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CHAPTER 2
REVIEW OF LITERATURE

The economic transition has changed the way people live. Changing lifestyles of

people, both in rural and urban areas are seen to transform the very structure of our society at

a rapid pace today. The shift from traditional to ‘modern’ foods, changing cooking practices,

increased intake of processed and ready-to-eat foods, intensive marketing of junk foods and

‘health’ beverages have affected people’s perception of foods as well as their dietary

behaviour (National Institute of Nutrition, 2011).

Irrational preference for energy-dense foods and those with high sugar and salt

content pose a serious health risk to the people, especially children. The increasing number of

overweight and obese people in the community and the resulting burden of chronic Non-

Communicable Diseases (NCD) necessitate systematic nutrition educational interventions on

a massive scale. Hence, there is a need for adoption of healthy dietary guidelines along with

strong emphasis on regular physical exercise.

Since people consume food, it is essential to advocate nutrition in terms of foods,

rather than nutrients. Dietary guidelines are a translation of scientific knowledge on nutrients

into specific dietary advice. They represent the recommended dietary allowances of nutrients

in terms of diets that should be consumed by the population. The guidelines promote the

concept of nutritionally adequate diets and healthy lifestyles from the time of conception to

old age.
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Dietary Guidelines for Indians

The Dietary Guidelines for Indians (DGI) were first published in 1998 by National

Institute of Nutrition (NIN) under the aegis of Indian Council of Medical Research (ICMR),

Government of India. This is an attempt to give consumers the science-based nutrition

recommendations they need to build a healthy diet and prevent diet-related chronic disease.

The guidelines strongly advice “balanced diet”. A balanced diet is one which provides

all the nutrients in required amounts and proper proportions with a judicious choice from a

variety of food groups. It can easily be achieved through a blend of the four basic food groups

namely:

1. Cereals, millets and pulses

2. Vegetables and fruits

3. Milk and milk products, egg, meat and fish

4. Oils & fats and nuts & oilseeds

Requirements of essential nutrients vary with age, gender, physiological status and

physical activity. Dietary intakes lower or higher than the body requirements can lead to

under-nutrition (deficiency diseases) or over-nutrition (diseases of affluence) respectively.

Eating too little food during certain significant periods of life such as infancy, childhood,

adolescence, pregnancy and lactation and eating too much at any age can lead to harmful

consequences.

Hence, an adequate diet, providing all nutrients, is needed throughout our lives.

According to the food pyramid illustrated in the manual of NIN’s revised “Dietary Guidelines
 53

for Indians” (2011), the nutrients must be obtained through a judicious choice and

combination of a variety of foodstuffs from different food groups (Figure 03). But, how-far

these guidelines are followed in packaged foods is a question for big debate.

Figure 03
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In India, in the last two decades, food and beverages advertised through mass media is

going contrary to the spirit of dietary guidelines. Particularly, celebrity endorsed

advertisements (on food and beverage products) have become ubiquitous in mass media in

general and television in particular.

Most of these products are rich in salt and sugar, which are advised to spare in the

dietary guidelines. But, in the advertisements, these products are strongly endorsed by

celebrities and flooded in mass media. As a result, messages of healthy dietary guidelines

have been overshadowed by these advertisements.

Celebrities: Gods of big deals

‘Business Today’, a leading business magazine of India, in one of its cover story (14th

April, 2013) has rightly pointed celebrities as gods of big deals (Figure 04). It is observed

that, including packed food or beverages, FMCGs (Fast Moving Consumer Goods) endorsed

by top celebrities could sustain their brand image and dominate the market. Mounting sales

graph of these products can be attributed to the charishma (glamour/ following) level of the

celebrity.
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Figure 04 Gods of Big deals

Nutrient content claims and sports celebrity endorsements on food packs influence

adults to prefer Energy-Dense and Nutrient-Poor (EDNP) products (Dixon et al 2014). In a

study to assess pre-adolescent children's responses to common child-oriented front-of-pack

food promotions, it was revealed that “children were more likely to choose EDNP products
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featuring nutrient content claims and sports celebrity endorsements”. This study concluded

as “nutrient content claims and sports celebrity endorsements influence adolescent children's

preferences towards EDNP food products displaying them”.

Food Advertisements: Obese Children

A preliminary study by Halford et al (2004) examined lean, over weight and obese

children's ability to recognize eight food and eight non-food related adverts in a repeated

measures design. Their consumption of sweet and savoury, high and low fat snack foods were

measured after both sessions.

