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Obesity presents major challenges for public health and the evidence is strong. Lessons from tobacco control indicate a need for changing the policy and environments to make healthy choices easier and to create more opportunities for children to achieve healthy weights. In April 2011, the Alberta Policy Coalition for Chronic Disease Prevention convened a consensus conference on environmental determinants of obesity such as marketing of unhealthy foods and beverages to children. We examine the political environment, evidence, issues, and challenges of placing restrictions on marketing of unhealthy foods and beverages within Canada. We recommend a national regulatory system prohibiting commercial marketing of foods and beverages to children and suggest that effective regulations must set minimum standards, monitor compliance, and enact penalties for non-compliance.
Strong evidence points to major public health consequences of obesity. More than 5.5 million Canadian adults1 and 500000 children are obese,2 and child and youth overweight/obesity rates in 2007–2009 were double than those of 1981.3 Obesity and its determinants – unhealthy diet and insufficient physical activity – are major risk factors for several chronic diseases that constitute the leading causes of death and disability worldwide.4 The case for action is clear.
The determinants of obesity are complex and include the physical, social, economic, and political environments.5 Because of the many interdependencies among the determinants of obesity, evidence points to strong associations between environmental factors and obesity.6 ‘Obesogenic environments, including physical, social, and economic environments, have contributed to higher obesity rates over the past 30 years by exerting powerful influences on people's overall calorie intake, on the composition of their diets, and on the frequency and intensity of physical activity at work, at home, and during leisure time'.7 Although the body of evidence correlating environments and obesity continues to grow, there are still very few studies, especially in a policy context, designed to evaluate the impact of modifying ‘obesogenic' environments on behavioural or health outcomes.8, 9 A serious evidence gap exists.
Lessons learned from tobacco control suggest the need for broad social change in environments and policy.10 Policies can create environments that make healthy choices easier and create opportunities to achieve healthy weights, but choosing among potential interventions poses a challenge to decision makers. To create momentum for change, the following framework can assist by addressing five overlapping and interconnected steps: (i) building a case (why act?); (ii) identifying contributing factors and associated points for intervention; (iii) defining the range of opportunities for action; (iv) evaluating potential interventions; and (v) creating a portfolio of programmes and policies based on evidence from evaluation.11 Research has addressed the first two steps: building a case for action and identifying contributing factors to suggest points for intervention. Opportunities for action have also been proposed12, 13 (Step 3). The evidence base is growing as policy and programme interventions are continually monitored and refined (Step 4).14, 15 Although further research is needed, we surely have sufficient evidence for action. Delaying remedial interventions because effectiveness is yet to be established makes little sense from a policy perspective as we need to avert future harm. What are the next best steps in a Canadian portfolio of policies? This consensus statement is a move towards answering that question.
In April 2011, the Alberta Policy Coalition for Chronic Disease Prevention convened a consensus conference with invited experts (listed under Acknowledgements) from research, policy, and practice fields in Canada, the United Kingdom (UK), and the United States (US). While the conference had an explicit Canadian focus, by drawing upon experiences and evidence from other jurisdictions, our recommendations can contribute in the broader global context. The purpose was to reach consensus on policy levers to reduce increasing rates of childhood obesity. We identified a range of opportunities for action, based on a synthesis of international recommendations, and previous priority setting within the Canadian policy milieu.16 Conference participants shared insights from their experiences (available political opportunities/appetite for change) and research (evidence of what works/does not work). Through facilitated discussion, we reached consensus.
We examine here the political environment, evidence, issues, and challenges of placing restrictions on marketing of unhealthy foods and beverages and present our consensus recommendations as the basis of ‘a best way' forward. We conclude with reflections on the role of policy to address childhood obesity, as well as barriers and opportunities for policy change.
