Article

The Ethics of Unhealthy Food and Beverage American Business Review

Nov. 2024, Vol.27(2) 706 - 774
Advertising to Children: A Bibliometric Analysis © The Authors 2024, CC BY-NC
ISSN: 2689-8810 (Online)
and Future Research Agenda ISSN: 0743-2348 (Print)

Parul Guptaa, Ritu Srivastavaa, Shalini Jainb, and Shailendra P. Jainc

https://doi.org/10.37625/abr.27.2.706-774

ABSTRACT
The widely advertised category of unhealthy food and beverages (F&B) is calorie-dense, nutrient-poor, and
associated with long-term harm, particularly for children. Business literature has been largely silent regarding
the ethicality of its advertising targeting children and lacks clarity on questions future research needs to
address. Based on a bibliometric analysis of 1,851 articles published between 1973 and 2021 containing 70,379
citations, we uncovered five intellectual clusters underlying research on the ethics of unhealthy F&B advertising
to children (ATC). Importantly, we propose a concrete roadmap featuring actionable and pertinent
unanswered questions to stimulate research in this crucial domain.

KEYWORDS
Ethics of Unhealthy Food and Beverage Advertising Targeting Children, Bibliometric Analyses, Co-Citation
Analysis, Cluster-Content Analysis

INTRODUCTION

The global unhealthy food and beverages (F&B) market is projected to grow from $972.74 billion (2021)
to $1,467 billion by 2028 (Fortune Business Insights, 2022), with advertising being a significant
contributor to this growth (Kelly et al., 2019). Children constitute a crucial demographic for F&B
marketers. For example, in 2019 in the US, not unlike its global peers, an average of 830 television (TV)
ads were seen by 2-5 year-olds (2.3 ads/day), 787 by 6-11 year-olds (2.2 ads/day), and 775 by 12-17 year-
olds (2.1 ads/day: Harris, et al., 2021).
Unhealthy F&B are calorie-dense, nutrient-poor, and high in added saturated/trans fats, sugar, or
sodium (HFSS; Story et al., 2008). Consuming them carries potential long-lasting harm to children,
ranging from physical, psychological, behavioral, social, and educational (Dittmar et al., 2014). One of
its most damaging outcomes is childhood obesity (Lauber, McGhee et al., 2021) which is linked to
chronic diseases that continue to manifest into adulthood, such as Type 2 diabetes, heart disease,
cancer, and osteoporosis (AHA, 2019).
Psychologically, children are unable to discern F&B advertisers’ persuasive intent, distinguish
between programs and commercials and between animated and human characters (Carter et al., 2011),
they disregard negative consequences (Kacen & Lee, 2002), making a higher frequency of purchase
requests impulsively (Kunkel et al., 2013). Such persuasive appeals are argued to undermine parental
authority (Linn, 2004; Antonetti & Baines, 2015), promoting ‘junk’ food as oppositional and cool (Schor
& Ford, 2007). Driven by a profit motive, firms ostensibly employ experts to tap into these
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a Management Development Institute Gurgaon, Haryana, India
b University of Washington Tacoma, Washington, U.S.A
c University of Washington Seattle, Washington, U.S.A

Corresponding Author:
S. P. Jain ([email protected])

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developmental vulnerabilities and allocate large budgets for advertising to children (ATC; Linn &
Novosat, 2008). Studies also point to lower ethicality associated with advertising targeting children
than targeting adults (Lee & Nguyen, 2013). Furthermore, advertising, even for general audiences,
often targets children (Warren et al., 2008).
Globally, F&B ATC-related policies have been introduced sporadically, with varying levels of
stringency, and with the US being the least regulated of its peers. For instance, Sweden’s effort to
regulate food advertising to children started in 1991. Other nations timelines were as follows: UK,
Germany, Finland, Romania (2007), Australia, Thailand (2008), Spain (2009), South Africa, Mexico
(2014), France, Chile (2016), Portugal (2019), and India (2020). Despite these protections, unhealthy
F&B consumption by children continues to increase (Gómez & Rajmil, 2022).

RESEARCH GAPS

These concerns have led to research in healthcare (Swinburn et al., 2011), media communications
(Strasburger & Council of Communications and Media, 2011), and public policy (Kelly et al., 2019).
However, business academia, a key owner of advertising scholarship, has yet to systematically
examine this phenomenon (see Bakir & Vitell, 2010; Rose et al., 2012; Srivastava & Gupta, 2021 for
exceptions). Notably, despite a transformed advertising landscape, two decades elapsed (1998-2018)
before a business journal (Journal of Advertising) published a Special Issue on advertising to children.
Between 2000 and 2022, only seven peer-reviewed articles were published in Financial Times 50
journals (FT50; Table 1). Of these, two evaluated the impact of regulation on unhealthy F&B ATC in
Chile and Canada (Alé-Chilet & Moshary, 2022; Dhar & Baylis, 2011), three examined how marketing
strategies (cartoons, incentives for healthful eating, and doubling of portion size) influenced children’s
fast food consumption (Campbell et al., 2016; Raju et al., 2010; Zlatevska et al., 2014), and only two
looked specifically at the ethics of unhealthy F&B ATC (Moore, 2004; Bakir & Vitell, 2010).
The scarcity of pertinent literature assumes greater importance when we consider the potential for
consumers to make even more unhealthy food choices with the advent of AI (Davenport et al. 2019).
This has led us to propose an advancement of this literature, setting our sights on four specific goals:

a) Review the most cited studies in the current body of literature;

b) Quantitatively synthesize perspectives from various knowledge groups, explore their
linkages, and illuminate their evolution over time,
c) Examine these findings through the lens of prominent ethical theories, and
d) Contemplate new avenues for research based on the above findings and those stemming
from a review of more recent research.

To accomplish the first goal, we invoke bibliometric (Donthu et al., 2021) and citation analysis
(Holsapple et al., 1993) of 1,851 articles with 70,379 cited references, helping us identify the 50 most
influential articles published between 1973 and 2021. Towards fulfilling our second goal, we document
a co-citation analysis revealing five intellectual clusters of the most frequently co-cited articles and a
cluster-content analysis that elaborates on the content of these clusters (Hausberg & Korreck, 2020).
Next, we examine these findings through the framework of the four most prominent business ethics
theories – social contract, deontology, utilitarianism, and relativism to identify the gap between
corporate action and normative perspectives. Finally, since more recent ATC literature is unlikely to
be heavily cited to be included in the bibliometric analysis, we comment on this scholarship
qualitatively to afford further insights. This supplementation of the past with the current leads us to
our ultimate goal – delineating a future research roadmap and a call for action.

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Table 1. Financial Times FT 50 Journal Articles Examining Food and Beverage Advertising to Children
(2000-2022)
# Authors Title Publication Findings Implications
The blurring of advertising and
entertainment targeted at children is
a social, political, and ethical issue
that deserves our collective
Moore Children and the attention. The range, level, and
Journal of
1 (2004) Changing World of sophistication of advertising
Business Ethics
Advertising targeted to children continues to
accelerate. It is time to resurrect
formal public debate about our
increasingly sophisticated media
system and its role in children’s lives.
Although both, younger and older
school children responded more
favorably to the competition
intervention than to the pledge or
Marketing Healthful incentive interventions, the effects of
Eating to Children: the competition and incentive
Raju et al.,
The Effectiveness of Journal of interventions were more pronounced
2 (2010)
Incentives, Pledges, Marketing among younger children. A second
and Competitions field study examined the role of
pledge reminders on adherence to
the pledge. The presence of a visible
reminder of a pledge resulted in
significantly better outcomes than no
reminder.
The Ethics of Food Ethical judgments and behavioral
Bakir & Vitell Advertising Targeted Journal of intentions are important constructs
3
(2010) Toward Children: Business Ethics for gaining insights regarding
Parental Viewpoint advertising directed at children.
Fast-Food
Consumption and the
Journal of Advertising bans can be effective
Dhar & Baylis Ban on Advertising
4 Marketing provided media markets do not
(2011) Targeting Children:
Research overlap.
The Quebec
Experience
A doubling of portion size leads to an
Sizing up the Effect average of 35% increase in
Zlatevska et of Portion Size on Journal of consumption. An extended analysis
5
al., (2014) Consumption: A Marketing shows that the effect of portion size
Meta-Analytic Review is curvilinear: as portions become
larger, the effect diminishes.

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Table 1. Continued
# Authors Title Publication Findings Implications
Three experiments with 6 to 14-year-
olds found that overweight cartoon
character primes can activate the
Kids, Cartoons, and
overweight stereotype, leading to
Cookies: Stereotype
Journal of elevated levels of food intake. This
Campbell et Priming Effects on
6 Consumer effect persisted when participants
al., (2016) Children's Food
Psychology were simultaneously exposed to a
Consumption
normal weight and an overweight
character together (study 2) and
were moderated by the activation of
health knowledge (study 3).
This paper examines the effect of
Beyond Consumer nutrition warning labels and
Switching: Supply advertising restrictions on the
Alé-Chilet, &
Responses to Food Marketing breakfast cereal market in Chile. It
7 Moshary
Packaging and Science finds that regulation induces
(2022)
Advertising consumers to switch to products
Regulation without warning labels. Children
serve simply as the context.

Our quantitative and qualitative investigation makes four contributions. We integrate the
intellectual structure of research on the ethics of unhealthy F&B ATC from four independent yet closely
related domains: advertising, child psychology, healthcare, and public policy. Such integration is
necessary as the topic (ethics of ATC) in and of itself draws from each of these domains, making a
multi-domain inquiry essential. Importantly, such a confluence is non-existent in extant work and helps
provide innumerable micro-level insights that a solitary domain focus is unlikely to do. Second, we
document how these disciplines have approached F&B ATC across five decades of research. A longer
temporal horizon enables a more robust tracking of the evolution and development of F&B ATC. In
addition, it helps us garner a deeper understanding of the various perspectives that have been brought
to bear on F&B ATC. Third, we highlight the gap between normative expectations and reality, and the
policy implications associated with the impact of unhealthy F&B ATC. Documentation of such a gap is
a crucial step toward the fourth contribution, whereby we propose concrete research questions to
motivate future research. These questions reveal an ocean of unaddressed possibilities that can
advance scholarship, nudge stakeholders toward more ethical practices, and help formulate policy
toward better outcomes.

LITERATURE REVIEW

Gathering existing knowledge, collecting available evidence, and assessing the state of an academic
field are essential for domain advancement (Kunisch et al., 2018). A search for cross-disciplinary
literature reviews on unhealthy F&B ATC published in the last five decades yielded no exhaustive,
quantitative benchmarks of the domain’s intellectual structure. We found three literature reviews
(Table 2) anchoring on the psychology of persuasion associated with fast-food digital advertising – a
systematic literature review (SLR; Kubacki et al., 2015), a meta-analysis (Folkvord & van’t Riet, 2018),
and a bibliometric analysis (Yoon, 2019). Of these, only Yoon (2019) quantitatively evaluated the impact
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Table 2. Unhealthy Food and Beverage Advertising Literature: Recent Literature Reviews
Author(s)/ Study #Articles
# Year Journal Discipline Methodology Period Reviewed Review Purpose
Examines the data
available on children's
Galbraith- exposure levels to the
Systematic
Emami & Obesity advertising of less healthy
1 Medicine Literature 2008-2013 21
Lobstein Reviews foods since the
Review (SLR)
(2013) introduction of the
statutory and voluntary
codes.
Identifies food and
beverage marketing
Health
Adeigbe et Health strategies used to
2 Education & SLR 1999-2015 194
al. (2015) Care influence food
Behavior
environments for Latinos
versus non-Latinos.
Reviews the extent to
which social marketing
principles are applied in
Kubacki et Young
3 Business SLR 2000-2014 81 interventions targeting
al. (2015) Consumer
children published in
peer-reviewed journals
between 2000 and 2014.
Examines the strength of
the effect of playing
Folkvord & Health Not advergames that promote
4 Appetite Meta-Analysis 15
Riet (2018) Care mentioned unhealthy foods on
(predictors of) eating
behavior among children.
Sheds light on why and
De how social media
Frontiers in Not
5 Veirman et Medicine SLR 8 influencers have
Psychology mentioned
al. (2019) persuasive power over
their young followers.
Explores how research on
Journal of
Yoon Bibliometric advertising within digital
6 Interactive Business 1995-2018 94
(2019) Analysis gaming has developed
Advertising
and evolved.
Captures core research
themes and describes the
intellectual structure of
Srivastava Australian articles published in the
7 & Gupta Journal of Business SLR 2009-2019 70 last decade to track the
(2021) Management adverse impact of
advertising on children’s
health and consumption
behavior.
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Table 2. Continued
# Author(s)/ Journal Discipline Methodology Study #Articles Review Purpose
Year Period Reviewed
Investigates social
media's food and
beverage advertisements'
Kucharczuk Health
8 Appetite SLR 2015-2020 6 role in influencing
et al. (2022) Care
adolescents' food choices
by appraising published
literature.

of advertising, but its scope was limited to digital gaming. The only review examining unhealthy F&B
ATC was qualitative (SLR; Srivastava & Gupta, 2021), which while meritorious, faces hurdles when a
large body of scholarship spanning extended periods is involved (Iacobucci et al., 2019).
To complement existing reviews and bridge the identified quantitative research gap, we use
bibliometric analysis, which, unlike other quantitative literature review methods, considers both,
quantitative and qualitative aspects of the domain of interest (Hota et al., 2019). It allows us to
systematically examine the intellectual linkages among the most influential articles (Janssen, 2007) in
the domain of unhealthy F&B ATC over time and offers a comprehensive view of the research
landscape (Hota et al., 2019). Furthermore, future research can build upon the mapped knowledge
development structure by integrating qualitative research avenues with topics traditionally explored
through quantitative methods or delving deeper into a particular area of interest within the research
field (Linnenluecke et al., 2020).

METHODS

To serve our first objective, we conduct a bibliometric analysis (Donthu et al., 2021) which, when
compared to qualitative reviews, a) captures large amounts of data spanning vast time periods, b)
provides visualization of the intellectual structure of a domain, c) maps linkages among
studies/domains, and d) offers insights regarding potential clustering of overlapping studies. Due to
its rigor and objectivity, bibliometric analysis is extensively used in disciplines such as entrepreneurship
(Hota et al., 2019), sustainability (Gupta & Chauhan, 2021), family business (Niebla-Zatarain et al., 2020),
and business ethics (Uysal, 2010). Within bibliometric analysis, we use citation, document co-citation,
and cluster content analyses to capture, map, and analyze unhealthy F&B ATC research.