Whilst there was no significant difference in the number of non-food adverts

recognized between the lean and obese children, the obese children did recognize

significantly more of the food adverts. The ability to recognize the food adverts significantly

correlated with the amount of food eaten after exposure to them.

This study reveals that, the overall snack food intake of the obese and overweight

children was significantly higher than the lean children in the control (non-food advert)

condition. The consumption of all the food offered increased post food advert with the

exception of the low-fat savoury snack.

These data demonstrate obese children's heightened alertness to food related cues.

Moreover, exposure to such cues induce increased food intake in all children. As suggested
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the relationship between TV viewing and childhood obesity appears not merely a matter of

excessive sedentary activity. “Exposure to food adverts promotes consumption”.

In India, promotion of packed food including EDNP products through mass media has

become a common feature. Conventional food and snack habits of Indians in compliance with

healthy dietary guidelines are fading out in urban India. This deviation in dietary guidelines is

posing threat for lifestyle diseases.

Moreover, so-called lifestyle diseases, including diabetes, heart disease, cancer,

osteoporosis, and especially obesity, have become more prevalent in the population, with

dramatic increases in some conditions such as obesity and overweight (Rowe et al, 2011).

Obesity: A Public Health Issue

Obesity has become the public health issue of the day (Bassett & Perl, 2004).

Although dietary guidance has become increasingly science based, there seems to be an ever-

widening gap between the scientific evidence and consumer behavior (WHO, 2002). The

dietary transition is associated with the escalating trends of Non-communicable diseases

(NCDs).

Life style diseases including nutrition-deficiency disorders are posing a challenge to

public health experts. ‘Public health’ as defined by World Health Organization (WHO) is

“the science and art of preventing disease, prolonging life, and promoting health through

organized efforts of society”. One of the well known approaches to public health is

Regulatory or legal approach. In India, food safety and standards authority is the prime

regulatory body which handles food related issues.

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FSSAI Guidelines

The Food Safety and Standards Authority of India (FSSAI) has been established

under Food Safety and Standards Act, 2006 which consolidates various acts & orders that

have hitherto handle food related issues in various Ministries and Departments. FSSAI has

been created for laying down science based standards for articles of food and to regulate their

manufacture, storage, distribution, sale and import to ensure availability of safe and

wholesome food for human consumption.

The Food Safety and Standards Act- 2006 Section 3 (j) defines “Food” as any

substance, whether processed, partially processed or unprocessed, which is intended for

human consumption and includes primary food, genetically modified or engineered food or

food containing such ingredients, infant food, packaged drinking water, alcoholic drink,

chewing gum, and any substance, including water used into the food during its manufacture,

preparation or treatment, but does not include any animal feed, live animals unless they are

prepared or processed for placing on the market for human consumption, plants, prior to

harvesting, drugs and medicinal products, cosmetics, narcotic or psychotropic substances.

Section 3 (d) of the Act defines (food) “claim” as any representation which states,

suggests, or implies that a food has particular qualities relating to its origin, nutritional

properties, nature, processing, composition or otherwise.

Section 3 (b) of the same Act defines “advertisement” as any audio or visual

publicity, representation or pronouncement made by means of any light, sound, smoke, gas,
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print, electronic media, internet or website and includes through any notice, circular, label,

wrapper, invoice or other documents.

One of the key functions FSSAI has been mandated by this Act is “to promote general

awareness about food safety and food standards by creating an information network across

the country so that the public, consumers, Panchayats etc receive rapid, reliable and objective

information about food safety and issues of concern”.

Food Advertisements Vs Awareness Campaigns

In this context, advertisements by food manufacturers are outshining awareness

campaigns on food safety and standards. “In India, global food manufacturers’ marketing

bombardment has been filling TV screens and billboards to fight it out for a slice of India's

growing fast food market” (The guardian daily, 2012). “McDonald's, Dunkin' Donuts,

Subway, Pizza Hut, KFC, Coca-Cola and PepsiCo are just some of the international food

brands now aggressively touting their wares to the Indian public”.

