ABSTRACT

OBJECTIVE:

Analyze marketing communication strategies (MCS) of labels of food products consumed by children under 5 years of age from the Brazilian National Health System (SUS) in the city of Rio de Janeiro.

METHODS:

In total, 390 labels of ultra-processed foods and industrialized baby foods were analyzed. The products were organized by similarity into 24 groups. Photographs of labels from each group were analyzed to identify the MCS, which were categorized into “presence of characters and/or celebrities,” “emotional appeal,” “freebies offering,” “health appeal,” “sensory stimulation,” “brand or slogan use,” “promotional price,” “advertisement under advertisement,” and “sustainability appeal.” The percentage frequency of labels according to the number of MCS per label; the total and average frequency of MCS according to the food group; the frequency of MCS type according to the food group; and communication resources by type of MCS were computed.

RESULTS:

1 to 19 strategies were found per label and an average of 7.2 MCS per label, totaling 2,792 occurrences. The MCS “sensory stimulation,” “health appeal,” “brand or slogan use,” and “advertisement under advertising” were observed in all food groups. “Freebies offering” and “promotional price” were observed in eight and six food groups, respectively. In food groups of bread; dairy products; and sweets, candies, and goodies, all nine types of MCS included in the study were identified. The groups that presented fewer types of MCS (n=5) were: peanuts, instant noodles, and margarines. Of the total MCS identified on the labels, the most frequent were “sensory stimulation” (29.4%) and “health appeal” (18.2%); and the least frequent were “freebies offering” (0.8%) and “promotional price” (0.4%). The “emotional appeal” strategy presented the highest diversity of communication resources.

CONCLUSION:

Rigorous regulatory measures are required to protect consumers from massive exposure to MCS on food labels.

DESCRIPTORS:
Children's Health; Food Labeling; Food Advertising; Child Nutrition

INTRODUCTION

Excess weight in children has significantly increased in the last decades, affecting 38.2 million children under 5 years of age worldwide¹1 Pan American Health Organization. World Health Organization. 53rd Directing Council. 154th Session of the executive committee. Plan of action for the prevention of obesity in children and adolescents. Washington, DC; 2014 [cited 2023 Sep 22]. Available from: https://iris.paho.org/bitstream/handle/10665.2/4627/CE154-16-e.pdf?sequence=1&isAllowed=y
https://iris.paho.org/bitstream/handle/1... ,²2 World Health Organization. Obesity and overweight. 9 jun 2021 [cited 2023 Sep 22]. Available from: https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight
https://www.who.int/news-room/fact-sheet... . An important factor for this phenomenon is the increase in consumption of ultra-processed foods (UPF). In Brazil, in 2019, the prevalence of UPF consumption among children aged 6 to 23 and 24 to 59 months was 80.5% and 93%, respectively³3 Universidade Federal do Rio de Janeiro. Alimentação infantil I: prevalência de indicadores de alimentação de crianças menores de 5 anos: ENANI 2019. Rio de Janeiro: UFRJ; 2021 [cited 2023 Sep 22]. Available from: https://enani.nutricao.ufrj.br/wp-content/uploads/2021/12/Relatorio-5_ENANI-2019_Alimentacao-InfantiL.pdf
https://enani.nutricao.ufrj.br/wp-conten... .

UPFs are hyper-palatable foods that compromise healthy eating habits. Most of them have an unbalanced nutritional composition, with high amounts of fats, sugars, salt, and food additives with cosmetic roles, such as emulsifiers, thickeners, coloring materials, sweeteners, among others, not used in homemade preparations⁴4 Monteiro CA, Cannon G, Lawrence M, Louzada ML C, Machado PP. Ultra-processed foods, diet quality, and health using the NOVA classification system. Rome: FAO; 2019.. In addition to being associated with poor diet quality and obesity, the consumption of these foods is also related to other unfavorable health outcomes, including tooth decay, increased risk of cardiovascular disease, insulin resistance, type 2 diabetes, and micronutrient deficiency⁵5 Oliveira PG, Sousa JM, Assunção DGF, Araujo EKS, Bezerra DS, Dametto JFS, et al. Impacts of consumption of ultra-processed foods on the maternal-child health: a systematic review. Front Nutr. 2022;9:821657. https://doi.org/10.3389/fnut.2022.821657
https://doi.org/10.3389/fnut.2022.821657... ,⁶6 De Amicis R, Mambrini SP, Pellizzari M, Foppiani A, Bertoli S, Battezzati A, et al. Ultra-processed foods and obesity and adiposity parameters among children and adolescents: a systematic review. Eur J Nutr. 2022 Aug;61(5):2297-311. https://doi.org/10.1007/s00394-022-02873-4
https://doi.org/10.1007/s00394-022-02873... .

