the WHO nutrient profile model for the EMR Lara Nasreddine, PhD - - PowerPoint PPT Presentation

Assessment of the nutritional quality of food advertised to children in Lebanon: the first study to use the WHO nutrient profile model for the EMR

Lara Nasreddine, PhD

Department of Nutrition and Food Sciences Faculty of Agricultural and Food Sciences American University of Beirut, Lebanon

5th Dubai International Nutrition Congress, 24-26 October 2019, Dubai

Obesity in Lebanon

Like other countries of the EMR, Lebanon is undergoing the nutrition transition with its characteristic shift in diet, lifestyle and obesity prevalence

Economic growth Modernization Globalization of trade and marketing Rapid urbanization Changes in food environment Reduced physical activity

Childhood Obesity in Lebanon

Prevalence of Overweight and Obesity (%) in Children (0-5yrs)

(Nasreddine et al., unpublished data)

At risk of overweight (+1< BMI-for-age z-score ≤+2) Obese (BMI-for-age z-score >3) Overweight and obese (BMI-for-age z-score > 2)

25.1 8.1 3.3 11.9 5 10 15 20 25 30 At risk of

• verweight

Overweight

• nly

Obesity Overweight & Obesity %

Prevalence of overweight and obesity in children aged 0-5 y in 2010

8.5 6.7 8.7 17 7.6 6.4 4.9 5.2 3.5 4.6 14.7 6.9 9.6 7.2 6.8 3.5 6.1 11.7 6.7 2 4 6 8 10 12 14 16 18 Africa Eastern Middle Northern Southern Western Asia Eastern South Central Southeastern Western Latin America and Caribbean Caribbean Central America South America Oceania Developing countries Developed countries Global

Africa Asia

Latin America & Caribbean

Lebanon: 11.9 %

(de Onis & Blössner, 2010)

1Nasreddine et al., 2012 (6-19yrs); 2Nasreddine et al., 2010 (15-18yrs); 3Malik and Bakir, 2007 (14-17yrs); 4Bader et al., 2008 (15-18yrs); 5El-Bayoumy et al.,

2009 (10-14yrs); 6Bener , 2006 (12-17yrs); 7Al Dossary et al., 2010 (2-18yrs); 8Taheri et al., 2013 (6-11 yrs); 9Aounallah-Shikri et al., 2008 (15-19yrs);

10Khader et al., 2009 (6-12yrs)

38.5 37.2 32.3 29.5 44.5 36.5 44.4 21.9 21.5 24.4 26.6 27.8 32.2 36.8 46.3 23.6 39.6 16.2 25.1 25.4 5 10 15 20 25 30 35 40 45 50

Lebanon 1 (WHO 2007) Syria 2 (IOTF) UAE 3 (IOTF) Bahrain 4 (WHO 1995) Kuwait 5 (NCHS 1976-1980) Qatar 6 (IOTF) Saudi Arabia 7 (CDC 2000) Iran 8 (CDC 2000) Tunisia 9 (WHO 1995) Jordan 10 (IOTF)

Overweight and Obese (%) Country Boys Girls

Prevalence of overweight and obesity (%) among children & adolescents in Lebanon and other Middle-Eastern countries

Trends in Overweight & Obesity in Lebanon

National Study conducted among children and adolescents in Lebanon to determine the trends in childhood obesity between 1997 and 2009 (12 years)

(Nasreddine et al., 2012)

→ Obesity increased by almost 50% in boys & girls

Trends of Childhood Obesity: Lebanon (1997-2009)

10.2 5.4 7.3 15.5 6.9 10.9 2 4 6 8 10 12 14 16 18 Boys Girls Both Genders % 1997 2009

(Nasreddine et al., 2012)

6-11 years: High fast food intake Urban High SES 0-2 years: Sugar intake > 1-%EI Maternal BMI 12-19 years: High intake of SSB Parental obesity Sedentarity 2-5 years: Fat intake>25% EI Frequency of eating in front of TV High SES

What Are the Factors Associated with Childhood Obesity in Lebanon?

(Nasreddine et al., 2017; Nasreddine et al., 2014; Nasreddine et al., unpublished data)

(UK Government’s Foresight Programme, 2007)

Media exposure as a modulator

• f eating patterns

Food marketing and eating patterns in children

• Children are affected by advertisement at all ages and are the

most susceptible compared to other age groups.

• Advertising is effective in getting children to request more energy

rich food.

