Assessment of the nutritional quality of food

advertised to children in Lebanon: the first study to use

the WHO nutrient profile model for the EMR

Lara Nasreddine, PhDDepartment of Nutrition and Food Sciences

Faculty of Agricultural and Food SciencesAmerican University of Beirut, Lebanon

5th Dubai International Nutrition Congress, 24-26 October 2019, Dubai

Obesity in Lebanon

Like other countries of the EMR, Lebanon is undergoing the nutrition transition with its characteristic shift in diet, lifestyle and obesity prevalence

Economic growthModernization

Globalization of trade and marketing

Rapid urbanization

Changes in food environment

Reduced physical activity

Childhood Obesity in Lebanon

Prevalence of Overweight and Obesity (%) in Children (0-5yrs)

(Nasreddine et al., unpublished data)

At risk of overweight (+1< BMI-for-age z-score ≤+2)Obese (BMI-for-age z-score >3)Overweight and obese (BMI-for-age z-score > 2)

25.1

8.1

3.3

11.9

0

5

10

15

20

25

30

At risk ofoverweight

Overweightonly

Obesity Overweight &Obesity

%

Prevalence of overweight and obesity in children aged 0-5 y in 2010

8.5

6.7

8.7

17

7.6

6.4

4.9

5.2

3.5

4.6

14.7

6.9

9.6

7.2

6.8

3.5

6.1

11.7

6.7

0 2 4 6 8 10 12 14 16 18

Africa

Eastern

Middle

Northern

Southern

Western

Asia

Eastern

South Central

Southeastern

Western

Latin America and Caribbean

Caribbean

Central America

South America

Oceania

Developing countries

Developed countries

Global

Africa

Asia

Latin America

& Caribbean

Lebanon: 11.9 %

(de Onis & Blössner, 2010)

1Nasreddine et al., 2012 (6-19yrs); 2Nasreddine et al., 2010 (15-18yrs); 3Malik and Bakir, 2007 (14-17yrs); 4Bader et al., 2008 (15-18yrs); 5El-Bayoumy et al., 2009 (10-14yrs); 6Bener , 2006 (12-17yrs); 7Al Dossary et al., 2010 (2-18yrs); 8Taheri et al., 2013 (6-11 yrs); 9Aounallah-Shikri et al., 2008 (15-19yrs);

10Khader et al., 2009 (6-12yrs)

38.537.2

32.3

29.5

44.5

36.5

44.4

21.9 21.5

24.426.6

27.8

32.2

36.8

46.3

23.6

39.6

16.2

25.1 25.4

0

5

10

15

20

25

30

35

40

45

50

Lebanon 1

(WHO 2007)

Syria 2 (IOTF) UAE 3 (IOTF) Bahrain 4 (WHO

1995)

Kuwait 5 (NCHS

1976-1980)

Qatar 6 (IOTF) Saudi Arabia 7

(CDC 2000)

Iran 8 (CDC

2000)

Tunisia 9 (WHO

1995)

Jordan 10

(IOTF)

Ov

erw

eig

ht

an

d O

bes

e (%

)

Country

BoysGirls

Prevalence of overweight and obesity (%) among children & adolescents in Lebanon and other

Middle-Eastern countries

Trends in Overweight & Obesity in Lebanon

National Study conducted among children and adolescents in Lebanon to determine the trends in childhood obesity between 1997 and 2009 (12 years)

(Nasreddine et al., 2012)

→ Obesity increased by almost 50% in boys & girls

Trends of Childhood Obesity: Lebanon (1997-2009)

10.2

5.4

7.3

15.5

6.9

10.9

0

2

4

6

8

10

12

14

16

18

Boys Girls Both Genders

% 1997

2009

(Nasreddine et al., 2012)

6-11 years:High fast food

intake

Urban

High SES

0-2 years:Sugar intake > 1-%EI

Maternal BMI

12-19 years:High intake of SSB

Parental obesity

Sedentarity

2-5 years:Fat intake>25% EI

Frequency of eating in front of TV

High SES

What Are the Factors Associated with Childhood Obesity in Lebanon?

(Nasreddine et al., 2017; Nasreddine et al., 2014; Nasreddine et al., unpublished data)

(UK Government’s Foresight Programme, 2007)

Media exposure as a modulator of eating patterns

Food marketing and eating patterns in children

• Children are affected by advertisement at all ages and are the most susceptible compared to other age groups.

• Advertising is effective in getting children to request more energy rich food.

• Frequent use of media has also been associated:- ↑ intakes of total energy, fat, sweet and savory snacks and soft drinks- ↓ intakes of fruits and vegetables- ↓ physical activity

• The term “ObesiTV” proposed by Boulos et al., 2012 “How television is influencing the obesity epidemic”.