The exposure of children to these products is a consequence of an increase in working hours of parents, including the time spent commuting between home and work, the overload of women with household chores, low cooking skills, lack of healthy options in schools and other food environments⁷7 Henriques P, Sally EO, Burlandy L, Beiler RM. Regulamentação da propaganda de alimentos infantis como estratégia para a promoção da saúde. Cienc Saude Coletiva. 2012 Fev;17:481-90. https://doi.org/10.1590/S1413-81232012000200021
https://doi.org/10.1590/S1413-8123201200... –⁹9 Smith R, Kelly B, Yeatman H, Boyland E. Food marketing influences children's attitudes, preferences and consumption: a systematic critical review. Nutrients. 2019 Apr;11(4):875. https://doi.org/10.3390/nu11040875
https://doi.org/10.3390/nu11040875... , and the massive use of abusive and misleading marketing strategies for these products, including those directed to children¹⁰10 Kiefner-Burmeister A, Burmeister JM. Deceptively unhealthy foods targeting parents and children. J Health Psychol. 2021 Oct;26(12):2213-9. https://doi.org/10.1177/1359105320903485
https://doi.org/10.1177/1359105320903485... .

These strategies include the use of packaging, given its strategic role in the communication between the manufacturer and the consumer¹¹11 Pontes TE, Costa TF, Marum ABRF, Brasil ALD, Taddei JA de AC. Orientação nutricional de crianças e adolescentes e os novos padrões de consumo: propagandas, embalagens e rótulos. Rev Paul Pediatr. 2009 Mar;27:99-105. https://doi.org/10.1590/S0103-05822009000100015
https://doi.org/10.1590/S0103-0582200900... . Packaging attracts consumers and, when choosing food, establishes a direct communication channel for the supposed advantages of the product. Food industries have invested in the development of packaging design, constituting a powerful communication channel between the manufacturer and the consumer that has been increasingly used to spread meanings and images that promote the acceptance, repurchase, and use of products¹¹11 Pontes TE, Costa TF, Marum ABRF, Brasil ALD, Taddei JA de AC. Orientação nutricional de crianças e adolescentes e os novos padrões de consumo: propagandas, embalagens e rótulos. Rev Paul Pediatr. 2009 Mar;27:99-105. https://doi.org/10.1590/S0103-05822009000100015
https://doi.org/10.1590/S0103-0582200900... .

Marketing strategies focus their actions on children due to their great ability to persuade their parents⁷7 Henriques P, Sally EO, Burlandy L, Beiler RM. Regulamentação da propaganda de alimentos infantis como estratégia para a promoção da saúde. Cienc Saude Coletiva. 2012 Fev;17:481-90. https://doi.org/10.1590/S1413-81232012000200021
https://doi.org/10.1590/S1413-8123201200... . Exposure to advertisements and other marketing communication strategies (MCS) to promote UPFs broadcasted in the most diverse media channels – mainly television and the internet – are more harmful to children and adolescents, due to the lack of cognitive maturity for discernment and understanding of advertising and hidden objectives¹²12 Pereira Júnior JA. Autonomia privada na sociedade de consumo o problema da regulação da publicidade infantil. Belo Horizonte: Dialética; 2020 [cited 2022 Feb 3]. Available from: http://public.eblib.com/choice/PublicFullRecord.aspx?p=6430437
http://public.eblib.com/choice/PublicFul... . For this reason, food advertisements worldwide for children and adolescents have been addressed in public policies, such as those that regulate food advertising and labeling¹1 Pan American Health Organization. World Health Organization. 53rd Directing Council. 154th Session of the executive committee. Plan of action for the prevention of obesity in children and adolescents. Washington, DC; 2014 [cited 2023 Sep 22]. Available from: https://iris.paho.org/bitstream/handle/10665.2/4627/CE154-16-e.pdf?sequence=1&isAllowed=y
https://iris.paho.org/bitstream/handle/1... ,¹³13 Stoltze FM, Reyes M, Smith TL, Correa T, Corvalán C, Carpentier FRD. Prevalence of child-directed marketing on breakfast cereal packages before and after chile's food marketing law: a pre- and post-quantitative content analysis. Int J Environ Res Public Health. 2019 Nov;16(22):4501. https://doi.org/10.3390/ijerph16224501
https://doi.org/10.3390/ijerph16224501... .

