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. Author manuscript; available in PMC: 2019 Jun 20.
Published in final edited form as: Appetite. 2016 Oct 14;108:295–302. doi: 10.1016/j.appet.2016.10.014

Child-Targeted TV Advertising and Preschoolers’ Consumption of High-Sugar Breakfast Cereals

Meghan R Longacre 1, Keith M Drake 2,3, Linda J Titus 1,3,4, Jennifer Harris 5, Lauren P Cleveland 1, Gail Langeloh 1, Kristy Hendricks 1, Madeline A Dalton 1,3,6
PMCID: PMC6585950  NIHMSID: NIHMS824949  PMID: 27746213

Abstract

Breakfast cereals represent the most highly advertised packaged food on child-targeted television, and most ads are for cereals high in sugar. This study examined whether children's TV exposure to child-targeted, high-sugar breakfast cereal (SBC) ads was associated with their consumption of those SBC brands. Parents of 3- to 5-year-old children were recruited from pediatric and Women, Infants, and Children (WIC) clinics in Southern New Hampshire, USA, and completed a cross-sectional survey between April-December 2013. Parents reported their child's consumption of SBC brands; whether their child had watched any of 11 kids’ channels in the past week; their child's TV viewing time; and socio-demographics. Children's exposure to child-targeted SBC TV ads was calculated by combining TV channel and viewing time with advertising data for SBC ads aired on kids’ TV channels during the same timeframe. Five hundred forty-eight parents completed surveys; 52.7% had an annual household income of $50,000 or less. Children's mean age was 4.4 years, 51.6% were female, and 72.5% were non-Hispanic white. In the past week, 56.9% (N=312) of children ate SBCs advertised on kids’ channels. Overall, 40.6% of children were exposed to child-targeted SBC TV ads in the past week. In fully adjusted analyses, the number of SBC brands children consumed was positively associated with their exposure to child-targeted SBC ads. Children consumed 14% (RR=1.14, 95% CI: 1.02, 1.27) more SBC brands for every 10 SBC ads seen in the past 7 days. Exposure to child-targeted SBC TV advertising is positively associated with SBC brand consumption among preschool-aged children. These findings support recommendations to limit the marketing of high-sugar foods to young children.

Keywords: High-sugar breakfast cereal, food marketing, children, television, cereal consumption

Introduction

Public health advocates are concerned about the marketing of high-sugar, ready-to-eat breakfast cereals (SBCs) to young children (Federal Trade Commission, 2008, 2012; Institute of Medicine, 2006; World Health Organization, 2010). In the U.S., the breakfast cereal industry is the second leading food advertiser to children under age 12, spending $173 million annually directly marketing ready-to-eat cereals to children (Federal Trade Commission, 2012). Many ready-to-eat cereal brands have a lengthy history of marketing their products to child consumers, particularly by using animated brand mascots (e.g., General Mills’ Trix rabbit; Kellogg's Tony the Tiger), and more recently through the use of cross-promotional tie-ins with popular licensed media characters (e.g., Nickelodeon's SpongeBob SquarePants) appearing on cereal boxes (Kraak & Story, 2015b). Ample evidence suggests that the cereals most heavily advertised to children are the least nutritious, primarily because they contain the greatest amounts of added sugars (Batada, Seitz, Wootan, & Story, 2008; Kraak & Story, 2015a; LoDolce, Harris, & Schwartz, 2013; Schwartz et al., 2010; Schwartz, Vartanian, Wharton, & Brownell, 2008). The Rudd Center for Food Policy and Obesity demonstrated that child-targeted cereals contained 57% more sugar than adult-targeted cereals (LoDolce et al., 2013; Rudd Center for Food Policy and Obesity, 2012). In an analysis of cereal brands, the Environmental Working Group found that 78% of child-targeted cereals contained over two teaspoons of sugar per serving (Environmental Working Group, 2014).

