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

Assessment of the nutritional quality of food advertised to children in Lebanon: the first study to use the WHO nutrient profile model for the EMR Lara Nasreddine, PhD Department of Nutrition and Food Sciences Faculty of Agricultural and Food Sciences American University of Beirut, Lebanon 5th Dubai International Nutrition Congress, 24-26 October 2019, Dubai

Obesity in Lebanon Like other countries of the EMR, Lebanon is undergoing the nutrition transition with its characteristic shift in diet, lifestyle and obesity prevalence Economic growth Modernization Globalization of trade and marketing Rapid urbanization Reduced physical Changes in food activity environment

Childhood Obesity in Lebanon

Prevalence of Overweight and Obesity (%) in Children (0-5yrs) 30 25.1 25 20 % 15 11.9 10 8.1 3.3 5 0 At risk of Overweight Obesity Overweight & overweight only Obesity At risk of overweight (+1< BMI-for-age z- score ≤+2 ) Obese (BMI-for-age z-score >3) Overweight and obese (BMI-for-age z-score > 2) (Nasreddine et al., unpublished data)

Prevalence of overweight and obesity in children aged 0-5 y in 2010 Global 6.7 Lebanon: Developed countries 11.7 Developing countries 6.1 11.9 % Oceania 3.5 Latin America South America 6.8 & Caribbean Central America 7.2 Caribbean 9.6 Latin America and Caribbean 6.9 Western 14.7 Southeastern 4.6 Asia South Central 3.5 Eastern 5.2 Asia 4.9 Western 6.4 Southern 7.6 Africa Northern 17 Middle 8.7 Eastern 6.7 Africa 8.5 0 2 4 6 8 10 12 14 16 18 (de Onis & Blössner, 2010)

Prevalence of overweight and obesity (%) among children & adolescents in Lebanon and other Middle-Eastern countries 50 46.3 44.5 44.4 45 39.6 38.5 40 37.2 36.8 Boys 36.5 Girls Overweight and Obese (%) 35 32.3 32.2 29.5 30 27.8 26.6 25.4 25.1 24.4 23.6 25 21.9 21.5 20 16.2 15 10 5 0 Lebanon 1 Syria 2 (IOTF) UAE 3 (IOTF) Bahrain 4 (WHO Kuwait 5 (NCHS Qatar 6 (IOTF) Saudi Arabia 7 Iran 8 (CDC Tunisia 9 (WHO Jordan 10 (WHO 2007) 1995) 1976-1980) (CDC 2000) 2000) 1995) (IOTF) Country 1 Nasreddine et al., 2012 (6-19yrs); 2 Nasreddine et al., 2010 (15-18yrs); 3 Malik and Bakir, 2007 (14-17yrs); 4 Bader et al., 2008 (15-18yrs); 5 El-Bayoumy et al., 2009 (10-14yrs); 6 Bener , 2006 (12-17yrs); 7 Al Dossary et al., 2010 (2-18yrs); 8 Taheri et al., 2013 (6-11 yrs); 9 Aounallah-Shikri et al., 2008 (15-19yrs); 10 Khader et al., 2009 (6-12yrs)

Trends in Overweight & Obesity in Lebanon National Study conducted among children and adolescents in Lebanon to determine the trends in childhood obesity between 1997 and 2009 (12 years) (Nasreddine et al., 2012)

Trends of Childhood Obesity: Lebanon (1997-2009) → Obesity increased by almost 50% in boys & girls 18 15.5 16 14 12 10.9 10.2 10 1997 % 8 7.3 2009 6.9 5.4 6 4 2 0 Boys Girls Both Genders (Nasreddine et al., 2012)

What Are the Factors Associated with Childhood Obesity in Lebanon? 6-11 years: High fast food 0-2 years: intake Sugar intake > 1-%EI Urban Maternal BMI High SES 2-5 years: 12-19 years: Fat intake>25% EI High intake of SSB Frequency of eating in front of TV Parental obesity High SES Sedentarity (Nasreddine et al., 2017; Nasreddine et al., 2014; Nasreddine et al., unpublished data)

(UK Government’s Foresight Programme, 2007)

Media exposure as a modulator of eating patterns

Food marketing and eating patterns in children • Children are affected by advertisement at all ages and are the most susceptible compared to other age groups. • Advertising is effective in getting children to request more energy rich food. • Frequent use of media has also been associated: - ↑ intakes of total energy, fat, sweet and savory snacks and soft drinks - ↓ intakes of fruits and vegetables - ↓ physical activity • The term “ ObesiTV ” proposed by Boulos et al ., 2012 “How television is influencing the obesity epidemic”. (Robinson et al., 2017; Boulos et al., 2012; Coon and Tucker, 2002)

