Abstracts

Introduction

The World Health Organization (WHO) estimates that 41 million children were overweight or obese in 2016 ¹1. World Health Organization. Facts and figures on childhood obesity. 2015. https://www.who.int/end-childhood-obesity/facts/en/ (accessed on 05/Oct/2019).
https://www.who.int/end-childhood-obesit... , making childhood overweight and obesity one of the most pressing public health issues today. Latin America has the highest prevalence in the world: 20 to 25% of children and adolescents are overweight or obese ²2. Pan American Health Organization. Obesity prevention. 2016. https://www.paho.org/hq/index.php?option=com_content&view=article&id=11506:obesity-prevention-home&Itemid=41655&lang=en (accessed on 05/Oct/2019).
https://www.paho.org/hq/index.php?option... . In Argentina, the most recent National Nutrition and Health Survey (ENNyS 2018) indicates that the prevalence of overweight and obesity among children under 5 years old was 10.6% and 3%. Excess weight was observed in 41.1% of the children and teenagers of 5 to 17 years of age: 20.7% were overweight and 20.4% were obese ³3. Secretaría de Gobierno de Salud de la Nación. 2º Encuesta Nacional de Nutrición y Salud 2018. http://www.msal.gob.ar/images/stories/bes/graficos/0000001565cnt-ennys2_resumen-ejecutivo-2019.pdf (accessed on 05/Oct/2019).
http://www.msal.gob.ar/images/stories/be... .

Marketing of unhealthy foods and its influence on children’s food choices is one of the main drivers of the increase in overweight and obesity ⁴4. Wiecha JL, Peterson KE, Ludwig DS, Kim J, Sobol A, Gortmaker SL. When children eat what they watch: impact of television viewing on dietary intake in youth. Arch Pediatr Adolesc Med 2006; 160:436-42.^,55. Zimmerman FJ, Bell JF. Associations of television content type and obesity in children. Am J Public Health 2010; 100:334-40.^,66. Utter J, Scragg R, Schaaf D. Associations between television viewing and consumption of commonly advertised foods among New Zealand children and young adolescents. Public Health Nutr 2006; 9:606-12.^,77. Magnus A, Haby M, Carter R, Swinburn B. The cost-effectiveness of removing television advertising of high-fat and/or high-sugar food and beverages to Australian children. Int J Obes 2009; 33:1094-102.^,88. Hastings G, Stead M, McDermott L, Forsyth A, MacKintosh AM, Rayner M, et al. Review of research on the effects of food promotion to children. http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.134.1856&rep=rep1&type=pdf (accessed on 05/Oct/2019).
http://citeseerx.ist.psu.edu/viewdoc/dow... ^,99. Cairns G, Angus K, Hastings G, Caraher M. Systematic reviews of the evidence on the nature, extent and effects of food marketing to children. A retrospective summary. Appetite 2013; 62:209-15.. Children are particularly vulnerable to marketing strategies because they lack the capacity “to process advertising in a conscious and critical way”10. Research suggests that, up to the age of ¹⁰10. Rozendaal E, Buijzen M, Valkenburg P. Children's understanding of advertisers' persuasive tactics. Int J Advert 2011; 30:329-50.^,1111. Letona P, Chacon V, Roberto C, Barnoya J. Effects of licensed characters on children's taste and snack preferences in Guatemala, a low/middle income country. Int J Obes (Lond) 2014; 38:1466-9.^,1212. Dixon H, Scully M, Niven P, Kelly B, Chapman K, Donovan R, et al. Effects of nutrient content claims, sports celebrity endorsements and premium offers on pre-adolescent children's food preferences: experimental research. Pediatr Obes 2014; 9:e47-57., children are not fully able to identify the persuasive intent behind advertising techniques ¹⁰10. Rozendaal E, Buijzen M, Valkenburg P. Children's understanding of advertisers' persuasive tactics. Int J Advert 2011; 30:329-50.. Front-of-pack marketing techniques such as endorsement by licensed characters ¹¹11. Letona P, Chacon V, Roberto C, Barnoya J. Effects of licensed characters on children's taste and snack preferences in Guatemala, a low/middle income country. Int J Obes (Lond) 2014; 38:1466-9. or sports celebrities ¹²12. Dixon H, Scully M, Niven P, Kelly B, Chapman K, Donovan R, et al. Effects of nutrient content claims, sports celebrity endorsements and premium offers on pre-adolescent children's food preferences: experimental research. Pediatr Obes 2014; 9:e47-57. and branding ¹³13. Elliott CD, Carruthers Den Hoed R, Conlon MJ. Food branding and young children's taste preferences: a reassessment. Can J Public Health 2013; 104:e364-8.^,1414. Robinson TN, Borzekowski DL, Matheson DM, Kraemer HC. Effects of fast food branding on young children's taste preferences. Arch Pediatr Adolesc Med 2007; 161:792-7. have been proven to influence taste perception and food preferences among children. Consumers are more likely to have positive associations and purchase food products whose packaging features health or nutrition claims ¹⁵15. Hawkes C. Nutrition labels and health claims: the global regulatory environment. Geneva: World Health Organization; 2004.^,1616. Andrews JC, Burton S, Netemeyer RG. Are some comparative nutrition claims misleading? The role of nutrition knowledge, ad claim type and disclosure conditions. J Advert 2000; 29:29-42.. Health claims such as “reduced fat content” or “low sugar” become a powerful tool to influence consumer choices.