“What's good for business, however, may not be best for India's public health. Diet-

related illnesses are skyrocketing. With more than 50 million sufferers, India has the largest

diabetes population in the world, according to the World Health Organization” (World

Diabetes Foundation, 2012). Meanwhile, heart disease has also spiked, becoming the biggest

single cause of death in both urban and rural areas, a recent study by the Indian Council of

Medical Research shows (Mail Today, 2010). A largest-ever study of deaths shows heart

ailments have replaced communicable diseases as the biggest killer in rural and urban India.
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Public health campaigners have been quick to make the link with India's growing taste

for high processed, high-calorie food and drinks. "Excess consumption of these so-called 'fast

foods', coupled with low levels of physical activity, can lead to obesity" (Oliver Balch, 2012).

“Young people are especially vulnerable”.

According to National Diabetes, Obesity and Cholesterol Foundation (N-DOC), a

recent study on adolescents in New Delhi found that the prevalence of obesity had increased

from 16% to 24% between 2002 and 2007. "These foods are available right in the school

canteen and in the outside markets well within the reach of children,"

Half of India's 1.2 billion populations are under 25 years old. That holds out the

possibility of "a massive public health burden for years to come," (Raj Patel, 2008). "India's

public health officials need to do something about that now." Little action has been taken on

the issue at the heart of the debate: namely marketing to children.

The huge marketing muscle of western brands is rapidly altering public perceptions

(The guardian daily, 2012). "It has become a kind of status symbol to eat in McDonalds' and

similar fast food chains, and to drink colas and soft drinks." "Even the very poor people think

it is something like a show of upward mobility if they consume these products".

"As a result (of product advertising), children have started preferring these so called

fast foods over balanced diets … This can have a devastating effect on their nutritional
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status." (Oliver Balch, 2012). Between 7-8% of average calorie intake in the US comes from

sweetened beverages that are "empty of nutrients”. In the US, an alarming percentage of the

population is obese … It is rather sobering to watch India heading down the same pathway.

Indian researchers are more skeptical still about voluntary nutritional messaging.

Research by the Delhi-based Centre for Science and Environment (CSE, 2014) on 16 fast

food brands suggests the practice is riddled with inaccuracies or misinformation. "It's parents'

responsibility to bring up children to make smart choices" (Raj Patel, 2008). "But when the

global ratio of junk food marketing to health food marketing is about 500: 1 then parents

haven't got a chance in hell."

Bombardment of Food Ads

In India, leave alone children, majority of adults including educated, are unaware of

dietary guidelines and regulations of food safety and standards. On the other side, their minds

are bombarded with food advertisements in print and electronic media. In earlier studies,

most of these were categorized as junk food advertisements. “Healthy foods are not

advertised nearly as much as unhealthy foods, which continue to be a major public health

concern” (Maheshwar et al, 2014). This seems to suggest a pressing need for marketing

promotions that focus on healthier food options, particularly targeting vulnerable populations

such as children.

In a study conducted by Vijayapushpam et al (2014), the findings revealed that,

“food-related advertisements in Indian television continue to promote less healthful food

products. Misleading health claims are rife. Only a handful of advertisements shown are for
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food with a high nutrient content, such as fruit-based food, low-fat milk and milk products.

Advertising of foods of poor nutritional value to children was prevalent”.

Relationship between Media and HRB

In the last two decades, studies have drawn a relationship between exposure to mass

media and Health-Related Behaviour (HRB) of teenagers. Global Adult Tobacco Survey

(GATS) conducted during 2009-10 states that closer to 9% of students’ between the age

group of 13 to15 years use tobacco (Gupta et al 2012). GATS report elaborates that 24% of

tobacco users are initiated before 18 years of age.

A new study reported in The Times of India (2014-B), has revealed what one expert

called “very poor” representation of food and diet in TV shows aimed at children. Unhealthy

foods accounted for nearly half of the food shown, with sweet snacks as the most commonly

shown items. Sugary drinks represented a quarter of all the drinks displayed on the screen.

Researchers analyzed more than 82 hours of television broadcast between 6-11 am in July

and October, 2010, on the BBC and on Ireland’s public service broadcaster RTE.

This study, published in the Journal Archives of Disease in Childhood, is the first to

analyze in detail the levels of exposure to unhealthy eating habits on TV. The majority of

programming for children from the U.S. and Europe presented an unhealthy representation of

eating and diet. “The impression by the show was: ‘On a regular day, after school, let’s go

and have fast food’”. Researchers emphasized that, “the programmes were not showing the

effects of eating all of these high fat and high sugar foods that we would expect children to

show in real life. That’s unrealistic.”

