Trends in Children’s Exposure to Food and Beverage Advertising on Television

Key Points Question How has children’s exposure to food-related advertising on television, including for products high in nutrients to limit, changed following changes to the voluntary industry self-regulatory Children’s Food and Beverage Advertising Initiative? Findings This repeated cross-sectional study found that, from 2013 to 2022, advertisements seen declined by 77.6% for children aged 2 to 5 years and by 78.5% for those aged 6 to 11 years, but both age groups continued to see more than 1000 advertisements per year, and the majority of food and beverage products seen were unhealthy. Meaning These findings show that children’s exposure to food-related advertisements on television remains high, suggesting the need for government regulations based on time of day.


Introduction
Reducing children's exposure to advertisements that promote unhealthy foods and beverages is a key global strategy to improve children's diets and reduce childhood obesity.Accordingly, the World Health Organization (WHO) has called for government-mandated policies to restrict marketing of unhealthy food to children. 1 However, few countries have enacted such policies, and industry has responded to public health concerns by introducing self-regulatory initiatives focused primarily on television advertising directed to children younger than 12 or 13 years. 2,3Furthermore, worldwide reviews have found limited improvements in children's exposure to advertising of nutritionally poor products associated with food industry self-regulation. 4,5e US voluntary industry self-regulatory Children's Food and Beverage Advertising Initiative (CFBAI) was introduced in 2006.Companies pledged to advertise only better-for-you products (using individual company-defined nutrition criteria) in child-directed programming. 6Yet following implementation, in 2009, children aged 2 to 11 years continued to view more than 4000 foodrelated advertisements per year. 7,8Moreover, nearly all (84%) food and beverage (FB) products in television advertisements viewed by children promoted products high in saturated fat, trans fat, total sugars, and/or sodium, including 98% of CFBAI-company advertisements viewed on children's programming. 910] In 2014, the CFBAI introduced uniform nutrition criteria with limits on calories, saturated fat, sodium and total sugars that varied by product category, with further revisions in 2020. 11It also updated its definition of child-directed programming to child-audience share of 30% or higher. 12[15] In addition, although previous evaluations have demonstrated reductions in children's exposure to food-related television advertising since 2009, these reductions were largely attributed to declines in the amount of time that children spend watching traditional television (ie, commercial broadcast and cable channels). 10,14,16,17For example, from 2013 to 2016, the number of food-related TV advertisements viewed by children aged 2 to 5 and 6 to 11 years declined by 13% for both age groups, whereas TV viewing declined by 15% for preschoolers aged 2 to 5 years and by 20% for children aged 6 to 11 years over this time period. 10aluations have also identified limitations in CFBAI protections for more vulnerable children.
Although most CFBAI companies promise not to advertise to children younger than 6 years, young children (aged 2-5 years) viewed only 5% to 7% fewer total food-related TV advertisements compared with somewhat older children (aged 6-11 years) in 2016, including on children's television channels. 109][20][21] In addition, evidence shows that Black children see disproportionately more food advertisements, even after taking into consideration differences in amount of time spent watching television. 19For example, Black children (aged 2-5 and 6-11 years) viewed at least 80% more food-related TV advertisements than White children in 2017, which was higher than differences in time spent watching TV (46% more and 72% more, respectively). 19ven changes in CFBAI program requirements, changes in television viewing patterns and ongoing racial differences in children's exposure to advertising, it is important to continue to evaluate trends and the status of US children's exposure to food-related television advertising.This study uses television ratings data to provide a comprehensive examination of exposure to food-related television advertising among children (aged 2-5 and 6-11 years) from 2013 to 2022.

JAMA Network Open | Health Policy
Trends in Children's Exposure to Food and Beverage Advertising on Television

Data
This repeated cross-sectional study followed the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guideline. 22This study did not require institutional review board approval or informed consent because no individual participant data were used, in accordance with 45 CFR §46.Changes in exposure to food-related television advertisements following the introduction (2014) and revision (2020) of CFBAI category-specific uniform nutrition standards were assessed using television ratings data for 2013, 2014, 2015, 2018, and 2022 licensed from The Nielsen Company.Nielsen data are based on a national sample of television-equipped households in the US (average of 41 000 households).Sampling frames for housing units are obtained from Census data and used to select housing units from which households are sampled.
Household-level and person-level data are weighted by Nielsen to ensure a match between the sample and known population totals using iterative proportional fitting (ie, to provide projections for all US television households).Self-reported race is collected from sampled households as part of periodic personal interviews conducted by Nielsen.
The Nielsen Company provided television program ratings data aggregated across households for advertisements shown for each product on each program and channel.Separate ratings data were obtained for children aged 2 to 5 and 6 to 11 years, including by race.The television ratings measure the percentage of children (among households with televisions) who saw a program or advertisement.The ratings data in this study covered exposure from broadcast network, cable network, and syndicated television advertising, as well as spot television advertising shown only to local broadcast markets, from all programming (regardless of audience composition) and from children's programming (defined as programming with Ն35% child-audience [aged 2-11 years] share), excluding Spanish-language programming.Spot television advertising was not available by race.Sensitivity analyses assessed exposure from programming with different child-audience shares (30%, 25%, and 20%).