The Argentinean Codex Alimentarius (ACA) regulates the content and form of food labeling in the country ¹⁷17. Código Alimentario Argentino. Capítulo V: normas para la rotulación y publicidad de los alimentos. 2005. http://www.anmat.gov.ar/alimentos/codigoa/Capitulo_V.pdf (accessed on 05/Oct/2019).
http://www.anmat.gov.ar/alimentos/codigo... . Ingredient lists and nutritional information panels are mandatory labeling elements, while optional labeling includes supplementary nutritional information, such as nutrition or health claims, which must comply with the mandatory label components. However, there are no rules regarding using nutrition and health claims and marketing techniques in the packaging of products with high content of critical nutrients (either sodium, sugar, fats and/or saturated fats) following a specific nutrient profile model. The only Latin American country that has regulations in place to restrict marketing techniques and health and nutrition claims on food packaging according to the nutrient value of food products is Chile ¹⁸18. Corvalan C, Reyes M, Garmendia M, Uauy R. Structural responses to the obesity and non-communicable diseases epidemic: the Chilean Law of Food Labeling and Advertising. Obes Rev 2013; 14:79-87..

Most research on food packaging marketing has been conducted in Europe, North America and Australia; little comparable research has been published in Latin America, except for Guatemala, Uruguay and Brazil ¹¹11. Letona P, Chacon V, Roberto C, Barnoya J. Effects of licensed characters on children's taste and snack preferences in Guatemala, a low/middle income country. Int J Obes (Lond) 2014; 38:1466-9.^,1919. Ares G, Arrúa A, Antúnez L, Vidal L, Machín L, Martínez J, et al. Influence of label design on children's perception of two snack foods: comparison of rating and choice-based conjoint analysis. Food Qual Prefer 2016; 53:1-8.^,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 Saúde Pública 2017; 33:e00032116.^,2121. Perry A, Chacon V, Barnoya J. Health claims and product endorsements on child-oriented beverages in Guatemala. Public Health Nutr 2018; 21:627-31.^,2222. Chacon V, Letona P, Barnoya J. Child-oriented marketing techniques in snack food packages in Guatemala. BMC Public Health 2013; 13:967.^,2323. Ferreira JSG, Silva Y, de Moraes OMG, Tancredi RP. Marketing de alimentos industrializados destinados ao público infantil na perspectiva da rotulagem. Vigil Sanit Debate 2015; 3:75-84.. Recent work has evaluated TV advertising of ultra-processed food products and their nutritional quality in Argentina ²⁴24. Allemandi L, Castronuovo L, Tiscornia MV, Ponce M, Schoj V. Food advertising on Argentinean television: are ultra-processed foods in the lead? Public Health Nutr 2017; 21:238-46., but with no available information on marketing techniques in food packaging. Developing effective, evidence-based public policy to tackle the childhood obesity epidemic depends heavily on generating such evidence locally.

