Progress achieved in restricting the marketing of high-fat, sugary and salty food and beverage products to children

Abstract In May 2010, 192 Member States endorsed Resolution WHA63.14 to restrict the marketing of food and non-alcoholic beverage products high in saturated fats, trans fatty acids, free sugars and/or salt to children and adolescents globally. We examined the actions taken between 2010 and early 2016 – by civil society groups, the World Health Organization (WHO) and its regional offices, other United Nations (UN) organizations, philanthropic institutions and transnational industries – to help decrease the prevalence of obesity and diet-related noncommunicable diseases among young people. By providing relevant technical and policy guidance and tools to Member States, WHO and other UN organizations have helped protect young people from the marketing of branded food and beverage products that are high in fat, sugar and/or salt. The progress achieved by the other actors we investigated appears variable and generally less robust. We suggest that the progress being made towards the full implementation of Resolution WHA63.14 would be accelerated by further restrictions on the marketing of unhealthy food and beverage products and by investing in the promotion of nutrient-dense products. This should help young people meet government-recommended dietary targets. Any effective strategies and actions should align with the goal of WHO to reduce premature mortality from noncommunicable diseases by 25% by 2025 and the aim of the UN to ensure healthy lives for all by 2030.


Introduction
In May 2010, the 192 Member States of the World Health Organization endorsed Resolution WHA63.14. The aim of this resolution is to restrict the marketing of unhealthy food and non-alcoholic beverage products to children and adolescents to reduce the prevalences of overweight, obesity and diet-related noncommunicable diseases. 1 Globally, about 42 million children younger than 5 years and 155-200 million school-aged children are overweight or obese. 2,3 Nearly 2.7 billion adults will be overweight or obese by 2025. 4 The rapid increase in the prevalence of overweight and obesity among children in low-and middle-income countries has been described as a time bomb that could cause immense damage to health-care systems worldwide. 5 We examined the actions taken, between 2010 and early 2016, by the World Health Organization (WHO) -via its headquarters and six regional offices -and other United Nations (UN) organizations to offer technical and policy guidance to Member States to implement Resolution WHA63.14. We subsequently assessed the extent of the same resolution's implementation by the national governments of Member States and investigated the supportive actions of relevant civil society organizations, philanthropic institutions and transnational industrial actors -e.g. food and beverage manufacturers, retailers, restaurant companies and industrial trade groups. We focused on actions designed to restrict young people's exposure to the powerful and pervasive marketing of branded unhealthy food and non-alcoholic beverage products -i.e. products that are high in saturated fats, trans fatty acids, free sugars and/or salt. Below, we present the results of these investigations and suggest strategies and actions to accelerate the implementation of Resolution WHA63.14.

Marketing, diet and health risks
A robust evidence base accumulated between 2003 and 2013 demonstrated how the extensive and persistent exposure to the powerful marketing of unhealthy food and beverage products could affect the food and drink preferences and purchase requests of children and adolescents. [6][7][8][9][10] Rigorous reviews have documented how the often sophisticated and integrated marketing communications of transnational food and drink industries continue to influence the dietary behaviours of young people and contribute to energy-dense and nutrient-poor diets, increased risks of unhealthy weight gain and negative health outcomes. [7][8][9][10] As they have a biological preference for sweet and salty tastes, infants and young children younger than 5 years are considered especially vulnerable to marketing practices that promote sugary and salty food and beverage products. 11 Children's recognition of branded food logos increases with age 12 and overweight children are more likely to recognize the brands of fast food restaurants than those of other food and beverage products. 13 Compared with other children, those who recall branded unhealthy food and beverage products have stronger preferences for such products. 14 Children's knowledge of unhealthy food and beverage products increases their obesity risk. 15 Adolescents aged 12-18 years have more discretionary income than children and are uniquely susceptible to an immersive and evolving digital marketing landscape that normalizes unhealthy food and beverage products. 16 Such Abstract In May 2010, 192 Member States endorsed Resolution WHA63.14 to restrict the marketing of food and non-alcoholic beverage products high in saturated fats, trans fatty acids, free sugars and/or salt to children and adolescents globally. We examined the actions taken between 2010 and early 2016 -by civil society groups, the World Health Organization (WHO) and its regional offices, other United Nations (UN) organizations, philanthropic institutions and transnational industries -to help decrease the prevalence of obesity and diet-related noncommunicable diseases among young people. By providing relevant technical and policy guidance and tools to Member States, WHO and other UN organizations have helped protect young people from the marketing of branded food and beverage products that are high in fat, sugar and/or salt. The progress achieved by the other actors we investigated appears variable and generally less robust. We suggest that the progress being made towards the full implementation of Resolution WHA63.14 would be accelerated by further restrictions on the marketing of unhealthy food and beverage products and by investing in the promotion of nutrient-dense products. This should help young people meet government-recommended dietary targets. Any effective strategies and actions should align with the goal of WHO to reduce premature mortality from noncommunicable diseases by 25% by 2025 and the aim of the UN to ensure healthy lives for all by 2030.