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A survey of over 2,000 teenagers done by ASSOCHAM (The Associated

Chambers of Commerce & Industry of India), proved that kids spent nearly 14-16

hours in a week on television/ computer as revealed by a majority of 90% parents

(KPMG-FICCI, 2014). In India, 93% males and 87% females between the age group

of 15-49 are exposed to mass media (NFHS-3). 73% of urban households possess at

least one television set and over 75% of metropolitan kids tune in to violent video

games when parents are away. This has led to severe aggression and violent behaviour

among children of 5-17 age groups (ASSOCHAM-2010).

Cell Phone Use: Low Academic Performance

Researchers of Kent State University have found that cell phone use (to

browse Internet) among students was negatively related to cumulative college Grade

Point Average (GPA) and positively related to anxiety in students (Lepp et al, 2014).

The study surveyed more than 500 university students. Cell phone use was recorded

along with a clinical measure of anxiety and students’ level of satisfaction with their

own life and happiness.

The results showed that cell phone use was negatively related to GPA and

positively related to anxiety. Following this, GPA was positively related to happiness

while anxiety was negatively related to happiness. Thus, for the population studied,

high frequency cell phone users tended to have lower GPA, higher anxiety, and lower

satisfaction with life (happiness) relative to their peers who used the cell phone less

often.
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Social Media Effects

Psychiatrists warned that, easy access to Internet and an overdose of social media is

causing serious behavioural damage to the youth (The Times of India, 2014-A). Increased

activity on social networking websites is causing youngsters to lose touch with the real world

and is leading to depression, isolation and aggression. This study by a group of international

researchers revealed that excessive use of social networking sites makes people miserable.

This survey done among young adults showed that the more they access these sites, the less

satisfied they felt with their own lives.

In India, the situation is not very different as teenagers and young adults of the cities

are increasingly feeling discontented with their own lives due to overexposure to ‘happy’

images and videos of other people’s lives online.

Experts have gone as far as to say that social network addiction is as serious as

addiction to alcohol, smoking or gambling (Radhika Acharya, 2014). “Internet addiction has

to be treated like any other addiction for which the person must undergo rehabilitation.

Patients are first counselled, advised to undergo digital fasting and are also made to go

through cognitive behavioral therapy”.

TV Viewing and Alcohol Consumption

Longitudinal studies in United States of America found a positive correlation between

television viewing and alcohol consumption among teens (Robinson et al, 1998; Austin et al

2000-B). In India, a similar survey of four metro cities (Delhi, Mumbai, Hyderabad,

Chandigarh) conducted by ASSOCHAM revealed that 32% of adolescents (15-19 yrs)

consume alcohol (ASSOCHAM-2012; The Times of India, 3-11-2011).

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Watching television and consuming junk foods are associated with a higher

prevalence of overweight (Laxmaiah et al-2007). Mass media influences intake of

snacks in children and purchasing pattern of food products in middle income group

women (Vijayapushpam et al, 2014).

Researchers have observed that there is direct correlation between a linear

increase in school failure to an increase in the hours spent on the computer, mobile

and video games; with less or no control by parents (The Times of India, 1-2-2015).

The results demonstrated that exposure to information and communication

technologies begin at an early age and it affects the studies of the students.

At the time of this survey, 98% of the students had Internet at home and 89%

already owned a mobile phone before turning 13 years of age. The use of video games

reached 54.2%. The lack of parental control and intense use of the computer to play

video games are associated with a higher index of young people suffering from

alcohol intoxication or cannabis or other toxic consumption.

Media, be it print, television, the Internet or films, is guilty of unpardonable

presentation of the female form. The media seems to take a high moral ground but it

is responsible for the steady decline in reverence for females with its constant barrage

of indecent publications (Deepak Mahan, 2013). Irrespective of the content need, the

media thrusts a female body into the viewers’ face, but nowhere is this trend of

grotesque titillation more visible than in cinema, where in the name of love, romance

and requirements of a story, cinema does incalculable harm to women’s dignity.

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“The roughening up of female protagonist, the subsequent submission to their

‘molesters’ as a trend is still being glorified on screen by many actors. Obviously, such

behavioural traits need to be discouraged by any civil society but when these are portrayed by

superstars and adulated by millions; they send distorted signals about male superiority and

motivate many to abuse women at will. None can deny the enormous power of the cinema to

distort or influence the popular opinion” (Deepak Mahan, 2013).

