Even a very intense exposure to TV advertising promoting fruit consumption is not enough to make children eat more fruit: results from an experimental study in Italy

Abstract

OBJECTIVE:

The consumption of fruits and vegetables is important for a healthy lifestyle. The intake of fruits and vegetables is recommended to be at least 5 portions/per day, but currently, less than 15% of children between the ages of 4–8 years reach that consumption level. How to promote and increase fruit consumption in children is still an open issue. This study aimed to experimentally assess the efficacy of intense pro-fruit advertising on actual consumption in children during snacking.

STUDY DESIGN:

The study was conducted on 12 children (ages 6–10 years) exposed to a 9-minute movie containing a total of 3.30 minutes of advertising (25% of the total time). Advertising was classified as healthy if the message focused on fruit and vegetable consumption and as unhealthy if it focused on hypercaloric foods. Children were randomized to have equicaloric snacks of apples in slices (packaging of 80 grams) or chips (25 grams) in four groups of three children each: fruit-healthy ads, fruit-unhealthy ads, chips-healthy ads, and chips-unhealthy ads.

RESULTS:

No significant differences (p = 0.762) were found regarding kcal intake deriving from fruit consumption among the group exposed to chip advertising (20.20 kcal mean difference, 95% C.I. 1.01–32.93). Overall, children had a higher consumption of chips (11.35 grams, 0–22.86) than fruit (0 grams, 0.00–44.91).

CONCLUSIONS:

Even an intense exposure to TV advertising for fruits and vegetables did not increase the consumption of fruit during snack time. More innovative approaches may be necessary to stimulate the intake of fruits and vegetables in children.

1. Introduction

Vegetables and fruits are nutritionally complex foods, containing more than 100 potentially beneficial vitamins and minerals, fiber, and other phytochemicals that may help to maintain a healthy lifestyle and to prevent obesity, chronic diseases and cancer [1 –3]. According to the World Health Organization (WHO), an insufficient intake of fruit and vegetables is estimated to cause approximately 14% of gastrointestinal cancer deaths, approximately 11% of ischemic heart disease deaths and approximately 9% of stroke deaths globally [4]. A daily consumption of at least 400 g of fruits and vegetables is recommended by experts [5]; many countries have included this recommendation in their guidelines [3, 5], while others have adopted the message “5 a day”, related to the consumption of 5 portions (80 grams each) of fruits and vegetables daily [6].

Though the beneficial effects of fruit and vegetable consumption are well-established, and though there is an increase in campaigns that promote their consumption, the intake of this type of food falls below the recommended guidelines in children, especially in Western countries [7, 8]. In Italy, the daily consumption of fruits and vegetables in children and adolescents was low. Data indicate that fruit consumption was approximately 45.5% among 11-year-olds, 39.9% among 13-year-olds and 38.4% in 15-year-olds, while the daily vegetable consumption prevalence was 21.1%, 19.6%, and 20.2%, respectively, in those groups [9]. Among the factors associated with fruit and vegetable consumption and preference among children and adolescents, being exposed since childhood to a specific taste, parental modeling and the availability of a specific food in everyday life were identified as key parameters in developing a balanced nutritional approach [10]. Parental modeling and parental fruit and vegetable consumption were positively associated with children’s dietary habits, suggesting that family is an essential environment for the promotion of a healthy lifestyle and healthy eating behaviors among children. The consumption of fruits and vegetables among children is currently decreasing, and the consumption of unhealthy food and soft drinks among children is on the rise [11].

Time spent watching TV seems to be one of the factors associated with the consumption of high energy-dense foods, often due to advertising addressed to children during TV programs. The advertising is focused on snacks and unhealthy foods and is the cause of a child’s preference for one food compared to another [12]. Furthermore, some researchers tagged TV as an obesogenic factor, which promotes a sedentary lifestyle to the detriment of physical activity and the ability to maintain a correct energetic balance [13]. In recent years, several programs aimed at spreading the knowledge of the beneficial effects of fruit and vegetable consumption were developed. These programs were addressed mainly to children, because the eating patterns established during childhood and adolescence tend to continue in adulthood [14]. Children are exposed to several information sources on healthy dietary habits, especially in school where programs on food education are on the rise. The impact of child exposure to images or information regarding healthy foods is a current topic of research. Osborn and Forestell demonstrated how teaching regarding fruit and vegetable consumption and an exposure to a wide variety of these foods increase the acceptability and the inclination to test these foods among children [15].