Television is the primary type of media used by preschool-age children (Common Sense Media, 2013), and much of child-targeted cereal marketing occurs on television (Federal Trade Commission, 2012). Ready-to-eat cereals represent the most highly advertised packaged-food category to children on TV, with estimates indicating children view hundreds of televised cereals ads annually (LoDolce et al., 2013; Powell, Szczypka, & Chaloupka, 2007). Hingle and colleagues analyzed a sample of food advertisements aired during children's TV programming in 2013 and compared product nutrient data to the voluntary nutrition guidelines proposed by a coalition of four federal agencies (Hingle, Castonguay, Ambuel, Smith, & Kunkel, 2015; Interagency Working Group on Foods Marketed to Children, 2011). Ready-to-eat cereals accounted for over one-third of TV ads in this sample, yet none of the advertised cereals met the federal nutrition guidelines for added sugar (i.e., not more than 8 g of sugar per serving) (Hingle et al., 2015). Exposure to child-targeted ready-to-eat cereal TV advertising is associated with family purchases of the advertised products. Using Nielsen household panel food purchasing data, Castetbon and colleagues showed that households were 13 times more likely to purchase child-targeted cereals advertised on TV than cereal brands without advertising (Castetbon, Harris, & Schwartz, 2012). That study, however, did not examine actual consumption of purchased cereals.

Globally, marketing of high-sugar, high-fat foods to children has been identified as a risk factor for childhood obesity (Healthy Eating Research, 2015; Institute of Medicine, 2006; White House Task Force on Childhood Obesity, 2010; World Health Organization, 2012). Numerous international studies – primarily using experimental designs in controlled laboratory settings – indicate that children's food preferences, requests, and short-term consumption are influenced by exposure to child-targeted food marketing (Boyland & Halford, 2013; Boyland et al., 2016; Cairns, Angus, Hastings, & Caraher, 2013; Harris, Pomeranz, Lobstein, & Brownell, 2009). Additional research in non-controlled settings is needed to understand the potential impact of food marketing on children's usual eating behaviors in real-world environments with greater external validity (Institute of Medicine, 2006; White House Task Force on Childhood Obesity, 2010). Research meeting this criteria is mounting (Andreyeva, Kelly, & Harris, 2011); however, to date this evidence is primarily for foods (e.g., fast food, sugar-sweetened beverages) other than ready-to-eat breakfast cereals. We are unaware of any studies that have quantified the association between children's exposure to SBC TV ads and their actual cereal consumption. The purpose of this study was to assess whether children's TV exposure to child-targeted SBC ads was associated with their consumption of those SBC brands outside of a laboratory setting.

Materials and Methods

Study Design

Between April 2013 and March 2014, trained research assistants invited parents at pediatric outpatient and Women, Infants, and Children (WIC) clinics, located in Manchester and Nashua, NH, to complete a 15-minute written survey about children's media use and food choices. Our recruitment sites were chosen because they provide access to a broad cross-section of families with young children located in our catchment areas. WIC is a supplemental nutrition program in the U.S. To qualify, families cannot earn more than 185% of the poverty income level. Surveys were pre-tested with a demographically comparable sample for comprehension, face validity, and completion time. Eligibility for study participation included children's age (3-5 years) and parents’ ability to complete a written consent form and survey in English or Spanish. If parents had multiple age-eligible children, we selected the child present for an appointment. If more than one child had an appointment, we randomly selected one. Parents received a $10 gift card and children received a toy for participating. The study was approved by [BLINDED] Institutional Review Board.

Seventy-one percent of eligible parents completed a survey. The primary reason for not participating was insufficient time (44% of refusals). For this analysis, we assessed data from 548 parents surveyed between April and December 2013, which corresponded to our advertising data time period.

Measures

SBC Consumption

We examined ten SBCs that were top-ranked in terms of child-targeted advertising (Rudd Center for Food Policy and Obesity, 2012) and were advertised on kids’ TV channels during the last three quarters of 2013 (Kantar Media, 2013). The sugar content for these SBCs in 2013 ranged from 9 to 12 grams of added sugar per ounce of cereal (i.e., approximately one serving size). We ascertained the number of advertised SBC brands children consumed by asking parents, “In the past 7 days, did your child eat any of the following cereals? (Apple Jacks, Honey Nut Cheerios, Cocoa Puffs, Cinnamon Toast Crunch, Froot Loops, Frosted Flakes, Lucky Charms, Pebbles—all flavors, Reese's Puffs, Trix)?” Responses were combined into a single count variable indicating the number of SBC brands each child had eaten in the past 7 days. For simplicity, we hereafter refer to this as SBC consumption.