Seventy eight per cent of youth in urban India between the age group of 14-30 years

consume at least one dietary supplement such as pill, energy drinks, steroids and high protein

supplements. (ASSOCHAM’s Social Development Forum- ASDF- 2012). This survey

revealed that, youth are obsessed by substances that promise to boost energy, appearance,

performance, immunity and overall health. Dietary supplements are popular among youth in

Delhi, Mumbai, Chandigarh, Hyderabad and Ahmedabad. In boys of 12th grade, ASDF

survey established that steroids use increased. Drugs availability, its efficacy is also being

targeted to youth through use of mobile and social media.

Cyber Bullying

According to Microsoft’s “Global Youth Online Behavior Survey” of 25 countries,

India ranked third with 53 percent of respondents (children aged between 8-17 years) saying

they have been bullied on line (Manokaran and Hudson, 2012). India ranks behind China (70

percent) and Singapore (58 percent). Cyber bullying can be defined as use of technology to

harass, threaten, embarrass or target another person.

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This global survey was conducted among more than 7,600 children aged 8 to

17 years across 25 countries, including Australia, France, Germany, Japan, Pakistan,

Russia, Spain, the UAE, the UK and the US. The survey focused on how kids are

treating one another online and whether parents are addressing online behaviors. In

India, the survey found that more than five in 10 children said “they have experienced

what adults might consider online bullying, while a similar number said they had done

something their parents may consider it as online bullying.”

According to the National Longitudinal Survey of Youth Cohort (NLSY-

2009) a strong dose-response relationship was found between television viewing and

the prevalence of overweight in children. Adolescents from 10 to 15 years old who

reported watching more than 5 hours of television per day developed over weight

compared to others who watch TV for less than 5 hours (Brown, et al, 2011).

Obesity and TV Watching

In 2001, Crespo et al reported that “under-12 children are strongly influenced

by television. “Kids who watch more than three hours of TV per day are 50 percent

more likely to be obese than kids who watch fewer than two hours." This study

examined the relationship between television watching, energy intake, physical

activity, and obesity status in US boys and girls, aged between 8 to 16 years.

The Researchers collected data on 4069 children and found that the prevalence

of obesity is lowest among children watching below 1 hour of television in a day, and

is highest among those who watch 4 or more hours of television. Television watching
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was positively associated with obesity among girls, irrespective of age, race/ethnicity, family

income, weekly physical activity, and energy intake.

A study conducted by Gable, Chang and Krull of University of Missouri (2007)

identified eating and activity factors associated with children of school going age, which

supported theories regarding the contributions of television watching to overweight. After

examining 8,000 children (sample), researchers identified three mutually exclusive groups of

children as (i) never overweight, (ii) overweight onset and (iii) persistent overweight.

The results showed that, children who watched more television and ate fewer meals

together with the family were more likely to be overweight. Children who watched more

television, ate fewer meals together with the family, and lived in neighbourhoods and

perceived by parents as less safe for outdoor play were more likely to be persistently

overweight. Child aerobic exercise and opportunities for activity were not associated with a

greater likelihood of weight problems.

Fat Foods: Precautions in European Nations

In countries like Sweden, Norway, and Finland commercials are not allowed during

children’s programming, this is based on past legislation which suggested policies to protect

children from advertising (Rideout, et al 2010).

In Denmark, “Fat Tax” on high carbo-fat foods was introduced to dissuade consumers

from buying such foods. A public-spirited policy framed for the health of the people.

Media Use: Cardiovascular Fitness

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Obesity in adults and children stem from habits of poor diet and physical

inactivity that develop during formative years. It is currently, the second leading cause

of actual death according to the Centre for Disease Control and Prevention

(Schneider, et al 2007). This study investigated the relative associations of TV

viewing and interactive media use with body fat and BMI, controlling for both

physical activity participation and cardiovascular fitness.

Female high-school adolescents (N=194) were assessed for cardiovascular

fitness (cycle ergo meter), percent body fat and BMI (Body Mass Index). Analysis of

the data showed that only interactive media use was associated with percentage body

fat and BMI, and the relationship remained strong even after controlling for physical

activity participation and cardiovascular fitness.

A study conducted at the University of Minnesota found reduced metabolic

rate in adolescence due to an increased incidence of eating while watching television

advertising (Barr-Anderson, et al 2009). This study examined the associations

between television viewing behaviors with dietary intake five years later.