Recently, studies were conducted with the aim to integrate theoretical nutritional programs with fruit and vegetable exposure to increase their consumption in children. Several researchers estimated how exposure to different kinds of fruits and vegetables, supported by nutritional programs, increased the consumption of healthy foods in children compared to those who were exposed only to theoretical nutritional programs [15, 16].

This study aimed to experimentally assess the efficacy of intense pro-fruit advertising on the actual consumption of fruit in children during snacking.

2. Materials and methods

2.1. Study design

The experimental study was a 2x2 factorial ad-libitum eating design. The first factor was exposure to food (fruit or chips), and the second factor was exposure to advertising (ads), healthy or unhealthy. Participants were randomly assigned to four groups: fruit-healthy ads, fruit-unhealthy ads, chips-healthy ads, and chips-unhealthy ads. Advertising was classified as healthy if the message was focused on fruits and vegetables and as unhealthy if it was focused on hypercaloric foods (filled sandwiches, fried food, potato chips). Both advertisements had background music without words and were not commonly seen by children, since they were developed by an expert operator. The movie used was a 9 minute cartoon of Donald Duck ^©, filled with a total of 3.30 minutes of advertising, which was approximately 25% of the total watching time (1.10 minutes of ads for every 2.5 minutes of the cartoon). This was considered an “intense” exposure compared to the current levels of advertising in common TV programs and Italian regulations [17]. For the duration of the cartoon, the participants were given the opportunity to eat the offered food ad libitum (fruit or chips, depending on the group).

2.2. Study setting

The study involved twelve children aged 6–10 years, equally divided by gender, enrolled in an elementary school in Trieste (Italy). People with cognitive disorders, metabolic diseases or allergies to the products offered during the experimental session were excluded from the study. Children were observed during the afternoon break, in a quiet room. Parents were asked to sit in a lateral or back position in order to complete the parent questionnaire without being seen by the children. The children sat at a table, facing a monitor. Each child was video-recorded via four hidden HD cameras, positioned to record frontal, posterior and sides images, while an assistant was sitting at the child’s side to easily interact with her/him.

Parent informed consent was obtained for all children prior to beginning the study. Participant treatment followed the guidelines and ethics issued by the American Psychologist Association (APA, 2002). Appropriate permission was obtained from the Institutional Review Boards.

2.3. Parent questionnaire

The questionnaire administered to the children’s parents was divided into two parts. The first section was aimed at determining the sociodemographic characteristics of the entire family, parental educational level, the BMIs of the parents and siblings, and a detailed set of questions covering the principal meals and basic physical activities performed within the family. The second part of the questionnaire aimed at assessing the child’s eating behavior, TV viewing and the physical activity habits of the children and their families.

2.4. Anthropometric measurements

Children were measured and weighed in light clothing and without shoes using an electronic stand-up balance scale and a rigid metric belt after the experimental session. Measurements were taken by positioning the child’s back against the wall, with the back of the feet touching the wall and a straight angle formed between the wall and the floor. Afterward, a straight surface was placed over the child's head, and a mark was fixed on the wall corresponding to the height of the child. Weights and heights were utilized to calculate body mass index (BMI) values according to CDC Pediatric Growth Charts [18]. BMI z-scores were computed for each child [19].

2.5. Brand awareness

A validated questionnaire to assess children’s brand awareness, the IBAI (Italian Brand Awareness Instrument) questionnaire, was utilized in this study [20]. The questionnaire was composed of 12 images of food products currently available on the market both nationally and internationally. Children were asked after the experimental session to recognize the brand, matching it to an image chosen among four different options. In the end, the interviewer questioned the child on the specific name of the product. Brand Awareness Scores (IBAI-score) could range from a minimum of 0 to a maximum of 36, with a cut-off set at 16 points. Children were divided into two groups: low brand awareness children (<16) and high brand awareness children (>16) [20].