A global advocacy movement targets reducing marketing of unhealthy food products to children and adolescents.17 One of its key arguments focuses on a societal responsibility to protect vulnerable age groups who may not be able to understand, or maturely interpret, the persuasive intent of advertising.18
Since 2003, the World Health Organization (WHO) has published increasingly strong statements about the need to control marketing to children.17 In May 2010, a World Health Assembly Resolution called for governments to take action. The resolution stated ‘settings where children gather should be free from all forms of marketing of foods high in saturated fats, trans-fatty acids, free sugars, or salt'.17 The International Obesity Task Force (IOTF) and the European Network on reducing marketing pressure put forth other strong recommendations.19, 20, 21 While more than 12 multinational food and beverage corporations pledged to reduce marketing to children in 2007, each company still sets its own standards – commonly weaker than the recommendations of health organizations. The IOTF has responded by proposing international standards defining ‘child', specifying media to include foods that should not be promoted, and who is accountable for monitoring the application of standards (the StanMark Project).22 Consumers International developed a manual for monitoring food marketing to children.23 The Political Declaration of the UN High-Level Meeting on the Prevention and Control of Non-communicable Diseases (September 2011) recommended action on marketing and advertising to children.24
At a country level, some interventions aim to limit the impact of marketing of food and beverages to children – with varying degrees of success. Since 2007 in the UK the OfCom initiative's efforts resulted in regulations restricting high fat, sugar, salt (HFSS) food and drink advertising on children's TV.25 OfCom (an independent regulator for UK communication industries) reported a 37 per cent reduction in children's exposure to HFSS advertising between 2005 and 2009, with younger children benefitting the most due to their propensity to watch children's channels with stricter criteria.26 Monitoring by OfCom does not continue. Beyond TV, there are few restrictions and the current political climate in the UK favours a voluntary approach, with regulation as a last resort. The National Heart Forum (UK) mapped current marketing to children, including a detailed analysis of gaps in UK regulations; it identified a rapidly changing media environment with sophisticated, integrated marketing techniques that exceed the reach of current regulations.25
Most Canadian provinces rely on self-regulation through the Broadcast Code for Advertising to Children, some station-specific policies, and an industry-initiated Children's Food and Beverage Advertising Initiative (CAI).27 The province of Quebec is an exception, where since 1980, the Québec Consumer Protection Act (QCPA)28 has prohibited all commercial advertising (not just foods and beverages) directed at children under 13 years of age. The Act withstood a Supreme Court challenge in 1989.28, 29 Although the total ban has the advantage of not requiring nutrition criteria to determine which foods/beverages are allowed to be promoted, the QCPA has some limitations. ‘Child-directed' means that children may still be exposed to advertising as long as the advertisement is not considered to ‘appeal' to children. The Act only protects children during peak viewing times (with children at least 15 per cent of the viewers). These times, defined in the early 1980s, have never been revised. Exposure of Québec's children extends to marketing strategies beyond traditional advertising, and to cross-border ‘leakage' of media from other markets, including the US. Enforcement relies on complaints. Only recently have ‘watchdog' groups such as Coalition Poids conducted ad-hoc surveillance; their complaints provoked investigations, prosecutions, and guilty pleas from several large food and beverage companies for their contravention of the QCPA.30 Québec children may, nonetheless, benefit from a less commercialized food environment.
Other Canadian jurisdictions interested in Québec's example are considering restricting advertising to children as a key policy opportunity to address upstream determinants of the obesity epidemic. In addition, there seems to be public and, potentially, political support.31 A Canada-wide survey of 2000 people in April 2010 showed that 79 per cent of respondents agreed that food marketing targeted to children contributes to overweight and obesity; 82 per cent agreed that marketing of unhealthy food to children should be restricted; and 64 per cent agreed that advertising targeted at kids should be banned in Canada.32 Recent surveys of decision makers in Alberta also show support for such policy, with 71 per cent of respondents from all levels of government, schools, and workplaces supporting prohibiting advertising and promotion of unhealthy food and beverages to those under the age of 16.33 As recently as June 2012, a Member of Parliament introduced a Private members' bill (C-430) in the House of Commons, has called for amendments to the Competition and Food and Drug Acts to protect children from advertising exploitation.34 Although this has not moved beyond first reading, the reintroduction of similar bills by other Members suggests political interest.
