Testing a conceptual Hierarchy of Effects model of food marketing exposure and associations with children and adolescents' diet-related outcomes.

OBJECTIVE: Children's exposure to unhealthy food marketing contributes to poor diets by influencing the foods that children like, request, buy and consume. This study aimed to use confirmatory mediational analyses to test a hypothetical model of marketing effects, to better understand the mechanisms behind food marketing's impacts on children. DESIGN: Children responded to a cross-sectional online survey about their attitudes towards, and purchase and consumption behaviours of, ten frequently promoted food/beverage brands and their media use. Structural equation modelling tested a priori potential pathways for the effects of food marketing exposure on children's diets. PARTICIPANTS: 10-16-year-old children (n 400). SETTING: Australia. RESULTS: There was a significant positive correlation between children's commercial screen media use and their attitudes towards brands (related to perceived social norms) and their brand purchasing behaviours, including their own purchases and requests to parents. The use of strategies to avoid advertising in commercial screen media reduced but did not remove the association between media use and brand purchases. Other brand exposures (on clothing, outdoor advertising, sponsorships) had a positive association with children's perceived social norms about brands and their brand purchases and requests. Non-commercial screen media use was not associated with any brand-related outcomes. CONCLUSIONS: Commercial screen media use and other brand exposures were strongly positively associated with children's perceptions and purchasing behaviours of frequently marketed food/beverages. Regulations to restrict children's exposures to food marketing on-screen and through other media are required to reduce the effect of marketing exposure on children's food purchasing behaviours.

Digital food and beverage marketing appealing to children and adolescents: An emerging challenge in Mexico.

BACKGROUND: Digital food marketing is increasing and has an impact on children's behaviour. Limited research has been performed in Latin America. OBJECTIVES: To determine the extent and nature of Mexican children's and adolescents' exposure to digital food and beverage marketing during recreational internet use. METHODS: A crowdsourcing strategy was used to recruit 347 participants during the COVID-19 lockdown. Participants completed a survey and recorded 45 minutes of their device's screen time using screen-capture software. Food marketing was identified and nutrition information for each marketed product was collected. Healthfulness of products was determined using the Pan-American Health Organization and the Mexican Nutrient Profile Model (NPM). A content analysis was undertaken to assess marketing techniques. RESULTS: Overall, 69.5% of children and adolescents were exposed to digital food marketing. Most frequently marketed foods were ready-made foods. Children and adolescents would typically see a median of 2.7 food marketing exposures per hour, 8 daily exposures during a weekday and 6.7 during a weekend day. We estimated 47.3 food marketing exposures per week (2461 per year). The most used marketing technique was brand characters. Marketing was appealing to children and adolescents yet most of the products were not permitted for marketing to children according to the NPMs (>90%). CONCLUSIONS: Mexican children and adolescents were exposed to unhealthy digital food marketing. The Government should enforce evidence-based mandatory regulations on digital media.

The nature and extent of food marketing on Facebook, Instagram, and YouTube posts in Mexico.

Food and beverage marketing appealing to children and adolescents has an impact on their food preferences, purchases requests, consumption patterns, health outcomes, and obesity. The objective of this study was to assess the nature and extent of food and beverage marketing on Facebook, Instagram, and YouTube posts in Mexico. This was a content analysis that followed the World Health Organization CLICK methodology to comprehend the landscape of digital food marketing campaigns of the top-selling food products and brands and the most popular accounts carried out between September and October 2020. A total of 926 posts from 12 food and beverage products and 8 brands were included. Facebook was the social media platform with the most posts and greatest engagement. The most prevalent marketing techniques were brand logo, image of packaging, image of the product itself, hashtags, and engagement to consume. Fifty percent of the posts were assessed as appealing to children, 66% to adolescents, and 80% to either children or adolescents. Ninety-one percent of products (n = 1250) were classified as unhealthy according to the Mexican warning labels nutrient profile; 93% of the food promoted on posts appealing to either children or adolescents were unhealthy. Hashtags commonly referred to the COVID-19 pandemic. Most of the unhealthy food digital marketing features marketing techniques that appeal to children or adolescents; moreover, the use of the pandemic hashtag reflected brands' responsiveness to the environment at the time of the study. The present data contribute to evidence supporting the strengthening of food marketing regulations in Mexico.