• Frequent use of media has also been associated:
• ↑ intakes of total energy, fat, sweet and savory snacks and soft

drinks

• ↓ intakes of fruits and vegetables
• ↓ physical activity
• The term “ObesiTV” proposed by Boulos et al., 2012 “How

television is influencing the obesity epidemic”.

(Robinson et al., 2017; Boulos et al., 2012; Coon and Tucker, 2002)

Directing marketing towards the youth as young as toddlers → To create brand recognition and loyalty → Direct and causal effect

• n children’s food

preference, behaviors, purchase and consumption

(Story and French, 2004)

Marketing Techniques 1) Food product appeals: premium offers, quality, novelty 2) Emotional appeals: fun, action, peer acceptance, hero, coolness, energy 3) Visual elements: animation, promotional characters, cartoon, celebrities, meal portrayal, food setting

“Art of Persuasion”

(Hebden et al., 2011)

How do children understand food advertisements?

• Product preference in children occurs just after 1 single

commercial exposure.

• A 30-second exposure significantly modifies food preference

in pre-school children.

(Borzekowski et al., 2003)

Media Literacy and Children

Media literacy, the ability to analyze and evaluate messages put into different contexts, significantly varies by age1

• Under the age of 7 years:
• Accept advertisements as being “truthful, accurate and unbiased”. -

Do not fully comprehend the persuasive intentions2

• Between 8 and 10 years:
• Have the cognitive ability to evaluate misleading advertisement
• But do not necessarily apply these skills spontaneously2
• Above 10 years:

Emotional appeal exploited in advertisements can influence adolescents’ food choices regardless of their cognitive maturity2

(Livingstone and Helsper, 2004)

Nutrient profiling as a tool to limit food marketing

According to the WHO: Nutrient profiling is one mechanism that countries can use in implementing the set of recommendations

• n the marketing of foods and non-alcoholic

beverages to children that were endorsed by the 63rd World Health Assembly (WHA63.41).

(World Health Organization, 2011)

Nutrient Profiling: Definition

(World Health Organization, in press)

In the Eastern Mediterranean Region, the WHO has recently developed a nutrient profiling system adapted to the dietary guidelines

• f the region

(World Health Organization EMRO, 2017)

Study in Lebanon

Objectives:

• 1. Analyze the frequency and types of food and drink

advertisements during children’s viewing time in Lebanon.

• 2. Examine the nutritional content of the advertised food products

in reference to the nutrient thresholds specified by the WHO EMR nutrient profile model.

• 3. Assess the proportion of food advertisements that include health

messages and disclaimers.

(Nasreddine et al., 2019)

Methodology

Content analysis of food and beverage advertisements broadcasted on local TV channels during children’s viewing time in Lebanon. Selection of local TV channels was based on TV ratings and viewership share data acquired from IPSOS Lebanon. Selection was based on viewership data pertinent to the age group 4–14 years. Channels with a viewership share exceeding 20% were included in the study. Accordingly, 3 out of 9 nine local TV channels were selected: Channel A, Channel B, and Channel C . Recorded broadcasts from the 3 channels were purchased from IPSOS, covering the period between September 2016 and January 2017: One week was randomly selected within each month, and within each week three weekdays and one weekend day were randomly selected. Month of December 2016 was excluded.

(Nasreddine et al., 2019)

Methodology

For weekdays, analysis covered all programs broadcasted between 3 pm (i.e. after the end of the school day) and 10 pm. For weekend days, analysis covered all programs broadcasted between 8 am and 10 pm. As such, the sample covered 385 hours of TV broadcasting and included 12 weekdays and 4 weekend days. Within these timeslots, programs that rated highest in terms of viewership among children and adolescents (4–14 years) were selected for analysis. Accordingly, current affairs programs, news, cooking, and political talk shows were excluded. Programs that were included in the analysis comprised:

• Children’s shows or C-rated programs;
• G-rated (those suitable for children to view without adult

supervision);

• PG-rated programs (such as local soap operas or series and some

entertainment programs).

(Nasreddine et al., 2019)

Methodology

Of the 385 h, 226 h were analyzed. Data collection: For each food or drink Ad, the coders recorded: Time of day, type of food or drink being advertised, brand, whether the advertisement included health or nutrition claims, or health disclaimers (warning about excess consumption).

(Nasreddine et al., 2019)

A total of 1,393 Ads were for foods or beverages, representing 31% of total Ads.