The survey data, which included television viewing time and food frequency

questionnaires, were analyzed for 564 middle school students (younger cohort) and

1366 high school students (older cohort) who had complete data available at Time 1

(1998–1999) and five years later at Time 2.

The Respondents were categorized as limited television users (<hours/daily),

moderately high television viewers (2–5 hours/daily), and heavy television viewers
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(≥5 hours/daily). Among the younger cohort, Time 1 heavy television viewers reported lower

fruit intake and higher sugar sweetened beverage consumption than the other two groups.

Among the older cohort, watching five or more hours of television per day at Time 1,

predicted lower intakes of fruits, vegetables, whole grain and calcium-rich foods, and higher

intakes of trans fat, fried foods, fast food menu items, snack products, and sugar-sweetened

beverages (products commonly advertised on television) five years later.

This study concluded as television viewing in middle and high school stages predicted

poorer dietary intake five years later. Adolescents are primary targets of advertising for fast

food restaurants, snack foods, and sugar-sweetened beverages, which may influence their

food choices. Television viewing, especially during high school, may have long-term effects

on eating choices and contribute to poor eating habits in young adulthood.

In a meta-analysis study by Marshall, et al (2004), a statistically significant

relationship exists between TV viewing and body fatness among children and youth although

it is likely to be too small to be of substantial clinical relevance. The relationship between TV

viewing and physical activity is small but negative. The strength of these relationships

remains virtually unchanged even after correcting for common sources of bias known to

impact study outcomes.

While the total amount of time per day engaged in sedentary behaviour is inevitably

prohibitive of physical activity, media-based inactivity may be unfairly implicated in recent

epidemiologic trends of overweight and obesity among children and youth. Relationships

between sedentary behavior and health are unlikely to be explained using single markers of

inactivity, such as TV viewing or video/computer game use.

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Advertising and Food Preferences

Borzekowski and Robinson in 2001 conducted a study titled “The 30-Second

Effect: An Experiment Revealing the Impact of Television Commercials on Food

Preferences of Pre-school children”. This study observed that even brief exposure

from advertising can influence food preferences and looked into how embedded

commercials in a popular cartoon influence children on food preferences.

This study was conducted to describe the amounts and types of foods that

children consume while watching television, compare those types with the types

consumed at other times of the day, and examine the associations between children’s

Body Mass Index (BMI) and the amounts and types of foods consumed during

television viewing. Findings of the study revealed that, the fat content of foods

consumed during television viewing was associated with BMI.

Another study conducted by Lisa et al, (2007) concluded as “an overwhelming

majority of food-product advertisements seen on television by American children and

adolescents are of poor nutritional content”. Researchers of this study drew samples

of top-rated television shows by using ratings data to examine the nutritional content

for fat, saturated fat, sugar, sodium, and fibre of food-product advertisements seen on

television by both children and adolescents.

Food products were examined in aggregate and by 5 separate categories that

included cereal, sweets, snacks, drinks, and other food products. For 2- to 11-year-

olds and 12- to 17-year-olds, respectively, a sample of 50351 and 47955 were
 72

exposed to 30-second-equivalent food-product advertisements and their related nutritional

content were weighted by television ratings data to provide actual exposure measures of the

nutritional content of food advertising seen by children and adolescents.

This study results showed that 97.8% and 89.4% of food-product advertisements

viewed by children between age group 2 to 11 years old and adolescents 12 to 17 years old,

respectively, were high in fat, sugar or sodium. On average, 46.1% and 49.1% of total

calories among the products advertised came from sugar in the advertisements seen by these

respective age groups.

Exposure to Media: Consumption of F & V

Boynton et al (2003) conducted a prospective study over a 19-month period on a

sample of 548 ethnically diverse students (average age: 12 years) from public schools in 4

Massachusetts communities. They examined the associations between baseline and change in

hours of television and video viewing per day and change in energy-adjusted intake of fruits

and vegetables by using linear regression analyses to control for potentially confounding

variables and the clustering of observations within schools.

The findings of this study revealed that for each additional hour of television viewed

per day, fruit and vegetable servings per day decreased. Baseline hours of television viewed

per day was also independently associated with change in fruit and vegetable servings. This

study concluded that television viewing is inversely associated with intake of fruit and

vegetables among adolescents. These associations may be a result of the replacement of fruits

and vegetables in youths’ diets by foods highly advertised on television.