BIBLIOMETRIC ANALYSIS: CITATION, CO-CITATION, AND CLUSTER CONTENT ANALYSIS

The first step in bibliometric analysis is to use citation counts to identify the most influential articles
within the domain of interest, the linkage between the citing articles, and the journals publishing the
cited work. Using citation frequency as a source to evaluate the relative influence of an article is a
reliable and commonly used practice (Gundolf & Filser, 2013). Citation analysis goes beyond assessing
an article’s historical value and gets to the intellectual structure of a field, such as when major articles
were written, their temporal influence, and current research utility (Pilkington and Meredith, 2009).
Co-citation analysis shows us what topics, authors, journals, and research methods are central to the
field and how they may have changed over time (Leydesdorff & Vaughan 2006). It graphically
illustrates the most influential citations for each factor, how they are related, and the strength of the
relationship. Co-citation analysis is based on the premise that if two articles are cited together often
by an article appearing chronologically later, even if they disagree in terms of their opinions/findings
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(Acedo et al., 2006), their research domains are related (Hota et al., 2019). “The analysis assumes that
the more two authors are cited together, the closer the relationship between them” (White & Griffith,
1981: 1). It is a recommended method to capture avenues for future research as it provides a holistic
overview of the evolutionary and development paths of a research domain and interlinkages among
the influential works (Yu et al., 2018). We use individual articles as the unit of analysis and the frequency
of their co-occurrence in the reference list of the principal dataset to plot a co-citation map (White &
Griffith, 1981). Lastly, we use cluster content analysis to synthesize the noteworthy findings of these
publications.

DATA COLLECTION

Figure 1 captures our process of data collection and analysis (Gupta & Chauhan, 2021). The citation
index was obtained through SCOPUS, a database covering over 5,000 publishers and 24,600 journals
from varied disciplines. Based on the F&B ATC scholarship (Srivastava & Gupta, 2021), we used a search
string of keywords to identify relevant articles. These keywords included ‘advertising,’ advertisement,’
‘promotion,’ ‘marketing,’ AND ‘children,’ ‘child,’ ‘kids,’ ‘young consumers,’ AND ‘unhealthy food,’ ‘junk
food,’ ‘preserved food,’ and ‘beverages.’ The search, from 1973 to 2021, was limited to publications in
peer-reviewed journals and conference proceedings (García-Lillo et al., 2017), generating 1,851 articles
with 70,379 cited references (mean=38). This information was imported in csv-comma-delineated
form, a frequently used format to conduct citation and document co-citation analysis and data
visualization (Hota et al., 2019). The filtered list featured various documents, including journal articles,
books, book chapters, conference proceedings, reports, dissertations, and master’s theses. To ensure
the reliability and accuracy of the results, redundancies, such as citations of multiple editions of the
same book, were manually removed.

Figure 1. Study Design and Data Collection

DEVELOPING CITATION MATRIX, CO-CITATION MAP, AND INTELLECTUAL STRUCTURE CLUSTERS

The next step was to shortlist articles as it was impossible to perform citation and document co-
citation analysis of 70,379 references of 1,851 studies or examine the intellectual structure of the most
influential articles that significantly impacted unhealthy F&B ATC research. Following convention, we
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used citation count to identify these influential articles. Documents cited ten or more times (C≥10)
were selected for citation and document co-citation analysis. While the literature does not provide a
universally accepted threshold number for citation or co-citation analysis, the choice is based on
generating a co-citation matrix suitable for the graphical representation (Hota et al., 2019). We
prepared a list of the 50 most-cited articles from 1,008 documents with a citation count of ten or more
(Table 3A).
Visualization of Similarities (VOS) mapping for data clustering and visualization using multi-
dimensional scaling (MDS) was used. VOS mapping and clustering techniques effectively handle large
datasets and offer precise visual representations of relationships between items, making it easier to
identify patterns and clusters within the data (Donthu et al., 2021). The well-established and widely
accepted VOS measures the distance between two items, and the closely related items are mapped
onto a low-dimension space. Distance between two items determines their similarity or dissimilarity: the
lower the distance, the greater the similarity. In other words, the frequency of co-occurrence of items
indicates similarity or relatedness. While multi-dimensional scaling (MDS) and VOS perform the same
task, they use different methods. VOS relies on association strength for normalizing the frequencies of
co-occurrences, which is considered a better similarity measure than others, such as the Jaccard index
(van Eck & Waltman, 2010). The computational formula of similarity between the items p & q (Spq)
based on association strength is shown below:

Spq = Cpq / WpWq

• Spq: similarity between p and q;
• Wp and Wq: total number of occurrences of items p and q or co-occurrences of items p and
q;
• Cpq: frequency of co-occurrence of items p and q.

This method assumes that items p and q are statistically independent. Next, these items were
positioned on co-citation maps by minimizing the weighted sum of squared distances between all item
pairs. Three transformations were applied to achieve consistent optimal results. (Appio et al., 2014):

i. the solution was translated suitably to ensure that it is central to its origin;
ii. using principal component analysis, the solution was rotated to maximize the variance
on horizontal dimension; and
iii. the solution was reflected on horizontal and vertical dimensions. For instance, x and y
represent the items with correspondingly the lowest and the highest coordinates on
the horizontal axis, and p and q represent the items with correspondingly the lowest
and the highest coordinates on the vertical axis. When x>y, the solution is reflected on
the vertical axis. Similarly, if p>q, the solution is reflected on the horizontal axis.

VOSviewer version 1.6.16 was used to develop a citation matrix and document co-citation map for
data visualization and intellectual clusters of the highly cited and co-cited articles.

RESULTS

CITATION AND RESEARCH TREND ANALYSES

The research landscape on unhealthy F&B ATC has evolved significantly over the study period (1973-
2021). The 50 most influential articles published during this period were cited between 149 and

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Table 3A. The 50 Most Influential Articles on Unhealthy Food and Beverage Advertising to Children
Author(s)/ Citation Age
Rank Year Count Journal Name Discipline Media Type Country Group Findings
Need a public health campaign to encourage
He &
J. of Human Health 4 –14 consumers to use less salt to reduce the
1 MacGregor, 716 Multiple UK
Hypertension Care years effects of high BP, cardiovascular disease &
2009
obesity.
Rising obesity is a severe health risk in
populations of both high- and low-income
Swinburn et Public Health Health Adults &
2 694 Multiple Australia nations, including children. There is a need
al., 2004 Nutrition Care children
for comprehensive initiatives to reverse the
epidemic.
The lack of governmental supervision has led
to the aggressive promotion of energy
drinks, mostly aimed at young men. This
Reissig et al., Drug & Alcohol Health Broadcast Adults &
3 626 USA could be the starting point for drug abuse.
2009 Dependence Care Media children
Clinical and regulatory implications for
children/adolescents and labeling/advertising
are discussed.
Establish an association between exposure
Anderson et Alcohol & Health USA, Belgium, > 18
4 612 Multiple to alcohol advertising and its consumption in
al., 2009 Alcoholism Care Germany, NZ years
teenagers.
Nutrient profiling is a desirable step toward
Lobstein et 6 –14
5 592 The Lancet Medicine Television Multicounty combating obesity and other non-
al., 2015 years
communicable disorders.
National Discuss the detrimental effects that F&B
McGinnis et 2 –18
6 577 Academies Medicine Multiple USA marketing has had on American children's
al., 2006 years
Press eating habits and overall health.
Reviews previous studies and their
Glickman et National 2 –18 recommendations concerning obesity,
7 507 Medicine Multiple USA
al., 2012 Academies Press years including child obesity, and presents a
systems approach to tackle the challenge

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Table 3A. Continued

Author(s)/ Citation Age
Rank Year Count Journal Name Discipline Media Type Country Group Findings
Evaluates public health initiatives to address
behavioral risk factors for chronic diseases
Cecchini et Adults &
8 499 The Lancet Medicine Multiple Multicounty strongly associated with obesity, such as
al., 2010 children
physical inactivity, diet, and limiting
unhealthy F&B ATC.
Morbidity & Propose tactics for preventing obesity in
Khan et al., Medicine – Adults &
9 441 Mortality Multiple USA communities, focusing on children, and
2009 Epidemiology children
Weekly Report suggest measurement for each tactic.
Investigate the marketing/advertising
Int. J. of
Healthcare – channels for food that are used to reach
Story & Behavioral 2 – 12
10 437 Nutritional Multiple USA children/teenagers in the US, the effect that
French, 2004 Nutrition & years
Science food advertising has on eating habits, and
Physical Activity
the present laws and regulations.
The study offers info. on several areas of
Healthcare – research implementation priorities and
Cairns et al., Television, 2–5
11 360 Appetite Human UK suggests a worldwide framework for
2013 Internet years
Nutrition coordinated intervention to limit unhealthy
food marketing with high-level support.
Praise government efforts to restrict the
marketing of sugar-filled products and
The Lancet Medicine- identify significant obstacles facing
Popkin & Television, Adults &
12 343 Diabetes & Diabetes and Global researchers/policymakers: the lack of
Hawkes 2016 Internet children
Endocrinology Endocrinology agreement on the relationship between fruit
juices/beverages with low-calorie sweeteners
and cardiometabolic outcomes.
To avoid diet-related disorders like diabetes
Brownell & New England J. 2 – 17 and obesity, this article offers the advantages
13 337 Medicine Multiple USA
Frieden 2009 of Medicine years and disadvantages of the proposed taxes on
sugar-filled beverages.

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Table 3A. Continued

Author(s)/ Citation Age
Rank Year Count Journal Name Discipline Media Type Country Group Findings
J. of Clinical Suggest practice guidelines for the
August et al., Medicine-
14 330 Endocrinology & Television USA Children treatment and prevention of pediatric
2008 Endocrinology
Metabolism obesity.
Archives of Find that F&B brands influence children's
Robinson et Pediatrics & 3–6 taste perception, call for restricting ATC, and
15 315 Healthcare Television USA
al., 2007 Adolescent years propose that branding can positively
Medicine influence children's eating habits.
Family, school, and community are essential
American J. of in encouraging teenagers to choose healthy
Lytle et al., 10 –15
16 315 Health Healthcare Multiple USA food. Nutrition education should start at the
2000 years
Promotion elementary/middle school levels and in
children’s social/physical surroundings.
Evaluate changes in the nutritional content
of advertised items and how spending
Powell et al., Medicine – 2 – 18 relates to juvenile exposure to food
17 296 Obesity Reviews Multiple USA
2013 Obesity years marketing. Argue that continuous
monitoring/ adjustment of food marketing
to children is required.
J. of the
Healthcare – Continued improvements to school food
Briefel et al., American 8 – 18
18 285 Nutrition and Multiple USA environments and practices are required to
2009 Dietetic years
Dietetic better children's diets and reduce obesity.
Association
The study recommends five environmental
Wechsler et Preventive Multiple – 8 – 15
19 283 Medicine USA interventions to promote children's physical
al., 2000 Medicine School years
activity & healthy eating.
Researchers and policymakers have not given
Print
Story et al., Future of 5 – 15 sufficient attention to how childcare settings
20 270 Public Policy Advertising – USA
2006 Children years may impact dietary intake and healthy
School
lifestyles to combat obesity.

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Table 3A. Continued

Author(s)/ Citation Age
Rank Year Count Journal Name Discipline Media Type Country Group Findings
Parenting interventions: monitor children's
Health
Arredondo et food consumption, physical activity, and
21 266 Education Healthcare Multiple USA Parents
al., 2006 health-related behaviors and use positive
Research
reinforcement.
There exists a correlation between juvenile
Archives of
calorie consumption and increased TV
Wiecha et al., Pediatrics and Medicine – 10 – 12
22 264 Television USA viewing. Increased consumption of calorie-
2006 Adolescent Pediatrics years
dense, low-nutrient items regularly
Medicine
promoted on TV is a mediating factor.
Children were exposed to many harmful food
Kelly et al., American J. of > 13 ads on TV, which used persuasive strategies.
23 261 Healthcare Television Multicounty
2010 Public Health years Propose regulating food advertising during
children's peak viewing times.
Even among children from socially
disadvantaged neighborhoods, an
Muckelbauer Medicine – 5–8 environmental and pedagogical school-based
24 246 Pediatrics Multiple Germany
et al., 2009 Pediatrics years intervention showed benefits in preventing
overweight among elementary school
students.
Science – There are ethnic variations along several
Kumanyika Physiology & Behavioral routes that could raise the risk of developing
25 230 Multiple USA Children
2008 Behavior Neuroendocri obesity during pregnancy, infancy, childhood,
nology and adolescence.
Healthcare – Public health policy initiatives that limit kids'
Boyland et American J. of Television, UK and >18
26 222 Human exposure to advertisements for harmful
al., 2016 Clinical Nutrition Internet Australia years
Nutrition foods are required.
Strasburger & Suggest banning junk food advertising in
Council on Medicine – 5 – 15
27 221 Pediatrics Multimedia USA children's TV programming because of its
Communications Pediatrics years
and Media, 2011 detrimental health effects.

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Table 3A. Continued

Author(s)/ Citation Age
Rank Year Count Journal Name Discipline Media Type Country Group Findings
Summarizes research on the connection
Coon & Minerva Medicine – 2 – 17 between children's food intake and TV use
28 215 Television USA
Tucker 2002 Pediatrica Pediatrics years published in peer-reviewed journals since
1970.
Identifies different factors that lead to
Medicine – >5 obesity in children and recommends a
29 Musaiger 2011 213 J. of Obesity Television Multicounty
Nutrition years national plan to overcome obesity to reduce
the economic and health burden.
It would be beneficial to normalize/reinforce
Dixon et al., Social Science & 12 – 15 healthy eating if food advertising on
30 207 Social Science Television Australia
2007 Medicine years children's TV shifted to a format that favored
healthy foods and ignored bad food.
The study analyzed the prior successes and
setbacks in the food business's self-
Sharma et al., American J. of > 12
31 200 Healthcare Multiple USA regulation and established eight
2010 Public Health years
requirements for self-regulation to be
successful.
Int. J. of
Healthcare – This study shows that several parental
Yee et al., Behavioral 4 – 12
32 198 Nutritional Multiple NA actions correlate with their children's food
2017 Nutrition & years
science consumption habits.
Physical Activity
Summarize data from clinical
J. of the
trials/epidemiological studies assessing the
Malik & Hu American Medicine – 2 – 15
33 196 Multiple USA impact of added sugars in beverages on the
2015 College of Cardiology years
risk of obesity, diabetes, and cardiovascular
Cardiology
disease and discuss reduction strategies.
A thorough analysis of the main issues that
Schwartz & Medicine – 6 – 17
34 196 Obesity Reviews Multiple USA obese children and their families must deal
Puhl 2003 Obesity years
with.