This study was conducted as part of a broader research initiative to promote effective regulation of food packaging and protect children’s health. We analyzed marketing techniques and health and nutrition claims in food packages and evaluated the nutritional quality in sweet biscuits, breakfast cereals and dairy-based desserts - three ultra-processed food categories prevalent in Argentinean dietary and advertising patterns. According to the 2012-2013 National Survey of Household Expenditure, sweet biscuits accounted for nearly 33% of mean monthly expenditure on food and beverages. Moreover, Argentina registered the highest per capita consumption of sweet biscuits in the world in 2018 ²⁵25. Euromonitor International. Sweet biscuits, snack bars and fruit snacks in Argentina. https://www.euromonitor.com/sweet-biscuits-snack-bars-and-fruit-snacks-in-argentina/report (accessed on 05/Oct/2019).
https://www.euromonitor.com/sweet-biscui... . Many breakfast cereals are ultra-processed, high sugar, and high sodium products, that reduce the nutritional quality of children’s breakfast, while contributing greatly to increase their daily sugar intake ²⁶26. Harris JL, Schwartz MB, Ustjanauskas A, Ohri-Vachaspati P, Brownell KD. Effects of serving high-sugar cereals on children's breakfast-eating behavior. Pediatrics 2011; 127:71-6.. Evidence suggests that breakfast cereals advertised to children have higher sugar content than those targeting a general audience ²⁷27. Schwartz MB, Vartanian LR, Wharton CM, Brownell KD. Examining the nutritional quality of breakfast cereals marketed to children. J Am Diet Assoc 2008; 108:702-5.. Dairy-based desserts are the most frequently advertised food products in Argentinean children’s TV ²⁴24. Allemandi L, Castronuovo L, Tiscornia MV, Ponce M, Schoj V. Food advertising on Argentinean television: are ultra-processed foods in the lead? Public Health Nutr 2017; 21:238-46. - they include ready-to-eat, flavored dairy products that usually contain sugar or synthetic sweetener, and other ingredients and additives (e.g., modified food starch, modified corn starch, flavorings and food colors).

Methods

This is a cross-sectional, descriptive study of marketing techniques using sweet biscuits, breakfast cereals and dessert packages as the unit of analysis. The sample comprised all the products available in a specific retail store during the data collection period (June 2016). This supermarket was chosen because it was one of the largest retailers in Argentina, based on Euromonitor data ²⁵25. Euromonitor International. Sweet biscuits, snack bars and fruit snacks in Argentina. https://www.euromonitor.com/sweet-biscuits-snack-bars-and-fruit-snacks-in-argentina/report (accessed on 05/Oct/2019).
https://www.euromonitor.com/sweet-biscui... .

Two trained field-workers photographed all sides of the product packages (all brands and presentations) included in the three selected categories (n = 301), with consent from the store management. A few products were purchased to facilitate coding as workers were unable to obtain clear photographs of the labels in-store. The images were uploaded to an online database (http://lfstatistics.ddns.net/ENC/DBFIC0001/index.php) for further processing.