Results

Proportion of food Ads was the highest during C-rated programs (43.2%) compared to G- and PG-rated programs.

(Nasreddine et al., 2019)

• But, in our study, only 11 h of the total 226 analyzed hours

were devoted to C-rated programs, highlighting the scarcity of such programs on Lebanese TV channels.

• Thus, in our study, the majority of food-related

advertisements came from G-rated programs, with a total of 818 advertisements, at a frequency of six per hour. The highest proportion of food advertisements was observed during C-rated programs.

(Nasreddine et al., 2019)

14% 2% 6% 8% 4% 2% 2% 26% 6% 8% 2% 2% 2% 16%

Percentage (%) of advertised food in each category Energy drinks, alcohol and coffee were advertised during G and PG programs. Most highly advertised categories were chocolate & sweets, and cakes, biscuits & pastries.

(Nasreddine et al., 2019)

33.3 16.7 13.9 11.1 25 5 10 15 20 25 30 35 Chocolate sugar and sweets Savory snacks Milk drinks

• ther beverages

Cheeses

% of food Ads by food category during C programs

(Nasreddine et al., 2019)

Comparison of the Nutrient Content of Advertised Food to Nutritional Standards

Food Composition Data 1- Nutrition Fact labels on pre-packaged items Trained nutritionists visited large supermarket chains to obtain food items that were advertised → Energy and nutrients from Nutrition Fact Labels of pre-packaged foods were extracted. 2- Manufacturer’s website For food items with no nutrition facts on the package, the official manufacturer website was visited for relevant data on the specific item advertised. 3- Nutritionist Pro software When data was not available on packages and website, food items with nutritionally similar food items were consulted using the USDA database

• n the Nutritionist Pro software.

(Nasreddine et al., 2019)

Regional Nutrient Profile Model

Food advertised to children in Lebanon: evaluated for content of energy and 6 nutrients against the marketing threshold values of each nutrient per each food category Are the food advertised to children allowed for promotion?

• Energy (Kcal/100 g)
• Total fat (g/100 g)
• Saturated fat (g/100 g)
• Added sugar (g/100 g)
• Total sugar (g/100 g)
• Sodium (g/100 g)
• Added sweeteners

(presence/absence)

(World Health Organization EMRO, 2017; Nasreddine et al., 2019)

Foods Advertised for Children

WHO Regional Nutrient Profile Model ALLOWED for advertising: 16.3% PROHIBITED from advertising: 83.7%

(Nasreddine et al., 2019)

Proportion of TV food advertisements assessed as ‘permit ted’ or ‘not permitted’ for marketing to children, based on the WHO EMR model

(Nasreddine et al., 2019)

Rationale for Prohibiting Advertised Food Items

10 20 30 40 50 60 70 Sugar Total fat Saturated fat Salt Sweetener

58.3 % 62.5 % 55.6 % 27.8 % 1.4 %

(Nasreddine et al., 2019)

Proportions (%) of food advertisements with health and nutrition claims or health disclaimers, by type of TV program All the advertisements that comprised a health or nutrition claim and that were broadcasted during the C-rated programs were for foods that did not meet the nutritional standards of the WHO EMR model. Also the majority in G and PG programs.

(Nasreddine et al., 2019)

Conclusion and Future Perspectives Approximately 8 out of 10 food Ads were for foods or drinks that did not meet the nutrition standards set by the model.

These results are similar to the US (9/10) while being higher than estimates reported from Spain, Canada, New Zealand, the UK (5-6/10), and Norway (2/10).

The advertising of healthier options was very low

(Romero-Fernandez et al., 2013; Jenkin et al., 2009; Adams et al., 2009; Batada et al., 2008)

Conclusion

TV food Ads during children’s viewing times is disproportionately promoting the consumption

• f foods high in fat, sugar,

and salt, thus promoting unhealthy dietary patterns in children. A particularly concerning finding in this study was the frequent advertisement of alcoholic drinks during and around the G- and PG-rated programs.

(Nasreddine et al., 2019; Zuppa et al., 2003)

Jan 25, 2016: Commission on Ending Childhood Obesity (ECHO) presented its final report to the Director- General of WHO 2-year process that involved discussions with more than 100 countries

Important questions:

• 1. Why have efforts to date failed to stop the

rise in childhood obesity?