(Robinson et al., 2017; Boulos et al., 2012; Coon and Tucker, 2002)

Directing marketing towards the youth as young as toddlers

→ To create brand recognition and loyalty

→ Direct and causal effect on children’s food preference, behaviors, purchase and consumption

(Story and French, 2004)

Marketing Techniques

1) Food product appeals: premium offers, quality, novelty

2) Emotional appeals: fun, action, peer acceptance, hero, coolness, energy

3) Visual elements:animation, promotional characters, cartoon, celebrities, meal portrayal, food setting

“Art of Persuasion”

(Hebden et al., 2011)

How do children understand food advertisements?

• Product preference in children occurs just after 1 single commercial exposure.

• A 30-second exposure significantly modifies food preference in pre-school children.

(Borzekowski et al., 2003)

Media Literacy and Children

Media literacy, the ability to analyze and evaluate messages put into different contexts, significantly varies by age1

• Under the age of 7 years:- Accept advertisements as being “truthful, accurate and unbiased”. -Do not fully comprehend the persuasive intentions2

• Between 8 and 10 years:- Have the cognitive ability to evaluate misleading advertisement- But do not necessarily apply these skills spontaneously2

• Above 10 years:Emotional appeal exploited in advertisements can influence adolescents’ food choices regardless of their cognitive maturity2

(Livingstone and Helsper, 2004)

Nutrient profiling as a tool to limit food marketing

According to the WHO:

Nutrient profiling is one mechanism that countries

can use in implementing the set of recommendations

on the marketing of foods and non-alcoholic

beverages to children that were endorsed by the

63rd World Health Assembly (WHA63.41).

(World Health Organization, 2011)

Nutrient Profiling: Definition

(World Health Organization, in press)

In the Eastern Mediterranean Region,the WHO has recently developed a nutrient profiling system adapted to the dietary guidelines of the region

(World Health Organization EMRO, 2017)

Study in Lebanon

Objectives:1. Analyze the frequency and types of food and drink

advertisements during children’s viewing time in Lebanon.2. Examine the nutritional content of the advertised food products

in reference to the nutrient thresholds specified by the WHO EMR nutrient profile model.

3. Assess the proportion of food advertisements that include health messages and disclaimers.

(Nasreddine et al., 2019)

MethodologyContent analysis of food and beverage advertisements broadcasted on local TV channels during children’s viewing time in Lebanon.

Selection of local TV channels was based on TV ratings and viewership sharedata acquired from IPSOS Lebanon.

Selection was based on viewership data pertinent to the age group 4–14 years.

Channels with a viewership share exceeding 20% were included in the study.

Accordingly, 3 out of 9 nine local TV channels were selected: Channel A, Channel B, and Channel C .

Recorded broadcasts from the 3 channels were purchased from IPSOS, covering the period between September 2016 and January 2017:

One week was randomly selected within each month, and within each week three weekdays and one weekend day were randomly selected. Month of December 2016 was excluded.

(Nasreddine et al., 2019)

MethodologyFor weekdays, analysis covered all programs broadcasted between 3 pm

(i.e. after the end of the school day) and 10 pm.

For weekend days, analysis covered all programs broadcasted between 8 am and 10 pm.

As such, the sample covered 385 hours of TV broadcasting and included 12 weekdays and 4 weekend days.

Within these timeslots, programs that rated highest in terms of viewership among children and adolescents (4–14 years) were selected for analysis.

Accordingly, current affairs programs, news, cooking, and political talk shows were excluded.

Programs that were included in the analysis comprised: • Children’s shows or C-rated programs;• G-rated (those suitable for children to view without adult

supervision);• PG-rated programs (such as local soap operas or series and some

entertainment programs). (Nasreddine et al., 2019)

MethodologyOf the 385 h, 226 h were analyzed.

Data collection:For each food or drink Ad, the coders recorded:

Time of day, type of food or drink being advertised, brand, whether the advertisement included health or nutrition claims, or health disclaimers (warning about excess consumption).

(Nasreddine et al., 2019)

A total of 1,393 Ads were for foods or beverages, representing 31% of total Ads.

Results

Proportion of food Ads was the highest during C-rated programs (43.2%) compared to G- and PG-rated programs.

(Nasreddine et al., 2019)

• But, in our study, only 11 h of the total 226 analyzed hours were devoted to C-rated programs, highlighting the scarcity of such programs on Lebanese TV channels.

• Thus, in our study, the majority of food-related advertisements came from G-rated programs, with a total of 818 advertisements, at a frequency of six per hour.

The highest proportion of food advertisements was observed during C-rated programs.

(Nasreddine et al., 2019)

14%

2%

6%8%

4%2% 2%

26%

6%8%

2% 2% 2%

16%

Percentage (%) of advertised food in each category

Energy drinks, alcohol and coffee were advertised during G and PG programs.