Food Categories and Nutritional Content Classification
Food-related products were categorized into 7 categories: beverages, cereal, snacks, sweets, other foods (eg, fruits, vegetables, meats, pasta, condiments, and so forth), fast-food restaurants (ie, Nielsen's quick-service restaurant classification), and full-service restaurants (non-quick-service restaurants).Nutritional content was assessed for the 5 FB (ie, nonrestaurant) product categories.
Information on energy and nutritional content (grams of saturated fat, trans fat, and total sugars, and milligrams of sodium) for advertised FB products was determined from the following sources: manufacturer's website, product nutrition facts panels from food labels on grocery store websites or in person, US Department of Agriculture (USDA) Food Data Central (formerly known as the USDA Nutrient Database), or the Minnesota Nutrient Data System.Across years, we were unable to obtain nutritional information on less than 9% of the FB advertising seen by children because they were either a nonspecific FB product (eg, Dairy Association or general food company) or nutritional content was not available from our aforementioned sources.
The nutritional content of each FB product was assessed according to nutrition guidelines developed by the Federal Trade Commission, Centers for Disease Control and Prevention, Food and Drug Administration, and USDA to identify FBs that should not be marketed to children (Interagency Working Group [IWG] guidelines). 23Advertised FB products were categorized as either an individual or a main dish and/or meal item and were assessed for nutrients to limit (NTL) based on IWG principle B for recommended limits on saturated fat, trans fat, total sugars, and sodium.Measures were generated to indicate whether each FB product was high in each and any recommended NTL.
Individual items were classified as high in saturated fat if the item contained more than 1 g per reference amount customarily consumed (RACC) or more than 15% of total calories came from saturated fats.Meals and/or main dishes were considered high in saturated fat if they contained more Milk, whole eggs, and nuts were exempted from the saturated fat guidelines.All products were limited to less than 0.5 g of trans fat per RACC for individual items or labeled serving size for meals and/or main dishes.The IWG recommended that added sugars be limited to 13 g per RACC for individual items or labeled serving size for meals and/or main dishes.However, because nutrition facts panels did not list added sugars before 2020, plain or flavored milk products and yogurt were allowed an additional 12.5 g and 16 g of sugar, for a total of 25.5 g and 29 g of total sugars, respectively, to account for naturally occurring sugars in these products.In addition, fruits and 100% fruit and/or vegetable juices were exempt from the total sugars limit.Finally, a food item was considered high in sodium if it contained more than 210 mg per RACC for individual items or 450 mg per labeled serving size for meals and/or main dishes.For foods with a small RACC (Յ30 g per the Federal Register 24-27 ), recommendations refer to the amount per 50 g of food.RACCs for the general food supply were used for all products except baby or toddler products, which used RACCs for infants and children aged 1 to 3 years.

Statistical Analysis
Analyses Assessing the nutritional content of products, Table 2 shows a decrease in the proportion of FB products that were high in NTL, with greater declines for advertisements on children's programming and for CFBAI member companies.In 2013, more than 90% of CFBAI-member products in advertisements seen on children's programming were high in NTL, compared with 51.0% (for children aged 6-11 years) and 51.5% (for children aged 2-5 years) in 2022.However, the majority of FB    YouTube videos is now popular with young children younger than 9 years, 20,30,31 and two-thirds of popular child-influencer videos feature at least 1 food-related appearance within the video content. 32reover, recent international studies 33,34 indicate that children are frequently exposed to food marketing in digital media and social media platforms (estimates of 1560-2461 messages per year).
2][33][34] It will be important for future US-based work to examine children's exposure to food-related marketing, including product nutritional content, across a variety of digital media platforms.