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“Advertisements featuring products like chocolates, soft drinks, snacks, toys,

confectionaries, cookies and fast food are specifically targeted for children, in order to

motivate them to buy more and try new brands. A strong correlation has been

observed between children and television advertisements, which are full of fascination

and excitement for children when they watch TV spots” (Halan, 2003).

Adolescent Smoking Imitations & Movies

Exposure to smoking in movies has been linked with adolescent smoking initiation in

cross-sectional studies. Researchers Dalton et al (2003) conducted a prospective study to

ascertain whether exposure to smoking in movies predicts smoking initiation. They assessed

exposure to smoking shown in movies in 3547 adolescents, aged 10–14 years, who reported

in a baseline survey that they had never tried smoking.

In this study, exposure to smoking in movies was estimated for individual respondents

on the basis of the number of smoking occurrences viewed in unique samples of 50 movies,

which were randomly selected from a larger sample pool of popular contemporary movies.

The researchers successfully re-contacted 2603 (73%) students 13–26 months later for a

follow-up interview to determine whether they had initiated smoking.

The findings revealed that, overall, 10% (n=259) of students initiated smoking during

the follow-up period. In the highest quartile of exposure to movie smoking, 17% (107) of

students had initiated smoking, compared with only 3% (22) in the lowest quartile. After

controlling for baseline characteristics, adolescents in the highest quartile of exposure to

movie smoking were 2·71 (95% CI 1·73–4·25) times more likely to initiate smoking

compared with those in the lowest quartile.

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The effect of exposure to movie smoking was stronger in adolescents with non-

smoking parents than in those whose parent smoked. In this cohort, 52·2% of smoking

initiation can be attributed to exposure to smoking in movies. “The results provide strong

evidence that viewing smoking instances in movies promotes smoking initiation among

adolescents.”

Thin Body Images: Bad Eating Habits

Researchers from Brigham and Women’s Hospital in Boston questioned over 12,000

children between the ages of 9-14 and found that boys and girls who made effort to look like

media figures were more likely to worry about their weight and were prone to chronic

dieting. The mass media continues to promote excessively thin body images and plays a

negative role in the development of bad eating habits among girls. It appears that the

unrealistic image so often predicted by the media is taking its toll. (Field et al 2001).

Davison and Birch (2001) of Pennsylvania State University linked overweight with

low self-esteem in girls, suggesting that young children are aware of society’s fixation on

thinness. This study of 197 girls included 48 who were overweight had lower body self-

esteem than those of normal weight. In contrast, girls who were prone to early dieting had

their growth impede and parents were asked not to ignore weight problem of children.

A study conducted by the School of Nutrition, Science and Policy at Tufts

University (Coon et al, 2001) found that children whose families routinely watched TV at

mealtime ate more salty snack foods and sodas, and fewer fruits and vegetables than those

who turned the televisions off. Participants included families from Washington DC area. The
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findings suggest that television ads show a very unrealistic view of what constitutes a

normal diet, though other factors such as level of parents’ education also plays a role,

said researchers.

Villani (2001), a Medical Director of school programmes in Baltimore has reviewed

the past ten years of research literature on the impact of media on children and adolescents

with computer technology. The study included television and movies, rock music and music

videos, advertising, video games, and computers and the Internet.

Prior to 1990, the research documented that children learn behaviors and have their

value systems shaped by media. Media research since has focused on content and viewing

patterns. The study concluded that, primary effects of media exposure increased violent and

aggressive behavior, increased high-risk behaviors, including alcohol and tobacco use, and

accelerated onset of sexual activity.

Parents and Media Use of Children

The influence of the media depends heavily upon the contexts of use;

particularly in the family (Buckingham, et al 2004). The media become meaningful in

different ways in different contexts. How children use or read a text in private may be

very different from how they speak about it with peers, where there may be

considerable pressure not to ‘take it too seriously’.

Children use media consumption as an opportunity to rehearse or police

gendered identities – as boys use pornography to harass girls, or older children use

their knowledge of media to display their sexual sophistication. Parents can ‘model’

or reinforce particular responses to sexual material, and hence particular sexual

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identities for their children. The media do not have an autonomous ability either to sexually

corrupt children or to sexually liberate them.

Research on the media’s impact on health is becoming increasingly sophisticated and

theoretically based, moving toward more complicated longitudinal designs that put media

exposure into the context of individuals’ lives (Bryant et al 2009).