Rising to the challenge: Introducing protocols to monitor food marketing to children from the World Health Organization Regional Office for Europe.

Unhealthy marketing has been unequivocally linked to children's food preferences, requests, purchases and eating behaviors and hence to childhood obesity. Regulating children's exposure to such marketing has been identified as a key challenge to which States must rise. Regulation mandates the need for monitoring and hence for credible data that are comparable between countries, regions and across time. However, there are major challenges presented by the complexity of the digital marketing ecosystem including the personalized targeting with persuasive, exploitative advertising to which children are subject. This narrative review identifies challenges faced by researchers in the digital ecosystem; reviews recent papers attempting to address these and specifies benefits and limitations; and introduces a set of WHO protocols with templates and guidance for studies of food marketing to children.

The Devil is in the Detail: Challenging the UK Department of Health's 2019 Impact Assessment of the Extent of Online Marketing of Unhealthy Foods to Children.

BACKGROUND: How much unhealthy marketing do children see on digital devices? Marketing of unhealthy food and beverages has long been identified as a factor in children's preferences, purchase requests and consumption. Rising global obesity mandates States to craft environments that protect children and young people's health, as recommended by the World Health Organization, among others. However, assessing the impact of marketing restrictions is particularly challenging: the complexity of digital advertising markets means that measurement challenges are profound. In 2019, the UK Department of Health published an Impact Assessment that applied a novel method aiming to calculate costs and benefits of restricting unhealthy food and beverage advertising on digital devices (planned for implementation by 2022). It estimated UK digital unhealthy marketing to children at 0.73 billion advertising impressions annually, compared to television impacts of 3.6 billion. AIM AND METHOD: We assessed this conclusion by reviewing the UK Department of Health/Kantar Consulting's Online Baseline Methodology (the "Government Model"). We examined the model's underlying premise and specified the seven analytic steps undertaken. For each step, we reviewed industry and academic evidence to test its assumptions and the validity of data applied. RESULTS: We found that, in each step, the Government Model's assumptions, and the data sources selected, result in underestimates of the scale of digital advertising of unhealthy foods-at least tenfold, if not substantially more. The model's underlying premise is also problematic, as digital advertising spend data relate poorly to digital advertising exposure, leading to further underestimation of market scale. CONCLUSION: We conclude that the Government Model very substantially underestimates the impact of digital unhealthy food advertising restrictions on health. This analysis has relevance for global policy and for the impact of regulation on children's health and well-being.

#Healthy: smart digital food safety and nutrition communication strategies-a critical commentary.

This paper explores how food safety and nutrition organisations can harness the power of search engines, games, apps, social media, and digital analytics tools to craft broad-reaching and engaging digital communications. We start with search engines, showing how organisations can identify popular food safety and nutrition queries, facilitating the creation of timely and in-demand content. To ensure this content is discoverable by search engines, we cover several non-technical aspects of search engine optimisation (SEO). We next explore the potential of games, apps, social media, and going viral for reaching and engaging the public, and how digital data-based tools can be used to optimise communications. Throughout, we draw on examples not only from Europe and North America, but also China. While we are enthusiastic about the benefits of digital communications, we recognise that they are not without their drawbacks and challenges. To help organisations evaluate whether a given digital approach is appropriate for their objectives, we end each section with a discussion of limitations. We conclude with a discussion of General Data Protection Regulation (GDPR) and the practical, philosophical, and policy challenges associated with communicating food safety and nutrition information digitally.

See, Like, Share, Remember: Adolescents' Responses to Unhealthy-, Healthy- and Non-Food Advertising in Social Media.