Studies on this topic have analyzed specific foods or food groups available in supermarkets or based on some theoretical criteria¹⁴14 Elliott C, Truman E. The power of packaging: a scoping review and assessment of child-targeted food packaging. Nutrients. 2020 Mar;12(4):958. https://doi.org/10.3390/nu12040958
https://doi.org/10.3390/nu12040958... . This study seeks to contribute to the state-of-the-art knowledge of food advertising and labeling using a different approach: the analysis of the main MCS present on labels of UPFs and industrialized baby foods that are actually consumed by children under 5 years of age from the Brazilian National Health System (SUS) in the city of Rio de Janeiro.

METHODS

This study was based on a survey carried out in 2014 with a probabilistic sample of 536 children aged 6 to 59 months, assisted in the basic health services in the city of Rio de Janeiro. Trained nutritionists applied 24-hour dietary recalls (24HR) to parents or guardians of children. Information was collected regarding the types of foods, quantities, preparation methods, time and place of consumption, and, in the case of processed foods and UPFs, their respective brands and flavors. A detailed description of this investigation is available in Anastácio et al.¹⁵15 Anastácio COA, Oliveira JM, Moraes MM, Damião JJ, Castro IRR. Perfil nutricional de alimentos ultraprocessados consumidos por crianças no Rio de Janeiro. Rev Saude Publica. 2020 set;54:89. https://doi.org/10.11606/s1518-8787.2020054001752
https://doi.org/10.11606/s1518-8787.2020...

After analyzing all foods consumed, UPFs were identified with the NOVA food classification. Industrialized baby foods were also included as they present similar attributes to those of UPFs¹⁶16 Ministério da Saúde (BR). Guia alimentar para crianças brasileiras menores de 2 anos. Brasília, DF: Ministério da Saúde 2019 [cited 2023 Sep 22]. Available from: http://189.28.128.100/dab/docs/portaldab/publicacoes/guia_da_crianca_2019.pdf
http://189.28.128.100/dab/docs/portaldab... . In case of doubt, the authors of the NOVA food classification were contacted. Then, 459 products were selected for the study.

Between March and December 2015, the labels of UPFs and industrialized baby foods, according to the flavor and/or brand mentioned in the 24HR, were photographed in stores located in different areas of the city. All types of packaging with the same product available in these stores were photographed (e.g. soft drinks in cans and PET bottles). In this case, only one label per product was included in an image bank – the label presenting the highest number of MCS.

Before going to the stores, field researchers were trained to photograph all faces of the labels in order to obtain the necessary information for all study objectives. The training included a presentation class and a practical activity in stores. The photos were taken with a cell phone and stored in Google Drive files.

In total, 390 labels of UPFs and industrialized baby foods were analyzed; 69 (15%) labels out of total 459 could not be analyzed for the following reasons: photo available from only one face of the label that contained the nutritional table or absence of the label photo (product not found in stores or on the internet). In general, the image bank had three to four photos of the various faces of every product. However, 79 products (20.3% of 390 analyzed products) did not have photos of all label faces.

The products were organized by similarity into 24 food groups, described in Chart 1.