We adapted the data collection instrument from the International Network for Food and Obesity/non-communicable diseases Research, Monitoring and Action Support (INFORMAS) protocol, which has been developed to evaluate food environments and assist in designing policies to improve them ²⁸28. Swinburn B, Sacks G, Vandevijvere S, Kumanyika S, Lobstein T, Neal B, et al. INFORMAS (International Network for Food and Obesity/non-communicable diseases Research, Monitoring and Action Support): overview and key principles. Obes Rev 2013; 14 Suppl 1:1-12.. The adaptation consisted of translating to Spanish and incorporating variables relevant under ACA terms. The instrument was designed to gather information regarding mandatory and optional labelling and marketing techniques, as detailed in Tables 1 and 2. Mandatory labelling variables included the presence of an ingredient list and nutrition information panel, as regulated by the ACA ¹⁷17. Código Alimentario Argentino. Capítulo V: normas para la rotulación y publicidad de los alimentos. 2005. http://www.anmat.gov.ar/alimentos/codigoa/Capitulo_V.pdf (accessed on 05/Oct/2019).
http://www.anmat.gov.ar/alimentos/codigo... ; variables were constructed to evaluate compliance with these instructions. Optional labelling elements included the Guideline Daily Amounts system (GDA), endorsement by health or nutrition organizations and nutritional and health claims (Box 1). Marketing techniques of interest included using brand and licensed characters, celebrity endorsements, child images, event sponsorship, “limited edition” claims, premiums (collectibles, prizes), games, messages related to price/promotions, sports references, and contests (Box 1).

Nutritional quality was evaluated using the Pan American Health Organization Nutrient Profile (PAHO NPM) ²⁹29. Pan American Health Organization. Nutrient profile model. Washington DC: Pan American Health Organization; 2016. and the WHO Regional Office for Europe Nutrient Profile (WHO Euro NPM) models ³⁰30. WHO Regional Office for Europe. Nutrient profile model. Copenhagen: World Health Organization; 2015.. They establish maximum threshold contents for different nutrients to differentiate between food products “that are more likely to be part of a healthy diet from those that are less likely (notably those foods that may contribute to excess consumption of energy, saturated fats, trans fats, sugar or salt)” ³⁰30. WHO Regional Office for Europe. Nutrient profile model. Copenhagen: World Health Organization; 2015. (p. 2). Both nutrient profiles aim to provide a tool to facilitate the design and implementation of policies selectively targeting less healthy foods. WHO Euro NPM was explicitly formulated to support restrictions in marketing of less healthy foods targeting children ³⁰; in turn, PAHO NPM has a broader policy scope ²⁹29. Pan American Health Organization. Nutrient profile model. Washington DC: Pan American Health Organization; 2016.. Both NPM are used here to increase comparability with previous and future studies.

PAHO NPM sets across-the-board thresholds for all processed food products, including limits for sugar (amount of energy from sugars ≥ 10% of the total energy), salt (ratio between the amount of sodium (mg) and the total amount of energy (kcal) ≥ 1:114), saturated fats (amount of energy from saturated fats ≥ 10% of the total amount of energy), trans fats (the amount of energy from trans fats ≥ 1% of the total amount of energy) and total fat (the amount of energy from total fats ≥ 30% of the total energy) ²⁹29. Pan American Health Organization. Nutrient profile model. Washington DC: Pan American Health Organization; 2016..

Regarding WHO Euro NPM, the thresholds are applied by food category and certain categories are considered a priori as unhealthy foods, regardless of their nutrient content, meaning that no specific nutrient threshold is available. Such is the case of sweet biscuits and desserts categories which are classified as unhealthy and thus should not be allowed to be marketed to children. Breakfast cereals have maximum nutrient thresholds of > 10g of total fat, > 15g of sugar, > 640mg of sodium and > 1g of trans fat/100g of total fat. These amounts are normalized to 100g of ready-to-eat food product ³⁰30. WHO Regional Office for Europe. Nutrient profile model. Copenhagen: World Health Organization; 2015..

Products were classified as “less healthy” when one or more nutrients exceeded the threshold value in a given product. Regarding WHO Euro NPM, all products included in the sweet biscuits and dessert categories were considered as less healthy foods, regardless of their nutrient content.

Two trained research assistants coded this information to identify compliance with ACA mandatory labeling, marketing techniques, nutrition/health claims and nutritional quality of the product. A pilot study was conducted on a sub-sample of 23 products, to analyze reliability and improve the coding instrument; inter-rater agreement was measured using Cohen’s kappa and percentage of agreement. This sample size was calculated assuming a 90% agreement rate (95% confidence interval - 95%CI; 10% error). The 23 products were selected by systematic sampling; the total sample was ordered by coder and product category and subdivided in periodic intervals of 13 products.