Policy & practice
Restricting the marketing of unhealthy foods and beverages Vivica I Kraak et al.
marketing is also associated with materialistic values and aspirational lifestyles that often have harmful impacts among young people. 17

Technical and policy guidance
Following the adoption of Resolution WHA63.14, 1 WHO released 12 recommendations 18 that encouraged national governments to: (i) implement policies to restrict the marketing of unhealthy food and beverage products in settings where children spend time; (ii) reduce the impact of the cross-border marketing of such products; and (iii) monitor the nature and extent of the marketing of such products and the effectiveness of government regulations to restrict young peoples' exposure to -and the harmful impacts of -such marketing. We summarize below the evidence of the leadership provided, between 2010 and early 2016, by WHO's headquarters and regional offices and other UN agenciesvia the provision of technical and policy guidance and tools to assist Member States in the protection of young people from the marketing of unhealthy food and beverage products (Fig. 1).
In 2011, the Pan American Health Organization (PAHO) adapted WHO's 12 recommendations for use in 47 countries. 19 In 2012, WHO developed a comprehensive framework that offered Member States the technical support they might need to restrict and monitor marketing practices that promoted unhealthy branded food and beverage products across media platforms, various settings and country borders. 20 In 2013, however, WHO's Regional Office for Europe released data, from monitoring activities in 53 countries, that demonstrated many weaknesses in the framework -e.g. an overreliance on voluntary pledges, the exploitation of loopholes by food, beverage and restaurant industries and insufficient government regulation and enforcement. 21 In 2012, inspired by the protect, respect and remedy accountability framework previously developed by the UN, the United Nations Children's Fund (UNICEF), the UN Global Compact and Save the Children jointly released model business practices to protect children's rights. 22 These practices were reinforced   Restricting the marketing of unhealthy foods and beverages Vivica I Kraak et al.
in 2015 by the UN Global Compact's release of the Business for the rule of law framework. 23 In 2013, WHO released the Global action plan for the prevention and control of noncommunicable diseases, 2013-2020. This plan included an indicator to monitor the restriction of the marketing of unhealthy food and beverage products to individuals aged 0-18 years, to help reduce premature mortality from noncommunicable diseases by 25% by 2025. 24 WHO asked policy-makers and decision-makers within national governments to mobilize the political will, allocate the financial resources and create the transparent accountability mechanisms needed to ensure national legislation to monitor this marketing indicator. 24,25 In 2014, WHO's Regional Office for the Western Pacific outlined strategies that national governments could use to regulate practices that encouraged the marketing of unhealthy food and beverage products and counteract the attempts of some food industries to undermine the development of supportive policies. 26 Over 2200 people, including representatives of 170 Member States, attended the Second International Conference on Nutrition in November 2014. The attendees endorsed the Rome Declaration on Nutrition that called for "improvements in diet and nutrition and requiring a relevant legislative framework … while avoiding inappropriate marketing and publicity of foods and non-alcoholic beverages to children, as recommended by Resolution WHA63.14". 27 The conference's Framework for action urged national governments to implement coherent policies and coordinated actions across sectors to "regulate the marketing of food and non-alcoholic beverages to children according to the WHO's 2010 recommendations. " 28 In 2015, WHO's Regional Office for Europe released a food-and nutrientbased profiling model to help governments reduce the marketing of unhealthy food and beverage products to young people. 29 This model is currently being adapted for use by the Regional Offices for the Eastern Mediterranean and Western Pacific (Chizuru Nishida, WHO, personal communication, 2015). In 2016, PAHO released a nutrientprofile model developed for several purposes, including the reduction of the marketing of unhealthy food and beverage products to young people. 30 In 2016, WHO's Report of the commission on ending childhood obesity 31 recognized that the "settings where children and adolescents gather and the screen-based offerings they watch, should be free of marketing of unhealthy foods and sugar-sweetened beverages". The report also noted, with concern, that Member States had failed to give significant attention to Resolution WHA63.14 and requested that they address this issue. The Commission urged Member States to: (i) implement the recommendations to restrict young people's exposure to -and the power of -the marketing of unhealthy food and beverage products; (ii) cooperate to reduce the impact of the cross-border marketing of such products; and (iii) develop nutrient-profiling systems to identify and regulate such products. 31