SBC TV Ad Exposure

Children's exposure to child-targeted SBC TV ads was based on parental report of children's viewing time and channels watched. For viewing time, we asked, “On average, how many days a week does your child do the following activities: watch TV (regular, cable, or satellite)? (0, 1-2, 3-4, 5-6, 7 days).” We then asked, “On days when your child does the following activities, about how much time does your child spend: watching TV (regular, cable or satellite)?” [response choices ranged from 0 to 6+ hours with 30-minute segments]. For channels, we asked, “In the past 7 days, has your child watched any of the following TV channels? [Boomerang; Cartoon Network; The Disney Channel; Disney Junior; Disney XD; The Hub (now called Discovery Family); Nickelodeon; Nick Jr.; Nicktoons; PBS Kids; Sprout]” For each child, we calculated weekly TV viewing time by multiplying the number of days/week by the number of hours/day the child watched TV. We then estimated each child's weekly exposure to specific TV channels by dividing weekly viewing time by the number of kids’ channels the child watched in the past 7 days.

All child-targeted SBC ads aired on kids’ channels between April-December 2013 were obtained from Kantar Media™, a company that tracks TV commercials on an hourly basis. We assumed that all cereal ads aired on kids’ channels were child-targeted. The SBCs asked about in the survey accounted for 97.5% of all SBC ads aired on kids’ channels during this time period. For each day, we calculated channel-specific averages of the number of SBC ads aired per hour between 6am –11pm or during child programming. For example, we did not include ads aired during Nick-at-Nite, which begins as early as 8pm and shares channel space with Nickelodeon, because its programming is aimed at older audiences. We then multiplied each child's channel-specific weekly exposure time by the average number of SBC ads aired per hour on that channel during the 7 days prior to each survey. The resulting advertising exposure score approximates the mean number of child-targeted SBC ads each child was exposed to during the week prior to the survey.

Covariates

In the parent survey, we assessed demographics (i.e., child gender, race, and age) and SES (i.e., child participation in WIC, parent education, and household income). We assessed children's other screen time (i.e., hours of DVD's/VHS, streaming, apps, internet use, and electronic games) using the TV viewing question format. We also measured the frequency with which children ate any type of cereal by asking parents, “How often does your child eat cereal? (Never; Less than once a week; 1-2 times a week; 3-4 times a week; 5 or more times a week).”

Statistical Analysis

We used Poisson regression with robust variance estimates to calculate rate ratios for the number of SBC brands consumed in the past 7 days for every 10 SBC ads to which children were exposed (Huber, 1967; Zou, 2004). The fully adjusted model includes demographics, SES, and other screen time. To maximize the sample size, we used multiple imputation by chained equations to impute values for all variables in the multivariate models with missing data (0.2-5.8% per variable) (Azur, Stuart, Frangakis, & Leaf, 2011). All analyses were conducted in STATA version 14 (StataCorp LP, College Station, Texas).

Results

Sample Characteristics

Children's mean age was 4.4 (SD=0.8) years and 51.6% were female. Seventy-three percent were non-Hispanic white; the majority (59.4%) of the others were Latino. Most (86.7%) participating parents were mothers. Approximately half (52.7%) the parents reported an annual household income of $50,000 or less; 48.5% reported “high school or less” as their highest level of education.

SBC Advertising

Overall, 27,080 SBC ads were identified for this analysis. There was some variability in the distribution of advertising by SBC brand (i.e., 2.6% to 13.5% of all SBC ads), but no single brand accounted for more than 14% of the SBC ads. Only five of the 11 kids’ channels aired SBC ads during the study period, and over two-thirds of SBC ads aired on Nickelodeon (37.8%) and Nicktoons (33.3%) (Figure 1).

Figure 1.

Figure 1

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Distribution of high-sugar breakfast cereal (SBC) ads by kids’ channels.

Children's TV Viewing and SBC Advertising Exposure

On average, children spent 21.5 (SD=19.9) hours per week using electronic media. Children's viewing of regular, cable or satellite TV accounted for nearly half of their overall screen time, averaging 9.3 (SD=8.3) hours per week. Eighty-nine percent of children watched at least one kids’ TV channel (regardless of SBC advertising) during the week before the survey. Overall, these children viewed a mean of 3.2 (SD=2.2) kids’ channels. On average, during the 7 days preceding each survey, kids’ channels aired between 0 and 2.7 SBC ads per hour (Table 1).

Table 1.