Photographs of the labels of each food group were analyzed to identify MCS. The MCS were defined according to the literature about communication through food labels and consumer perceptions, and organized according to the categorization in Chart 2¹⁷17 Aerts G, Smits T. Child-targeted on-pack communications in Belgian supermarkets: associations with nutritional value and type of brand. Health Promot Int. 2019 Feb;34(1):71-81. https://doi.org/10.1093/heapro/dax057
https://doi.org/10.1093/heapro/dax057... –²⁰20 Giménez A, Saldamando L, Curutchet MR, Ares G. Package design and nutritional profile of foods targeted at children in supermarkets in Montevideo, Uruguay. Cad Saude Publica. 2017;33(5). https://doi.org/10.1590/0102-311X00032116
https://doi.org/10.1590/0102-311X0003211... :

Label information was extracted in three stages: (1) first label analysis conducted by two researchers (each reviewed part of the labels); (2) review of the first analysis of all labels by a third researcher; and (3) resolution of doubts and inconsistencies between the two analyses by a new pair of researchers. The occurrences of each MCS were added to a Microsoft Excel 2010 spreadsheet and grouped according to the types of communication resources, which are used to support the strategies. They are based on thematic elements (e.g. cookery, health, nutrition, etc.) or visual elements (heart drawings, colors, packaging shape, etc.). Then, the types of resources were totaled by MCS and by product, and the occurrences of each MCS by food groups were added. The results were organized in two tables and a chart that show the percentage frequency of labels according to number of MCS per label, total and average frequency of MCS according to food group, frequency of MCS types on labels by food groups, systematization of MCS and types of communication resources with respective examples.

This study was approved by the Human Research Ethics Committee of the Municipal Health Department of the City of Rio de Janeiro (process n° 93/2013).

RESULTS

In total, 2,792 marketing communication strategies were identified, ranging from 1 to 19 per label. The following distribution by category of MCS occurrence was observed: 33.6% of the labels showed 1 to 5 strategies; 57.9% showed 6 to 11 strategies; and 8.5% had 12 to 19 strategies, with an overall average of 7.2 strategies per label, ranging from 3.7 to 11.8. Soy drinks, flours, and breakfast cereals had the highest MCS averages per label (11.8, 11.2, and 10.8, respectively), and guarana soft drinks, margarines, and chocolate powders and similar products showed the lowest averages (4.8, 4.5, and 3.7) (Table 1).

The strategies “sensory stimulation,” “health appeal,” “brand or slogan use,” and “advertisement under advertisement,” were observed in all food groups. “Freebies offering” and “promotional price” were identified in eight and six food groups, respectively. In breads; dairy products; and sweets, candies, and goodies, all nine types of MCS included in the study were identified. The groups with fewer types of MCS (n=5) were peanuts, instant noodles, and margarine (Table 2).

Of total MCS identified on the labels, the most frequent were “sensory stimulation” (29.4%) and “health appeal” (18.2%); and the least frequent were “freebies offering” (0.8%) and “promotional price” (0.4%).

“Stimulation to the senses” was the most frequent strategy in 17 of total 24 food groups, ranging from 53.3% in the group of ready-made toasted manioc flour to 27.2% for crackers. “Health appeal” was the most frequent strategy in the following groups: soy drinks (45.5%), flours (28.2%), food supplements and complements (25%), and juice cartons (24.5%). In the group of food supplements and complements, “advertisement under advertisement” had the same frequency as “health appeal” (25%). “Emotional appeal” was the most frequent MCS in the group of chocolate powders and similar products (22.7%). In the group of industrialized baby foods, “health appeal” and “sensory stimulation” presented the same frequency (25%). In the group of peanuts, “emotional appeal” and “slogan use” also had the same frequency (28.6%) (Table 2).

Chart 3 shows all types of communication resources observed and their respective examples by MCS. The highest number of communication resources (n=13) was observed in “emotional appeal,” with “tradition, originality, exclusivity, and trust in the brand” as the most frequent type of resource.