National governments
Since 2010, many national governments have favoured self-regulation by industry to restrict the marketing of unhealthy food and beverage products. [32][33][34] A survey of 59 countries in 2011 showed that, although national governments had developed or implemented some relevant statutory measures, the nature and extent of the marketing restrictions differed across countries and regions. 35 No Member State has implemented comprehensive legislation or enforced mandatory regulations to prohibit the marketing of fatty, salty and/or sugary branded food and non-alcoholic beverage products to young people.

Transnational industrial actors
In 2012, the International Chamber of Commerce released a Framework for responsible food and beverage marketing communications that reflected principles of a broader International Code on Advertising. These principles, which are supported by the World Federation of Advertising and other International Chamber of Commerce members, were designed to promote ethical and legal standards for voluntary self-regulation of business marketing practices (Fig. 2). 36 Many of the largest food and beverage manufacturers worldwide have pledged to restrict the advertising -but not all forms of the marketing -of branded food and beverage products with high levels of fat, sugar and/or salt to children younger than 12 years. In 2014, 11 companies within the International Food and Beverage Alliance reported that they had stronger voluntary pledges than in 2011, 37 continued to support third-party compliance monitoring -by Accenture (Dublin, Ireland) -and promised that, by 2016, they would only advertise products to children younger than 12 years that met common nutrition criteria based on scientific dietary guidelines. 37 In 2014, the members of the Consumer Goods Forum -a consortium of over 400 food manufacturers and retailers across 70 countries -pledged that, by 2018, they would stop advertising, to children younger than 12 years, food and beverage products that do not meet science-based nutrition criteria (Fig. 2). 38 The Access to Nutrition Foundation -a private health-related philanthropic institution -released its first Access to nutrition index, a global monitoring report, in 2013. 39 This report rated 22 transnational food and beverage manufacturers across nine indicators, one of which was responsible food and beverage marketing practices. A score of 10 represented the highest level of coordinated actions to support responsible marketing to children and adults. Among the companies within the International Food and Beverage Alliance, the scores for responsible marketing fell from 5.2 for Danone, to 4.8 for Unilever, 4.6 for PepsiCo, 4.4 for Kraft Foods, 4.1 for The Coca-Cola Co., 4.0 for Nestlé and 2.7 for Kellogg. In the corresponding report for 2016, many companies' marketing scores were higher than their 2013 values, with Danone (8.5), Unilever (7.7) and Nestlé (7.4) leading the marketing index. 40 Compared with the 2013 report, the 2016 report indicated no measurable improvement in the prioritization and implementation of a global policy for the responsible marketing of healthy food and beverage products. Both the 2013 and 2016 reports of the Access to Nutrition Foundation recommended that transnational food and beverage firms increase their transparency and accountability to enable independent monitoring bodies to assess their progress and develop corrective actions.
No company has yet restricted the marketing of unhealthy food and beverage products comprehensively -i.e. in all settings, for all practices and across all media platforms -either to children

Policy & practice
Restricting the marketing of unhealthy foods and beverages Vivica I Kraak et al.
younger than 12 years or to adolescents aged 12-18 years. Moreover, food retailers, entertainment companies and many firms that operate fast food restaurants in chain franchises have failed to adopt any global commitments similar to the pledges made by the Consumer Goods Forum, the International Food and Beverage Alliance or the International Chamber of Commerce.
Some transnational companies use private-sector alliances to persuade legislators and the public to oppose healthrelated restrictions on food and drink marketing. These attempts have fuelled government inaction and weakened civil society's response to the implementation of Resolution WHA63.14. 41 However, industry actors are partnering with some UN agencies, including UNICEF and the World Food Programme, to address the problems of hunger and undernutrition in countries with rising prevalences of obesity and diet-related noncommunicable diseases. 41 These partnerships must be carefully vetted to prevent, manage and mitigate any potential conflicts of interest and avoid the risks and consequences associated with the promotion of unhealthy food and beverage products while addressing undernutrition.

