The growing epidemic of childhood overweight and obesity is a major public health concern. Currently 15% of US youth are overweight, a prevalence nearly twice as high in children and three times as high in adolescents compared to 1980 prevalence rates. [13] Almost two-thirds (60%) of overweight children have at least one cardiovascular risk factor (e.g., hypertension, hyperlipidemia) [14] and the prevalence of type 2 diabetes mellitus is increasing in youth. [15] These trends may seriously compromise the future health and productivity of the US population and add to health care costs.

While multiple factors influence eating behaviors and food choices of youth, one potent force is food advertising. [16] Today's youth live in a media-saturated environment. Over the past 10 years, US children and adolescents have increasingly been targeted with intensive and aggressive forms of food marketing and advertising practices through a range of channels. [17-22] Marketers are interested in children and adolescents as consumers because they spend billions of their own dollars annually, influence how billions more are spent through household food purchases, and are future adult consumers. [18,23] It is estimated that US adolescents spend $140 billion a year. Children under 12 years of age spend another $25 billion, but may influence another $200 billion of spending per year. [23,24]

Advertising expenditures for US food products were $7.3 billion in 1999. [27] In 1997, the US advertising expenditures for various foods were: breakfast cereals – $792 million; candy and gum – $765 million; soft drinks – $549 million; and snacks – $330 million. Total expenditure for confectionery and snacks was $1 billion. [26] In contrast, during the same year, the US Department of Agriculture spent $333 million on nutrition education, evaluation, and demonstrations. [26] Advertising budgets for specific brands of foods, beverages, and fast food restaurants are also revealing (Table ​(Table1).1). It is unclear how much money is spent on food advertising specifically directed at children and adolescents, but estimates are available for overall youth-oriented advertising in the US. It is estimated that over $1 billion is spent on media advertising to children, mostly on television. [28] In addition, over $4.5 billion is spent on youth-targeted promotions such as premiums, sampling, coupons, contests, and sweepstakes. About $2 billion is spent on youth-targeted public relations, such as broadcast and print publicity, event marketing, and school relations. In addition, roughly $3 billion is spent on packaging especially designed for children. [28]

The heavy marketing directed towards youth, especially young children, appears to be driven largely by the desire to develop and build brand awareness/recognition, brand preference and brand loyalty. Marketers believe that brand preference begins before purchase behavior does. [28] Brand preference in children appears to be related to two major factors: 1) children's positive experiences with a brand, and 2) parents liking that brand. [28] Thus, marketers are intensifying their efforts to develop brand relationships with young consumers, beginning when they are toddlers. [29] Marketers know that toddlers and preschool children have considerable purchase influence and can successfully negotiate purchases through what marketers term the "nag factor" or "pester power". [28] A child's first request for a product occurs at about 24 months of age and 75% of the time this request occurs in a supermarket. The most requested first in-store request is breakfast cereal (47%), followed by snacks and beverages (30%) and toys (21%). Requests are often for the brand name product. [28] Isler, et al, examined the location, types, and frequency of products that children ages 3-11 requested of their mothers over 30 days. Food accounted for over half (54%) of total requests made by children and included snack/dessert foods (24%), candy (17%), cereal (7%), fast foods (4%), and fruit and vegetables (3%). [30] Almost two-thirds (65%) of all cereal requests were for presweetened cereals. Preschool children made more requests than the older elementary school children. Parents honored children's requests for food about 50% of the time, soft drinks (60%), cookies (50%), and candy (45%). [28] These findings show that food advertisers spend large amounts of money targeting children, in an attempt to build brand loyalty and to persuade them to desire a particular food product, starting when they are toddlers.

A variety of study designs have been used to study the effects of food advertising on children's food behavior and food preferences but most are field experiments or survey research/ cross-sectional correlational studies. A strength of correlational studies is that external validity can be high given the broad range of potential influences that can be studied. A major weakness is that causality cannot be established. Longitudinal studies that prospectively link exposure to food advertising to children's food intake or behavior have not been done. There also have not been any meta-analyses review studies conducted in which effect-size estimates from multiple studies are combined. Further, the studies to date have focused almost exclusively on television food advertising. However, considering all the evidence to date, the weight of the scientific studies suggests that television food advertising is associated with more favorable attitudes, preferences and behaviors towards the advertised product. [37,66] The research evidence is strong showing that preschoolers and grade school children's food preferences and food purchase requests for high sugar and high fat foods are influenced by television exposure to food advertising. [30,37,66-68] Only a few studies have been done on food advertising and the effects on children's actual food intake. [69,70] Gorn and Goldberg [69] conducted a novel, well-designed experimental field study which randomly assigned children ages 5–8 years old attending a summer camp to one of four conditions to examine television exposure of snack food commercials to actual food consumption. Daily for two weeks, children watched 30 minutes of a television cartoon with about 5 minutes of advertising embedded. The four experimental conditions differed in the type of food advertising included with the cartoon: ads for candy and Kool-Aid; ads for fruit and fruit juice; control (no ads); and public service ad announcements for healthy foods. Each day after the television exposure, the children were given a selection of fruits, juices, candy, or Kool-Aid to choose to eat. Children in the candy/Kool-Aid commercials condition selected the most candy/Kool-Aid and the least fruit and juice. For example, those in the candy commercial condition selected significantly less fruit (25%) than those in the fruit commercial condition (45%).