All variables analyzed were categorical; results are presented as percentages of the total sample. Main outcomes include percentages of products that displayed a complete ingredient list, that informed nutritional content in compliance with the ACA, as well as percentages of “healthy” and “less healthy” products making specific nutritional/health claims or displaying particular marketing techniques.

Fisher’s exact test was applied to evaluate differences among sub-groups, such as differential use of nutrition/health claims and marketing techniques between healthy and less healthy foods; p-values under 0.05 were considered statistically significant. Statistical analyses were conducted using R 3.6.1. software (http://www.r-project.org).

After completing the database, we tested the inter-rater reliability on a subsample of 23 products assuming a 90% agreement rate (95%CI; 10% error), following the same systematic sampling method used in the pilot study. All coded variables presented high (k ≥ 0.61 < 0.8) to very high (k ≥ 0.81-0.99) inter-coder agreement.

Results

Of the total sample of 301 products included in the study, 69% were sweet biscuits, 17% were dairy-based desserts (from here onwards, “desserts”) and 14% were breakfast cereals. Except for one breakfast cereal that had no ingredient list, all product packages displayed the mandatory nutritional information (Box 2).

Results on optional labeling elements related to health and nutrition are shown in Table 3. Four breakfast cereals, one sweet biscuit and one dessert presented institutional endorsement logos, representing 2% of the total sample. A 20% of the total sample included the GDA system label: none of the dessert products showed the GDA label, while 27% of sweet biscuits and 7% of breakfast cereals did. Of the total product sample, 40% displayed nutrition claims, including most breakfast cereals and half of the desserts sub-sample. Less frequent in the total sample, health claims (9%) appeared mostly in breakfast cereals.

The analysis of marketing techniques focused on the display of characters and premium offers (prizes, collectibles and games) (Table 1). Messages (e.g., charity and sponsorship of non-sports events) and sensorial appeal features were absent from the sample, so results are not reported for these categories. Approximately one-third of the total sample display characters in their packages, but these percentage vary among the three product categories, presenting a higher frequency in desserts. Only dessert products offered collectible containers, representing 6% of the total sample and 36% of the desserts category. Gifts were included in 9% of the total sample, mainly in sweet biscuits, while games accounted for 5% of the total sample (Table 1).

Regarding nutritional quality, most of the sample was classified as less healthy products: 87%, following the PAHO NPM, and 91% by WHO Euro NPM standards (Table 2). Among the less healthy products according to the PAHO NPM, 2% included a health organization endorsement logo and 37% made nutrition claims. Characters were displayed in 32% of these products, while 16% offered premiums or collectible containers. Nutrition and health claims were more frequent among the healthier product subsample; the GDA system, characters, and premiums were more frequent among the less healthy products (statistically significant differences; p < 0.05) (Table 3).

Among the products classified as less healthy under the WHO NPM standards, 1% included a health organization endorsement logo and 36% made nutrition claims. Of these products, 33% portrayed licensed characters and 17% offered premiums or collectible containers. Nutrition and health claims were more frequent among the healthier product subsample (statistically significant differences; p < 0.05). We found no significant differences in the use of other optional labeling elements and marketing techniques between the healthier and less healthy food groups (Table 3).