Civil society and philanthropic organizations
The focus of civil society efforts has been to monitor the policies and actions of transnational industrial actors and national governments (Fig. 2). In 2011, Consumers International released a guide to encourage civil society organizations to monitor the marketing of unhealthy food and beverage products that targeted children and adolescents. 42 Between 2010 and 2015, comprehensive monitoring and evaluation reports published by academics and civil society organizations 32,[43][44][45][46] showed several inconsistencies among the voluntary pledges used by various transnational industrial actors across geographical areas. These reports emphasized the inherent weaknesses of industry-funded self-regulatory programmes, and decision-makers who lack the authority and resources to hold underperforming or non-compliant businesses accountable for marketing practices that contribute to obesity and diet-related noncommunicable diseases. The Rudd Center's   Restricting the marketing of unhealthy foods and beverages Vivica I Kraak et al. 46 revealed that none of the 24 companies investigated had extended pledges to cover all food and/or beverage marketing practices that targeted adolescents aged 14-18 years.

monitoring of the voluntary pledges of transnational industrial actors across 17 countries and four global areas
In 2013, the World Cancer Research Fund International established the NOURISHING framework to monitor the progress of national governments to implement restrictions on the marketing of unhealthy food and beverage products. 34 The International Network for Food and Obesity/Non-communicable Diseases Research, Monitoring and Action Support (INFORMAS) was established to monitor the progress of national governments and diverse industrial sectors in improving the healthiness of food -including the restriction of marketing of unhealthy food and beverage products to children and adolescents. 45,47 In 2014, Consumers International and the World Obesity Federation outlined guiding principles, general obligations and 14 specific articles for a model Framework Convention to Protect and Promote Healthy Diets 48 and advocated for WHO to work with Member States to enact mandatory actions and strong accountability structures to address unhealthy diets. Table 1 summarizes our recommendations for policy development, implementation, monitoring and evaluation by diverse stakeholders. If followed, these recommendations should help in the full implementation of Resolution WHA63.14, the reduction of the prema-ture mortality from noncommunicable diseases by 25% by 2025 25 and the sustainable development goal to achieve healthy lives for all by 2030. 49

Civil society and philanthropic organizations
Health-related civil society and philanthropic organizations can support national governments in establishing and strengthening regulatory bodies that are empowered to define and restrict the marketing of unhealthy foods and beverages targeted at children and adolescents -and to hold private-sector businesses to account for such marketing. Smaller civil society organizations will need support to develop the effective advocacy and social momentum they will need to build an enabling environment -i.e. one in which national governments and UN agencies may fulfil their commitment to enact and Table 1. Priority strategies and actions for accelerating progress towards full implementation of Resolution WHA63.14 by 2025

Health-related civil society and philanthropic organizations
Provide advocacy and socialmovement building skills to create an enabling environment for national governments and UN agencies to uphold strong legislation to support this issue. Offer clear guidelines for voluntary engagement and disengagement with transnational industrial actors through alliances and partnerships.
Use media advocacy to raise public awareness about the global costs of an unhealthy diet, to strengthen public support for restrictions on HFSSFBP and establish strong accountability systems that include financial penalties for non-compliant companies and industry sectors that do not protect young people from the marketing of HFSSFBP.
Conduct and publish independent monitoring and evaluations of progress achieved by Member States and transnational industrial actors to restrict the marketing of HFSSFBP.