In 2006, the US Institute of Medicine (IOM) published a report titled Food Marketing to Children and Youth: Threat or Opportunity? This review of 123 studies concluded that marketing strongly influences children's preferences, requests, and consumption, and that food and drinks advertising on TV is associated with obesity of children (strong evidence) and youth (weaker evidence).18 A WHO literature review on the impact of food and beverage marketing on children found modest but consistent evidence that promotional marketing has a causal effect on nutrition knowledge, food preferences, consumption patterns, and adverse health outcomes.35
The IOM report also highlighted research explaining the vulnerability of children to marketing, in particular, that until 8 years of age children are unable to distinguish between programme content and the persuasive intent of advertising.36 Further, a multi-country survey revealed that the intent of advertising, to sell a product for profit, is not understood until early adolescence.37 The importance of protection is, therefore, clear. Emerging data suggest that children and youth may require protection from new media (Internet gaming and ads, text ads, social marketing, sponsorships and so on) to an older age. As cognitive defences continue to develop through the teen years, overt marketing intent may be less clear in these media, and exposure may be prolonged, as sponsored games may draw youth to Websites for extended periods.38 The IOM report proposed that if industry does not effectively self-regulate, legislation should follow, to restrict marketing to children and youth to counteract this strong influence.18
An international comparison study found Canada to have some of the highest rates of TV advertising of nutritionally poor foods and beverages in the world (3–7 ads/hour/channel).39 Research by one of us (MPK) examining the impact of the QCPA on children's exposure to advertisements showed less frequent targeting of French-speaking children in Quebec than English-speaking children in Quebec or Ontario.40 Quebec French TV advertisements for foods and beverages use significantly fewer spokes-characters, contests, and sponsorships, and a higher proportion of advertisements seen by Quebec French children are comparatively healthier than those seen by Ontario English children – indicating the usefulness of the Quebec Act.41
An examination of food expenditure data to assess the impact of the QCPA on fast food expenditures found a significantly reduced propensity to purchase fast food – by 13 per cent – a reduction in estimated fast food consumption that would translate to US$88 million/year.42 Incidentally (but not attributable solely to the ban), Quebec snack consumption rates (including soft drinks) are Canada's lowest, and its fruit and vegetable consumption rates among the highest.43
Outside of Quebec, self-regulation through the industry-sponsored Children's Food and Beverage Advertising Initiative (CAI) remains insufficient. Although eight corporations adhere to pledges not to advertise on children's specialty channels, and four companies did not advertise at all during children's programming, in general, CAI companies advertise significantly more foods higher in fats, sugar, sodium, energy and promote food with greater repetition, and use of media characters than in Quebec.44
In summary, evidence suggests that:
New and Emerging media: Marketers are making increasing use of new and emerging media – the Internet, adver-gaming, mobile messaging, and viral marketing. The ubiquity of marketing challenges monitoring, and the emergence of new media challenges development of legislative standards to adequately cover marketing modes not yet anticipated.
Cross border ‘leakage': Differences in legislative frameworks across jurisdictions, Quebec versus the rest of Canada, increase the likelihood of media ‘leakage' into jurisdictions with more stringent standards. Setting comparable standards throughout all Canadian jurisdictions can minimize this. Assessment of the quantity and content of media crossing the border from the US to Canada remains to be done.
Perceptions: ‘Freedom of choice versus supporting parents'. Critics of legislation argue that exclusive responsibility rests with parents to monitor children's media viewing and food and beverage intake, and that legislation limits consumers' freedom of choice.45 Of course, the intent of marketing is to influence consumer ‘choice' – often in ways inconsistent with public health goals.