2.6. Study conduct

Each child participated in the study separately. Children were asked to sit at a table in front of the television. The two snacks included in the study were i) prepackaged fresh apples in a single dose of 80 grams, served in sliced and ii) Fonzies ^® chips in a single dose of 25 grams. Both the snacks were offered on a tray, placed on the table in front of the child. The child could eat ad libitum up to a maximum of 6 snack packages. Snacks were offered using a predeveloped protocol, in a way to control, as much as possible, the investigator’s influence on child behavior. All snacks offered to the children were previously weighed. The residues of each product were weighed after the study and recorded in a database to estimate the quantity eaten by each child. At the end of the cartoon, children were measured to calculate their BMI and physical characteristics, and afterward, the IBAI questionnaire was administered to children by the interviewer.

All the sessions were digitally recorded for subsequent examination and data quality assurance.

2.7. Sample size calculation

The sample size was calculated to have at least 0.97 power and 0.05 significance (alpha level) to detect a difference of snack consumption of 26 grams (assuming an equal standard deviation in the two groups of approximately 13 grams) between the two groups of advertising. This difference is equivalent to a reduction of one package of chips within the experimental session by adopting advertising targeted to fruits. Twelve children were needed to reach the study target.

2.8. Statistical analysis

Data are shown as the median (95% confidence interval) or percentage (absolute numbers) whenever appropriate. The p-values were estimated using the nonparametric Wilcoxon-Kruskal-Wallis test with an F distribution, and they were adjusted with the Bonferroni method in the case of multiple comparisons. P-values less than 0.05 were considered statistically significant.

A multivariable model was estimated to model the effect of advertising on energy intake, adjusting for some confounders such as snacks, IBAI score, and physical activity. An analysis of variance was performed to evaluate the significance of the model. All analyses were performed with the R system.

3. Results

3.1. Sample characteristics

All children completed the study. The median age was 7 years (95% C.I. 5.27; 10), and the BMI z-score was 0.74 (95% C.I. – 0.45; 2.41). Only eight mothers and nine fathers agreed to have their BMI calculated, and the values showed a median of 20.9 for the mothers and 23.9 for the fathers. The median total hours/week of TV watching for the child was approximately 8.3 hours. Exposure to advertising, as measured by the IBAI score, had a median value of 13 (95% C.I. 2.375–22.45), corresponding to a low brand awareness score [20]. The overall energy intake during the experimental session was (median value) approximately 10.1 kcal (I and II quartile 0 and 109.97). This is in between the fruit group, with a median of 0 kcal (I-III quartile 0–31.93) and the snack group, with a median of 56.27 kcal (I-III quartile 0–115.39). All data are presented in Table 1.

Table 1
Description of the sample. Summaries for categorical variables are expressed as percentages (absolute numbers in parenthesis), and continuous variables are expressed as the median (quartiles I – III in parentheses)

Sample characteristics N

Child BMI 12 17.62 (15.09–21.17)

Mother BMI 8 20.93 (20.07–28.56)

Father BMI 9 23.89 (22.80–30.25)

Number of sisters 0 12 58% (7)

1 33% (4)

2 8% (1)

Number of brothers 0 12 50% (6)

1 50% (6)

Frequency of breakfast before school 1–2 times per week 12 0% (0)

3–4 times per week 0% (0)

Never 0% (0)

Every day 100% (12)

Daily fruit portions 1 12 42% (5)

2 25% (3)

3 25% (3)

4 8% (1)

Daily vegetable portions 1 12 50% (6)

2 50% (6)

Chips and salty snack consumption More than once/day 12 0% (0)

Once/day 0% (0)

At least once/week 42% (5)

Rarely 58% (7)

Never 0% (0)

Sweet snack consumption More than once/day 12 0% (0)

Once/day 25% (3)

At least once/week 50% (6)