The resource “product” (which includes the presence of product image, among others), related to the strategy of “sensory stimulation,” was used on the labels of all 24 food groups. The resources “highlighting aspects of the nutritional composition of the product” related to the strategy “health appeal” and “availability of brand website, social media pages, QR code, and virtual store” related to the strategy “advertisement under advertisement” were used on the labels of 23 of total 24 food groups. The resources “brand highlight” related to the strategy “brand/slogan use” (in 22 food groups), “colors” related to the strategy “sensory stimulation” (in 22 groups), and “recyclable product” related to the strategy “sustainability appeal” (in 20 groups) were also frequently used.

DISCUSSION

The UPFs analyzed had an average of 7.2 MCS per label, ranging from one to 19 strategies; the most frequent ones were “sensory stimulation” and “health appeal.” In a study that analyzed 93 product labels and evaluated the quality of industrialized foods sold in supermarkets in the south area of Rio de Janeiro, up to eight MCS were identified in products for children²¹21 Ferreira JSG, Silva YD, Moraes OMG, Tancredi RP. Marketing de alimentos industrializados destinados ao público infantil na perspectiva da rotulagem. Visa Debate. 2015 maio;3(2):75-84. https://doi.org/10.3395/2317-269x.00293
https://doi.org/10.3395/2317-269x.00293... . The presence of these strategies on these labels can lead to brand or product loyalty²²22 Borges AR, Soares SA, Coelho A, Persilva D. A embalagem sedutora na gôndola do supermercado: garantia de atratividade e estímulo ao desejo de consumo do público infantil. Paidéia. 2017;12(18). and encourages children to persuade their parents to purchase these products²³23 Henriques P, Dias PC, Burlandy L. A regulamentação da propaganda de alimentos no Brasil: convergências e conflitos de interesses. Cad Saude Publica. 2014 jun;30:1219-28. https://doi.org/10.1590/0102-311X00183912
https://doi.org/10.1590/0102-311X0018391... .

Exception for the group of guarana drinks, all groups of drinks had an average number of MCS equal to or greater than 7.4. Other studies using similar methods to that in our study, conducted with foods for children, obtained an average of 2.4 MCS per label for carbonated drinks or artificial juices in 2012 and an average of 4.4 MCS per label for juices, fruit nectars, and fruit drinks in 2013²¹21 Ferreira JSG, Silva YD, Moraes OMG, Tancredi RP. Marketing de alimentos industrializados destinados ao público infantil na perspectiva da rotulagem. Visa Debate. 2015 maio;3(2):75-84. https://doi.org/10.3395/2317-269x.00293
https://doi.org/10.3395/2317-269x.00293... ,²⁴24 Sousa JS. Estratégias de persuasão para o público infantil utilizadas em embalagens de alimentos [dissertation]. Brasília, DF: Universidade de Brasília; 2012..

A higher frequency of the strategy “sensory stimulation” agrees with the results of another study in which a third of the packages contained images or illustrations of in natura foods or the main ingredient²¹21 Ferreira JSG, Silva YD, Moraes OMG, Tancredi RP. Marketing de alimentos industrializados destinados ao público infantil na perspectiva da rotulagem. Visa Debate. 2015 maio;3(2):75-84. https://doi.org/10.3395/2317-269x.00293
https://doi.org/10.3395/2317-269x.00293... . In products for children sold in Uruguay, this was most common strategy in the group of cookies and sweets²⁰20 Giménez A, Saldamando L, Curutchet MR, Ares G. Package design and nutritional profile of foods targeted at children in supermarkets in Montevideo, Uruguay. Cad Saude Publica. 2017;33(5). https://doi.org/10.1590/0102-311X00032116
https://doi.org/10.1590/0102-311X0003211... .