Discussion

This was the first study conducted in Argentina that analyzed marketing strategies and nutrition and health claims in food packaging. Approximately 90% of the products in the total sample were classified as less healthy by both WHO Euro and PAHO NPM standards and should not be marketed to children. These results are consistent with previous research in Argentina ²⁴24. Allemandi L, Castronuovo L, Tiscornia MV, Ponce M, Schoj V. Food advertising on Argentinean television: are ultra-processed foods in the lead? Public Health Nutr 2017; 21:238-46., indicating that the vast majority of food products advertised on TV are processed or ultra-processed foods with low nutritional value. Our results also show that the packages of these products often include powerful marketing elements. Brand/licensed characters or celebrity endorsements, which have been found to exert a powerful influence over child food choices ¹¹11. Letona P, Chacon V, Roberto C, Barnoya J. Effects of licensed characters on children's taste and snack preferences in Guatemala, a low/middle income country. Int J Obes (Lond) 2014; 38:1466-9.^,1212. Dixon H, Scully M, Niven P, Kelly B, Chapman K, Donovan R, et al. Effects of nutrient content claims, sports celebrity endorsements and premium offers on pre-adolescent children's food preferences: experimental research. Pediatr Obes 2014; 9:e47-57.^,1919. Ares G, Arrúa A, Antúnez L, Vidal L, Machín L, Martínez J, et al. Influence of label design on children's perception of two snack foods: comparison of rating and choice-based conjoint analysis. Food Qual Prefer 2016; 53:1-8.^,2121. Perry A, Chacon V, Barnoya J. Health claims and product endorsements on child-oriented beverages in Guatemala. Public Health Nutr 2018; 21:627-31.^,2222. Chacon V, Letona P, Barnoya J. Child-oriented marketing techniques in snack food packages in Guatemala. BMC Public Health 2013; 13:967.^,3131. Ogle AD, Graham DJ, Lucas-Thompson RG, Roberto CA. Influence of cartoon media characters on children's attention to and preference for food and beverage products. J Acad Nutr Diet 2017; 117:265-70.^,3232. Roberto CA, Baik J, Harris JL, Brownell KD. Influence of licensed characters on children&apos;s taste and snack preferences. Pediatrics 2010; 126:88-93^,3333. Kraak VI, Story M. Influence of food companies' brand mascots and entertainment companies' cartoon media characters on children&apos;s diet and health: a systematic review and research needs. Obes Rev 2015; 16:107-26., feature in 32% of less healthy products. Brand and licensed characters/celebrity endorsement display and premiums such as prizes and collectible containers were more frequent among the less healthy food products than among products with no nutrient excess as per PAHO NPM standards.

Our study also suggests that the food labeling policy currently in force in Argentina is insufficient to protect the health of the population. ACA stipulates that supplementary nutritional information (claims) “must not be presented in such a way that leads to incorrect interpretations or are deceptive to consumers; may promote overconsumption of certain foods; or may suggest that the food product is nutritionally complete” ¹⁷17. Código Alimentario Argentino. Capítulo V: normas para la rotulación y publicidad de los alimentos. 2005. http://www.anmat.gov.ar/alimentos/codigoa/Capitulo_V.pdf (accessed on 05/Oct/2019).
http://www.anmat.gov.ar/alimentos/codigo... . Despite this regulation, nutritional claims appear in almost 40% of less healthy food product packages, exposing consumers to food products whose real nutritional value is at odds with that claimed on the product package. Nutrition/health claims have also been found to influence children’s perception of products as healthy ³⁴34. Soldavini J, Crawford P, Ritchie LD. Nutrition claims influence health perceptions and taste preferences in fourth-and fifth-grade children. J Nutr Educ Behav 2012; 44:624-7.. We found endorsement by health organizations in a small subset of the sample, but all of these products were deemed less healthy foods under PAHO NPM. A study described a similar scenario for sweetened drinks in Guatemala, where most of the beverages endorsed by health organizations were classified as less healthy. Conflict of interest is in fact a concern when dealing with partnerships between the food industry and health organizations ³⁵35. Nestle M. Corporate funding of food and nutrition research: science or marketing? JAMA Intern Med 2016; 176:13-4.; if this type of collaboration cannot be avoided, organizations should consider using at least one of the nutrient models presented here to identify healthier products worthy of endorsement and, ideally, refuse to endorse products that fail to achieve the standards set by the model.