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Table 3A. Continued

Author(s)/ Citation Age
Rank Year Count Journal Name Discipline Media Type Country Group Findings
Print The results imply that licensed characters
Roberto et Medicine – 4–6
35 188 Pediatrics Advertising – USA should not be used to promote junk food to
al., 2010 Pediatrics years
Packaging young audiences.
Process evaluation is rarely used to assess
the effectiveness of health promotion
Health initiatives. Doing so will improve our
Baranowski & 11 – 13
36 185 Education & Healthcare Multiple USA knowledge of how/why treatments work,
Stables 2000 years
Behavior the most beneficial intervention programs,
strengthening the studies' internal and
external validity.
Archives of
Investigates a childcare program that
Taveras et al., Pediatrics & Medicine – 5 – 11
37 180 Multiple USA reduced TV watching but had no discernible
2011 Adolescent Pediatrics years
influence on BMI.
Medicine
Important to know the nutritional factors,
energy intake/ diet composition,
Flodmark et Healthcare – Europe and > 13 nutrition/hormonal status, food
38 177 Int. J. of Obesity Multiple
al., 2004 Nutrition USA years preferences/behavior, the influence of non-
nutritional factors that lead to obesity, and
ways to prevent it.
Propose that interventions when customized
Health
Van der Horst 10 –13 to the participants' overall parenting style,
39 175 Education Healthcare Television Netherlands
et al., 2007 years will be more effective in promoting healthy
Research
parenting habits.
J. of the
Healthcare – Dietetics specialists, parents, and caregivers
Nicklas & American 2 – 11
40 170 Nutrition and Multiple USA are given specific advice to enhance the
Johnson 2004 Dietetic years
Dietetic nutritional well-being of children.
Association

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Table 3A. Continued

Author(s)/ Citation Age
Rank Year Count Journal Name Discipline Media Type Country Group Findings
When school-based interventions target
children's physical activity and diet,
De
Medicine – 6 –18 combining educational and environmental
41 Bourdeaudhuij 160 Obesity Reviews Multiple Europe
Obesity years components that focus on both sides of the
et al., 2011
energy balance results in more relevant
impacts.
Advocate for the use of cutting-edge
consumer-focused and community-
Spoth et al., Medicine – > 10
42 157 Pediatrics Multiple USA participatory models in developing and
2008 Pediatrics years
studying interventions to address underage
drinking and increase the public impact.
As students advance through the grades, the
food situations in their schools grow less
Finkelstein et Multiple – 8 –18
43 156 Pediatrics Pediatrics USA healthy. Junk food containing low-nutrient,
al., 2008 School years
high-energy F&B is offered a la carte in
school cafeterias and vending machines.
A convenience line that offered healthy food
Hanks et al., J. of Public 5 –18 options to students in a school lunchroom
44 155 Healthcare Multiple USA
2012 Health (UK) years nudged healthy eating behavior, which can
be replicated
Batis et al., 2 –11 Support the need to eliminate important
45 155 J. of Nutrition Healthcare Multiple USA
2011 years unhealthy foods from the American diet.
Current Opinion
Ventura & Healthcare – Technology Offer fresh insights into how to alter
in Clinical 2 –15
46 Mannella 151 Clinical Enabled USA children's consumption/preferences of sweet
Nutrition & years
2011) Nutrition Advertising foods to enhance the diet quality.
Metabolic Care
Nutrient profiling should be done
Lobstein & Public Health Broadcast Adults &
47 151 Healthcare UK consistently for the benefit of
Davies 2009 Nutrition Media children
manufacturers, merchants, and consumers.

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Table 3A. Continued

Author(s)/ Citation Age
Rank Year Count Journal Name Discipline Media Type Country Group Findings
Pilot study showed that culturally
appropriate obesity prevention treatments
Beech et al., Ethnicity & 8 –10
48 149 Healthcare Multiple USA for pre-adolescents and their
2003 Disease years
parents/caregivers were feasible, acceptable,
effective.
Children/adolescents who are exposed to
screen media are more likely to become
obese because of eating more while
Robinson et Medicine – 4 – 15 watching, being exposed to high-calorie, low-
49 149 Pediatrics Multimedia Multicounty
al., 2017 Pediatrics years nutrient F&B marketing that shapes
children's preferences, requests for
purchases, and consumption habits, and
getting less sleep.
Unhealthy F&B marketing during or soon
Sadeghirad Medicine – 2 –18
50 148 Obesity Reviews Multiple Multicounty after exposure to commercials affected
et al., 2016 Obesity years
children's nutritional intake and preferences.
Note: *Full citations provided in Supplementary Appendix I

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719 times, and Table 3A summarizes the key findings from each article.
A three-phase progression of scholarly attention below summarizes key trends and shifts in
research focus.

PHASE I: EARLY RESEARCH (2004-2009)

The early research phase marked by pivotal work such as Swinburn et al. (2004) and He & MacGregor
(2009), concentrated on identifying the health risks associated with sedentary lifestyles and the
consumption of unhealthy F&B products. SLRs by Lobstein & Dibb (2005) and McGinnis et al. (2006)
reported on how ATC influenced nutritional beliefs, consumption preferences, and outcomes for
children and youth. These studies laid the groundwork by emphasizing the role of aggressive
advertising in promoting high-salt, energy-dense foods, and its direct link to childhood obesity and
other serious health issues like ventricular hypertrophy and renal disease.

PHASE II: FOCUS ON POLICY AND GOVERNANCE (2009-2010)

As research matured, the focus expanded beyond the health implications to include policy and
governance dimensions of F&B advertising. Influential works by Khan et al. (2009) and Cecchini et al.
(2010) examined ATC from this perspective, discussing the need for measures to protect vulnerable
consumers, particularly children, who are highly susceptible to persuasive advertising. They also
highlighted strategies for designing effective policies at community and local government levels and
emphasized the importance of strengthening governance frameworks to mitigate the impact of
unhealthy F&B ATC on eating habits and consumption patterns. These studies called for more robust
governance to safeguard children's health and explored how ATC shapes children's nutritional beliefs
and behaviors.

PHASE III: INTERDISCIPLINARY RESEARCH (2010 AND BEYOND)

By 2010, research by Cecchini et al. (2010) and Cairns et al. (2013) saw a shift towards a more
interdisciplinary approach, involving medicine, healthcare, advertising, and marketing. These studies
focused on the governance strategies needed to mitigate the influence of persuasive advertising on
vulnerable consumers, including children. They also explored the effectiveness of community and local
government policies in curbing unhealthy eating.
In sum, the evolution of unhealthy F&B ATC (Table 3B) reflects a dynamic shift from understanding
the direct health impacts to addressing the broader policy and governance challenges. This trend
underscores the growing recognition of unhealthy F&B ATC as a complex, interdisciplinary issue
requiring coordinated efforts across multiple disciplines to protect children's health and well-being
effectively.

CO-CITATION ANALYSIS

From our database, the co-citation map generated by VOSviewer charts 35 frequently co-cited articles
(C≥10) with a co-citation count ranging from 10 to 71. Recall that the unit of document co-citation is a
pair of articles cited in a subsequent article. The dot size indicates the corresponding article's co-
citation count in the core dataset. VOS viewer groups these co-cited articles into five distinct
intellectual clusters (Figure 2). The bi-dimensional visual of the co-citation network, where each article

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Table 3B. Trend Analysis – Evolution of Research on Unhealthy Food & Beverage Advertising to
Children
Phase Key Focus Areas
The impact of sedentary lifestyles and dietary choices on childhood
obesity.
Early Research Focus
The role of advertising in promoting unhealthy food choices among
(2004-2009)
children.
Consolidation of existing scientific and policy research on unhealthy
F&B ATC.
Policy strategies to protect children from persuasive advertising.
Emergence of Policy and Analysis of how advertising influences children’s eating habits and
Governance Focus nutritional beliefs.
(2009-2010) Advocacy for policy measures to improve food supply governance
and marketing regulations.
Interdisciplinary approaches combining insights from medicine,
social sciences, and public policy.
Expansion into
Strengthening the regulatory framework to limit the impact of
Interdisciplinary Research
unhealthy F&B ATC.
(2010 and beyond)
The impact of cutting-edge technology in interactive/digital
marketing of unhealthy F&B ATC

is denoted by a circle grouped in a cluster, helped us identify the intellectual structure and
relationships of highly cited ATC research articles. The influence of the article and the distance
between the two circles indicates the similarity or difference between them. For example, Harrison
and Marske’s (2005) article delineating advertisers’ media choices and consequences was grouped
within a cluster of articles that were co-cited more than ten times. This placement demonstrates the
strong linkage among articles within the cluster and helps map the intellectual structure of the domain.

CLUSTER-CONTENT ANALYSIS

Next, based on a qualitative content analysis of these co-cited articles, we identified the theme of each
of the five clusters (with some overlaps) and named them government regulation and industry self-
regulation, social and environmental factors, media channels, persuasion techniques, and ethical
implications (Table 4). We now provide an overview of these clusters, capturing their links and
contributions.

CLUSTER 1: GOVERNMENTAL REGULATION AND INDUSTRY SELF-REGULATION

The largest cluster, comprising 11 articles (published between 2009 and 2016), focuses on the need for
governmental regulation at a global level to constrain unhealthy F&B ATC. Several researchers note
the inevitability of government intervention (Harris et al., 2010; Hawkes & Lobstein, 2011; Andreyeva
et al., 2011). Cairns et al. (2013) point to policy failure concluding that oversight might be needed
globally. Harris et al. (2009) identify the lack of a global consensus between the industry and regulators
on F&B nutrient profiling as the key reason for policy failure. Congenially, Swinburn et al. (2011) note
the worldwide absence of leadership and statutory measures to address childhood obesity, making it
difficult to inhibit the supply-side drivers. Boyland et al. (2016) and Zimmerman & Bell (2010) also argue
in favor of regulation as the aggregate effect of repeated exposure to unhealthy F&B ATC amplifies its
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adverse impacts, especially when advertising is executed in multiple platforms and contexts. Galbraith-
Emami and Lobstein's (2013) SLR reveals that while academia provides evidence of nutritionally
deficient F&B ATC to children globally, industry-sponsored research claims strict compliance with self-
regulation. Hawkes and Lobstein (2011) propose that any regulation on unhealthy F&B ATC should
clearly state objectives and achievement indicators to measure the food industry’s accountability and
progress. In sum, scholars agree on the need for comprehensive statutory regulations with provisions for
regular monitoring, progress evaluation, and strict sanctions for non-compliance for unhealthy F&B ATC.

Figure 2. Co-Citation Map

CLUSTER 2: SOCIAL/ENVIRONMENTAL FACTORS

This cluster (n=10) emphasizes the influence of social and environmental factors on children’s
unhealthy eating habits and obesity. These include demographics, lifestyle, food consumption habits,
prolonged TV exposure to unhealthy F&B advertising (Ludwig et al., 2001; Cole et al., 2000), easy
availability and accessibility of ultra-processed and packaged (UPP) F&B at home and school, lack of
parental oversight in TV and social media viewing, less time spent with parents and siblings, non-
authoritative feeding style, and parental intake of unhealthy F&B (Barlow, 2007). Other influential
social factors are parents' education, time constraints, ethnicity (Patrick & Nicklas, 2005), at-home
mealtime structure, infrequent common mealtimes, TV viewing during meals, meal sources (e.g.,
restaurants, schools), and the availability of unhealthy food in school settings (James et al., 2004;
Wang et al., 2008). Environmental and other forces including sedentary lifestyles (Ebbeling et al.,
2002), easy availability of high-added saturated/trans fats, sugar, or sodium (HFSS) and energy-dense
foods (Birch, 1999), and phenotypic food preferences (sweet and salty tastes over sour and bitter
tastes; Birch & Fisher, 1998) are posited to also impact children’s intake. The collective impact of these
factors combined with unhealthy F&B ATC has led scholars to recommend multi-pronged
interventions at school, at home, and in neighborhoods. Examples include parents spending more time
with children, supervising mealtimes, inculcating good eating habits, regulating media and ATC
exposure, limiting the availability of unhealthy F&B at home and in school, and educating children on
the benefits of healthy eating habits. Summarily, this cluster identifies social and environmental factors
contributing to unhealthy eating among children and proposes several interventions.
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Table 4. Co-Citation Clusters and Contributors

Total
Cluster Central Theme Articles Contributors
Andreyeva et al., 2011; Boyland et al., 2016; Cairns
Governmental Regulation
et al., 2013; Folkvord et al., 2015; Galbraith-Emami
and Industry Self-
1 11 & Lobstein, 2013; Harris et al., 2009, 2010; Hawkes
Regulation
& Lobstein, 2011; Kelly et al., 2010; Swinburn et al.,
2011; Zimmerman & Bell, 2010
Barlow, 2007; Birch, 1998, 1999; Cole et al., 2000;
Social and Environmental Ebbeling et al., 2002; James et al., 2004; Ludwig et
2 10
Factors al., 2001; Patrick & Nicklas, 2005; Vartanian et al.,
2007; Wang et al., 2008
Borzekowski & Robinson, 2001; Kelly et al., 2007;
3 Media Channels 7 Ogden et al., 2006; Robinson, 1999; Story & Frech,
2004; Harrison & Marske, 2005; Taras & Gage, 1995
Connor, 2006; Hastings et al., 2010; Lobstein &
4. Persuasion Techniques 3
Dibb, 2005
Ogden et al., 2010; Vartanian, Herman, et al., 2007;
5 Ethical Implications 4
Malik et al., 2006; Story et al., 2008
Total 35

CLUSTER 3: MEDIA CHANNELS

The seven articles in this cluster explore the primarily targeted segment, advertisers’ goals, and
marketing communication channels and media choices. Story and French (2004) report that in the
early 2000s, advertisers commenced unhealthy F&B ATC in recognition of children’s purchase
influence, spending power, and potential for early loyalty, noting similarities vis-à-vis strategies used
by the tobacco industry. The media channels used to reach children include video gaming, in-school
communication, product placements, kids' clubs, the internet, cross-selling, toys and products with
brand logos, youth-focused promotion, and TV. Even brief exposure to F&B commercials on TV
strongly influences the food preferences of preschool children (Borzekowski & Robinson, 2001)
including a causal relationship between TV viewing, video gaming, and increased adiposity (Ogden et
al., 2006; Robinson, 1999). Harrison and Marske (2005) observe that snacks, convenience/fast foods,
and sweets dominate F&B advertisements during primetime children's TV programs. Their findings
underscore a shift in advertisers' focus to newer promotion channels for ATC. In brief, this cluster
delineates advertisers’ media choices, their evolution over time, and some of the consequences.

CLUSTER 4: PERSUASION TECHNIQUES

A small fourth cluster (n=3) constituting articles in healthcare journals scans messaging and persuasion
techniques. Lobstein and Dibb (2005) find the content of TV and internet F&B ATC to mediate the
relationship between watching children's programs and childhood obesity. They identify two factors
underlying this mediation: a) children’s inability to critically judge the persuasive intent of F&B
advertisers, and b) the difficulty for parents to selectively regulate children’s exposure. Connor (2006)
offers a congenial perspective – advertising targeting toddlers and preschoolers features compelling
appeals and techniques relying on fun and happiness to garner early brand recognition, awareness,
and loyalty. Hastings et al. (2010) discuss the vulnerability of young consumers to advertising linking
drunkenness to potency, sexual attractiveness, and social success. The authors in this cluster argue for
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regulation of social media and the internet to reduce the excessive consumption of energy-dense foods,
restrictions on cinema and TV prime time ATC, and limits on online and offline promotions in
programming frequented by children and adolescents.