Media-saturated digital environments seek to influence social media users' behaviour, including through marketing. The World Health Organization has identified food marketing, including advertising for unhealthy items, as detrimental to health, and in many countries, regulation restricts such marketing and advertising to younger children. Yet regulation rarely addresses adolescents and few studies have examined their responses to social media advertising. In two studies, we examined adolescents' attention, memory and social responses to advertising posts, including interactions between product types and source of posts. We hypothesized adolescents would respond more positively to unhealthy food advertising compared to healthy food or non-food advertising, and more positively to ads shared by peers or celebrities than to ads shared by a brand. Outcomes measured were (1a) social responses (likelihood to 'share', attitude to peer); (1b) brand memory (recall, recognition) and (2) attention (eye-tracking fixation duration and count). Participants were 151 adolescent social media users (Study 1: n = 72; 13-14 years; M = 13.56 years, SD = 0.5; Study 2: n = 79, 13-17 years, M = 15.37 years, SD = 1.351). They viewed 36 fictitious Facebook profile feeds created to show age-typical content. In a 3 × 3 factorial design, each contained an advertising post that varied by content (healthy/unhealthy/non-food) and source (peer/celebrity/company). Generalised linear mixed models showed that advertisements for unhealthy food evoked significantly more positive responses, compared to non-food and healthy food, on 5 of 6 measures: adolescents were more likely to wish to 'share' unhealthy posts; rated peers more positively when they had unhealthy posts in their feeds; recalled and recognised a greater number of unhealthy food brands; and viewed unhealthy advertising posts for longer. Interactions with sources (peers, celebrities and companies) were more complex but also favoured unhealthy food advertising. Implications are that regulation of unhealthy food advertising should address adolescents and digital media.

General practitioners' (GP) attitudes and knowledge about attention deficit hyperactivity disorder (ADHD) in Ireland.

BACKGROUND: ADHD is the most frequent reason for attendance at Child and Adolescent Mental Health Services (CAMHS). General practitioners (GPs) play a key role in recognising symptoms, referring for assessment and supporting ongoing treatment. However, there is an ambiguous understanding of ADHD among GPs, and different attitudes regarding the validity of ADHD as a construct. The present study aims to explore and identify GPs attitudes and beliefs about ADHD in the Irish context, and to find out the association of those attitudes with other factors. METHODS: Representative sample of qualified GPs registered to the Irish Medical Directory. The survey included questions about GPs' practice, attitudes towards ADHD, knowledge of symptoms and workup for ADHD, previous training and personal experience of ADHD. RESULTS: A hundred and forty GPs participated (response rate 28%). Factor analysis indicated 58.8% expressed a positive attitude towards ADHD. Those who have positive attitudes were more likely to be between 36 and 55 years old, seeing fewer children with suspected ADHD per year and working as part of a primary care team. Years of practice, personal experience of ADHD, training and knowledge in ADHD and access to CAMHS or psychology were not significantly related to either positive or negative ADHD attitudes. CONCLUSIONS: Despite the high rates of ADHD among children, a slim majority of Irish GPs have positive attitudes towards ADHD. This could lead to undiagnosed or misdiagnosed cases. Strategies need to be considered to address this.

How do adults define the treats they give to children? A thematic analysis.

One in four children on the Island of Ireland are overweight or obese. The consumption of energy-dense, nutrient-poor foods such as snacks, contribute to one fifth of children's calorie intake. However the snack food literature has failed to draw firm conclusions between snack food intake and obesity. Within this literature, the word snack and treat are used interchangeably, inconsistently and in differing contexts, which may explain the poor link between snacks or extra foods, and overweight or obesity. There is currently no academic definition of the word 'treat' relevant to an Irish population. Defining how adults perceive the treats they give children is of particular importance in the context of children's diets, and may provide insight into the relative contribution of treats to energy intakes. With ten focus groups of adult caregivers of children, across the Island of Ireland, this study aimed to investigate treat giving behaviour. This research highlights a paradoxical definition of treats: a treat was identified as an energy-dense food that gave pleasure, was deserved and believed to be infrequent; participants perceived this to be the true definition of treats which was coined "real treats". However, in reality, treats were given and consumed frequently, downgrading the status of these treats to "regular treats" which reflected their real-life use. Developing the definition of treats for an adult population, may enhance our understanding of why adults give food treats to children, the role this has on the development of eating habits, the design of interventions and communication strategies to reduce the consumption of non-nutritive foods, labelled by adults as treats.