National governments of Member States
Set clear goals and targets to restrict young people's exposure to branded HFSSFBP.
Enact legislation and regulation in accordance with Resolution WHA63.14 and the 2016 ECHO report and establish performance targets that use a standardized, governmentdefined, nutrient-profiling model across national borders and continents, accompanied by a timeline for expected outcomes. We also need such organizations to: (i) use media-based advocacy to raise public awareness about the global costs of an unhealthy diet, 50 to strengthen public support for restrictions on the marketing of unhealthy food and beverage products; (ii) conduct relevant monitoring and research; and (iii) advocate for strong accountability systems that include financial penalties for noncompliant companies and industrial sectors that fail to protect young people from the marketing of unhealthy food and beverages. 51

National governments
Decision-makers in national government should set clear goals to restrict young people's exposure to unhealthy branded food and beverage products, enact legislation and regulation in accordance with Resolution WHA63.14 and establish performance targets -using a government-defined, standardized nutrient-profiling system that applies across national borders and geographical areas and is accompanied by a defined timeline for expected outcomes. The decision-makers also need to allocate funding to: (i) establish or strengthen voluntary industrial selfregulatory programmes; (ii) support the monitoring of food and beverage marketing expenditures and practices; and (iii) enable regulatory bodies to hold non-compliant companies accountable for young people's exposure, via all marketing practices and media platforms, to unhealthy food and beverage products. 51

Transnational industrial actors
The industrial actors should adopt a comprehensive global policy on responsible marketing to children and adolescents that is accessible to all stakeholders in the public domain. The policy should include all forms of integrated marketing communications -e.g. company-owned, brand-equity mascots and licensed media characters used on in-store food packaging and at points of sale, in-school food marketing, sponsorships, celebrity endorsements, charitable donations and fundraising activities. 18,20,47 Industrial actors should also: (i) commit to clear targets set by national governments to restrict young people's exposure to unhealthy branded food and beverage products; (ii) use a governmentapproved nutrient-profiling system to guide the development of acceptable products; (iii) not oppose government actions to implement health-protecting legislation and regulation; (iv) design and implement competitive business plans to shift their marketing resources from unhealthy products to promote profitable but nutrient-dense products -and so help young people meet their recommended dietary targets for fruits and vegetables, whole grains and lowfat or non-fat dairy or dairy-substitute products; and (v) amend existing selfregulatory programmes to protect the diet and health of all individuals aged 18 years and younger. Finally, industrial actors must demonstrate transparency and share relevant information on their websites and with independent monitoring bodies, to facilitate the evaluation of progress to restrict the marketing of unhealthy food and beverage products to young people -within and across countries and globally.

WHO
WHO should support Member States by integrating the marketing of breast-milk substitutes, infant foods and unhealthy food and beverage products into a strong overarching Code of Conduct for the marketing of healthy foods and beverages -with long-term funding to support robust monitoring, reporting and accountability systems. WHO's headquarters and its regional offices should provide Member States with technical assistance to adopt a standardized, global food and nutrient-profiling system, enact legislation and policies to restrict the marketing of unhealthy food and beverage products to young people, and publish regular updates on the progress that Member States are making towards the full implementation of Resolution WHA63.14 by 2025.

Conclusion
The five-year anniversary of Resolution WHA63.14 encourages us to reflect on the progress achieved and further actions required to protect young people from the harmful impacts of the marketing of unhealthy food and beverage products -especially given the rising prevalences of obesity and diet-related noncommunicable diseases worldwide. Several UN agencies offered useful leadership between 2010 and early 2016, by providing technical and policy guidance to Member States. However, no Member State has implemented comprehensive legislation or enforced mandatory regulations to prohibit the marketing of unhealthy food and beverage products to young people. The Access to Nutrition Foundation 2016 scorecard has confirmed that transnational food and beverage firms have not yet implemented a global pledge, to engage in responsible marketing to young people, that covers all practices. Moreover, no industrial sector uses a standardized, government-supported nutrient profiling system to restrict the marketing of unhealthy food and beverage products to those aged 14-18 years. Civil society organizations can develop model pledges to help Member States and industry accelerate progress. National governments and other relevant actors have future opportunities to build policy coherence across settings, sectors and continents and establish healthy food environments for young people. These actions should support the UN Convention on the Rights of the Child, the right to adequate nutrition, the reversal of the current upward trend in the prevalence of undernutrition, obesity and diet-related noncommunicable diseases, and the promotion of healthy lives for all by 2030. ■

Competing interests: None declared.
Restricting the marketing of unhealthy foods and beverages Vivica I Kraak et al.