Percent of children who watched kids’ channels and mean number of high-sugar breakfast cereal (SBC) ads aired per hour by channel during the 7 days preceding each survey.

Kids' Channels Viewed in past 7 days (N=548) % SBC Ads per hour1 Mean (SD)
Disney Junior 58.0 0
PBS Kids 53.3 0
Nick Jr. 52.0 0
The Disney Channel 46.2 0
Sprout 33.9 0
Nickelodeon 28.5 2.7 (1.0)
Cartoon Network 17.7 1.0 (0.3)
The Hub 2 11.0 0.5 (0.2)
Disney XD 8.2 0.3 (0.2)
Nicktoons 7.3 2.1 (0.7)
Boomerang 2.9 0
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1

Only ads aired between 6am-11pm or during child programming (for Nickelodeon and Cartoon Network) included.

2

Currently known as Discovery Family.

Less than half of children watched kids’ channels with SBC advertising; thus only 40.6% were exposed to child-targeted SBC ads during the past 7 days. Among these children, 39.0% had low exposure (<=3.0 ads), 33.0% moderate (3.01-10 ads), and 28.0% had high exposure (>10 ads). Children's SBC ad exposure was positively associated with the following child characteristics: male gender (p=0.02), non-white race (p<0.001), and hours of TV viewing (p<0.001); inversely associated with household income (p=0.021) and parent education (p<0.001); and not significantly associated with child age, WIC participation, or hours of other screen time.

Children's SBC Consumption

Fifty-seven percent (N=312) of children ate SBCs in the past week: 30.7% ate one SBC brand; 15.7% ate two SBC brands; and 10.6% ate 3 or more SBC brands. The most commonly consumed SBC brands were Honey Nut Cheerios and Froot Loops, consumed by 21.0% and 18.6% of children, respectively (Figure 2). The number of SBC brands children consumed was positively associated with their SBC ad exposure (Table 2). In unadjusted analyses, older age (i.e., 5 years), WIC participation, and the frequency with which they ate any cereal also were associated with a greater number of SBC brands consumed, whereas non-Hispanic white race, higher household income, and having college-educated parents were associated with lower SBC consumption. Child gender, overall hours of TV watching, and hours of other screen time were not associated with the number of SBC brands children consumed in the past 7 days (Table 2).

Figure 2.

Figure 2

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Percent of children who ate high-sugar breakfast cereal (SBC) in the past 7 days, by brand.

Table 2.

Number of high-sugar breakfast cereal (SBC) brandsa children ate in the past 7 days by child-targeted SBC ad exposureb and sample characteristics

N # SBC brandsa consumed in past 7 days Unadjusted Rate Ratio 95% CI
Mean SD
Child Characteristics
SBC ad exposureb
    0 SBC ads 319 0.85 0.98 Ref
    0.01-3.0 SBC ads 85 1.14 1.36 1.34 (1.01,1.78)
    3.01-10 SBC ads 72 1.23 1.52 1.46 (1.07,1.98)
    >10 SBC ads 61 1.39 1.46 1.64 (1.23,2.19)
Gender
    Female 283 0.96 1.13 Ref
    Male 265 1.05 1.27 1.10 (0.90,1.34)
Age
    3 years 193 0.85 1.09 Ref
    4 years 208 0.99 1.24 1.16 (0.90,1.48)
    5 years 146 1.22 1.24 1.43 (1.12,1.82)
Race
    Other 144 1.30 1.46 Ref
    Non-Hispanic White 380 0.90 1.08 0.69 (0.56,0.86)
WIC participation
    No 385 0.92 1.07 Ref
    Yes 163 1.20 1.43 1.30 (1.05,1.62)
TV watching (hours per week)
    <= 1 hour 55 1.00 1.05 Ref
    1.1-5 hours 126 1.00 1.28 1.01 (0.71,1.44)
    5.1 - 10 hours 130 1.04 1.09 1.04 (0.75,1.44)
    10.1-14 hours 139 0.94 1.13 0.94 (0.66,1.32)
    > 14 hours 83 1.14 1.46 1.14 (0.78,1.69)
Other screen time (hours per week)
    <= 1 hour 41 0.85 0.96 Ref
    1.1-5 hours 164 0.85 1.14 0.99 (0.67,1.48)
    5.1 - 10 hours 133 1.04 1.09 1.22 (0.83,1.79)
    10.1-14 hours 56 1.02 1.17 1.19 (0.76,1.88)
    > 14 hours 133 1.22 1.42 1.43 (0.96,2.12)
Frequency of cereal consumption (times per week)
    Never 21 0.14 0.36 Ref
    Less than once 48 0.69 0.99 4.81 (1.56, 14.81)
    1-2 times 135 0.85 1.03 6.02 (2.07, 17.50)
    3-4 times 200 1.12 1.19 7.84 (2.72, 22.60)
    5 or more times 135 1.26 1.42 8.82 (3.04, 25.59)
Parent Characteristics
Annual Household Income
    <= $25,000 150 1.48 1.49 Ref
    $25,001 - $50,000 122 0.95 0.98 0.64 (0.50,0.82)
    $50,001 - $100,000 156 0.91 1.12 0.62 (0.48,0.79)
    > $100,000 88 0.50 0.76 0.34 (0.24,0.48)
Parent Education
    High School or less 257 1.21 1.29 Ref
    Associates or technical degree 111 1.07 1.33 0.89 (0.68,1.16)
    Bachelor's or graduate degree 162 0.67 0.86 0.55 (0.44,0.70)
Total 548 1.00 1.20
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a