Rarely 25% (3)

Never 0% (0)

TV viewing (hours/week) 12 8.25 (3.78–18.73)

Television sets at home (n°) 12 1 (1-5)

Energetic intake (Kcal) 12 10.10 (0–47.29)

IBAI score 12 13 (2.38–22.45)

Sample characteristics	N
Child BMI		12	17.62 (15.09–21.17)
Mother BMI		8	20.93 (20.07–28.56)
Father BMI		9	23.89 (22.80–30.25)
Number of sisters	0	12	58% (7)
	1		33% (4)
	2		8% (1)
Number of brothers	0	12	50% (6)
	1		50% (6)
Frequency of breakfast before school	1–2 times per week	12	0% (0)
	3–4 times per week		0% (0)
	Never		0% (0)
	Every day		100% (12)
Daily fruit portions	1	12	42% (5)
	2		25% (3)
	3		25% (3)
	4		8% (1)
Daily vegetable portions	1	12	50% (6)
	2		50% (6)
Chips and salty snack consumption	More than once/day	12	0% (0)
	Once/day		0% (0)
	At least once/week		42% (5)
	Rarely		58% (7)
	Never		0% (0)
Sweet snack consumption	More than once/day	12	0% (0)
	Once/day		25% (3)
	At least once/week		50% (6)
	Rarely		25% (3)
	Never		0% (0)
TV viewing (hours/week)		12	8.25 (3.78–18.73)
Television sets at home (n°)		12	1 (1-5)
Energetic intake (Kcal)		12	10.10 (0–47.29)
IBAI score		12	13 (2.38–22.45)

3.2. Effect of advertising on fruit intake

Data on energy intake and consumption in grams are presented in Table 2. No significant association between healthy and unhealthy advertising exposure and chip consumption regarding energy intake was found (Fig. 1). The intake of Kcal from fruit in both the healthy and unhealthy advertising groups was evaluated, but no significant differences were observed (p = 0.762) (Fig. 2).

Table 2
Overall energy intake (Kcal) and consumption in grams (fruits, chips and total intake) during the experimental session, presented according to the type of advertising. Data are the medians (quartiles I – III in parentheses)

Healthy ads Unhealthy ads Total

Energy intake (Kcal) Fruit 0 (0–0) 20.2 (1.01–32.93) 0 (0-31.93)

Chips 38.3 (1.92–115.82) 74.24 (3.71–83.32) 56.27 (0–115.39)

Total 0 (0–109.7) 26.9 (0-82.61)

Consumption (grams) Fruit 0 (0–0) 28.9 (1.45–46.29) 0 (0–44.91)

Chips 7.4 (0.37–22.98) 15.3 (0.77–16.25) 11.35 (0–22.86)

Total 0 (0–21.75) 15.8 (0–44.91)

		Healthy ads	Unhealthy ads	Total
Energy intake (Kcal)	Fruit	0 (0–0)	20.2 (1.01–32.93)	0 (0-31.93)
	Chips	38.3 (1.92–115.82)	74.24 (3.71–83.32)	56.27 (0–115.39)
	Total	0 (0–109.7)	26.9 (0-82.61)
Consumption (grams)	Fruit	0 (0–0)	28.9 (1.45–46.29)	0 (0–44.91)
	Chips	7.4 (0.37–22.98)	15.3 (0.77–16.25)	11.35 (0–22.86)
	Total	0 (0–21.75)	15.8 (0–44.91)

Fig. 1.

Energy intake related to the chip consumption group exposed to healthy ads (left side) and unhealthy ads (right side).

Fig. 2.

Energy intake related to the fruit consumption group exposed to healthy ads (left side) and unhealthy ads (right side).

Dietary habits among children were characterized by a high intake of sweet snacks (10) followed by biscuits (5) and fruit (4), which was equal to the consumption of bread and sandwiches (4). All the data are presented in Fig. 3.

Fig. 3.

Dietary habits in children during snacking time in their everyday lives. Data are the number of children eating the given food item.