Limitations
This study is subject to several limitations.First, because data obtained from The Nielsen Company were aggregated across their sample providing projections for US television households, we were unable to account for sampling variability and formally test statistical significance of observed changes.Second, we did not assess nutritional content for restaurant advertisements because these often did not highlight menu offerings with enough specificity to assess their nutritional content.
Third, we did not examine additional ingredients of concern not captured in the IWG guidelines or CFBAI self-regulations including nonnutritive sweeteners (NNSs) and food dyes.Since the IWG guidelines were published, the American Academy of Pediatrics has recommended additional research on consumption of NNSs by children. 35For example, 52% of yogurts on the CFBAI list of products that may be advertised to children included NNSs. 13Additionally, some states are now seeking to limit food dyes in FB products because of their potential harm. 36,37Future work should monitor the extent of children's exposure to advertising of products that include NNSs and dyes.
Trends in Children's Exposure to Food and Beverage Advertising on Television nonparticipating companies.As a result, in 2022 CFBAI companies were responsible for just 29% of advertisements viewed on children's programming by 2-to 5-year-olds and 53% of advertisements viewed by 6-to 11-year-old children, compared with 73% for 2-to 5-year-olds and 74% for 6-to 11-year-olds in 2013.
included changes in children's (aged 2-5 and 6-11 years including by race for White and Black children) annual exposure to food-related television advertisements on all and child-directed programming and by CFBAI-company membership and food, beverage and restaurant category.Analyses also examined changes in the proportion of FB product advertisements seen for products that exceeded recommended guidelines for NTL following implementation of CFBAI revised nutrition criteria.Analyses were conducted in Stata/MP statistical software version 18.0 (StataCorp) from July 2023 to January 2024.ResultsTable1shows that between 2013 and 2022, children's total exposure to food-related advertisements on all television programming decreased by 77.6%, from 4611 to 1035 advertisements per year, among 2-to 5-year-olds and by 78.5%, from 4860 to 1046 advertisements per year, among 6-to 11-year-olds.Exposure to cereal advertisements decreased the most (by 87.4% for children aged 2-5 years and by 86.8% for children aged 6-11 years), whereas exposure to fast-food restaurant advertisements decreased the least (by 63.7% for children aged 2-5 years and by 65.7% for children aged 6-11 years).Fast-food advertisements also made up the largest category (36% for children aged 2-5 years and 38% for children aged 6-11 years) of food-related advertisements seen by children in 2022.Additionally, among FB categories, sweets represented a substantial portion of exposure (24% of nonrestaurant advertisements), whereas exposure decreased the least for beverage products (by 73.5% for children aged 2-5 years and 74.5% for children aged 6-11 years).Furthermore, of beverage advertisements seen on all programming in 2022, 54.3% seen by 2-to 5-year-olds and 54.6% seen by 6-to 11-year-olds promoted sugar-sweetened beverages (data not shown).remainedlow,even on programming with greater than or equal to 20% child audience-share (21% of advertisements for children aged 2-5 years and 18% of advertisements for children aged 6-11 years).Hence, regardless of the definition for children's programming, by 2022, 80% to 90% of exposure came from non-children's programming.In addition, exposure to advertisements from CFBAI member companies on children's programming declined at a higher rate compared withJAMA Network Open | Health Policy

Table 1 .
Children's Exposure to Food-Related Advertisements by Age, CFBAI Membership, Product Category, and Programming Audience, 2013-2022 a advertisements seen in 2022 on all programming and children's programming was still for products high in NTL: 68.9% for all programming and 63.9% for children's programming of products for 2-to 5-year-olds, and 68.4% for all programming and 60.6% for children's programming for 6to 11-year-olds.eTable 2 in Supplement 1 shows the greatest reductions for products high in total sugars, particularly on children's programming, where the proportion of advertisements seen for high-in-sugar products decreased from 79.5% to 38.8% for 2-to 5-year-olds and from 82.4% to Abbreviations: CFBAI, Children's Food and Beverage Advertising Initiative; NA, not applicable.aData are licensed from The Nielsen Company.Totals may not exactly equal subtotals as a result of rounding.product more in 2022).However, the proportion of products high in NTL was similar for advertisements seen by Black and White children in all programming and children's programming (eTable 3 in Supplement 1).There were also racial differences in time spent watching television (25% more for children aged 2-5 years and 62% more for children aged 6-11 years for Black vs White children; television viewing data from The Nielsen Company not shown in tables).

Table 2 .
Percentage of Food and Beverage Products in Television Advertisements Seen by Children High in Nutrients to Limit, by Age, Product Category, CFBAI Membership, and Programming Audience, 2013-2022 a Abbreviation: CFBAI, Children's Food and Beverage Advertising Initiative.aData are licensed from The Nielsen Company.It could not be determined whether certain food and beverage products were high in nutrients to limit; this affected less than 9% of food and beverage advertising seen by children aged 2 to 5 and 6 to 11 years across years.Those products are not included in the denominator of the percentages in this table.Restaurant advertising was not assessed for nutritional content and is not reflected in this table.

Table 3 .
Children's Exposure to Food-Related Advertisements by Race, Age, CFBAI Membership, Product Category, and Programming Audience, 2013-2022 a Trends in Children's Exposure to Food and Beverage Advertising on Television JAMA Network Open.2024;7(8):e2429671.doi:10.1001/jamanetworkopen.2024.29671(Reprinted) August 22, 2024 8/12 Downloaded from jamanetwork.comby guest on 08/30/2024 unhealthy food advertising to children would help to address diet-related health disparities due to disproportionate exposure to unhealthy food advertising among children in minoritized racial or ethnic communities. 1,29Also importantly, the overall reduction in exposure to food-related television advertisements was likely related to substantial reductions in children's television viewing, which have been accompanied by increases in other screen use.From 2013 to 2020, the average time that young children (aged 0-8 years) spent watching traditional television declined by more than 50%, while their total screen media use increased by 25%. 20Among somewhat older children (aged 8-12 years), total screen usage increased by 21% from 2015 to 2021, but watching on a television set increased by 11% (including streaming services) from 2019 to 2021. 21Accordingly, children's exposure to foodrelated marketing is prevalent in other media, including on digital devices.For example, viewing

Table 3 .
Children's Exposure to Food-Related Advertisements by Race, Age, CFBAI Membership, Product Category, and Programming Audience, 2013-2022 a (continued) Abbreviation: CFBAI, Children's Food and Beverage Advertising Initiative. a Data are licensed from The Nielsen Company.Totals may not exactly equal subtotals as a result of rounding.