In our analysis, the use of colors was very frequent. Considering that colors have a strong visual appeal, with subliminal messages and sensations, marketing and advertising professionals use them in packaging to highlight the product and attract the target audience. Children are generally attracted to colors like yellow, red, blue, and green. These colors influence stimulation, attention, and motivation to purchase and blue and green offer a feeling of calm and rest²⁵25 Santos B, Marques BMF, Barbosa CMR, Cabral CO, Lisboa LPS, Lima EPS. A influência das cores na construção das marcas e publicidade. Cad Grad – Cienc Humanas Sociais Unit. 2014 Mar;2(1):45-53.. In Uruguay, the use of bright colors on food packaging for children is a strategy frequently used on candy and chocolate labels²⁰20 Giménez A, Saldamando L, Curutchet MR, Ares G. Package design and nutritional profile of foods targeted at children in supermarkets in Montevideo, Uruguay. Cad Saude Publica. 2017;33(5). https://doi.org/10.1590/0102-311X00032116
https://doi.org/10.1590/0102-311X0003211... . In a study evaluating the visual memory of cookie packaging and bags of snacks, the colors most remembered by children in their drawings were red, blue, yellow, and brown²⁶26 Geraldo AP. Avaliação de estratégias de comunicação e da memória visual na embalagem de alimentos processados dirigidos ao público infantil [dissertation]. São Paulo: Universidade de São Paulo; 2010..

Another aspect that must be considered is the presence of nutrition claims on UPF packaging, categorized as one of the types of communication resources related to the strategy “health appeal.” It was the second most frequent MCS, in agreement with the results of a study which showed that themes related to health, such as enriched foods, relationship between consumption and good health and growth, and nutrient completeness, had a high frequency of persuasive strategies on labels. The use of claims about added vitamins and minerals was recurrent in food products for children (dairy products, cookies, pastries, breakfast cereals, instant food, soft drinks, and juices)²⁰20 Giménez A, Saldamando L, Curutchet MR, Ares G. Package design and nutritional profile of foods targeted at children in supermarkets in Montevideo, Uruguay. Cad Saude Publica. 2017;33(5). https://doi.org/10.1590/0102-311X00032116
https://doi.org/10.1590/0102-311X0003211... .

Highlighting one or more nutrition claims on the food label can convey the misleading idea that it is a healthy food, producing a positive perception among consumers²⁷27 Chandon P. How package design and packaged-based marketing claims lead to overeating. Appl Econ Perspect Policy. 2013;35(1):7-31. https://doi.org/10.1093/aepp/pps028
https://doi.org/10.1093/aepp/pps028... . A study conducted in Brazil showed that nutrition claims on UPF packaging for children influenced the perception of children aged 8 to 10 years about the quality of the product as a whole²⁸28 Zucchi ND, Fiates GMR. Analysis of the presence of nutrient claims on labels of ultra-processed foods directed at children and of the perception of kids on such claims. Rev Nutr. 2016 Dec;29:821-32. https://doi.org/10.1590/1678-98652016000600007
https://doi.org/10.1590/1678-98652016000... .

The adoption of sustainable diets has been encouraged by experts and institutions around the world, such as the Food and Agriculture Organization (FAO) of the United Nations²⁹29 Clark M, Macdiarmid J, Jones AD, Ranganathan J, Herrero M, Fanzo J. The role of healthy diets in environmentally sustainable food systems. Food Nutr Bull. 2020 Dic;41(2 suppl):31S-58S. https://doi.org/10.1177/0379572120953734
https://doi.org/10.1177/0379572120953734... . In this sense, the “sustainability appeal” is among the MCS practiced by the food industries, as seen in our study. However, in most of these messages, the focus was not on the UPF production process, but on warning consumers regarding packaging disposal and environmental sustainability, for example.

Emphasis on the brand and slogan was the third most frequent MCS on labels. Brand is an important element of an advertisement, as it favorably influences the consumer's purchase decision and identifies the product, distinguishing it from the competition²⁶26 Geraldo AP. Avaliação de estratégias de comunicação e da memória visual na embalagem de alimentos processados dirigidos ao público infantil [dissertation]. São Paulo: Universidade de São Paulo; 2010.. When a brand is promoted, all products of that company are favored³⁰30 Maciel WR, Oliveira DM, Lima-Filho DO, Sauer L, Quevedo-Silva F. Influência do consumidor infantil no processo de decisão de compra e consumo de alimentos na família: uma análise dos fatores determinantes. Rev Espac. 2016;37(28):12.. In another study assessing the same topic, conducted with parents of children aged 2 to 12 years, brand and manufacturer recognition was the second main factor in the purchase decision of parents³¹31 Gomes AR, Spinillo CG. The influence of visual appeals on food packaging for children and the purchase decision of parents: a study from the point of view of information design. Blucher Design Proc. 2019 Nov;6(4):2582-8. https://doi.org/10.5151/9cidi-congic-6.0036
https://doi.org/10.5151/9cidi-congic-6.0... .