Using the multivariable model (Table 3), after adjusting for brand-awareness, no significant association was seen between advertising and energy intake.

Table 3

Results of the linear regression for modeling energy intake. Data presented are the linear coefficients with their standard errors (S.E.) and the p-values. Coefficients are expressed in kcal and represent the effect of each factor included in the model on the energy intake of the child

	Coefficient	S.E.	P-value
Intercept	43.078	32.23	0.23
Ads (healthy vs. unhealthy adv)	–22.43	41.62	0.609
Snacks (fruits vs. chips)	–64.25	48.55	0.234
Brand Awareness (unit increment in the IBAI score)	1.11	2.44	0.666
Physical activity (4-6 hours vs.<4 hours)	27.08	30.06	0.402

4. Discussion

The main objective of this study was to compare the effect of healthy and unhealthy advertising on fruit intake in children. Independent of the type of ads, the study showed that children did not appreciate fruits during snacking and were more attracted to chips. In our study, the use of two types of ads allowed us to evaluate the role of the different advertising messages and their impact on fruit or chip intake among children. Despite the exposure to healthy advertising, the consumption of fruit among participants seemed to be very low. The results of our study are in line with other research. This is not, in fact, the first study which demonstrates a limited amount of fruit consumption even after exposure to a particular fruit consumption-oriented stimulus; Folkvord and colleagues demonstrated a major consumption of energy-dense food after exposure to an advergame with fruit compared to fruit intake [21], while the study conducted by Bezbaruah et al. showed a limited influence of cartoon characters on the increase of fruit and vegetable intake among children [22]. These results demonstrate that the use of advertising for fruit promotion does not necessarily stimulate fruit intake. Our study showed an increase in chip consumption after exposure to unhealthy ads compared to healthy ads, in line with Harris et al., who showed a direct relationship between advergames with energy-dense food and energy-dense snack consumption [23].

In this study, we decided to expose children to 3.30 minutes of healthy ads. The intensity of this stimulus is very high and does not reflect the reality of Italian television advertising [17].

Regarding content, ads of toys are more common than food ads in Italy, and the majority of food commercials promote foods that are high in sugar, fat, and salt [24]. In a survey conducted in 1995, Taras and Gage [25] studied food advertisements directed at children, especially for products high in fat, sugar, and salt, each with an average of 28.6 seconds. This was a shorter duration of ads than in our study. Advertising for healthy foods was not observed. Some years later, these results were confirmed by Batada et al., who showed that advertising for fruits and vegetables was extremely rare during Saturday morning TV programs addressed to children when compared to foods that were high in fat, sugar, or sodium [26].

The consumption of fruits and vegetables among children involved in our study was not high, and this is in line with other North American studies, where the intake of this class of food was also very low [27]. More specific studies are necessary to evaluate if exposure to healthy ads results in a reduction of food intake in children.

This study has some strengths. First, it is one of a few studies to address the effect of healthy advertising on fruit consumption in an experimental and controlled setting, thus, at least in principle, avoiding the confounding and biases typical of real-life data. Additionally, to the knowledge of the authors, this is the only study exposing children to very intense advertising for healthy foods. This has the major implication of representing a potential estimate of the upper threshold of the impact attainable by advertising in modifying children’s choices toward fruits and vegetables.

The study has some limitations. First, these results occurred in an experimental setting and need to be validated in real-life scenarios. We need to consider the potential biases associated with the voluntary participation of children in the study. Second, there was no possibility for the children to choose between different types of fruits, given the a priori decision to use a single type of snack that was adequate for the research objectives and measurements. Furthermore, the children’s diet was assessed by a parental self-reporting questionnaire, which is a source of potential bias. Fourth, the chosen snacks and fruits are very different in terms of palatability, and this could have influenced the choice of the food by the children. Finally, although the randomization should have negated any difference among baseline groups, the small size of the study may have caused an imbalance, which might explain the zero consumption of fruit in the healthy-ads group. This potential bias is, however, in favor of making our estimates even more conservative regarding the absence of an effect of fruit advertising on fruit consumption.

4.1. Final remarks

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