In the US, there are currently few policies or standards for food advertising and marketing aimed at children. The advertising industry maintains self-regulatory policies established by the Children's Advertising Review Unit (CARU) of the National Council of Better Business Bureaus. [75] CARU's guidelines apply to all forms of children's advertising, but it has no legal authority over advertisers and can only seek voluntary compliance. CARU has a group of about 20 advisors and 35 supporters, many of whom are from the food industry, such as Burger King, Frito-Lay, McDonald's, General Mills, Nabisco and Hershey. The CARU voluntary guidelines list seven basic principles, which address areas such as product presentation and claims, endorsement and promotion by program characters, sales pressures, disclosures and disclaimers and safety concerns. [75] It is questionable how well an organization like CARU, comprised primarily of interested food marketers, can self-regulate the food advertising behavior of its members.

At a federal level, the Federal Communications Commission (FCC) and the Federal Trade Commission (FTC) share authority for regulating advertising, although each agency has a different emphasis. [31] The FCC has the responsibility of establishing public interest obligations for television broadcasters, while FTC's responsibility is to regulate advertising deemed unfair or deceptive. [31]

A wide range of food advertising techniques and channels are used to reach children and adolescents to foster brand awareness to encourage product sales. [18] Marketing channels include television advertising, in-school marketing, product placements, kids clubs, the Internet, toys and products with brand logos, and youth-targeted promotions. The strong similarities between the marketing and promotional activities used by food companies to advertise unhealthy foods to children and those used by the tobacco industry to market cigarettes to children are striking. [82] For example, at one time tobacco companies were providing schools with free sports programs, scoreboards, and book covers featuring school logos on the front and cigarette ads on the back. [82] Young children were targeted with the sale of candy and bubble gum in packages that resembled those of actual cigarette brands. [82] Ads for cigarette brands popular with youth were selectively placed in magazines with large youth readerships. Promotional materials (caps, sports bags, lighters with cigarette brand logos), sweepstakes, and premiums were commonly used. The "Marlboro Man," with his image of independence and autonomy, struck a responsive chord among adolescent males. Studies of the use of the cartoon character Joe Camel to promote Camel cigarettes showed that 30% of 3-year olds and over 80% of 6-year olds could make the association between Joe Camel and a pack of cigarettes. [83] In the three years after the introduction of the cartoon camel character, preference for Camel cigarettes increased from 0.5 to 32% among adolescent smokers. [84]

Collectively, the advertising techniques and promotional campaigns targeting youth were highly successful in encouraging underage smoking. [85,86] A time-series study concluded that adolescents are three times as responsive to cigarette brand advertising as adults. [87] Several cross-sectional and longitudinal studies have clearly and strongly shown that exposure and receptivity to tobacco advertising and promotional activities is related to adolescent tobacco use. [86,88-90] Similar studies need to be conducted with food advertising and relationships to consumption of high fat, high sugar foods, and obesity.

Numerous studies have shown that foods heavily marketed to preschool and grade school children are predominantly high in sugar and fat, [36,40,41] which is the antithesis of healthful eating recommendations for children. Experimental studies have consistently shown that children exposed to food advertising prefer and choose advertised food products more frequently than those not exposed to such ads. [37] Purchase request studies with children under age 11 have also found strong associations between number of hours of television watched by children and number of children's requests to parents for those foods, as well as availability of those food items in the home. [37] Of concern is that African American and Hispanic children watch more television compared to white children. [33,34] Thus, they are exposed to more food ads. African American and Hispanic children also have a higher prevalence of obesity than white children. [13] Several studies have documented associations between the number of hours of television watched and the prevalence of obesity among children. [37] Research is needed to examine possible relationships between exposure to food advertising, eating behaviors and obesity.

Because marketing to children and adolescents has become so pervasive, many child advocates and media experts believe that such marketing constitutes an escalating public health problem. [73] Children, especially young children, are more susceptible to the effects of marketing than adults. Numerous studies have documented that children under 8 years of age are developmentally unable to understand the intent of advertisements and accept advertising claims as factual. [22] The intense marketing of high fat, high sugar foods to young children can be viewed as exploitation because they do not understand that commercials are designed to sell products and do not have the ability to comprehend or evaluate advertising. The purpose of advertising is to persuade, and young children have few defenses against such advertising. Older children and teens can be manipulated by the strong emotive messages in advertisements. [24] It can be argued that children, especially young children, are a vulnerable group that should be protected from commercial influences that may adversely impact their health, and that as a society that values children, there should be greater social responsibility for their present and future health. Social and environmental structures can actively support and promote healthy food choices for children. [81] Table ​Table77 provides examples of potential environmental strategies and policy recommendations for food advertising and marketing aimed at children and adolescents. There is a need for national discussion and dialogue on these issues.