Understanding how different marketing communication strategies reach adults and/or children still requires further analysis³²32 Taillie LS, Busey E, Stoltze FM, Dillman Carpentier FR. Governmental policies to reduce unhealthy food marketing to children. Nutr Rev. 2019 Nov;77(11):787-816. https://doi.org/10.1093/nutrit/nuz021
https://doi.org/10.1093/nutrit/nuz021... . A scoping review identified studies that tracked types of communication strategies or measured their effectiveness and concluded that further studies are required assessing the persuasive power of these strategies depending on their type and the age of the children¹⁴14 Elliott C, Truman E. The power of packaging: a scoping review and assessment of child-targeted food packaging. Nutrients. 2020 Mar;12(4):958. https://doi.org/10.3390/nu12040958
https://doi.org/10.3390/nu12040958... . An experimental study with pairs of children and guardians revealed that advertisements of unhealthy products promoted favorable product perceptions and increased the preferences of guardians for the advertised products. It also noted that counter-advertising interventions can reinforce the resistance of parents and guardians to persuasive advertisement of these products and help them better evaluate unhealthy products³³33 Dixon H, Scully M, Gascoyne C, Wakefield M. Can counter-advertising diminish persuasive effects of conventional and pseudo-healthy unhealthy food product advertising on parents?: an experimental study. BMC Public Health. 2020 Nov;20(1):1781. https://doi.org/10.1186/s12889-020-09881-1
https://doi.org/10.1186/s12889-020-09881... . Therefore, regulations for front-of-package labeling could constitute another formative element for families and become an education and health tool³⁴34 Carters-White L, Hilton S, Skivington K, Chambers S. Children's, parents’ and professional stakeholders’ views on power concerning the regulation of online advertising of unhealthy food to young people in the UK: a qualitative study. PLoS One. 2022 Jun;17(6):e0268701. https://doi.org/10.1371/journal.pone.0268701.eCollection2022
https://doi.org/10.1371/journal.pone.026... . The freebies strategy was one of the least frequent MCS in this study, unlike findings of the literature, which indicate a frequency of 3.6% to 10% of the presence of freebies, games, and prize draws²¹21 Ferreira JSG, Silva YD, Moraes OMG, Tancredi RP. Marketing de alimentos industrializados destinados ao público infantil na perspectiva da rotulagem. Visa Debate. 2015 maio;3(2):75-84. https://doi.org/10.3395/2317-269x.00293
https://doi.org/10.3395/2317-269x.00293... ,²⁴24 Sousa JS. Estratégias de persuasão para o público infantil utilizadas em embalagens de alimentos [dissertation]. Brasília, DF: Universidade de Brasília; 2012.. Our results may have underestimated the offer of freebies because the reference to freebies can be made via TV or the internet, or it can be a seasonal campaign and the study period did not coincide with it.

An alternative hypothesis would be an assessment of a tendency to reduction in the offer of freebies linked with products consumed by children. A potential explanation would be the implementation of Resolution no. 163 of March 13, 2014, issued by the Brazilian Council for the Rights of Children and Adolescents (Conanda), which provides regulations to prevent abusive advertising and marketing communications for children and adolescents, describing in Article 2 that abusive advertising refers to the promotions with distribution of prizes and collectible gifts or children appeal³⁵35 Secretaria de Direitos Humanos. Conselho Nacional dos Direitos da Criança e do Adolescente. Resolução no 163, de 13 de março de 2014. Dispõe sobre a abusividade do direcionamento de publicidade e de comunicação mercadológica à criança e ao adolescente. Diário Oficial União. 2014 Mar 13.. Abusive and misleading advertising to children violates the Federal Constitution, the Child and Adolescent Statute, and the Consumer Protection Code, since these legal provisions aim to protect children, who are considered vulnerable, due to their inability to identify commercial interests and persuasive aspects of advertisements³⁶36 Jaime PC, Prado RR, Malta DC. Family influence on the consumption of sugary drinks by children under two years old. Rev Saude Publica.51(suppl 1):13s. https://doi.org/10.1590/s1518-8787.2017051000038
https://doi.org/10.1590/s1518-8787.20170... .