CLUSTER 5: ETHICAL IMPLICATIONS

The final cluster, comprising four medical and public health articles, discusses the undesirable
consequences of eating habits promoted by unhealthy F&B ATC and ways to mitigate them. Story et
al. (2008) emphasize ‘nutrition’ to prevent chronic diseases among children and adults. They
summarize the literature over the past three decades showing that unhealthy F&B ATC of ultra-
processed and packaged HFSS food has created an inexpensive and convenient pull against its
nutritious and healthier counterpart leading to developmental problems in children. Vartanian et al.
(2007) argue that unhealthy F&B ATC fuels consumption stereotypes, and children who eat unhealthy
F&Bs (e.g., potato chips and soda) over healthy foods (apple) are viewed as being more fun to be
around (rather than being morally righteous and intelligent). Ogden et al. (2010) show that children
with high BMI tend to become obese adults who may then be prone to diabetes, cardiovascular
diseases, and even some types of cancers. Malik and colleagues (2006) show that lifestyle variables
largely influenced by F&B ATC led to an increase in consumption of sugary drinks and body weight
among children, and a concomitant reduction in milk consumption. Authors in this cluster recommend
curtailment of screen time, engaging in physical activity environments such as parks, educating children
about the positive and negative effects of healthy vs unhealthy foods, higher taxes on unhealthy F&Bs,
and interventions linked to food marketing, albeit with wide gaps that need bridging by government,
industry, and society.

ETHICAL FAULTLINES: THE ACTION-EXPECTATION GAP

A substantial body of marketing and advertising scholarship recommends four specific ethics-centered
frameworks/theories to establish guidelines for providing specific, well-grounded, and practical
recommendations to firms, policymakers, and consumer researchers (Cho, 2020; Murphy et al., 2016):
deontology, utilitarianism, social contract, and relativism. We provide a brief exposition of their
perspectives below to evaluate the foregoing clusters’ content and identify gaps between corporate
action and expectations through the lens of these theories.
Deontology argues that the fundamental rights of human beings must be protected and respected
in all decisions, viewing morality as the basis of duty that determines right or wrong (Cavanagh et al.,
1981). Utilitarianism proposes that an ethically correct decision is the one that brings the greatest
happiness to the greatest number of people (De George, 1990). Subscribers of this view assert that
actions are justified if they bring happiness and prevent pain for those affected (Alexander & Moore,
2021). Social contract theory posits an implicit agreement between business and society, where society
permits businesses to exist and earn a profit if they serve the interests of society, including consumers
and employee stakeholders (Donaldson, 1982; Byerly, 2013) and the environment. This agreement
results from an interdependent, reciprocal relationship between the two parties (van Buren, 2000).
Within this framework, advertisers contribute to the capitalist economy by generating demand in
exchange for the right to promote goods and services in the marketplace. Relativism taps the extent
to which ethical standards are considered context-specific and not universal (Bakir & Vitell, 2010). An
act considered morally correct in one social/cultural context may be considered unethical in another
(Robertson & Fadil, 1999) and organizations’ actions/decisions might be refined by context-specific
moral values (Shabbir et al., 2019). Together, these theoretical perspectives provide a lens to identify
gaps between actions and expectations, guiding directions for future research.
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GOVERNMENTAL REGULATION AND INDUSTRY SELF-REGULATION

Deontology emphasizes the volitional performance of moral duty towards others without considering
personal consequences (Mpinganjira & Maduku, 2019). It rejects practices that infringe upon children’s
right to health, privacy, and freedom from exploitation (Tatlow-Golden & Garde, 2020), engage in
racial profiling (Harris et al., 2005), dehumanization (Langer, 2004), and biased value systems and
consumption patterns (Linn, 2004). The food industry’s response to criticism of the harmful effects of
F&B ATC has been limited to compliance with the minimally existing regulation (Holder-Webb & Cohen,
2012). Deontologists would argue that ignoring moral responsibility leads to unethical judgments and
immoral action (MacQuillin & Sargeant, 2019). Viewed in this light, when advertisers promote the
consumption of unhealthy F&B products while using various strategies to stop, delay, or weaken the
passage or enforcement of related regulations, they serve their self-interest (Tselengidis & Östergren,
2019). Such action, according to deontology, would represent questionable ethical compliance
(Holder-Webb & Cohen, 2012) as it comes at the cost of the well-being of children.
Social contract theory posits an implied contractual relationship of shared values between business
and society – society allows business to exist and earn a profit, and in return, business agrees to serve
societal interests while protecting it from the potentially harmful effects of its actions (van Buren,
2000). Under this implied social contract, failure to educate children about the potential health
hazards associated with such consumption may result in advertisers being judged ethically liable, even
if they create some value for the consumers. The industry has pledged to voluntarily curtail food
marketing to children and label foods more responsibly. However, from the social contract theory lens,
resistance by advertisers to honor their commitment to societal interest may be viewed as unethical
(Torres & Nowson, 2007).

SOCIAL/ENVIRONMENTAL FACTORS

Relativism will predicate ethical judgments relating to unhealthy F&B ATC to be based on the
situation’s specifics and the associated moral code. Repetitive exposure to unhealthy F&B ATC
through multiple channels amplifies the impacts of children’s inability to understand the advertisers’
intent (Boyland et al., 2016), and relativists would expect advertisers to consider these impacts on the
health and overall welfare of children (Story & French, 2004). Children’s lack of cognitive abilities to
process persuasive messages has led some to place the onus on parents and schools to constrain the
persuasiveness of unhealthy F&B ATC. However, selectively prohibiting children from watching such
ads and explaining commercial persuasion can be challenging for parents and educators (Lobstein &
Dibb, 2005).

MEDIA CHANNELS

Utilitarianism, a cornerstone of the notion of utility maximization, propounds the viewpoint that a
decision or action that provides the greatest utility – the greatest happiness (good) to the greatest
number of people – is an ethical one (Mill et al., 2008). This approach places greater value on the
goodness of outcomes (consequences) rather than the rightness of actions, and happiness (i.e., lack
of pain) is pedestalized as the most preferred outcome (Alexander & Moore, 2021). The utilitarian test
of the greatest good for the most may be applied to scrutinize the industry’s spending on F&B ATC
and children’s exposure to pluralistic and integrated media channels used to motivate consumption of
and loyalty towards nutritionally deficient products (Kaplan & Haenlein, 2010). These include TV, radio,
print, sports sponsorships, streaming platforms, and digital and social media platforms (an umbrella
term for digital and internet-based applications including email and text messages), where users can
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generate and share content through both viral and word-of-mouth marketing (Kaplan & Haenlein,
2010). Our assessment leads to two conclusions: a) the F&B industry has invested extensively to reach
children (Harris et al., 2021); b) the industry has not given utilitarianism’s focus on the larger long-term
good of children due consideration. For example, one study documents that in only 40 years, the
number of school-age children with obesity has increased from 11 million to 124 million, and 80 percent
of all teenagers and 50 percent of all primary school children may fight obesity sometime in their life
(Bakir & Vitell, 2010). The long-term health implications of this have been documented extensively in
our introduction.

PERSUASION TECHNIQUES

Like media channels, utilitarianism dominates the influential work in this cluster. Influential work in
this cluster reveals that most unhealthy F&B ATC links products to fun and happiness (Hastings et al.,
2010). The food industry claims that entertainment and excitement bring happiness to children and
that limiting their freedom to pursue happiness is morally wrong (Alexander & Moore, 2021). However,
such “pleasure” marketing comes at the cost (Andreyeva et al., 2011; Zimmerman & Bell, 2010) of
health risks associated with junk food consumption (Elliott & Truman, 2019). For instance, the
advergaming technique (advertisement in the form of a game) situates HFSS foods at the center of
the game that children must play to progress. Ostensibly, children return to advergames websites
multiple times and often make more unhealthy food purchase requests (Nairn & Hang, 2012), with this
effect being more substantial one week after playing (Agante & Pascoal, 2019). These games also
significantly affect pester behaviors, food choices, and children's food intake (McCarthy et al., 2022).
They no longer eat to satiate hunger but rather to play and, as a result, consume more than they need
for fun, opening the door to obesity (Ertz & Le Bouhart, 2022). SLRs of marketing practices reveal that
characters are disproportionately used to promote HFSS foods to children (Hebden et al., 2011; Packer
et al., 2022) and that advertisers employ more subliminal persuasion tactics such as embedded content
on various digital formats to reach children during peak-time viewing.
The net utility test (Mill et al., 2008) would posit that the food industry has a fiduciary responsibility
towards society. Hence, even if the happiness maximization test (the fun and excitement that the
children achieve through consuming these advertisements) were met, if there is a breach of fiduciary
duty to society (escalating health care costs), ATC will conflict with public policy (Hawkes & Lobstein,
2011). Complementing the child-related obesity data trends provided in the previous section, one study
found that at an individual level, obese people are likely to incur over 30% higher medical expenses
than non-obese (Withrow & Alter, 2011), and another study estimates the economic cost of obesity to
be 0.8% – 2.4% of annual GDP and likely to increase to 4.8% by 2060 (WOF, 2022)

ETHICAL IMPLICATIONS

Researchers in this cluster seek accountability from the food industry for social values beyond profit.
Children are a vulnerable and powerless group and consequently need protection from exploitation
(Swinburn et al., 2011; Carter et al., 2011; Harris et al., 2009). For these reasons, the notion that a child
per se is a rational consumer does not pass scrutiny (Cawley, 2006). The deontological approach
suggests that an advertiser is a moral agent with the moral autonomy to shape morally sound
messages to sell their product. However, marketing ethics, defined as “the systematic study of how
moral standards are applied to marketing decisions, behaviors, and institutions” (Murphy et al., 2005,
p. xvii), has received little scholarly and empirical treatment with respect to F&B ATC.
The first empirical test of the ethicality of unhealthy F&B advertising found that only 1.58% of 380
ads passed the test – both in intrinsic moral value and outcome. The biggest obstacles to message
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ethicality were truthfulness (omission of information/deception) and authenticity. Further, ads

targeting children had lower ethicality than ads targeting adults (Lee & Nguyen, 2013). Professionals
from 29 US advertising agencies confirmed that consideration of ethics is largely absent at the
individual and organizational levels (Drumwright and Murphy, 2004). Some of the common
rationalizations offered included: 1) consumers are smart and hence would not be fooled by unethical
advertising; 2) holding individuals, families, community, government, and society responsible; 3)
equating legality with ethicality; 4) resorting to the First Amendment which protects advertisers from
censorship; and 5) arguing that ethics is bad for business – advertising constitutes the creation of
scintillating messages for competitive advantage. In sum, due to the non-disclosure of health risks,
unhealthy F&B ATC is morally questionable (Ertz & Le Bouhart, 2022).

REVIEW OF RECENT LITERATURE AND FUTURE RESEARCH

Finally, we supplement the above findings and analysis with a qualitative review of more recent articles
that could not be included in the quantitative analysis due to their recency. We conclude with a cluster-
specific array of questions to permit deeper deliberation on the ethics of unhealthy F&B ATC.

GOVERNMENTAL REGULATION AND INDUSTRY SELF-REGULATION

A critical gap plaguing existing literature is the lack of a compelling regulatory framework (Cairns et
al., 2013). Legislation, even if stringent, is compromised by a host of factors including the absence of
standardized criteria that define nutrient profiles of HFSS products, demographics of the target
customers, ages that need protection, the time of day to curb F&B ATC (when the largest # vs. largest
proportion of children are watching; Kelly et al., 2019), use if exploitative promotional techniques
(Corvalán et al., 2019), the lack of consistent data on advertising expenditure and exposure,
accountability measures (Potvin Kent et al., 2022), and data collection (Gómez & Rajmil, 2022).
Effective government regulation, however, is not without exemplars. Chile’s 2016 Food Labeling
and Advertising Law requires front-of-package warning labels, forbids HFSS foods in schools, and
restricts their marketing to children under 14 across different media platforms (Corvalán et al., 2019).
In the US, states with more stringent food laws regulating the sale and advertising of unhealthy F&B
products have lower childhood obesity in elementary schools (Palakshappa et al., 2016). From a self-
regulation perspective, some companies have chosen to voluntarily limit the use of influencers and
characters (Action on Sugar, 2020, Unilever, 2020), stop advertising to children under 13, adopt
uniform nutrition criteria for licensing their characters (Dindral, 2006), engage in constructive
partnerships to promote healthy lifestyles, and offer low cost media character licensing to produce
companies so that they may promote fruit and vegetables to children (Evich, 2013).
Yet, despite the endorsement that self-regulation has effectively curbed unhealthy F&B ATC (Avery
et al., 2022; BBB National Programs, 2023), our cluster-content analysis and supplemental research
have found the opposite, with two emerging themes. First, aggressive and unhealthy F&B ATC has
maintained its frequency and scope (Andreyeva et al., 2011). Second, self-regulation has led to adverse
long-term outcomes on the overall well-being of children (Lauber, Hunt, et al., 2021), partly because of
weak adoption/enforcement of voluntary standards (Gómez & Rajmil, 2022). The tension between
government and self-regulation leads us to delineate research questions such as the contributive role
of standardized national/global definitions, state/local policies, advocacy/community groups, third-
party certifications, and exemplar case studies of transformational leadership in voluntary code
adoption (Table 5A).

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SOCIAL/ENVIRONMENTAL FACTORS

HFSS foods have disproportionately targeted children vs. adults (Pinto et al., 2021), notably the
minority/economically disadvantaged (Harris et al., 2021), and male vs. female children (Castronuovo
et al., 2021). Other factors include the saturation of fast-food outlets in communities, the high cost of
fresh produce compared to fast food, which leads families to prioritize satiety over nutrition, parents
having little time for food preparation, and declining cooking skills. Additionally, misleading labeling
makes parents question their nutrition knowledge and often leads them to underestimate their
children’s exposure to and impact of food marketing, particularly in the digital ecosystem (Fleming‐
Milici et al., 2022). Also, unqualified influencers are being used to make unsubstantiated/inaccurate
claims about health/nutrition (Bromberg & Fitzgerald, 2021). Furthermore, marketing at schools lacks
parental oversight, blurring the lines between nutritious and junk food (Ertz & Le Bouhart, 2022).
Obesogenic environments (obesity-promoting; where HFSS foods are cheaply and widely available)
interfere with individuals’ ability to act in their long-term self-interest and contribute to the
development of unhealthy food preferences. Industry challenges these findings and shifts the burden
of unhealthy habits to personal responsibility and social/environmental factors (Ngqangashe et al.,
2022). Moreover, the industry’s information and analytics about children’s behavior and exposure to
HFSS foods are inaccessible to independent researchers creating a power asymmetry between
industry and public health advocates (World Health Organization Regional Office for Europe, 2016).
Our discussion highlights the need for grass-roots solutions to minimize the ‘costs’ of pervasive
unhealthy F&B ATC. For example, educating teens on the dangers of HFSS foods (Baspakova et al.,
2020), and parent education on parenting techniques (Chen et al., 2021) and nutrition (Chiong &
Figueroa, 2022) were positively related to healthier intake among children. Further, a nuanced school-
based media literacy program (Sekarasih et al., 2018) had a positive effect on children’s advertising
knowledge. Advertising disclosures have also been known to increase adolescents’ recognition of
embedded advertising in vlogs (video blogs) as well as their affective advertising literacy. These
findings suggest that making children aware of the negative consequences of unhealthy eating might
be a more successful way to motivate healthier nutritional intake. Based on these, we propose future
areas of inquiry (Table 5B) relating to the influence of age/gender, ethnicity/religion, socio-economic
status, lifestyle, social media engagement, and socializing agents such as schools, parents, community,
and social influencers.