• 2. Can emerging trends in low-income and

middle-income countries be reversed?

www.thelancet.com Published online January 25, 2016 http://dx.doi.org/10.1016/S0140- 6736(16)00140-9 1

Inadequate consideration of several factors has probably limited previous eff orts to address childhood

• besity.

Children increasingly growing up in an obesogenic environment (changes in food type, availability, affordability, and marketing, as well as a decline in physical activity)

www.thelancet.com Published online January 25, 2016 http://dx.doi.org/10.1016/S0140- 6736(16)00140-9 1

ECHO report proposes a set of policy recommendations for a comprehensive package of interventions to address three strategic objectives.

• 1. Tackle the obesogenic environment .
• 2. Reduce the risk of obesity during critical periods in the life

course— preconception and pregnancy, infancy and early childhood, and older childhood and adolescence.

• 3. Provide treatment for children who are obese to improve

their current and future health.

The WHO EMR profiling model may be used by policy makers as a tool to limit the marketing of foods that are high in fat, sugar, and salt during children’s viewing times.

(World Health Organization, 2010; Magnus et al., 2009; Zuppa et al., 2003; World Health Organization, 2000)

Tackling the

• besogenic

environement

Together we can make a difference

References

• Adams, J., Hennessy-Priest, K., Ingimarsdóttir, S., Sheeshka, J., Østbye, T., & White, M. (2009). Food advertising

during children’s television in Canada and the UK. Archives of Disease in Childhood, 94(9), 658-662.

• Al Dossary, S. S., Sarkis, P. E., Hassan, A., Ezz El Regal, M., & Fouda, A. E. (2010). Obesity in Saudi children: a

dangerous reality.

• Aounallah-Skhiri, H., Romdhane, H. B., Traissac, P., Eymard-Duvernay, S., Delpeuch, F., Achour, N., & Maire, B.

(2008). Nutritional status of Tunisian adolescents: associated gender, environmental and socio-economic

• factors. Public health nutrition, 11(12), 1306-1317.
• Bader, Z., Musaiger, A. O., Al-Roomi, K., & D'Souza, R. (2008). Overweight and obesity among adolescents in
• Bahrain. Anthropologischer Anzeiger; Bericht uber die biologisch-anthropologische Literatur, 66(4), 401-407.
• Batada, A., Seitz, M. D., Wootan, M. G., & Story, M. (2008). Nine out of 10 food advertisements shown during

Saturday morning children’s television programming are for foods high in fat, sodium, or added sugars, or low in nutrients. Journal of the American Dietetic Association, 108(4), 673-678.

• Bener, A. (2006). Prevalence of obesity, overweight, and underweight in Qatari adolescents. Food and nutrition

bulletin, 27(1), 39-45.

• Boulos, R., Vikre, E. K., Oppenheimer, S., Chang, H., & Kanarek, R. B. (2012). ObesiTV: how television is

influencing the obesity epidemic. Physiology & behavior, 107(1), 146-153.

• Borzekowski, D. L., & Robinson, T. N. (2001). The 30-second effect: an experiment revealing the impact of

television commercials on food preferences of preschoolers. Journal of the American Dietetic Association, 101(1), 42-46.

• Coon, K. A., & Tucker, K. L. (2002). Television and children’s consumption patterns. Minerva pediatrica, 54(5),

423-36.

References

• De Onis, M., Blössner, M., & Borghi, E. (2010). Global prevalence and trends of overweight and obesity among

preschool children. The American journal of clinical nutrition, 92(5), 1257-1264.

• El-Bayoumy, I., Shady, I., & Lotfy, H. (2009). Prevalence of obesity among adolescents (10 to 14 years) in
• Kuwait. Asia Pacific Journal of Public Health, 21(2), 153-159.
• Hebden, L., King, L., & Kelly, B. (2011). Art of persuasion: an analysis of techniques used to market foods to
• children. Journal of paediatrics and child health, 47(11), 776-782.
• Jenkin, G., Wilson, N., & Hermanson, N. (2009). Identifying ‘unhealthy’food advertising on television: a case

study applying the UK Nutrient Profile model. Public health nutrition, 12(5), 614-623.

• Khader, Y., Irshaidat, O., Khasawneh, M., Amarin, Z., Alomari, M., & Batieha, A. (2009). Overweight and obesity

among school children in Jordan: prevalence and associated factors. Maternal and child health journal, 13(3), 424.

