A word is indicated about the members of the IOM Committee on Food Marketing and the Diets of Children and Youth. Befitting the breadth of the topic, this was a committee of unusually varied expertise, experience, and perspective. It was, in addition, a committee that engaged the task with extraordinary energy, commitment, and resolve—both to undertake a rigorous assessment and to do it cooperatively. Shared leadership has been a central feature of the work, as members worked both individually and in groups to ensure that each dimension of the task was skillfully executed. The process has been thorough, the discussions vigorous, and the report represents a consensus document in the best sense of the word. We believe readers will find the documentation to be extensive, the evidence analyses to be seminal, and the findings to be carefully considered. As is so often the case with these studies, vital guidance and tireless energy were contributed to the work by the co-study directors, Jennifer Gootman and Vivica Kraak, who received highly skilled support from research associates Leslie Sim and Shannon Wisham. We are also grateful for the careful shepherding of the study by the directors of the two sponsoring boards: Linda Meyers of the Food and Nutrition Board and Rosemary Chalk of the Board on Children, Youth, and Families. There can be few matters of such compelling importance as the health of America’s children and youth. The committee is grateful for the opportunity to contribute this report as a resource for insight and action, and we are hopeful that its recommendations will help turn the threat of the current trends into an opportunity for change. J. Michael McGinnis, Chair Committee on Food Marketing and the Diets of Children and Youth

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Food Marketing to Children and Youth: Threat or Opportunity? Acknowledgments Beyond the hard work of the committee and IOM project staff, this report reflects contributions from various other individuals and groups that we want to acknowledge. The committee greatly benefited from the opportunity for discussion with the individuals who made presentations and attended the committee’s workshops and meetings including: Leann Birch, Brady Darvin, Mary Engle, Lance Friedmann, Marvin Goldberg, Bob McKinnon, Elizabeth Moore, Alisa Morris, Marlena Peleo-Lazar, Ken Powell, Morris Reid, Victoria Rideout, Marva Smalls, Ellen Taaffe, as well as all those who spoke during the open forum (Appendix H). This study was sponsored by the U.S. Department of Health and Human Services’ Centers for Disease Control and Prevention. We wish to thank William Dietz, Casey Hannan, Barbara Polhamus, and their colleagues for their support and guidance on the committee’s task. We appreciate the extensive contribution of Courtney Carpenter, Kunter Gunasti, Alan Mathios, Marvin Goldberg, and Edward Palmer for authoring commissioned papers that were used as background in the report. University students Amiee Adasczik, Frederick Eberhardt, Emily Evans, Shimada Hall, Kelly Horton, Glynnis Johnson, Linda Kao, Heather Kirkorian, and Meghan Malloy all provided outstanding assistance in reviewing literature and organizing data for the committee. We also thank the University of Texas at Austin students for their contribution to the product proliferation analysis working paper cited in the report. The committee acknowledges the contribution of Collier Shannon Scott

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Food Marketing to Children and Youth: Threat or Opportunity? and Georgetown Economic Services that shared three brief and relevant summaries of analyses—two of which had been prepared for the Grocery Manufacturers Association (GMA) and the Association of National Advertising, and the third was a collaborative endeavor between four GMA food and beverage company members—General Mills, Inc., Kellogg Company, Kraft Foods, Inc., and PepsiCo—which collectively responded to specific questions about advertising and marketing trends and company activities that were requested by the committee. We also thank Nielsen Media Research and Nielsen//Net Ratings, The Geppetto Group, KidShop, Strottman International, and Yankelovich for sharing relevant data. There were other colleagues who provided useful international data and reports to the committee: Martin Caraher in the United Kingdom, Corinna Hawkes, Filippa von Haartman in Sweden, Gitte Laub Hansen in Denmark, and Anne-Marie Hamelin in Quebec. There are others at the IOM who provided support to this project: Wendy Keenan for logistical support; Anton Bandy, Elisabeth Rimaud, and Gary Walker for financial oversight; and guidance from Clyde Behney, Jennifer Bitticks, Mark Chesnek, Jim Jensen, Jennifer Otten, and Christine Stencel. The report has been greatly enhanced by the public relations and creative work of Spectrum Science Communications staff including Erika Borodinsky, Susannah Budington, Rosalba Cano, Victoria Kirker, Pamela Lippincott, Leslie Priest, Susie Tappouni, Mark Trinkaus, Clarissa Vandersteen, and Jane Woo. We thank them for their creative efforts. J. Michael McGinnis, Chair Committee on Food Marketing and the Diets of Children and Youth

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Food Marketing to Children and Youth: Threat or Opportunity? Contents     EXECUTIVE SUMMARY   1 1   SETTING THE STAGE   17 2   HEALTH, DIET, AND EATING PATTERNS OF CHILDREN AND YOUTH   39 3   FACTORS SHAPING FOOD AND BEVERAGE CONSUMPTION OF CHILDREN AND YOUTH   91 4   FOOD AND BEVERAGE MARKETING TO CHILDREN AND YOUTH   133 5   INFLUENCE OF MARKETING ON THE DIETS AND DIET-RELATED HEALTH OF CHILDREN AND YOUTH   226 6   PUBLIC POLICY ISSUES IN FOOD AND BEVERAGE MARKETING TO CHILDREN AND YOUTH   319 7   FINDINGS, RECOMMENDATIONS, NEXT STEPS   373

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Food Marketing to Children and Youth: Threat or Opportunity?     APPENDIXES         A  Acronyms   391     B  Glossary   394     C  Literature Review   410     D  Chapter 2 Appendix   416     E  Chapter 4 Appendix   427     F  Chapter 5 Appendix   436     G  Chapter 6 Appendix   468     H  Workshop Program   481     I  Biographical Sketches of Committee Members and Staff   484     INDEX   497