Is it still a real treat? Adults' treat provision to children.

Consumption of high-energy foods in the absence of hunger has been identified as a key target to address in the area of obesity. For children, such foods are often provided by adults as treats. There is limited understating of adults' treat giving. The present study aimed to understand adults' provision of treats to children on the Island of Ireland. A total of 1039 participants, including parents, grandparents, child minders and education practitioners completed a face-to-face survey in their home. Participants defined their treats for children primarily as 'something nice', 'deserved/earned' and 'something special'. The top three motivations for treat foods provision were 'to reward for good behaviour' (42.3%), 'because the child(ren) ask' (42.2%) and 'to make the child(ren) feel better' (29.4%). Almost all participants would provide treat foods at celebrations and 52.5% always did so. In addition, 68% participants had structured weekly and/or daily treat for children. Treats provided to children were dominated by energy-dense foods. The top three were sweets, chocolates and ice-creams, being used by 45.2%, 45.1% and 38.8% participants. Variations were observed across different adult groups, in terms of their treat giving behaviour. The main observation was that adults' treat foods provision has become habitual. The findings can help develop targeted strategies to encourage the reduction or replacement of food treats for children.

Transitioning from child and adolescent mental health services with attention-deficit hyperactivity disorder in Ireland: Case note review.

In a context of international concern about early adult mental health service provision, this study identifies characteristics and service outcomes of young people with attention-deficit hyperactivity disorder (ADHD) reaching the child and adolescent mental health service (CAMHS) transition boundary (TB) in Ireland. The iTRACK study invited all 60 CAMHS teams in Ireland to participate; 8 teams retrospectively identified clinical case files for 62 eligible young people reaching the CAMHS TB in all 4 Health Service Executive Regions. A secondary case note analysis identified characteristics, co-morbidities, referral and service outcomes for iTRACK cases with ADHD (n = 20). Two-thirds of young people with ADHD were on psychotropic medication and half had mental health co-morbidities, yet none was directly transferred to public adult mental health services (AMHS) at the TB. Nearly half were retained in CAMHS, for an average of over a year; most either disengaged from services (40%) and/or actively refused transfer to AMHS (35%) at or after the TB. There was a perception by CAMHS clinicians that adult services did not accept ADHD cases or lacked relevant service/expertise. Despite high rates of medication use and co-morbid mental health difficulties, there appears to be a complete absence of referral to publicly available AMHS for ADHD youth transitioning from CAMHS in Ireland. More understanding of obstacles and optimum service configuration is essential to ensure that care is both available and accessible to young people with ADHD.

"Bursting" to Go and Other Experiences.

Children's use of the toilet at school, although rarely explored, is an important facet of school experience with consequences for physical and psychological health. A mixed methods study investigated views of 25 children (4-5 years) regarding potential stressors in the first school year, including views of toileting, in Dublin, Ireland. Despite very positive responses to school, most responses to toileting (15 of 25) were mixed or negative. Although some liked to go, or noted the toilets were clean, most indicated delayed toilet use ("bursting" to go) and ambivalent or negative experiences such as fear of not identifying the right toilet, fear of being alone, lack of privacy, and potential bullying. Many children did not expect to receive help from the teacher. As delaying toilet use can have lasting health consequences, teacher-nurse collaboration could be used to develop whole-school policies to support children's early adjustment in this sensitive area of functioning.

What do general practitioners know about ADHD? Attitudes and knowledge among first-contact gatekeepers: systematic narrative review.