MEDIA CHANNELS

Adolescents’ ability to evaluate marketing messages in social media formats is lower compared to
other channels, such as TV and billboards, because ad cues in social media messages are often
embedded within the entertainment content (Folkvord & de Bruijne, 2020) and designed to minimize
scrutiny and motivation to resist (Harris et al., 2021). Crucially, data on tracking children’s behavior is
used by advertisers for more effective targeting (Hudders et al., 2017), and there is currently almost
no regulation overseeing social media (Anderson & Jiang, 2018). Rummo et al. (2020) revealed that 27
HFSS F&B brands collectively maintained 6.2 million adolescent followers on Twitter (now X) and
Instagram, finding it troubling that large numbers of children were “opting in” to be exposed to
unhealthier F&B ads, that followers of unhealthy brands far outnumbered healthy brand followers,
and that unhealthy F&B brands had a disproportionately higher percentage of young followers
compared to any Twitter (now X) account. Ostensibly, marketing via social media amplifies the effects
of TV advertising on brand recall, liking, and reach than traditional advertising (World Health
Organization Regional Office for Europe, 2016). Table 5C proposes unexplored research questions
about media channel choices, F&B advertising expenditure, evaluation, and exemplars.
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Table 5A. Future Research – Government Regulation and Industry Self-Regulation

Indicators Measure Ongoing/Contemporary Research Findings Proposed Future Research Questions
*Russell et al. (2020) – Australia – Provide insight on
policymakers' framing/response to F&B ATC,
reflecting political party ideology. Liberal
parliamentarians call for minimal regulation/greater
*What are some ways to bridge the ideological
personal responsibility, and green parliamentarians
divide between minimal government intervention
frame the issue as systemic, highlighting the need
(individual/parental responsibility) and self-
for state intervention/social justice. This may inform
regulation vs. regulation as a collective
communication strategies for nutrition advocates.
responsibility to curb predatory F&B practices
*Lacy-Nichols et al. (2020) – Australia – Between
toward vulnerable groups?
1998-2006, the Beverage Council shifted from a
*How can we reframe the causes and solutions to
defensive strategy that denied the role of its
junk-food marketing to children from a matter of
products in obesity to a conciliatory strategy for
rights to consumer protections? Might shifting
Political Ideology, finding collaborative solutions. It timed the launch
from framing children as vulnerable consumers to
Corporate of its self-regulation to coincide with an intl. public
nutrient and ultra-processed food profiling be more
Political Activity, health congress event. Subsequently, it funded
effective?
Government Political Will research to demonstrate the efficacy of self-
*Do corporate political activism and lobbying
Regulation regulation and petitioned the government that
strategies used to resist F&B ATC regulation vary by
further regulation was unnecessary. Use self-
region and country?
regulation to bolster reputation and influence policy.
*What are some best practices of industry
*Lauber et al. (2021) – UK – In response to the
engagement that integrate conflict of interest
introduction of novel restrictions on HFSS
disclosures and scrutinize evidence claims in the
advertising, this study uncovered substantial and
collaboration process?
comprehensive efforts by F&B companies to lobby
against this policy
claiming that the regulations will not work, are not
evidence-based nor needed, and will have negative
consequences. Suggest strong commercial influence
on dietary public health regulation.
*Prowse (2017) – Canada – Significantly fewer ads
*How can exemplars (e.g., Chile’s laws restricting
Regulatory for “less healthy foods” watched by children on
unhealthy F&B ATC) be adapted/replicated to help
Successes Quebec’s French TV on Ontario’s English TV; small
change children’s consumption behavior? What
improvements in the nutritional quality of
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Table 5A. Continued

Indicators Measure Ongoing/Contemporary Research Findings Proposed Future Research Questions
advertised foods; did not fully protect Quebec
children since English-speaking children view TV
originating outside Quebec which is not restricted
by Quebec’s law.
*Brown et al. (2018) – Australia – restricts ads
during ‘P’ (pre-school) programs; bans HFSS product
ads on TV/radio till 9 pm, with regulations across
other advertising mediums.
*Corvalán et al. (2019) – Chile’s 2016 Food Labeling
and Advertising Law requires front-of-package
warning labels, forbids HFSS foods in schools, and might be the challenges in doing so in diverse
restricts their marketing to children under 14 across cultural contexts?
different media platforms. *What are the long-term health care costs and
*Stoltze et al. (2019); Dillman Carpentier et al. benefits associated with unhealthy F&B
(2020); Reyes et al. (2020) – Chile – Following 2016 consumption by children? How can longitudinal
Government Regulatory child-directed marketing regulation, children’s studies be designed to help answer this question?
Regulation Successes exposure to high-in food ads on TV has decreased *How can experimental researchers examine the
significantly with important decreases in sugar and cause-effect relationship between regulation and
sodium content in several groups of packaged F&Bs. outcomes?
*Martinez (2021) – Mexico – Cartoon Mascots *How effective are policy interventions such as
Banned from Food Packaging in Mexico to Combat enhanced taxation on curbing F&B ATC? How can
Childhood Obesity. the 4Ps be utilized in enhancing this effectiveness?
*Kenney et al. (2021) – Found that over 10 years,
strategies such as (1) eliminating the tax
deductibility of F&B advertising, (2) targeting TV
reduction during home visit programs, (3)
motivational interviewing to reduce home TV time
at WIC clinic visits, (4) adoption of a reduced TV
curriculum in child care, and (5) limiting TV in
licensed child care settings could reduce impact of
TV exposure and obesity risk but they are not widely
implemented.
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Table 5A. Continued

Indicators Measure Ongoing/Contemporary Research Findings Proposed Future Research Questions
*Gómez & Rajmil (2022) – Spain’s NAOS (Nutrition,
Regulatory physical activity, and obesity prevention) policy
Successes slightly decreased obesity levels for 6-9-year-olds
between 2011 and 2019.
*Otten et al. (2012) – Santa Clara County, CA,
became the fırst US jurisdiction to prohibit the
*What are the long-term effects of school
distribution of toys and other incentives to children
advertising policies on children’s mental and
with meals that do not meet minimal nutritional
State/Local physical health?
criteria.
Policies *What is the prevalence and effectiveness of media
*Palakshappa et al. (2016) – US states with more
literacy education in K-12 schools? How can such
stringent food laws regulating the sale and
literacy be implemented more widely?
advertising of unhealthy F&Bs have lower childhood
obesity in elementary schools.
*Morton et al. (2005) – Australia’s regulatory system
Government
has not shown more responsible food advertising
Regulation
and has seen widespread breaches.
*Goris et al. (2010) – In 1991, Sweden’s ban on ATC *What approaches and tools can be used to
>12 years was undermined by EU legislation that persuade government agencies (FDA, Health and
prevented Sweden from stopping this advertising Human Services, FTC) to collaborate with
from other countries. Need to cover multiple ad stakeholders to address the long-term impacts of
channels like tobacco to achieve optimal effects. childhood obesity?
Regulatory
*Kelly et al. (2019) – Global benchmarking of child *How can consumer protections on false and
Ineffectiveness
exposure to F&B ATC in 22 countries found that misleading marketing be extended to F&B ATC?
countries with existing regulatory arrangements did *What are the regulatory challenges and solutions
not create more favorable/healthy TV F&B ad associated with technology-enabled amalgamated
environments compared with countries without any advertising formats in an environment where cross-
such policies and the bulk of F&B ads derive from a border effects face few bounds?
few transnational companies.
*Gómez & Rajmil (2022) – 11 policy evaluations in 4
countries found small/no policy-related reductions in

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Table 5A. Continued

Indicators Measure Ongoing/Contemporary Research Findings Proposed Future Research Questions
Regulatory unhealthy F&B advertising because marketing
Ineffectiveness shifted to other channels or venues.
*Witkowski (2007) – exploring overlaps of economic
development, food marketing, and obesity, argues
that justifying advertising to children as rational
consumers is tenuous and does not pass scrutiny.
*Kelly et al. (2010) – Australia, Canada, China,
Greece, Spain, and the USA – restrictions are flawed
as they focus on the proportion vs. actual # of
children watching. One study found the restrictions
covered none of the five most popular programs
children watch. *What are the child ages and channels (including
*Kelly et al. (2019) – Global benchmarking of child social media) needing regulatory protection for
Government exposure to F&B ATC in 22 countries found that optimal effects?
Regulation Regulatory Gaps unhealthy F&B was promoted 4X more than *What are the most appropriate times of day and
in Protecting healthier F&B, and the rate of unhealthy F&B ads programming regulations must cover?
Children was higher during peak viewing times for children. *How effective is regulation aimed at reducing
*Boyland et al. (2024) – The dynamic/data-driven exposure to HFSS?
nature of digital food marketing poses barriers for *What factors explain the differential protections
researchers attempting to quantify its impact on offered to children and adults in F&B advertising?
children's eating habits and for policymakers
responsible for designing/implementing restrictive
measures.
*Gumiaraes et al. (2021) – Brazil – more than 90% of
food ads included at least one ultra-processed
product (UPP), 57.7% of ads targeting children used
some abusive technique and lax enforcement.
*Pinto et al. (2021) – HFSS foods have
disproportionately targeted children vs adults.

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Table 5A. Continued

Indicators Measure Ongoing/Contemporary Research Findings Proposed Future Research Questions
*Lobstein & Davies (2009) – UK – Most nutrient
profiling models do not clearly identify less-healthy
foods. UK uses the color-coded ‘traffic light’
signaling to limit F&B ATC. The development of
uniform nutrient profiles is desirable for consumers
and companies.
*Brinsden & Lobstein (2013) – Examined company-
and 3 govt.-specified nutrient profiling models in the
US/EU on sugar criteria. Found company profiles to
be less effective in restricting ads for energy-sense
foods and favored continuing ads of foods high in
sugar. *How can regulators and the F&B industry
Standardized
*Labonté et al. (2017); Elliott & Scime (2019) – collaborate to produce standardized definitions on
National
compared nutrient profiling models of New Zealand, 1) nutrient profiles; 2) HFSS; 3) ultra-processed
Definitions
Government WHO EU, Pan-American Health Organization (PAHO), products (UPP)?
Regulation and Health Canada. The stringency and agreement
between models vary greatly. These have health
implications as different foods will be framed as
“acceptable” depending on the model used.
Policymakers must carefully evaluate features to
determine the most suitable model to limit F&B ATC.
*Gómez & Rajmil (2022) – various countries revising
Nutrient Profiling Model (NPM; UK) 2005/revised
2018; Nutri-Score (France); WHO-NPM (Spain
adopted) 2005/ revised 2011 to address continuing
health issues related to F&B ATC.
*Goris et al. (2010) – There is a need for nationally *Governments often require annual data disclosure
representative data on the prevalence of obesity in on the gender/ethnic workforce balance. How can
Data Collection
children and studies on TV F&B advertising exposure F&B companies be incentivized to disclose data on
using comparable metrics. advertising expenditure, exposure by age and

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Table 5A. Continued

Indicators Measure Ongoing/Contemporary Research Findings Proposed Future Research Questions
*Needlman (2009); World Health Organization
Regional Office for Europe, (2016) – most empirical
Data Collection medium, and nutrient profiles used?
data are gathered/maintained by the food industry,
limiting an unbiased evaluation of research data.
*Sekarasih et al. (2018) – a nuanced school-based
media literacy program had a (+) effect on children’s
advertising knowledge.
*Gerritsen et al. (2019) – New Zealand project
highlights the effectiveness of group model building
for engaging a local community in systems change to
improve child nutrition and supplies a blueprint for
future qualitative system dynamics research.
*Baspakova et al. (2020) – Kazakhstan – a pre-post
experimental study exposing adolescents to the
Government impact of HFSS foods, saw a decline in respondents
Regulation intending to continue eating unhealthy foods. *What policies can help target sectors that
*Chen et al. (2021) – Examining the correlation disseminate F&B marketing to children, such as
Community between parenting styles (authoritative, sports organizations, daycare centers, parks,
authoritarian, indulgent, and uninvolved) and food recreation centers, theaters, and schools?
parenting practices (structure, coercive control, and
autonomy support) found (+) parenting practices
within structure were significantly related to
healthier dietary intakes and children with
authoritative parents consumed more fruits
compared to authoritarian /indulgent parents.
Suggests that parental education can enhance
parenting practices and influence children’s food
intake.
*Chiong & Figueroa (2022) – nutritionally educated
parenting was positively related to healthier intake
among children.

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Table 5A. Continued

Indicators Measure Ongoing/Contemporary Research Findings Proposed Future Research Questions
*Ertz & Le Bouhart (2022) – “Slow Food” (Italy)
Government
Community promotes eating unprocessed food and
Regulation
“Foodwatch” (EU) children’s rights advocacy.
*Caraher et al. (2006) – Significant differences in
*How can stakeholder activism encourage the F&B
3rd Party enforcement /monitoring of self-regulation in 20
industry to subscribe to 3rd party verification of
Certifications countries and little representation of public
compliance with their voluntary codes?
health/consumer groups on self-regulating bodies.
*Goris et al. (2010) – Australia – ‘Sydney Principles’
call for developing an International Code for
Marketing F&B to Children.
*Royo-Bordonada et al. (2016) – Spain – PAOS
(Publicidad, Actividad, Obesidad, Salud) Code
adoption is problematic because it fails to regulate
nutritional composition of the advertised products,
and it does not apply to time slots with a substantial
Self- child audience.
Regulation *Montaña et al. (2019) – Spain – The study shows
that Spanish F&B ATC has very low nutritional value
*What are the barriers and solutions to a globally
Global Standards products and violates the PAOS
accepted Code of F&B ATC?
Code in product description, benefits, and popular
characters use.
*Jiménez-Marín et al. (2020) – Newer
communication channels (social media) have looser
territorial boundaries; supranational solutions
needed to supplement individual government
regulation.
*Gallus et al. (2021) – Italy – TV channels promote
unhealthy F&B, increasing children's demand for
non-core foods, and most of these ads fail to meet
international guidelines.

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Table 5A. Continued

Indicators Measure Ongoing/Contemporary Research Findings Proposed Future Research Questions
*Unilever (2020); Action on Sugar (2020) –
voluntarily limit the use of influencers and
*Are there exemplars of successful industry self-
characters.
regulation in other contexts that can be used as
*Dindral (2006) – stopped advertising to children
templates/best practices? How can these models be
under 13 years and adopted uniform nutrition
Exemplars adapted/replicated to constrain unhealthy F&B
criteria for licensing their characters.
Self- ATC?
*Evich (2013) – engage in constructive partnerships
Regulation *How can F&B companies be incentivized to
to promote healthy lifestyles and offer low-cost
participate in industry self-regulatory programs?
media character licensing to produce companies to
promote fruit and vegetables to children.
*Successful advocacy has led to transformational
Transformational
changes in poultry processors, eliminating
Leadership
antibiotics

Table 5B. Future Research – Social and Environmental Factors

Indicators Measures Ongoing/Contemporary Research Findings Proposed Future Research Questions
*Kelly & Chapman (2007) – Food references in *How can the F&B industry be coopted to avoid
children’s magazines are standard and skewed aggressive advertising on unhealthy F&B ATC and
towards unhealthy foods. Children’s high magazine collaborate on finding mutually beneficial
readership rates and a lack of advertising and solutions?
product placement regulations in Australia make *How does the age of young consumers mediate
Demographic, this media an attractive target for food marketers. the impact of their affective responses elicited by
Social, and Of all magazines, those targeting males and children unhealthy F&B ads on their long-term eating
Age and Gender
Structural aged 7–12 years had the highest proportion of habits and consumption behavior?
Determinants unhealthy food references (78.1% and 69.8%, *How does children's limited cognitive capacity to
respectively) resist implicit and explicit persuasion of unhealthy
*Chernin (2008) – exposure to food commercials F&B ads grow over the years? Does exposure to
increased children's preferences for the advertised such persuasion techniques during childhood carry
products. The commercials equally persuaded over to adulthood? If so, how, why, and to what
younger and older children extent?