Governments enact legislation to support parents in protecting children and youth in a variety of domains: restricting access to and marketing of alcohol and tobacco to minors, lowering speed limits around schools, and setting legal standards for food and packaging, car seats, cribs, movie and TV show classification, clothing, and toy safety. More effective regulation of marketing to children and youth is a legitimate extension to better support parents in their attempts to promote healthy diet and physical activity.
Standards and guidelines are highly contested: Effective regulation (including self-regulation) requires standards and can level the competitive playing field for industry. Debate continues about what evidence to use for shaping standards for all elements (for example, defining an ‘unhealthy food' and ‘child-directed' advertising). Intense lobbying by industry that calls evidence into question fuels the debate.46 Waiting for ‘perfect evidence' to legislate standards maintains the status quo. Indeed, many barriers to effective self-regulation, including a lack of uniformity of guidelines, permit industry to set and interpret the rules to suit its own interests, including lack of independent review to question this interpretation, limited industry participation, lack of public awareness of standards that limit the power of complaints-based regulatory systems, and lack of penalties and enforcement power.47
To support families and to protect children from the adverse health effects of exposure to commercial marketing of unhealthy foods and beverages, overall we recommend:
These recommendation are consistent with the second most comprehensive approach advocated in the WHO Marketing Framework of 2012.48 Modifying the Quebec model and expanding it through all Canadian jurisdictions would effectively eliminate cross-provincial/territorial media ‘leakage'. Although conference participants debated a full Quebec-style prohibition of all marketing (not restricted to foods and beverages), we failed to reach consensus on whether a broad approach should be a starting point for recommendations. This was forseeable given the context of the consensus discussion focused on childhood obesity, and not on the merits of commercial-free environments for children.
Define marketing: We recommend adoption of a broad definition of marketing that includes, but is not limited to, all media through which children are or can be targeted, such as ‘sponsorship, product placement, sales promotion, cross-promotions using celebrities, brand mascots, or characters popular with children, Websites, packaging, point-of-purchase displays, e-mails, and text messages, philanthropic activities tied to branding opportunities, and communication through ‘viral marketing'.17
Set clear criteria for products subject to the marketing prohibition: Criteria to enable restriction of ‘the promotion of the specific foods and beverages that are considered detrimental to children's diets'48 (p. 17) require a standardized and accepted nutrient-based profiling system (defining ‘unhealthy' versus healthy foods and beverages using clear criteria for high fat, free sugar, and salt). Our rationale for prohibiting all commercial marketing of foods and beverages, with exceptions for approved public health campaigns, acknowledges the urgency to take action in the absence of such a system in Canada.
Define ‘child-directed': As evidence is not yet clear with respect to the impact of marketing through new media and technologies on older children and youth, we recommend erring on the side of protection, prohibiting marketing to all children and youth who have not reached the age of legal majority (18 years). A major implication is the possibility of imposing restrictions in settings where children and youth spend significant proportions of their time (schools, recreation centres and so on).
Recommendations for standards specific to surveillance, monitoring, and enforcement of compliance:
Policies can create environments to make healthy choices easier, and provide greater support and expand incentives for children (and adults) to achieve healthy weights.49 Significant research has demonstrated the public health impact of obesity, and has created a case for action. Research has also identified contributing factors, suggesting points for intervention. Recent priority-setting exercises by organizations working to address the impact of obesity on chronic disease have defined a range of opportunities to act, and interventions have been evaluated. This consensus reflects a synthesis of available evidence, including that regarding political feasibility; to create recommendations for policies requires a process that follows a framework for prioritizing change.11 The recommendations included here comprise action towards the next best steps.
Our exploration of roadblocks for policy change encompassed in laws for healthy eating and activity in Canada concludes ‘jurisdictional wrangling, the threat of legal challenges, ideological opposition, and questions about effectiveness may stall adoption of legislation'. The authors argue that ‘a comprehensive approach must be built piece by piece, and it would be a mistake to allow skepticism about the impact of single legislative or policy interventions to preclude any action at all'.13 The need for a ‘comprehensive approach' became clear as we worked on recommendations. For example, while Quebec's QCPA is held as a model internationally, cross-border leakage and contested standards limit its comprehensiveness. Our recommendations take a step towards broader impact.
