Advertising, obesity and child health: the case of Spain

Childhood and adolescent overweight and obesity represent one of the most important health risks worldwide. Despite the measures adopted to control these conditions, Spain is one of the European and worldwide countries with the highest prevalence of childhood and adolescent obesity. Four out of ten schoolchildren (6 to 9 years old) are either overweight or obese, with the former more prevalent in girls and the latter more prevalent in boys.¹

In Spain, a new bill has recently been proposed to regulate the advertising of unhealthy foods and beverages aimed at children under 16 years old.²

Obesity has a multicausal origin related to social determinants, structural environments and lifestyles. Among the social determinants, family income, maternal educational level and family’s social class are the most relevant. The obesity rate is twice as high (23.2%) for those children (4–14 years old) coming from low-income families than for those living in high-income families (11.9%). In Spain, the epidemic is more frequent in schools located in districts with greater child poverty. Despite several interventions promoted at different levels, between 2011 and 2019, it has only been possible to reduce excess weight by 3.9% in those aged 6–9 years, which has decreased from 44.5% to 40.6%.¹ The decline is mainly due to fewer overweight (but not obese) children. This slight achievement could be associated to programmes addressed specifically at this age group, the majority of them integrated in a national strategy named NAOS (Nutrition, physical activity and obesity prevention).¹ The 2019 situation may have deteriorated as a result of the COVID-19 pandemic.

Obesity in children can have significant repercussions in adulthood. In addition to this, it is associated with a shorter life expectancy and quality of life deterioration along the life course.

An obesogenic environment promotes excess weight gain in the population, more sedentary behaviours, less physical activity, unbalanced sleep and mood, and unhealthy eating, from the consumption of calorie-dense, nutrient-poor and high in added saturated fat and/or trans fat, sugar, or sodium.

Advertising aimed at children and adolescents has a high influence on the consumption of unhealthy foods and beverages. It can promote greater consumption of unhealthy foods. Moreover, it induces a lower consumption of healthy foods overall in the diet which can lead to an increase in body weight.³ Children exposed to food advertising on TV and games consumed between 53.2 and 60 kcal more than children exposed to non-food advertising. This had an impact on the body mass index.⁴

European governments are increasingly implementing statutory policies that restrict market to children of unhealthy foods and beverages. Policies show variability regarding the foods and beverages they include in the restriction, in which ages are protected and communication channels and marketing techniques are covered. Nevertheless, the intake of unhealthy foods continues to increase. The interested industries invest a large budget with the aim of reaching the younger population through attractive advertisements and marketing strategies.

Eleven evaluations of policies in four different countries found small or no policy-related reductions in unhealthy foods and beverages advertising. This was due to marketing shifting to other channels or venues.⁵ Moreover, voluntary television marketing restrictions have been implemented in some countries, and studies show that television restrictions are generally not respected, as well as monitoring being challenging.⁶

Among the policies implemented at the European level, the UK government has announced new rules to regulate advertisements, both online and on TV before 21:00, in relation to unhealthy foods and beverages.⁷ The regulations will use the Nutrient Profiling Model (NPM), introduced/developed in 2005 and revised in 2018, to assess the dietary quality. The UK NPM consists of a score system which enables one to classify foods and beverages with an overall score that determines whether they can be advertised to children. The revised profile is more restrictive because it resulted in fewer food and drinks passing the model in comparison with the 2005 NPM (difference of 8 percentage points). Unfortunately, to date, it was maintained a co-regulation with enterprises’ voluntary participation. In 2019, it was found that almost half (47.6%) of all food adverts broadcast over the month on several channels were for less healthy foods and beverages. This rises to nearly 60% during the 18:00 and 21:00 slot. Therefore, it is clear that the current co-regulation failed.

In France, a law from 2016 restricted any commercial in public television programmes and websites aimed at children under 12 years old.⁸ This applies to all advertising including unhealthy foods and beverages. In non-public television channels, restrictions are also applied in relation to the advertising foods and beverages. All television advertising unhealthy foods and beverages, both addressed to children and adults, must be accompanied by a ‘healthy’ message based on the institute’s nutrition education principles. The dietary quality is assessed by the last version of the French Nutri-Score.

In Portugal, since 2019, restrictions on unhealthy foods and beverages have been applied, both in online and audiovisual channels, in the time slot that covers 30 min before and 30 min after the broadcast of programmes for children, as well as in TV programmes with a minimum of 25% audience under 16 years old or in movie theatres, publications, Internet and mobile applications aimed at children of the same ages.⁹

In Sweden, there has been since the 1990s a general ban on television advertising for all kinds of products during programmes aimed at children under 12 years od, which cannot be preceded or followed by advertising.¹⁰

In Spain, the Code of co-regulation of foods and beverages advertising aimed at minors, obesity prevention and health (PAOS Code—Corregulación de la Publicidad de Alimentos y Bebidas Dirigida a Menores, Prevención de la Obesidad y Salud) was adopted for the first time in 2005 and revised in 2011.¹¹ Currently, the government is working on a new royal decree that intends to apply the NPM, recommended by WHO, to define which foods and beverages marketing contents could be addressed to children. The WHO-NPM consists of a total of 17 food categories and is based on existing models developed by Norway and Denmark.¹² The rationale is that the models use ‘food category’ approaches, which are easier to adapt or modify rather than using a scoring system. The Spanish proposal bans advertising in all kinds of media, including TV, online platforms, influencers and characters, aimed at children under 16 years old. Moreover, the change from voluntary participation of the industry to a governmental control with potential penalty effects is crucial.² They argue that the current rules on unhealthy food advertising are not going far enough to protect children from seeing a significant amount of unhealthy adverts and do not account for the increasing amount of time children spend online. Similarly to the UK Government new rules, the Spanish regulation will be launched in early 2023 if it is finally approved. The current Spanish proposal is open to be discussed among the civil society and organisations, including food and beverage industries, despite the latter having only agreed partially with such proposal.

Among the limitations of the Spanish proposal, it is worth mentioning the absence of a motion for specific evaluation on the effectiveness of the adopted measures. It would be advisable for the government to commission this evaluation to a consortium of research groups with expertise in this field.

It seems that these regulations based on specific nutritional profiles, which include not only TV but all kinds of social media, with the potential to influence the younger population, are more effective to achieve the proposed objectives of improving foods and beverages preferences, dietary habits and finally contributing to reducing childhood obesity. It should also cover all types of media and timetable addressed to children, as well as consider an external evaluation by a neutral body and potential penalties to reduce marketing advertising that reach children.

In summary, the proposed measures are promising and can contribute to reducing excess weight if the aforementioned aspects are taken into account and are implemented along with other measures. In addition, a reduction in social inequalities (and policies aimed at reducing childhood poverty, economic and geographic access to healthy food) is needed. School, family and community interventions, and a holistic approach (including physical activity, sleep and psychological well-being promotion) should accompany the foods and beverages marketing regulations. Undoubtedly, tackling the childhood obesity epidemic requires complex and nationwide strategies starting by effective structural measures as regulating marketing addressed to children.

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