The development of regulations of front-of-package nutrition labeling is one of the priority measures of the regulatory agenda for the prevention and control of chronic non-communicable diseases³⁷37 World Health Organization. Tackling NCDs: “best buys” and other recommended interventions for the prevention and control of noncommunicable diseases. Geneva: World Health Organization; 2017 [cited 2023 Sep 22]. Available from: https://apps.who.int/iris/bitstream/handle/10665/259232/WHO-NMH-NVI-17.9-eng.pdf?sequence=1
https://apps.who.int/iris/bitstream/hand... . In addition to providing the population with clear and more objective information about the real nutritional composition of UPFs, legal provisions can also ensure mechanisms to limit the presence of MCS on labels and the availability of these foods in food environments, as observed in Chile³⁸38 Taillie LS, Reyes M, Colchero MA, Popkin B, Corvalán C. An evaluation of Chile's Law of Food Labeling and Advertising on sugar-sweetened beverage purchases from 2015 to 2017: a before-and-after study. Basu S, organizer. PLOS Med. 2020 Feb;17(2):e1003015. https://doi.org/10.1371/journal.pmed.1003015
https://doi.org/10.1371/journal.pmed.100... . In Brazil, the technical standard approved by the National Health Surveillance Agency (Anvisa) to adapt front-of-package labeling of processed and ultra-processed foods (Collegiate Board Resolution – RDC 429/2020) was restricted to information about the nutritional composition of products and did not address the use of MCS on labels³⁹39 Ministério da Saúde (BR). Agência Nacional de Vigilância Sanitária. Resolução da Diretoria Colegiada – RDC no 429, de 8 de outubro de 2020. Diário Oficial União. 2020 Oct 9..

The main study limitations were the fact that it was not possible to analyze 15% of all 459 products mentioned by the study participants as well as the partial analysis of 20.3% of all 390 labels included in the study. The analysis of a smaller number of products and partial sides of some labels may have led to errors (plus or minus) in the estimates of percentage and average frequencies of MCS analyzed in this study. Also important is the fact that 24-hour dietary recalls were applied between Tuesday and Friday, therefore not covering food consumption on weekends. It may have underestimated the number of UPFs consumed by the study children, assuming that the presence of UPFs is higher on weekends.

On the other hand, the analysis of labels of UPFs actually consumed by a probability sample of children from the SUS constitutes a strength of this study. When compared to the most frequent approach in the literature (analysis of products available in stores)¹⁴14 Elliott C, Truman E. The power of packaging: a scoping review and assessment of child-targeted food packaging. Nutrients. 2020 Mar;12(4):958. https://doi.org/10.3390/nu12040958
https://doi.org/10.3390/nu12040958... , this choice has the advantage of knowing the products actually consumed by children, regardless of whether the products were focused on them. Therefore, it can support the development of public policies for primary health care advice and food label regulation.

CONCLUSION

In this study, MCS was identified on all labels of UPFs and industrialized baby foods consumed by children. It is important to adapt and improve the labels of foods for children and the general public, based on regulatory measures that prevent misleading and abusive practices. This is because the different types of MCS used on labels, especially those that stimulate the senses, emphasize aspects related to health, and highlight the brand can generate an exaggerated consumption of foods with low nutritional content, favoring an increase in childhood obesity and negative effects on health. Recognition of risks to child health and nutrition related to MCS reinforces that strict regulatory measures are required to protect consumers from massive exposure to MCS on food labels.

Also, public policies must encourage the dissemination of reliable information, based on dietary guidelines, to the entire population and through different media channels. The use of dietary guidelines by health, education, social care, and other professionals can support the development of food and nutritional education actions that address label reading and understanding, increase the critical sense of families, and promote more adequate and healthy eating habits.

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