Jurisdictional responsibilities were also evident. While federal-provincial-municipal jurisdictions may blur when addressing marketing, clear opportunities exist at several levels of government to take independent action. In addition, opportunities for constructive intersectoral action to address obesity also exist.50 Obesity, healthy eating, and physical activity are not solely a concern of the health sector. While health impacts of obesity may be most acutely recognized by the health system, sources of and solutions to obesity lie in other sectors and policies: agriculture, transportation, education, and consumer protection. Private industry is implicated in both causes and solutions. We focused on ‘how to' address obesity in an integrated manner, with considerations to inter-ministerial/sectoral collaboration as recommended by the WHO.24 The experience of the province of Quebec in implementing a ‘whole of government' approach suggests the need to frame the problem of obesity as a societal problem, not just a health problem – thereby calling for health-promoting policies in other sectors.51 Engaging non-health sectors and ministries in identifying their roles in the problem helps to set more inclusive public agendas. The health sector may play a leading or coordinating role. Quebec's Public Health Act, for example, mandates health impact assessment (HIA) of legislation and policies. Legislated HIA, appropriately evaluated, would be highly supportive of moving recommendations forward. Although we direct many recommendations to governments, non-governmental organizations (NGOs) help by synthesizing evidence and funding pilot projects to assess effectiveness of interventions, with the implication that effective pilots could then be scaled up and funded by governments. NGOs, coalitions, voluntary organizations, and segments of the private sector, with all levels of government, are key to moving recommendations forward.
The authors wish to acknowledge Manuel Arango (Heart and Stroke Foundation), Susan Buhler (University of Alberta), Samantha Hartley-Folz (British Columbia Healthy Living Alliance), Bill Jeffery (Centre for Science in the Public Interest), Craig Larsen (Chronic Disease Prevention Alliance of Canada), Nazeem Muhajarine (University of Saskatchewan), Lisa Petermann (Canadian Partnership against Cancer), Shandy Reed (Alberta Policy Coalition for Chronic Disease Prevention), and Michele Simon (Legal Consultant) for their participation in the consensus conference. This work was funded by a Meeting, Planning, and Dissemination grant from the Canadian Institutes of Health Research.
Kim D. Raine, RD, PhD, is a Professor at the Centre for Health Promotion Studies in the School of Public Health, University of Alberta and holds an Applied Public Health Chair from Heart and Stroke Foundation and the Canadian Institutes of Health Research.
Tim Lobstein, PhD, is the Director of Policy for the International Association for the Study of Obesity (IASO).
Jane Landon, BA, FFPH, is the Deputy CEO (Policy) of the National Heart Forum (UK).
Monique Potvin Kent, PhD, is a Researcher in the Institute of Population Health, University of Ottawa.
Suzie Pellerin is the Director of the Coalition Québécoise sur la Problématique du Poids (Québec Coalition for Weight Related Problems).
Timothy Caulfield, LLM, is a Professor in the Faculty of Law and School of Public Health at the University of Alberta. He holds a Canada Research Chair in Health Law and Policy. He is a Health Senior Scholar at Alberta Innovates Health Solutions, and is a Research Director at Health Law and Science Policy Group.
Diane Finegood, PhD, is a Professor at the Department of Biomedical Physiology and Kinesiology in Simon Fraser University.
Lyne Mongeau, DtP, PhD, is a Professor in the Department of Social and Preventive Medicine at the University of Montréal.
Neil Neary, MPH-HP, is a PhD Student in the Centre for Health Promotion Studies at School of Public Health in the University of Alberta.
John C Spence, PhD, is a Professor and an Associate Dean (Research) at the Faculty of Physical Education and Recreation in the University of Alberta.