• Livingstone, S., & Helsper, E. (2004). Advertising foods to children: understanding promotion in the context of

children’s daily lives. London, UK: Department of Media and Communications, London School of Economics and Political Science.

• Magnus, A., Haby, M. M., Carter, R., & Swinburn, B. (2009). The cost-effectiveness of removing television

advertising of high-fat and/or high-sugar food and beverages to Australian children. International journal of

• besity, 33(10), 1094.
• Malik, M., & Bakir, A. (2007). Prevalence of overweight and obesity among children in the United Arab
• Emirates. Obesity reviews, 8(1), 15-20.

References

• Nasreddine, L., Hwalla, N., Saliba, A., Akl, C., & Naja, F. (2017). Prevalence and correlates of preschool
• verweight and obesity amidst the nutrition transition: findings from a national cross-sectional study in
• lebanon. Nutrients, 9(3), 266.
• Nasreddine, L., Mehio‐Sibai, A., Mrayati, M., Adra, N., & Hwalla, N. (2010). Adolescent obesity in Syria:

prevalence and associated factors. Child: care, health and development, 36(3), 404-413.

• Nasreddine, L., Naja, F., Akl, C., Chamieh, M., Karam, S., Sibai, A. M., & Hwalla, N. (2014). Dietary, lifestyle and

socio-economic correlates of overweight, obesity and central adiposity in Lebanese children and

• adolescents. Nutrients, 6(3), 1038-1062.
• Nasreddine, L., Naja, F., Chamieh, M. C., Adra, N., Sibai, A. M., & Hwalla, N. (2012). Trends in overweight and
• besity in Lebanon: evidence from two national cross-sectional surveys (1997 and 2009). BMC public

health, 12(1), 798.

• Nasreddine, L., Taktouk, M., Dabbous, M., & Melki, J. (2019). The extent, nature, and nutritional quality of

foods advertised to children in Lebanon: the first study to use the WHO nutrient profile model for the Eastern Mediterranean Region. Food & nutrition research, 63.

• Robinson, T. N., Banda, J. A., Hale, L., Lu, A. S., Fleming-Milici, F., Calvert, S. L., & Wartella, E. (2017). Screen

media exposure and obesity in children and adolescents. Pediatrics, 140(Supplement 2), S97-S101.

• Romero-Fernandez, M. M., Royo-Bordonada, M. A., & Rodríguez-Artalejo, F. (2013). Evaluation of food and

beverage television advertising during children's viewing time in Spain using the UK nutrient profile

• model. Public health nutrition, 16(7), 1314-1320.
• Story, M., & French, S. (2004). Food advertising and marketing directed at children and adolescents in the
• US. International Journal of Behavioral Nutrition and Physical Activity, 1(1), 3.

References

• Taheri, F., Kazemi, T., Chahkandi, T., Namakin, K., Zardast, M., & Bijari, B. (2013). Prevalence of overweight,
• besity and central obesity among elementary school children in Birjand, east of Iran, 2012. Journal of

research in health sciences, 13(2), 157-161.

• UK government. (2007). Reducing obesity: obesity system map.

https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/296290/

• besity-map-full-hi-res.pdf.
• World Health Organization. (2000). Obesity: preventing and managing the global epidemic. Report of a WHO

Consultation (WHO Technical Report Series 894). Geneva, Switzerland. https://www.who.int/nutrition/publications/obesity/WHO_TRS_894/en/.

• World Health Organization. (2010). Set of recommendations on the marketing of foods and non-alcoholic

beverages to children. https://apps.who.int/iris/bitstream/handle/10665/44416/9789241500210_eng.pdf?sequence=1.

• World Health Organization. (2011). Nutrient profiling: report of a WHO/IASO technical meeting. London,

United Kingdom: 4-6 October 2010. https://www.who.int/nutrition/publications/profiling/WHO_IASO_report2010.pdf?ua=1

• World Health Organization. Regional Office for the Eastern Mediterranean. (2017). Nutrient profile model for

the marketing of food and non-alcoholic beverages to children in the WHO Eastern Mediterranean Region. https://apps.who.int/iris/bitstream/handle/10665/255260/EMROPUB_2017_en_19632.pdf

• World Health Organization. (in press). Guiding principles and framework manual for the development or

adaptation of nutrient profile models.

• Zuppa, J., Morton, H., & Mehta, K. P. (2003). Television food advertising: Counterproductive to childrens health?

A content analysis using the Australian Guide to Healthy Eating. Dietitians Association of Australia.