Most highly advertised categories were chocolate & sweets, and cakes, biscuits & pastries.

(Nasreddine et al., 2019)

33.3

16.7

13.9

11.1

25

0

5

10

15

20

25

30

35

Chocolate sugarand sweets

Savory snacks Milk drinks other beverages Cheeses

% of food Ads by food category during C programs

(Nasreddine et al., 2019)

Comparison of the Nutrient Content of Advertised Food to Nutritional Standards

Food Composition Data

1- Nutrition Fact labels on pre-packaged itemsTrained nutritionists visited large supermarket chains to obtain food items that were advertised → Energy and nutrients from Nutrition Fact Labels of pre-packaged foods were extracted.

2- Manufacturer’s websiteFor food items with no nutrition facts on the package, the official manufacturer website was visited for relevant data on the specific item advertised.

3- Nutritionist Pro softwareWhen data was not available on packages and website, food items with nutritionally similar food items were consulted using the USDA database on the Nutritionist Pro software.

(Nasreddine et al., 2019)

Regional Nutrient Profile Model

Food advertised to children in Lebanon: evaluated for content of energy and 6 nutrients against the marketing threshold values of each nutrient per each food category

Are the food advertised to children allowed for promotion?

• Energy (Kcal/100 g) • Total fat (g/100 g)

• Saturated fat (g/100 g) • Added sugar (g/100 g)

• Total sugar (g/100 g) • Sodium (g/100 g)

• Added sweeteners(presence/absence)

(World Health Organization EMRO, 2017; Nasreddine et al., 2019)

Foods Advertised for Children

WHO Regional Nutrient Profile Model

ALLOWED for advertising: 16.3%PROHIBITED from advertising: 83.7%

(Nasreddine et al., 2019)

Proportion of TV food advertisements assessed as ‘permit ted’ or ‘not permitted’ for marketing to children, based on

the WHO EMR model

(Nasreddine et al., 2019)

Rationale for Prohibiting Advertised Food Items

0

10

20

30

40

50

60

70

Sugar Total fat Saturated fat Salt Sweetener

58.3 %62.5 %

55.6 %

27.8 %

1.4 %

(Nasreddine et al., 2019)

Proportions (%) of food advertisements with health and nutrition claims or health disclaimers,

by type of TV program

All the advertisements that comprised a health or nutrition claim and that were broadcasted during the C-rated

programs were for foods that did not meet the nutritional standards of the WHO EMR model. Also the majority in G

and PG programs. (Nasreddine et al., 2019)

Conclusion and Future Perspectives

Approximately 8 out of 10 food Ads were for foods or drinks that did not meet the nutrition standards set by the model.

These results are similar to the US (9/10) while being higher than estimates reported from Spain, Canada, New Zealand, the UK (5-6/10), and Norway (2/10).

The advertising of healthier options was very low

(Romero-Fernandez et al., 2013; Jenkin et al., 2009; Adams et al., 2009; Batada et al., 2008)

Conclusion

TV food Ads during children’s viewing times is

disproportionately promoting the consumption

of foods high in fat, sugar, and salt, thus promoting

unhealthy dietary patterns in children.

A particularly concerning finding in this study was

the frequent advertisement of

alcoholic drinks during and around the G- and

PG-rated programs.

(Nasreddine et al., 2019; Zuppa et al., 2003)

Jan 25, 2016: Commission on Ending Childhood Obesity (ECHO) presented its final report to the Director-General of WHO

2-year process that involveddiscussions with more than 100 countries

Important questions:

1. Why have efforts to date failed to stop the rise in childhood obesity?

2. Can emerging trends in low-income and middle-income countries be reversed?

www.thelancet.com Published online January 25, 2016 http://dx.doi.org/10.1016/S0140-6736(16)00140-9 1

Inadequate consideration of several factors has probably limited previous eff orts to address childhood

obesity.

Children increasingly growing up in an obesogenic environment

(changes in food type, availability, affordability, and marketing, as well as a decline in physical activity)

www.thelancet.com Published online January 25, 2016 http://dx.doi.org/10.1016/S0140-6736(16)00140-9 1

ECHO report proposes a set of policy recommendations for a comprehensive package of interventions to address three strategic objectives.

1. Tackle the obesogenic environment .

2. Reduce the risk of obesity during critical periods in the life course— preconception and pregnancy, infancy and early childhood, and older childhood and adolescence.

3. Provide treatment for children who are obese to improve their current and future health.

The WHO EMR profiling model may be used by policy makers as a tool to limit the marketing of foods that are high in fat, sugar, and salt during children’s viewing times.

(World Health Organization, 2010; Magnus et al., 2009; Zuppa et al., 2003; World Health Organization, 2000)

Tackling the

obesogenic

environement

Together we can make a difference

References

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