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Table 5B. Continued

Indicators Measures Ongoing/Contemporary Research Findings Proposed Future Research Questions
*Powell et al. (2011) – Exposure to fast-food ads on
TV for US children increased from 2003 to 2009 with
no improvement in nutritional content.
*Royo-Bordonada et al. (2016) – 40% of 12-year-olds
are still not aware of the persuasive intent of
advertising. *How do human-brand relationships shown in ATC
*Li et al. (2020) – FF consumption was consistently affect their perceptions of gender roles and their
high among 12–15-year-olds in 54 low- and middle- development?
income countries; factors such as age, sex, BMI, *How can the advertising industry meaningfully
Age and Gender
food insecurity, and sedentary behavior level were contribute to the social development of children?
found to be correlated with fast-food consumption *What is the symbolic meaning of unhealthy F&B
*Hallez et al. (2020) – Children’s developmental brands for children? How do these brands impact
stages a pivotal consideration to effectively children’s identities?
counteract/respond to the harmful effects of
Demographic,
persuasive techniques used for unhealthy F&B ATC.
Social, and
*Castronuovo et al. (2021); Amson et al. (2023) –
Structural
F&B firms use social media marketing techniques
Determinants
that have gender differences.
*Chaudhary et al. (2018) – Oman – Survey of 8-10-
*How do distinct spiritual influences (ritualistic,
year-olds, 25% preferred to buy stationary/books
theistic, and existential) impact children's
after parent consultation; 42.5% bought F&B
attitudes towards the advertising and
products without parent consultation despite
consumption of unhealthy F&B?
belonging to a conformist, collectivist culture
*How does exposure to unhealthy F&B ATC
Ethnicity and where children are obedient.
differentially influence the preference and eating
Religion *Harris (2020) – Industry spends disproportionately
habits of children from minority vs majority
higher amounts to reach Hispanic and African
groups?
American children; Black children/adolescents saw
*How and why does unhealthy F&B ATC on social
2X as many TV food ads compared to their White
media result in higher levels of engagement for
peers; disparities have increased. Marketing/access
some groups (Black, less-acculturated Hispanic)
to unhealthy F&B is also greater in low-income
more than others?
communities of color. Food brands often target

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Table 5B. Continued

Indicators Measures Ongoing/Contemporary Research Findings Proposed Future Research Questions
“multicultural” youth through celebrity
endorsements/music-sporting event sponsorships.
*Harris et al. (2021) – Restaurants continue to
disproportionately target unhealthy F&B ads to *What are the ways to educate/train these groups
Ethnicity and
Hispanic and Black youth. of vulnerable children about social media F&B
Religion
*Rummo et al. (2020) – Unhealthy F&B brands that advertising consumption?
target Black adolescents have a disproportionately
higher percentage of Black followers on social
media relative to White followers.
*Backholer et al. (2021) – Ethnic minority and socio-
*How do demographics such as family’s socio-
economically disadvantaged children are
economic status (SES) and children’s age influence
disproportionately exposed to unhealthy F&B ads,
perceptions and consumption of unhealthy F&Bs?
suggesting targeted advertising practices on
How can these insights be used to develop
Demographic, Black/Hispanic TV networks and neighborhoods in
parental education programs?
Social, and the US.
Socioeconomic *Does TV viewing time moderate the relationship
Structural *Fleming‐Milici et al. (2022) – Saturation of fast-
Status and between unhealthy F&Bs ATC and brand
Determinants Lifestyle food (FF) outlets in communities and prohibitive
attachment? If yes, do these links show variation
cost of fresh produce leads families to prioritize
across socioeconomic groups?
satiety over nutrition. Parents with less food prep
*What factors contribute to the
time, declining cooking skills, and misleading
efficiency/effectiveness of healthy F&B promotion?
labeling question their own nutrition knowledge,
How does the impact of these factors vary across
and often underestimate their children’s exposure
socioeconomic/other demographics?
to/impact from food marketing.
*Potvin Kent et al. (2019) – 72% of adolescent *How does children's media use (time spent using
participants were exposed to F&B ads on social social media apps) impact their preference for
media, of which 44% were for unhealthy food and unhealthy F&Bs?
Internet and 9% for sweetened beverages; more highly exposed *Which social media features
Social Media to food marketing in social media apps than (interactivity/augmentation) are instrumental in
children. enhancing the persuasion appeal of unhealthy F&B
*Andrews et al. (2020) – Cognitive defense ATC? How can social media platforms regulate the
strategies are highly effective in encouraging undesirable use of such technology features?
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Table 5B. Continued

Indicators Measures Ongoing/Contemporary Research Findings Proposed Future Research Questions
*How does online advertising integrated as
entertainment (e.g., through product placement)
targeting younger children influence their
preference for unhealthy F&B?
children/teens to limit access to their private
*What are the ethical concerns related to the
information online/control what they share on
evaluative conditioning format of online ATC
social media.
Internet and where an unhealthy F&B product/brand are paired
*Morton & Treviño (2021) – New ethical issues
Social Media with/shown as rewarding stimuli? How do ethicists
emerge from children's media consumption and
view interactive online ATC formats that move
advertisements through digital technologies and
away from information-based advertising?
online platforms.
*What can we learn from neuroscience about
exposure to unhealthy F&B ATC? How can these
Demographic, learnings minimize harm and enhance the
Social, and consumption of fruits and vegetables?
Structural *How does exposure to unhealthy F&B ATC in
Determinants *Huang et al. (2020) – Most advertisements on bus schools augment/cause adverse outcomes on
shelters near schools were for non-food items or preference for them?
services. Among those related to F&B, most *How can social media literacy programs be
promoted non-core food products. incorporated into school curricula? What type of
*Naderer (2021) –The most suitable approach to content can protect children from unhealthy F&B
counteracting the impact of unhealthy F&B ATC is consumption?
School
to provide children with a comprehensive media *How can advertising literacy be tailored
literacy education from an early age, focusing according to age, product, and type of brand?
specifically on persuasive strategies. *How does healthy F&B promotion in school
*Ertz & Le Bouhart (2022) – Advertisers exploit influence/counteract children’s physiological and
parental absence at schools to engage in branding, psychological responses to unhealthy F&B
blurring the lines between nutritious and junk food. advertising in other mediums and future
consumption behavior?

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Table 5B. Continued

Indicators Measures Ongoing/Contemporary Research Findings Proposed Future Research Questions
*How does the influence of family and peers
*Chung et al. (2021) – Social media influence among
impact children's exposure to (un)healthy F&B?
Peers adolescent peer groups can be a powerful change
*How can influencers facilitate positive change in
agent.
children’s advertising literacy and eating behavior?
*Folkvord & Hermans (2020) – Social influencers
must establish a warm personal relationship and
connection with their followers to promote a
healthy product successfully. Promoting healthy
*How do fictional (e.g., Tony the Tiger) versus real
foods could be more successful when using popular
influencers/endorsers differ in their impact on
and fit influencers.
children's purchase request behavior?
Social Influencers *De Jans et al. (2021) – In an experimental setting,
*What type of interventions by socializing agents
an influencer promoting a sedentary lifestyle
can help buffer children against the adverse effects
(compared to an athletic lifestyle) resulted in more
of unhealthy F&B ads?
children choosing the product high in nutritional
Influence of value and more often. There was less admiration for
Socializing the influencer when they portrayed a sedentary
Agents lifestyle versus an athletic lifestyle.
*Grønhøj & Gram (2020) – Parents' notions of
*What are parents’ views on effects of unhealthy
healthy diets for their children are unaligned with
F&B ATC?
common nutrition‐oriented recommendations. Also,
*How can media literacy programs for parents of
fathers were found to play a highly active role in
younger children be made effective? How and to
their children's food‐related consumer socialization.
what extent does parental advertising literacy
*Emond et al. (2019) – Parental FF consumption
transfer to children?
habits are strongly predictive of children's FF intake;
Parents *How does the interaction between parental rights
among children whose parents had FF less
for independence and unhealthy F&B ATC
frequently, high exposure to FF TV ads was as
manifest?
influential as having a parent who consumed FF
*What types of parental mediation are effective in
frequently.
helping children cope with unhealthy F&B ads?
*De Vliege et al. (2020) – Parents actively try to
What are their effectiveness moderators (e.g., age,
tutor their children about nutrition, although they
advertising literacy)?
reported feeling uncertain about their level of
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Table 5B. Continued

Indicators Measures Ongoing/Contemporary Research Findings Proposed Future Research Questions
nutrition knowledge. Children and parents indicated
that there is little nutrition education in school.
*Suprabha et al. (2022) – Parents cannot translate
their knowledge into action to modify their
children's diet as they lack self-efficacy and feel * What is the impact of parental transmission of
pressured by their children, the media, and the F&B rituals, body image judgements, gender
environment in which they live. stereotypes, and nutritional awareness on
*Naderer (2021) – Active parental mediation may children’s response to unhealthy F&B ads?
not be as effective for very young children, who may *What is the role of family structure in influencing
require additional cues/more controlled children’s response to unhealthy F&B advertising?
environment to ensure they are appropriately *What role do siblings play in mitigating the
exposed to persuasive content. negative impact of an obesogenic F&B advertising
*Driessen et al. (2022) – Unhealthy F&B marketing environment?
undermines parents' ability to provide healthy *How do parents’ self-efficacy perceptions relate
Influence of foods to their children. Additionally, parents often to/impact children’s preference for healthy vs.
Socializing Parents underestimate both the level of exposure their unhealthy F&B?
Agents children have to unhealthy F&B ATC and its impact, *What types of community programs can help
particularly within the digital ecosystem. improve parental cooking skills, nutritional
*Ravikumar et al. (2022) – Child preferences, knowledge, advertising literacy, and use of social
financial/time constraints, and location/access to media?
food outlets make it difficult to access healthy food. *How can different parental compositions (e.g.,
Parental nutrition education and feeding single, same gender, dual-income households,
approaches varied, but (+) outcomes from cohabitating), styles (free-range, helicopter, tiger,
interventions to address these behaviours will be and lawnmower), and mediation strategies
short-lived if inequities in health caused by poverty (permissive, authoritarian) be used to educate and
and access to affordable and healthy food are not guide children about unhealthy F&B ATC and nudge
addressed. them towards healthy F&B?
*Chiong & Figueroa (2022) – Parents’ favorability
towards F&B ads influence parent-adolescent
unhealthy food consumption, and families who
experience food insecurity are not just vulnerable to

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Table 5B. Continued

Indicators Measures Ongoing/Contemporary Research Findings Proposed Future Research Questions
food ads, but also to the consumption of ultra-
Parents
processed foods.
*Do low visibility and readability of the content
Influence of *Van Reijmersdal et al. (2017) – study shows that and character of advertisement disclosure dilute
Socializing brand placement disclosure had limited effects on its effectiveness?
Mandatory/
Agents adolescents’ understanding of persuasive intent, did *Which of the two is more effective audio
Voluntary
not mitigate persuasion, but did increase brand disclosure or video disclosure?
Disclosures
memory. Disclosure has fundamentally different *Is disclosure equally effective across children of all
effects on adolescents than on adults. ages and across different media channels (TV and
social media?

Table 5C. Future Research – Media Channels

Indicator Measure Ongoing/Contemporary Research Findings Proposed Future Research Questions
*Rummo et al. (2020) – Food and sugary drink
brands maintain millions of adolescent followers on
Media Reach – *What measures can F&B companies take to
Expenditure, social media. TV advertising expenditures were
(Clicks, Shares, counter the detrimental consequences of tracking
Media Reach positively associated with percentages of
CPMs, etc.) children’s behavioral data on digital media?
adolescent followers of the selected brands on
Twitter (now X).
*Smith et al. (2024) – Investigate how personalized
*How do traditional vs. new media differ in their
Brand Recall and ads impact children's brand attitudes and purchase
influence specific to F&B ATC? Do these influences
Interactivity, Engagement – intentions.
align with or conflict with children's cognitive,
Speed (Advergames, *Carroll et al. (2024) – Examine children's
emotional, intellectual, and moral development as
Likes, etc.) perception and interpretation of food marketing
consumers?
across digital media platforms.

Frequency/Impact *Veerman et al. (2009) – study suggests that from

Exposure – (Food Choices, one in seven up to one in three obese children in the *How does unhealthy F&B ATC on newer social
media platforms impact children’s dietary intake?
Preferences, etc.) USA might not have been obese in the absence of
advertising for unhealthy food on TV.

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Table 5C. Continued

Indicator Measure Ongoing/Contemporary Research Findings Proposed Future Research Questions
*Dalton et al. (2017) – Exposure to child-targeted
fast food (FF) TV advertising is positively associated
with FF consumption among pre-school-age
children, highlighting young children's vulnerability
to persuasive advertising.
Frequency/Impact *Signal et al. (2017) – A cross-section of 168 New
Exposure – (Food Choices, Zealand children were frequently exposed, across
Preferences, etc.) multiple settings, to non-core unhealthy F&B ATC.
* Théodore et al. (2021) – Companies used diverse
persuasive techniques, combining promotional
characters (79.1%), incentives (65.1%), and digital
techniques (78.3%). Digital marketing’s persuasive
techniques pose a major threat to Mexican children.
*Olstad et al. (2022) – The study aims to develop an
Artificial Intelligence (AI) system that identifies *Do modern technologies such as AI have the
unhealthy food marketing practices in a scalable, potential to provide effective monitoring solutions
objective, and repeatable way. that track unhealthy media practices and non-
Impact of Social
*Nieto et al. (2023) – A study found that adherence to regulations?
Media
adolescents and kids in Mexico were exposed to *How can regulatory protections for adolescents
harmful digital food marketing; based on the be incorporated into policies and voluntary codes
Evaluation evidence, they propose that digital media must be relating to social media?
regulated.
*Awaad et al. (2023) – Highlight the prevalence of
*What are the short-term and long-term
Physical/Mental overweight and obesity among children aged 2-5
measurable implications of the continuous
Outcomes Linked years and its association with unhealthy F&B
availability of personalized content for children’s
to Social Media – advertising, such as BMI and TV viewing; more
emotional and physical well-being and dietary
(Diet, BMI, Stress) research is needed to build these linkages and long-
choices?
term well-being.