Of the following brands advertised on kids’ TV channels: Apple/Cinnamon Jacks, Cinnamon Toast Crunch, Cocoa Puffs, Froot Loops, Frosted Flakes, Fruity & Cocoa Pebbles, Honey Nut Cheerios, Lucky Charms, Reese's Puffs, Trix.

b

Average number of SBC ads children saw on kids’ TV channels in the past 7 days.

Association between Children's SBC Consumption and Exposure to Advertising

In unadjusted analyses, children consumed 29% (RR=1.29, 95% CI: 1.20, 1.39) more SBC brands for every 10 SBC ads viewed in the past 7 days (Table 3). After adjusting for child demographics, SES, and other screen time, children consumed 14% (RR=1.14, 95% CI: 1.02, 1.27) more SBC brands for every 10 SBC ads seen in the past 7 days. In the fully adjusted model, child age and household income were also significant predictors of the number of SBC brands consumed. WIC participation, child race, and parent education were no longer significantly associated with SBC consumption in the adjusted model.

Table 3.

Rate ratios (RR) for high-sugar breakfast cereal (SBC) consumption in the past 7 days.

Unadjusted Adjustedc
RR 95% CI RR 95% CI
Child Characteristics
    SBC ad exposure (10 ads)b 1.29 (1.20, 1.39) 1.14 (1.02, 1.27)
    Male 1.11 (0.96, 1.29)
    Age 1.20 (1.05, 1.36)
    Non-Hispanic white 0.84 (0.64, 1.09)
    WIC participation 0.98 (0.78, 1.24)
    Other screen time (hours per week) 1.06 (0.94, 1.19)
Parent Characteristics
    Annual Household Income 0.79 (0.74, 0.85)
    Parent Education 0.92 (0.75, 1.14)
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RR=rate ratio; 95% CI=95% confidence interval

a Number of advertised SBC brands consumed in the past 7 days.

b

(Average number of SBC ads children saw on kids’ TV channels in the past 7 days) / 10

c

Adjusted for all other variables in the table.

Discussion

This is the first study to demonstrate a significant positive relationship between exposure to child-targeted SBC TV advertising and young children's consumption of SBCs outside a laboratory setting. In our community-based sample of preschool-age children, the number of SBC brands consumed was positively associated with the average number of child-targeted SBC ads viewed in the past week. After adjusting for family SES, child demographics, WIC participation, and other screen time, we found the number of SBC brands consumed was 14% higher for every 10 SBC ads viewed in the past week.