We also lack a regulatory framework concerning deceptive marketing of food products with low nutritional quality, especially among children and young adults. The WHO Euro NPM and the PAHO NPM provide the basis to develop such a framework in Argentina, since they enable a simple, straight-forward and evidence-based system for identifying less healthy food products whose marketing should be restricted. But the only policy in place related to unhealthy food advertising is included in the National Law of Food Disorders that stipulates that any form of advertising of foods with high energy density and low essential nutrients must include the disclaimer “Excessive consumption is harmful to health” ³⁶36. Presidencia de la Nación, Ministerio de Justiça y Derechos Humanos. National Act Ley 26.396. Declárase de interés nacional la prevención y control de trastornos alimentarios. http://servicios.infoleg.gob.ar/infolegInternet/anexos/140000-144999/144033/norma.htm (accessed on 05/Oct/2019).
http://servicios.infoleg.gob.ar/infolegI... . However, there are no criteria established by law to identify the food products whose advertisements or front-of-pack marketing elements should include the disclaimer.

This situation approaches a double regulatory void in Argentina, as in most Latin American countries: there are no objective tools in place to measure the overall healthiness of food products, and there are no policies in force to restrict marketing of less healthy foods. This reality underscores the need to strengthen food labeling regulations to ensure that consumers receive clear and accurate nutritional information to make healthier food choices. Labeling policies must change to incorporate the perspective of non-communicable chronic disease prevention. As party to both PAHO and WHO, Argentina should follow their guidelines to reduce childhood overweight and obesity, including the implementation of adequate labeling and restrictions to the marketing of less healthy food products ³⁷37. Pan American Health Organization. Plan of action for the prevention of obesity in children and adolescents. Washington DC: Pan American Health Organization; 2015.^,3838. World Health Organization. Report of the commission on ending childhood obesity. Geneva: World Health Organization; 2016..

The serious public health issue imposed by growing rates of childhood overweight and obesity today is no longer a subject of debate; what is still under discussion is what governments can do to tackle the obesity epidemic and protect the right to health of both children and the adult population. Our results underscore the need for straight-forward, effective regulations on using claims and marketing techniques on less healthy food packages, especially those targeting children. Packaging, however, is only one of the many media for food marketing; comprehensive legislation to reduce overall exposure to marketing of less healthy foods should also include specific regulations for TV, social media, and point of sale advertising. The recommendations put forth by PAHO and WHO to tackle childhood obesity ³⁷37. Pan American Health Organization. Plan of action for the prevention of obesity in children and adolescents. Washington DC: Pan American Health Organization; 2015.^,3838. World Health Organization. Report of the commission on ending childhood obesity. Geneva: World Health Organization; 2016. provide a good starting point for Argentina to develop its own regulatory framework.

Ours is the first analysis of optional labeling and child-oriented marketing in processed food packages in Argentina, conducted using an international protocol. This will allow both to inform decision makers and influence policy making for public health objectives, and to compare the local situation with other countries and establish a baseline to track future progress. The study dealt with resource and time constraints, but its main limitation concerns the inclusion of only three food categories. More research is needed to examine whether our results extend to other frequent advertised food groups, such as chips, cookies, crackers or sugar-sweetened beverages.

Data was collected from only one supermarket in the city of Santa Fe, Argentina. Although this store belongs to one of the largest retailers nationwide, the products included in the analysis do not represent all products sold in the country, thus preventing us from capturing the full extent of product packaging claims. Lastly, a significant deficiency of the study arises from the regulations currently in force in the country: sugar content is not a mandatory label element in Argentina, so this critical ingredient was disregarded in the analysis. As such, the nutritional value of some products could be overestimated, although about 90% of the products were found to be less healthy, even with this caveat.

Acknowledgments

The authors thank the FIC Argentina volunteers who collaborated with data entry, and Agustina Mozzoni, Juan Carballo and Slavenska Zec from FUNDEPS and Belen Rios from FIC Argentina for their legal contribution and participation in the broader research project of which this study was part of. We also thank Malena Pirola for her assistance in writing the paper and all FIC Argentina’s staff for their ongoing support. Finally, we thank the anonymous reviewer whose comments allowed us to improve on the original manuscript.

References

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