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Table 5C. Continued

Indicator Measure Ongoing/Contemporary Research Findings Proposed Future Research Questions
*Povtin Kent et al. (2023) – An experimental study
found that variations in the amount of time spent
*How can empirical studies (longitudinal as well as
watching F&B ads based on food categories and
Study Design causal experiments) document these implications
healthfulness indicate that food firms
to facilitate policy intervention?
disproportionately target teenagers due to
Evaluation voluntary standards.
*Can we identify social media case studies
*Powell & Pring, (2023) – Influencers can affect showing a successful transition to healthy F&B
Exemplars health outcomes in both positive and negative consumption among children? What can we learn
ways. from these case studies regarding the factors
responsible for this success?

Table 5D. Future Research - Persuasion Techniques

Indicator Measure Ongoing/Contemporary Research Findings Proposed Future Research Questions
*Nairn & Hang (2012) – children return to
*What is a typical customer journey for children?
advergames websites multiple times and make
How can understanding this journey help in
more unhealthy food purchase requests.
Toys, ‘plugging’ stimuli promoting healthy choices at
*De Jans et al. (2019) – A review of 138 academic
Mascots, different steps in the journey?
articles from 2006-2016 on F&B ATC >12 years found
Advergames, *How do different persuasion tactics such as toys,
that most TV spots advertised products with poor
Promotional promotional characters, and offers (including
nutritional content and had the potential to
Characters, digital ones) affect children’s processing of
Children's ability mislead audiences concerning products’ actual
Promotional unhealthy F&B ads? How do children relate these
to deal with nutritional value. The tactics of repetition/appeals
Offers, Viral indirect cues to the central advertising message?
persuasive intent of premium F&B offerings can influence the
Marketing, *How do these tactics influence their intellectual,
purchase intention.
Movie Tie- emotional, and moral development?
*Kelly et al. (2019) – Children who watched a
Ins, and *How do techniques such as advergames and
greater amount of TV had a stronger attachment to
Intellectual widgets impact young consumers’ attention span
their favorite drink brands, demonstrated by their
Development in general and advertising stimuli in particular?
preference for the drink-branded T-shirt. The more
*What is the impact of longer-term exposure to
TV that children watched, the more they were
unhealthy F&B ATC in advergame-type settings?
willing to pay for the drink-branded T-shirt and the
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Table 5D. Continued

Indicator Measure Ongoing/Contemporary Research Findings Proposed Future Research Questions
stronger their agreement with statements about
the drink brands’ connection to self.
*Agante & Pascoal (2019) – Effects of advergames
are stronger one week after playing.
Toys, Mascots, *Folkvord & Hermans (2020) – Research is needed
Advergames, to assess the efficiency/effectiveness of healthy
*To what extent do children comprehend
Promotional food promotion and to explore how marketing
advertisers’ persuasive intent in unhealthy F&B
Characters, techniques can improve children’s dietary
ads?
Promotional Children's ability behavior.
*What are the most effective ways to moderate
Offers, Viral to deal with *Ertz & Le Bouhart (2022) – Children no longer eat
the impact of persuasion strategies on children's
Marketing, persuasive intent to satiate hunger but rather to play, resulting in
preference for advertised unhealthy F&B?
Movie Tie-Ins, them consuming more than they need for fun,
*What constitutes an exploitative promotional
and opening the door to obesity.
technique and how can children be protected?
Intellectual *Packer et al. (2022) – Marketing practices reveal
Development that characters are disproportionately used to
promote HFSS foods to children. HFSS products
featuring characters was found to significantly
increase taste preference for these products
compared to HFSS packaging without characters.
*Coates et al. (2020) – Across 6 focus groups, *How and to what extent do endorsers
exposure to influencer marketing of HFSS F&Bs (celebrities, influencers, and characters)
increases children’s immediate intake. differentially influence children’s cognition,
Identity, *Fleming‐Milici et al. (2023) – In 2020, YouTube affect, and behavior?
Personality, prohibited food advertising on its "made-for-kids" *How can influencers be used to shift the focus
Celebrity channels, nevertheless, food-related appearances from unhealthy to healthy fun? Are there cultural
Popularity,
Endorsements, in kid influencer videos are becoming popular. variations in the content, frequency, and reliance
Influencing
Influencers Additional research needed to study these in detail on endorsers in F&B ATC?
Capabilities, Fans,
Followers and curb them. What factors underlie these differences?
*Potvin Kent et al. (2024) – Canada – Examined *What best practices can be adopted or adapted
children spending considerable time on digital in different country settings?
devices are exposed to harmful food marketing on *What are the implications of children’s
social media, particularly from influencers who are experiential learning about socially desirable
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Table 5D. Continued

Indicator Measure Ongoing/Contemporary Research Findings Proposed Future Research Questions
Identity, eating behavior through these persuasive
celebrities and who promote items. The study
Personality, techniques?
Celebrity explored how often and how powerfully Canadian
Popularity, *How do they impact children’s attitudes
Endorsements, kids-favorite influencers on YouTube, Instagram,
Influencing towards healthy/ unhealthy F&B in the long term?
Influencers and TikTok promote unhealthy foods in their
Capabilities, Fans, *How does this attitude impact the consumption
posts.
Followers of healthy/ unhealthy F&B among peers?
*How does the need for self-expression and
independence promote children’s intention to
consume unhealthy F&B? How does this effect
vary across traditional/digital formats?
*What motivations, goals, and beliefs underpin
impression management in children? How do
children use consumption stereotypes for
impression management in their peer groups?
*Fong et al. (2019) – The results of this study
*What are the techniques used in unhealthy F&B
demonstrate that rather than the rational aspect
ATC to influence behavior by relying on
of commercials—where the logic of health and
Emotional Logos, Pathos, social/peer pressure? What interventions can
nutrition claims is not a relevant concern—children
Appeals Ethos minimize/counteract such influence?
are more receptive to the emotional contents of
*Is there seasonal variation in content and
the adverts, which appeal to their emotional
frequency of unhealthy F&B ATC (e.g., during
impulses.
summer when school is off versus other times)?
How can the promotion of healthy behaviors be
modulated depending on such variation? Can
abstract construal in a persuasive
message/associated with a product – associated
with longer-term thinking be engendered among
children? If so, how? And what benefits might
accrue from such construal?

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Table 5D. Continued

Indicator Measure Ongoing/Contemporary Research Findings Proposed Future Research Questions
*Baldassarre et al. (2016) – Pestering is a real
attitude, particularly among the littlest children. *How can children’s cognitive skills and affective
Moreover, children influence their parents' awareness be enhanced vis-à-vis identifying an
Children's Ability
purchasing decisions, but this influence decreases ad's persuasion tactics?
to Influence
Pester Power when mothers and fathers are more aware of the *What type of parenting strategies can aid or
Parent Purchase
importance of a quality-based diet. hurt in achieving this goal? How and to what
Decisions
*McCarthy et al. (2022) – Advergames have a extent can school curricula be tailored to serve
significant effect on pester behaviors, food choice, this purpose?
and food intake of children.
*Should a standardized measurement
tool/approach be used to measure the effect of
Sentiment *Ares et al. (2024) – Examine the various food
different persuasion techniques and media
Analysis and literacy skills acquired during childhood and
channels?
Brand Metrics – adolescence, incorporating substantial data on
Evaluation *Given research that early childhood taste
Recognition, cognitive, social, and food-related development.
exposure to fruits and vegetables is the most
Recall, Perception Make recommendations on how to enhance
effective in motivating healthy food choices,
& Attitude children's healthy eating habits systematically.
what age-specific training is most effective in
improving children’s F&B advertising literacy?
*Kelly et al. (2023) – Different monitoring
strategies have been used in different contexts
depending on how far along a policy is in its *How can policy help shape F&B companies’ use
implementation. These have different resource and of product placement (child eye level), packaging
Voluntary
Standards opportunity costs, such as priority media settings, (black and white), and texture (soft and easy to
Codes
marketing strategies, food study design, and chew) to aid a shift to children making healthy
whether exposure evaluations are estimated or F&B choices?
observed based on kids' media consumption or
media content analysis.

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Table 5E. Future Research – Ethical Implications

Indicator Measure Ongoing/Contemporary Research Findings Proposed Future Research Questions
*Ertz & Le Bouhart (2022) – Framework outlining *What ethical perspectives are prevalent in the
linkages between F&B ATC and obesity, concludes F&B industry’s strategic decision-making? To
that while marketing is not solely responsible, it what extent do they represent children’s
Ethical Decision-
plays a central role through insidious/ deceptive interests relative to a profit motive? What
Making Models
practices (micromarketing) and by effective modifications can aid in ‘moving the needle’?
corporate lobbying to ensure the status quo *Are there any industry exemplars of responsible
(macroenvironmental). ATC?
*Have annual evaluations of industry practices
using the TARES model been conducted to
*Lee & Nyugen (2013) – Singapore –Study using examine trends?
TARES model (truthfulness, authenticity, respect, *What are the ethical implications of using
Empirical Analysis equity, and social responsibility) found lower implicit psychological processes in designing
of Practitioner ethicality associated with advertising to children unhealthy F&B ATC?
Scholarly Ethicality than adults lending empirical support to FF *What are the ethical implications of the trade-
Research advertising's insidious approach of targeting the offs between F&B ‘happiness maximizing’ ATC
young. and the associated health risks? How can
happiness maximization be gauged? What level of
happiness maximization is enough or too much?
*Wilson et al. (2022) – In testing a model on
training consumers to detect misleading
*What empirical models can be used to train
Consumer persuasion tactics, they found that general training
parents and/or children to detect misleading
Training Models focused on higher-level vigilance goals (skepticism
persuasion tactics in the F&B industry?
vs. a specific tactic) was more effective in helping
them identify unethical advertising tactics.
*How can research across other disciplines (e.g.,
Cross-Disciplinary humanities, linguistics) be incentivized to design
Research holistic solutions to the challenge of unhealthy
F&B ATC?

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Table 5E. Future Research – Ethical Implications

Indicator Measure Ongoing/Contemporary Research Findings Proposed Future Research Questions
*Jackson et al. (2015) – The ‘managerialization’ of *How do organizational leaders imbue,
Organizational
marketing ethics risks separating the process and communicate, and inculcate core ethical values
Culture, Policies,
application of marketing ethics from the principles about unhealthy F&B ATC? What are the gaps,
Organizational and Practices and context in which they were founded. and how can they be bridged?
Policies
*How can Puccio’s divergent thinking principles
Marketing or
be used towards creative advertising solutions to
Moral Imagination
encourage children to consume healthy F&B?
*How can business schools up the ante on
Revisiting How endeavors to educate the next generation
Marketing is specifically about unhealthy F&B ATC ethics? Can
Taught in Higher such content be integrated into core courses
Education rather than be a small part of a token course in
ethics?
Higher
*Mathur & Jain (2020) – Firms must adjust their
Education
business strategies to meet rapidly changing
Policy
consumer expectations of non-instrumental or
social norms. Compared to preceding generations, *How can ethically conscious millennials and Gen
Millennials and
millennials are skeptical of traditional marketing Z consumers be utilized as influencers, not just
Gen Z Consumers
approaches, and the food industry will need to pay for children but also for advertisers?
attention to the emerging trends in ‘values-driven’
decision-making to continue influencing their
purchase decisions.

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PERSUASION TECHNIQUES

The food industry uses sophisticated persuasion techniques to market ultra-processed and HFSS foods
to children, including the use of toys and licensed characters (co-brands, e.g., Disney characters) or
brand equity characters (created by the brand, e.g., Coco the Monkey) in packaging, product
placement, and promotions (Harris et al., 2021; Rummo et al., 2020). A content analysis found that
64.4% of 250 mainstream US films produced between 1991 and 2015 used at least one unhealthy food
brand placement, and there were more placements in films for children aged 6–12 than those for ages
12 and older (Naderer et al., 2019). An engaging and influential technique relying on fantasy is used to
generate attention, recognition, persuasion (Coates et al., 2019) and parasocial (one-sided)
relationships (Liebers & Schramm, 2019) with children. Notably, such “pleasure” marketing seeks to
divert attention away from the health risks associated with junk food consumption (Elliott & Truman,
2019).
Other reviews reveal that characters are disproportionately used to promote HFSS products to
children (e.g., Hebden et al., 2011) to engender higher taste preferences for HFSS foods. Persuasion
agents’ use of fun and play to engender positive behaviors may also have an upside. Children offered
toy premiums with only healthy options were three times more likely to select a healthy meal (Hobin
et al., 2012). Table 5D proposes a list of research questions to examine the impact of various persuasion
techniques and alternatives to pester power.

ETHICAL IMPLICATIONS

Children comprise a lucrative target market because of their purchasing power, influence on parents’
food purchase decisions, and lifetime value related to food. In their 22-country study benchmarking
children’s exposure to unhealthy F&B ATC on TV, Kelly et al. (2019) reported that one-third of all ads
came from a handful of global corporations with a combined market value of over $994 billion (2017).
All the products manufactured by these corporations were ultra-processed, typically HFSS, hyper-
palatable, shelf-stable, value-added, and marketed to increase their desirability and normality, build
brand loyalty to ensure lifelong purchases, and profitability (Haryanto et al., 2016).
The food industry concentration is an obstacle in addressing F&B ATC’s ethical implications.
Further, the industry, drawing on perspectives of personal freedom, resistance to state intervention,
and reliance on market-based solutions, has sought to shift responsibility to the individual and parents.
In addition, doubts exist about the link between eating behavior and advertising and childhood obesity
is too complex an issue to be addressed by advertising restrictions (Ngqangashe et al., 2022). Civil
society groups are launching local programs to remedy the deleterious outcomes of the HFSS food
culture to fill these gaps and signal consumers seeking authenticity and value alignment in their
purchases. Examples include “Slow Food” (Italy), which promotes eating unprocessed food, and
“Foodwatch” (Europe), which petitions for children’s rights and educates consumers through
documentaries such as Super-Size Me and Fed Up. Scholars, too, have documented interventions to
promote healthy eating of a half-size portion with a modest non-food incentive (e.g., Reimann et al.
2015). Table 5E proposes a list of future research questions, including using various ethical models in
research, re-examining organizational policies, and how marketing is taught in higher education to
address concerns with unhealthy F&B ATC.

CONCLUSION

Using a discovery-oriented approach, we conducted multiple qualitative and quantitative analyses to

review the highly impoverished but crucial F&B ATC ethics scholarship. These analyses revealed five
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novel yet-to-be-documented knowledge clusters. A deeper dive into each cluster through the lens of
four prominent theories of ethical judgment led to an articulation of a series of cluster-specific
questions that future research should address. We want to highlight that when we embarked on this
journey, we did not foresee the scope of our inquiry, which turned out to be overwhelming. We
described our contributions earlier, and the key takeaways from our article, which are captured in
Tables 5A-5E, specify a vast and exciting roadmap for future research. While some of the research
questions in these Tables may be easier to address, several others (and possibly some of the more
critical ones) may be more challenging. It is foreseeable that cracking the daunting code of improving
children’s health by curbing some of the questionable practices of F&B ATC may require a
nexus/association of firmly united and diverse stakeholders willing to do what it takes to move the
needle. More efforts to study the ethics of F&B ATC using other methodologies and databases (e.g.,
Web of Science) are welcome, particularly if they offer deeper and more actionable insights that can
enhance the health of Earth’s children. However, these efforts and their outcomes may remain a pie
in the sky if the pie on the ground is sweeter and not in the best interests of our children.