Of the 10 SBCs we examined, nine contained 10 or more grams of sugar per ounce of cereal at the time of the study. In 2014, the Children's Food and Beverage Advertising Initiative (CFBAI), a U.S.-based industry self-regulatory organization with the stated intent to “shift the mix of foods advertised to children under 12 to encourage healthier dietary choices,” (Better Business Bureau, 2014b) enacted updated nutrition criteria for products advertised to children. For ready-to-eat cereals, these revised nutrition standards specified that cereals advertised on child-targeted TV contain no more than 10 grams of total sugars per one ounce serving (Better Business Bureau, 2014a). Despite modest reductions in sugar content in response to the CFBAI updated nutrition guidelines, (Better Business Bureau, 2014a) the sugar content of many advertised cereals remains very high and further efforts to reduce the marketing of SBCs to children are warranted. Internationally, countries (e.g., Norway, Sweden, France, United Kingdom) have already taken steps to reduce children's exposure to food advertising on TV (Bugge, 2016; Lloyd-Williams et al., 2014; World Health Organization, 2013). By demonstrating that exposure to SBC TV advertising was associated with intake of these high-sugar products among preschool-aged children, our results emphasize the public health importance of these efforts in the U.S.

Nearly six out of 10 children in this study consumed at least one of the measured SBC brands in the past week. In light of associations between children's sugar intake and a variety of indicators of compromised health status -- including obesity, dental caries, and diabetes (Johnson et al., 2009; Welsh & Cunningham, 2011) -- reducing dietary consumption of added sugars among U.S. children's diets is a national target (USDA, 2015). Efforts that promote children's consumption of low-sugar breakfast cereals is one strategy that would contribute to this goal (Guthrie & Morton, 2000). Few independently conducted studies have examined differences between low-sugar and high-sugar cereals on children's health (Castetbon et al., 2012). Ready-to-eat cereals represent one of the most popular choices for children's breakfast, and breakfast consumption has been linked to improved cognitive performance, better nutrient intake, and lower body mass index among children (Hoyland, Dye, & Lawton, 2009; Pollitt & Mathews, 1998; Rampersaud, Pereira, Girard, Adams, & Metzl, 2005). The food industry has suggested that children strongly prefer presweetened cereals, and that enhancing the palatability of cereal through added sugar is justified because it encourages consumption of a product fortified with other important nutrients (Albertson et al., 2009; Frary, Johnson, & Wang, 2004; Thompson, Franko, & Barton, 2008). However, experimental evidence suggests that children like and will consume low-sugar cereals, and those who eat low-sugar cereals may also simultaneously increase their intake of other recommended food groups (e.g., fruits) (Harris, Schwartz, Ustjanauskas, Ohri-Vachaspati, & Brownell, 2011).

SBC companies have a long history of employing a continuous line-up of child-appealing brand mascots (e.g., Kellogg's Tony the Tiger on Frosted Flakes and Toucan Sam on Froot Loops) and cross promotional tie-ins with licensed media TV and movie characters (e.g., Nickelodeon's SpongeBob SquarePants; Marvel Comic's Avengers characters) to promote their products (Batada et al., 2008; Harris, Schwartz, & Brownell, 2010; Kraak & Story, 2015a, 2015b). SBC TV advertising features a wide array of brightly colored, animated and anthropomorphic characters that are highly appealing and memorable to young children. Evidence suggests that this marketing approach leads children to “pester” their parents for the advertised product (Huang et al., 2016). Additionally, this approach prompts young children to request multiple cereals, including the one with the most recent appeal (Bridges & Briesch, 2006). Thus, it is not surprising that breakfast cereal advertising seems to encourage “brand switching” rather than brand loyalty, especially among young children (Shum, 2004). Based on this, we believe our outcome measure of the number of SBC brands consumed in the past week is a meaningful indicator of children's susceptibility to SBC advertising. However, we recognize that future work should also explore the extent to which exposure to child-directed SBC advertising impacts the quantity of SBC consumed.

Five of the 11 kids’ channels that we examined aired SBC commercials. However, the hourly dose of SBC ads on these channels ranged widely, from 0.3 per hour (Disney XD) to nearly 3 ads per hour (Nickelodeon). Nickelodeon was the most viewed channel of the five channels with SBC advertising, with more than one-quarter of all preschoolers in our sample having watched it in the past week. Prior public health campaigns to reduce child-directed food advertising have focused specifically on Nickelodeon (Blumenthal, Rockefeller, Harkin, & Durbin, 2013; Center for Science in the Public Interest, 2013). These efforts seem warranted, given Nickelodeon's status as the primary point of exposure to SBC ads in this study. In contrast, almost sixty percent of children in this study were unexposed to child-targeted TV ads for SBCs because they only watched kids’ channels without commercial food advertising (e.g., Disney Junior; PBS Kids) or did not watch any kids’ channels at all. Notably, these children had the lowest weekly consumption of SBC brands. However, their SBC brand intake was not zero, indicating that SBC TV advertising is not the only factor associated with consumption. Other factors may include parental or sibling preference for the consumed SBC, as well as point-of-purchase exposure to advertising, both of which have been noted in prior research (Devi et al., 2014; Lapierre, Vaala, & Linebarger, 2011; Soo, Letona, Chacon, Barnoya, & Roberto, 2016). Identifying the relative influence of these other factors is an important direction for future work. Additionally, examining the impact of preschoolers’ exposure to cereal marketing via online sources will be increasingly important as preschoolers’ access to and time spent with mobile and online sources of media increases (Common Sense Media, 2013).