Directing marketing towards the youth as young as toddlers → To create brand recognition and loyalty → Direct and causal effect on children’s food preference, behaviors, purchase and consumption (Story and French, 2004)

“Art of Persuasion” Marketing Techniques 1) Food product appeals: premium offers, quality, novelty 2) Emotional appeals: fun, action, peer acceptance, hero, coolness, energy 3) Visual elements : animation, promotional characters, cartoon, celebrities, meal portrayal, food setting (Hebden et al., 2011)

How do children understand food advertisements? • Product preference in children occurs just after 1 single commercial exposure. • A 30-second exposure significantly modifies food preference in pre-school children. (Borzekowski et al., 2003)

Media Literacy and Children Media literacy, the ability to analyze and evaluate messages put into different contexts, significantly varies by age 1 • Under the age of 7 years: - Accept advertisements as being “ truthful, accurate and unbiased ”. - Do not fully comprehend the persuasive intentions 2 • Between 8 and 10 years: - Have the cognitive ability to evaluate misleading advertisement - But do not necessarily apply these skills spontaneously 2 • Above 10 years: Emotional appeal exploited in advertisements can influence adolescents’ food choices regardless of their cognitive maturity 2 (Livingstone and Helsper, 2004)

Nutrient profiling as a tool to limit food marketing

According to the WHO: Nutrient profiling is one mechanism that countries can use in implementing the set of recommendations on the marketing of foods and non-alcoholic beverages to children that were endorsed by the 63rd World Health Assembly (WHA63.41). (World Health Organization, 2011)

Nutrient Profiling: Definition (World Health Organization, in press)

In the Eastern Mediterranean Region, the WHO has recently developed a nutrient profiling system adapted to the dietary guidelines of the region (World Health Organization EMRO, 2017)

Study in Lebanon

Objectives: 1. Analyze the frequency and types of food and drink advertisements during children’s viewing time in Lebanon. 2. Examine the nutritional content of the advertised food products in reference to the nutrient thresholds specified by the WHO EMR nutrient profile model. 3. Assess the proportion of food advertisements that include health messages and disclaimers. (Nasreddine et al., 2019)

Methodology Content analysis of food and beverage advertisements broadcasted on local TV channels during children’s viewing time in Lebanon. Selection of local TV channels was based on TV ratings and viewership share data acquired from IPSOS Lebanon. Selection was based on viewership data pertinent to the age group 4 – 14 years. Channels with a viewership share exceeding 20% were included in the study. Accordingly, 3 out of 9 nine local TV channels were selected: Channel A, Channel B, and Channel C . Recorded broadcasts from the 3 channels were purchased from IPSOS, covering the period between September 2016 and January 2017: One week was randomly selected within each month, and within each week three weekdays and one weekend day were randomly selected. Month of December 2016 was excluded. (Nasreddine et al., 2019)

Methodology For weekdays, analysis covered all programs broadcasted between 3 pm (i.e. after the end of the school day) and 10 pm. For weekend days, analysis covered all programs broadcasted between 8 am and 10 pm. As such, the sample covered 385 hours of TV broadcasting and included 12 weekdays and 4 weekend days. Within these timeslots, programs that rated highest in terms of viewership among children and adolescents (4 – 14 years) were selected for analysis. Accordingly, current affairs programs, news, cooking, and political talk shows were excluded. Programs that were included in the analysis comprised: • Children’s shows or C-rated programs; • G-rated (those suitable for children to view without adult supervision); • PG-rated programs (such as local soap operas or series and some entertainment programs). (Nasreddine et al., 2019)

Methodology Of the 385 h, 226 h were analyzed. Data collection: For each food or drink Ad, the coders recorded: Time of day, type of food or drink being advertised, brand, whether the advertisement included health or nutrition claims, or health disclaimers (warning about excess consumption). (Nasreddine et al., 2019)

Results A total of 1,393 Ads were for foods or beverages, representing 31% of total Ads. Proportion of food Ads was the highest during C-rated programs (43.2%) compared to G- and PG-rated programs. (Nasreddine et al., 2019)

The highest proportion of food advertisements was observed during C-rated programs. • But, in our study, only 11 h of the total 226 analyzed hours were devoted to C-rated programs, highlighting the scarcity of such programs on Lebanese TV channels. • Thus, in our study, the majority of food-related advertisements came from G-rated programs, with a total of 818 advertisements, at a frequency of six per hour. (Nasreddine et al., 2019)