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APPENDICES

APPENDIX I

SUPPLEMENTARY REFERENCES: TOP 50 MOST INFLUENTIAL ARTICLES (TABLE 3A)

1. Anderson, P., De Bruijn, A., Angus, K., Gordon, R., & Hastings, G. (2009). Impact of alcohol
advertising and media exposure on adolescent alcohol use: A systematic review of
longitudinal studies. Alcohol and Alcoholism, 44(3), 229-243.
2. Arredondo, E. M., Elder, J. P., Ayala, G. X., Campbell, N., Baquero, B., & Duerksen, S. (2006).
Is parenting style related to children's healthy eating and physical activity in Latino
families? Health Education Research, 21(6), 862-871.
3. August, G. P., Caprio, S., Fennoy, I., Freemark, M., Kaufman, F. R., Lustig, R. H., Silverstein,
J. H., Speiser, P. W., Styne, D. M., Montori, V. M., & Endocrine Society (2008). Prevention
and treatment of pediatric obesity: An endocrine society clinical practice guideline based
on expert opinion. The Journal of Clinical Endocrinology and Metabolism, 93(12), 4576–4599.
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Education & Behavior, 27(2), 157-166.
5. Batis, C., Hernandez-Barrera, L., Barquera, S., Rivera, J. A., & Popkin, B. M. (2011). Food
acculturation drives dietary differences among Mexicans, Mexican Americans, and non-
Hispanic whites. The Journal of Nutrition, 141(10), 1898-1906.
6. Beech, B. M., Klesges, R. C., Kumanyika, S. K., Murray, D. M., Klesges, L., McClanahan, B.,
Slawson, D., Nunnally, C., Rochon, J., McLain-Allen, B., & Pree-Cary, J. (2003). Child- and
parent-targeted interventions: The Memphis GEMS pilot study. Ethnicity & Disease, 13(1
Suppl 1), S40–S53.
7. Boyland, E. J., Nolan, S., Kelly, B., Tudur-Smith, C., Jones, A., Halford, J. C., & Robinson, E.
(2016). Advertising as a cue to consume: A systematic review and meta-analysis of the
effects of acute exposure to unhealthy food and nonalcoholic beverage advertising on
intake in children and adults. The American Journal of Clinical Nutrition, 103(2), 519–533.
8. Briefel, R. R., Crepinsek, M. K., Cabili, C., Wilson, A., & Gleason, P. M. (2009). School food
environments and practices affect dietary behaviors of US public school children. Journal
of the American Dietetic Association, 109(2), S91-S107.
9. Brownell, K. D., & Frieden, T. R. (2009). Ounces of prevention—The public policy case for
taxes on sugared beverages. New England Journal of Medicine, 360(18), 1805-1808.
10. Cairns, G., Angus, K., Hastings, G., & Caraher, M. (2013). Systematic reviews of the evidence
on the nature, extent, and effects of food marketing to children. A retrospective summary.
Appetite, 62, 209–215.
11. Cecchini, M., Sassi, F., Lauer, J. A., Lee, Y. Y., Guajardo-Barron, V., & Chisholm, D. (2010).
Tackling of unhealthy diets, physical inactivity, and obesity: Health effects and cost-
effectiveness. The Lancet, 376(9754), 1775–1784.
12. Coon, K. A., & Tucker, K. L. (2002). Television and children’s consumption patterns. Minerva
Pediatrica, 54(5), 423-436.
13. De Bourdeaudhuij, I., Van Cauwenberghe, E., Spittaels, H., Oppert, J. M., Rostami, C., Brug,
J., Van Lenthe, F., Lobstein, T., & Maes, L. (2011). School-based interventions promoting
both physical activity and healthy eating in Europe: A systematic review within the HOPE
project. Obesity Reviews : An Official Journal of the International Association for the Study of
Obesity, 12(3), 205–216. https://doi.org/10.1111/j.1467-789X.2009.00711.x
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14. Dixon, H. G., Scully, M. L., Wakefield, M. A., White, V. M., & Crawford, D. A. (2007). The
effects of television advertisements for junk food versus nutritious food on children's food
attitudes and preferences. Social Science & Medicine, 65(7), 1311-1323.
15. Finkelstein, D. M., Hill, E. L., & Whitaker, R. C. (2008). School food environments and
policies in US public schools. Pediatrics, 122(1), e251-e259.
16. Flodmark, C. E., Lissau, I., Moreno, L. A., Pietrobelli, A., & Widhalm, K. (2004). New insights
into the field of children and adolescents’ obesity: The European perspective. International
Journal of Obesity, 28(10), 1189-1196.
17. Glickman D., Parker L., Sim L. J., del Valle Cook H., & Miller E. A. (2012). Accelerating
progress in obesity prevention: Solving the weight of the nation. Committee on
Accelerating Progress in Obesity Prevention.
18. Hanks, A. S., Just, D. R., Smith, L. E., & Wansink, B. (2012). Healthy convenience: Nudging
students toward healthier choices in the lunchroom. Journal of Public Health, 34(3), 370-
376.
19. He, F. J., & MacGregor, G. A. (2009). A comprehensive review on salt and health and
current experience of worldwide salt reduction programmes. Journal of Human
Hypertension, 23(6).
20. Kelly, B., Halford, J. C. G., Boyland, E. J., Chapman, K., Bautista-Castaño, I., Berg, C., Caroli,
M., Cook, B., Coutinho, J. G., Effertz, T., Grammatikaki, E., Keller, K., Leung, R., Manios, Y.,
Monteiro, R., Pedley, C., Prell, H., Raine, K., Recine, E., … Summerbell, C. (2010). Television
food advertising to children: A global perspective. American Journal of Public Health,
100(9), 1730–1736.
21. Khan, L., Sobush, K., Keener, D., Goodman, K., Lowry, A., Kakietek, J., & Zaro, S. (2009).
Recommended Community Strategies and Measurements to Prevent Obesity in the United
States. Morbidity and Mortality Weekly Report, 58(No. RR-7).
22. Kumanyika, S. K. (2008). Environmental influences on childhood obesity: Ethnic and
cultural influences in context. Physiology & Behavior, 94(1), 61-70.
23. Lobstein, T., & Davies, S. (2009). Defining and labelling ‘healthy’ and ‘unhealthy’
food. Public Health Nutrition, 12(3), 331-340.
24. Lobstein, T., Jackson-Leach, R., Moodie, M. L., Hall, K. D., Gortmaker, S. L., Swinburn, B. A.,
James, W. P. T., Wang, Y., & McPherson, K. (2015). Child and adolescent obesity: Part of a
bigger picture. The Lancet, 385(9986), 2510-2520.
25. Lytle, L. A., Seifert, S., Greenstein, J., & McGovern, P. (2000). How do children's eating
patterns and food choices change over time? Results from a cohort study. American
Journal of Health Promotion, 14(4), 222-228.
26. Malik, V. S., & Hu, F. B. (2015). Fructose and cardiometabolic health: What the evidence
from sugar-sweetened beverages tells us. Journal of the American College of
Cardiology, 66(14), 1615-1624.
27. McGinnis, J. M., Gootman, J. A., & Kraak, V. I. (Eds.). (2006). Institute of Medicine. Food
marketing to children and youth: Threat or opportunity? National Academies Press.
28. Muckelbauer, R., Libuda, L., Clausen, K., Toschke, A. M., Reinehr, T., & Kersting, M. (2009).
Promotion and provision of drinking water in schools for overweight prevention:
Randomized, controlled cluster trial. Pediatrics, 123(4), e661-e667.
29. Musaiger, A. O. (2011). Overweight and obesity in Eastern Mediterranean region:
Prevalence and possible causes. Journal of Obesity, 2011.
30. Nicklas, T., & Johnson, R. (2004). Position of the American Dietetic Association: Dietary
guidance for healthy children ages 2 to 11 years. Journal of the American Dietetic
Association, 104(4), 660-677.
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31. Popkin, B. M., & Hawkes, C. (2016). Sweetening of the global diet, particularly beverages:
Patterns, trends, and policy responses. The Lancet Diabetes & Endocrinology, 4(2), 174-186.
32. Powell, L. M., Harris, J. L., & Fox, T. (2013). Food marketing expenditures aimed at youth.
American Journal of Preventive Medicine, 45(4), 453–461.
33. Reissig, C. J., Strain, E. C., & Griffiths, R. R. (2009). Caffeinated energy drinks - A growing
problem. Drug and Alcohol Dependence, 99(1–3), 1–10.
34. Roberto, C. A., Baik, J., Harris, J. L., & Brownell, K. D. (2010). Influence of licensed
characters on children's taste and snack preferences. Pediatrics, 126(1), 88-93.
35. 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.
36. Robinson, T. N., Borzekowski, D. L., Matheson, D. M., & Kraemer, H. C. (2007). Effects of
fast food branding on young children's taste preferences. Archives of Pediatrics &
Adolescent Medicine, 161(8), 792-797.
37. Sadeghirad, B., Duhaney, T., Motaghipisheh, S., Campbell, N. R. C., & Johnston, B. C. (2016).
Influence of unhealthy food and beverage marketing on children's dietary intake and
preference: A systematic review and meta‐analysis of randomized trials. Obesity
Reviews, 17(10), 945-959.
38. Schwartz, M. B., & Puhl, R. (2003). Childhood obesity: A societal problem to solve. Obesity
Reviews, 4(1), 57-71.
39. Sharma, L. L., Teret, S. P., & Brownell, K. D. (2010). The food industry and self-regulation:
Standards to promote success and to avoid public health failures. American Journal of
Public Health, 100(2), 240–246.
40. Spoth, R., Greenberg, M., & Turrisi, R. (2008). Preventive interventions addressing
underage drinking: State of the evidence and steps toward public health
impact. Pediatrics, 121(Supplement 4), S311-S336.
41. 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.
42. Story, M., Kaphingst, K. M., & French, S. (2006). The role of childcare settings in obesity
prevention. The Future of Children, 143-168.
43. Strasburger, V. C. & Council on Communications and Media. (2011). Children, adolescents,
obesity, and the media. Pediatrics, 128(1), 201–208.
44. Swinburn, B. A., Caterson, I., Seidell, J. C., & James, W. P. T. (2004). Diet, nutrition and the
prevention of excess weight gain and obesity. Public Health Nutrition, 7(1a), 123–146.
45. Taveras, E. M., Gortmaker, S. L., Hohman, K. H., Horan, C. M., Kleinman, K. P., Mitchell, K.,
Price, S., Prosser, L. A., Rifas-Shiman, S. L., & Gillman, M. W. (2011). Randomized controlled
trial to improve primary care to prevent and manage childhood obesity: The High Five for
Kids study. Archives of Pediatrics & Adolescent Medicine, 165(8), 714–722.
https://doi.org/10.1001/archpediatrics.2011.44
46. Van der Horst, K., Kremers, S., Ferreira, I., Singh, A., Oenema, A., & Brug, J. (2007).
Perceived parenting style and practices and the consumption of sugar-sweetened
beverages by adolescents. Health Education Research, 22(2), 295-304.
47. Ventura, A. K., & Mennella, J. A. (2011). Innate and learned preferences for sweet taste
during childhood. Current Opinion in Clinical Nutrition & Metabolic Care, 14(4), 379-384.
48. Wechsler, H., Devereaux, R. S., Davis, M., & Collins, J. (2000). Using the school environment
to promote physical activity and healthy eating. Preventive Medicine, 31(2), S121-S137.

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49. Wiecha, J. L., Peterson, K. E., Ludwig, D. S., Kim, J., Sobol, A., & Gortmaker, S. L. (2006).
When children eat what they watch: Impact of television viewing on dietary intake in
youth. Archives of Pediatrics & Adolescent Medicine, 160(4), 436-442.
50. Yee, A. Z., Lwin, M. O., & Ho, S. S. (2017). The influence of parental practices on child
promotive and preventive food consumption behaviors: A systematic review and meta-
analysis. International Journal of Behavioral Nutrition and Physical Activity, 14(1), 1-14.

APPENDIX II

SUPPLEMENTARY REFERENCES: CO-CITATION CLUSTERS (TABLE 4)

1. Andreyeva. T., Kelly, I. R. & Harris, J. L. (2011). Exposure to food advertising on television:
Associations with children’s fast food and soft drink consumption and obesity. Economics &
Human Biology, 9(3), 221–233.
2. Barlow, S. E. (2007). Expert committee recommendations regarding the prevention,
assessment, and treatment of child and adolescent overweight and obesity: Summary report.
Pediatrics, 120(4), 164–192.
3. Birch, L. L. (1999). Development of food preferences. Annual Review of Nutrition, 19, 41–62.
4. Birch, L. L., & Fisher, J. O. (1998). Development of eating behaviors among children and
adolescents. Pediatrics, 101, 539–549.
5. Borzekowski, D. L. G., & 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.
6. Boyland, E. J., Nolan, S., Kelly, B., Tudur-Smith, C., Jones, A., Halford, J. C., & Robinson, E.
(2016). Advertising as a cue to consume: A systematic review and meta-analysis of the effects
of acute exposure to unhealthy food and nonalcoholic beverage advertising on intake in
children and adults. American Journal of Clinical Nutrition, 103(2), 519–533.
7. Cairns, G., Angus, K., Hastings, G. & Caraher, M. (2013). Systematic reviews of the evidence on
the nature, extent and effects of food marketing to children. A retrospective summary.
Appetite, 62, 209–215.
8. Cole, T. J., Bellizzi, M. C., Flegal, K. M., & Dietz, W. H. (2000). Establishing a standard definition
for child overweight and obesity worldwide: International survey. British Medical Journal ,320,
1240.
9. Connor, S. M. (2006). Food-related advertising on preschool television: Building brand
recognition in young viewers. Pediatrics, 118(4), 1478–1485.
10. Ebbeling,, C. B., Pawlak, D. B. & Ludwig, D. S. (2002). Childhood obesity: Public-health crisis,
common sense cure. Lancet, 360, 473–482.
11. Folkvord, F., Anschütz, D. J., Wiers, R. W., & Buijzen, M. (2015). The role of attentional bias in
the effect of food advertising on actual food intake among children. Appetite, 84, 251–258.
12. Galbraith-Emami, S. & Lobstein, T. (2013). The impact of initiatives to limit the advertising of
food and beverage products to children: A systematic review. Obesity Reviews 14(12), 960–974.
13. Harris, J. L., Bargh, J. A., & Brownell, K. D. (2009). Priming effects of television food advertising
on eating behavior. Health Psychology, 28(4), 404–413.
14. Harris, J. L., Schwartz, M. B., & Brownell, K. D. (2010). Marketing foods to children and
adolescents: Licensed characters and other promotions on packaged foods in the
supermarket. Public Health Nutrition, 13(3), 409–417.
15. Harrison, K. & Marske, A. L. (2005). Nutritional content of foods advertised during the
television programs children watch most. American Journal of Public Health, 95(9), 1568–1574.
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