The current study is notable for several reasons. We focused on a preschool-age population, considered a highly vulnerable group given their developmental susceptibility to marketing that features familiar, beloved characters, and their cognitive inability to defend against such marketing practices (Harris, Brownell, & Bargh, 2009; Harris & Graff, 2012). Major cereal companies (e.g., General Mills, Kellogg, Post) indicate that they do not direct their TV advertising to children under age 6, but rather to children ages 6-11 (Better Business Bureau, 2014b). Our results demonstrate that younger children are nevertheless seeing these ads on TV, and are being affected by them. In our analyses, the overall average hours per week children watched TV, as well as their other screen time, were not associated with children's SBC brand consumption. This finding demonstrates that preschoolers’ SBC consumption was not merely a function of high screen time, and supports the specificity of advertising exposure as a possible explanatory mechanism. We found similar associations between children's exposure to advertising and consumption of fast food in this sample (Dalton et al., in press). Taken together, these studies quantify the link between advertising exposure and children's diet in real-world settings, and demonstrate that the effect is not limited to one particular food product. Our estimate of child TV viewing is consistent with other research using parental report of children's screen time (Common Sense Media, 2011, 2013; Loprinzi & Davis, 2015). Finally, our regional sample was diverse in terms of socioeconomic status.

We also note several study limitations. The study was conducted in a geographic area with limited racial and ethnic representation, and thus warrants replication in more diverse settings. We did not ask parents to report their child's weekly TV viewing time by channel, and thus the advertising exposure measure assumed equal exposure across the channels each child watched. If a child watched one channel much more frequently than another, this assumption could have resulted in exposure misclassification. However, the directionality of any potential bias is uncertain. Research with more precise measures of advertising exposure based on children's actual weekly viewing of channels is challenging with large samples but would offer more precise estimates. Similarly, our measure of children's SBC consumption is based on parent report rather than observation, which is possible in laboratory-based studies. Our measure of SBC consumption does not capture the overall quantity; however, children who consumed cereal more frequently also ate a wider variety of SBCsfu We also did not inventory all cereals in the household, so cannot address whether advertised SBC were the only cereals in the household, or whether children were choosing these SBC over another cereal option. This would be an interesting direction for future work. Finally, the cross-sectional nature of the study design warrants caution in drawing conclusions about the causal nature of the association between advertising exposure and SBC brand consumption.

Conclusions

The current study demonstrates a significant positive association between preschoolers’ exposure to child-targeted SBC TV ads and their intake of advertised SBC brands. These findings support the recommendations by the Institute of Medicine, the White House Task Force on Childhood Obesity, the World Health Organization, and other public health authorities, to restrict the marketing of foods high in sugar to young children (Healthy Eating Research, 2015; Institute of Medicine, 2006; White House Task Force on Childhood Obesity, 2010; World Health Organization, 2012).

Acknowledgements

This study was supported by the National Institutes of Health, grant number R01HD071021. The National Institutes of Health had no role in the design, analysis or writing of this article.

Footnotes

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

Conflict of Interest: All authors declare that we have no conflicts of interest in the authorship or publication of this manuscript.

Authorship: MRL, LJT, KH, and MAD designed the study; LPC and GL were responsible for acquisition of the data; KMD and MAD analyzed the data; MRL, KMD and MAD drafted the manuscript; LJT and JH critically revised the manuscript; all authors had input on the interpretation of the data and approved the final version of the manuscript.

Ethical Standards Disclosure: This study was conducted according to the guidelines laid down in the Declaration of Helsinki and all procedures involving human subjects were approved by the Committee for the Protection of Human Subjects at Dartmouth College. Written informed consent was obtained from all subjects.

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