BACKGROUND: Attention Deficit Hyperactivity Disorder (ADHD) is a common childhood disorder with international prevalence estimates of 5 % in childhood, yet significant evidence exists that far fewer children receive ADHD services. In many countries, ADHD is assessed and diagnosed in specialist mental health or neuro-developmental paediatric clinics, to which referral by General (Family) Practitioners (GPs) is required. In such 'gatekeeper' settings, where GPs act as a filter to diagnosis and treatment, GPs may either not recognise potential ADHD cases, or may be reluctant to refer. This study systematically reviews the literature regarding GPs' views of ADHD in such settings. METHODS: A search of nine major databases was conducted, with wide search parameters; 3776 records were initially retrieved. Studies were included if they were from settings where GPs are typically gatekeepers to ADHD services; if they addressed GPs' ADHD attitudes and knowledge; if methods were clearly described; and if results for GPs were reported separately from those of other health professionals. RESULTS: Few studies specifically addressed GP attitudes to ADHD. Only 11 papers (10 studies), spanning 2000-2010, met inclusion criteria, predominantly from the UK, Europe and Australia. As studies varied methodologically, findings are reported as a thematic narrative, under the following themes: Recognition rate; ADHD controversy (medicalisation, stigma, labelling); Causes of ADHD; GPs and ADHD diagnosis; GPs and ADHD treatment; GP ADHD training and sources of information; and Age, sex differences in knowledge and attitudes. CONCLUSIONS: Across times and settings, GPs practising in first-contact gatekeeper settings had mixed and often unhelpful attitudes regarding the validity of ADHD as a construct, the role of medication and how parenting contributed to presentation. A paucity of training was identified, alongside a reluctance of GPs to become involved in shared care practice. If access to services is to be improved for possible ADHD cases, there needs to be a focused and collaborative approach to training.

Perspectives of family members of people with an intellectual disability to a major reconfiguration of living arrangements for people with intellectual disability in Ireland.

AIM: To document the views of family members of people with an intellectual disability regarding implementation of a personalized model of social support in Ireland. METHOD: Forty family members participated in six focus groups. Data were thematically analysed. RESULTS: Family members' preference for particular types of living arrangements were highly reflective of their lived experience. Facilitators to community living included timely information on proposed moves, adequate staffing, suitable properties and locations and consideration of the characteristics of individuals who share a property. Barriers included high support needs, advanced age, a fear of relinquishing current supports, a fear of the sustainability of newer models of residential support and concerns about community opposition. CONCLUSION: The family perspective to reform is characterized by fear and suspicion of the motivation behind these reforms, with cost efficiencies being perceived as a main driver. Greater information is required to empower families to make informed decisions.

Young children's food brand knowledge. Early development and associations with television viewing and parent's diet.

Brand knowledge is a prerequisite of children's requests and choices for branded foods. We explored the development of young children's brand knowledge of foods highly advertised on television - both healthy and less healthy. Participants were 172 children aged 3-5 years in diverse socio-economic settings, from two jurisdictions on the island of Ireland with different regulatory environments. Results indicated that food brand knowledge (i) did not differ across jurisdictions; (ii) increased significantly between 3 and 4 years; and (iii) children had significantly greater knowledge of unhealthy food brands, compared with similarly advertised healthy brands. In addition, (iv) children's healthy food brand knowledge was not related to their television viewing, their mother's education, or parent or child eating. However, (v) unhealthy brand knowledge was significantly related to all these factors, although only parent eating and children's age were independent predictors. Findings indicate that effects of food marketing for unhealthy foods take place through routes other than television advertising alone, and are present before pre-schoolers develop the concept of healthy eating. Implications are that marketing restrictions of unhealthy foods should extend beyond television advertising; and that family-focused obesity prevention programmes should begin before children are 3 years of age.

'Big, strong and healthy'. Young children's identification of food and drink that contribute to healthy growth.

Growing awareness of the importance of healthy diet in early childhood makes it important to chart the development of children's understanding of food and drink. This study aimed to document young children's evaluation of food and drink as healthy, and to explore relationships with socioeconomic status, family eating habits, and children's television viewing. Data were gathered from children aged 3-5 years (n=172) in diverse socioeconomic settings in Ireland, and from their parents. Results demonstrated that children had very high levels of ability to identify healthy foods as important for growth and health, but considerably less ability to reject unhealthy items, although knowledge of these increased significantly between ages 3 and 5. Awareness of which foods were healthy, and which foods were not, was not related to family socioeconomic status, parent or child home eating habits, or children's television viewing. Results highlighted the importance of examining young children's response patterns, as many of the youngest showed a consistent 'yes bias'; however, after excluding these responses, the significant findings remained. Findings suggest it is important to teach children about less healthy foods in the preschool years.