In the context of adolescent smoking adoption, Gunther et al (2006) examined the

presumed influence hypothesis, a theoretical model suggesting that smoking-related media

content may have a significant indirect influence on adolescent smoking via its effect on

perceived peer norms. That is, adolescents may assume that smoking-related messages in the

mass media will influence the attitudes and behaviors of their peers and these perceptions in

turn can influence adolescents’ own smoking behaviors.

Analyzing data from a sample of 818 middle school students, researchers found that

both pro- and antismoking messages indirectly influenced smoking susceptibility through

their perceived effect on peers. However, this indirect effect was significantly stronger for

pro-smoking messages than for antismoking messages, an outcome that most likely increases

adolescents’ susceptibility to cigarettes.

Portrayal of Alcohol

A cohort study assessed the impact of alcohol advertising and media exposure on

alcohol use by adolescent. Alcohol advertising and promotion increases the likelihood that

adolescents will start to use alcohol, and to drink more if they are already using alcohol.
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Researchers Anderson et al (2009) came to this conclusion after reviewing 13

longitudinal studies that followed up a total of over 38,000 young people.

All these studies measured teenagers’ exposure to advertising and promotion

of alcohol in a variety of ways. All the 13 longitudinal studies consistently suggest

that exposure to media and commercial communications on alcohol is associated with

the likelihood that adolescents will start to drink alcohol, and with increased drinking

amongst baseline drinkers.

Based on the strength of this association, the consistency of findings across

numerous observational studies, temporality of exposure and drinking behaviours are

observed. These observations include dose-response relationships, as well as the

theoretical plausibility regarding the impact of media exposure and commercial

communications.

Twelve of the above thirteen studies concluded an impact of exposure on

subsequent alcohol use, including initiation of drinking and heavier drinking amongst

existing drinkers. There was variation in the strength of association, and the degree to

which potential confounders were controlled for. The thirteenth study, which tested

the impact of outdoor advertising placed near schools failed to detect an impact on

alcohol use, “but found an impact on intentions to use.”

Austin, et al (2000-A), quoted that “parental meditation is correlated with

better academic performance of their children and has been shown to increase

beliefs in social norms, and to decrease fear.” In their study on ‘Media’s effects on
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adolescents’ use of alcohol’, they stated that, the process that connects media use with

alcohol-related beliefs and behaviours has not been well documented. Adolescents make

drinking decisions using a progressive, logical decision-making process that can be

overwhelmed by wishful thinking.

The potential risk of frequent exposure to persuasive portrayals of alcohol

consumption via late-night talk shows, sports, music videos, and prime-time television for

underage drinking is moderated by parental reinforcement and counter-reinforcement of

messages. Interventions need to acknowledge and counter the appeal of desirable and

seemingly realistic alcohol portrayals in the media and alert parents to their potential for

unintended adverse effects (Austin, et al 2000-B).

Media & Sex Related Issues

Brown (2002) found that, media is the prime source for majority of teenagers to learn

about sex and related issues. “When asked where they have learned the most about sex,

younger adolescents (13-15 years old) rank the mass media fourth behind parents, friends,

and schools. Older adolescents (16-17 years old) put friends first, then parents, and then the

media.

More than half of the high school boys and girls in a national survey in 1997 said they

had learned about birth control, contraception, or preventing pregnancy from television;

almost two thirds (63%) of the girls and 40% of the boys said they had learned about these

topics from magazines”. Hence, movies, television and magazines are ways and guides for

teenagers seeking information about sex including other topics.

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A study conducted by L’Engle, et al (2006) compared influences from the

mass media (television, music, movies, magazines) on adolescents’ sexual intentions

and behaviours to other socialization contexts, including family, religion, school, and

peers. This study with a sample of 1011 Black and White teenagers of United States

of America concluded that, adolescents who are exposed to more sexual content in the

media, and who perceive greater support from the media for teen sexual behaviour,

report greater intentions to engage in sexual intercourse and more sexual activity.

Mass media turns out to be an important context for adolescents’ sexual

socialization, and media influences should be considered in research and interventions

with early adolescents to reduce sexual activity.

Strasburger, et al (2010) reviewed the most recent research on the effects of

media on the health and well-being of children and adolescents. Studies of their

review have shown that media can provide information about safe health practices and

can foster social connectedness. “However, recent evidence raises concerns about

media's effects on aggression, sexual behaviour, substance use, disordered eating, and

academic difficulties”. Researchers’ recommended to parents, practitioners, the

media, and policy makers, among others, to look into the ways to increase the benefits

and reduce the harm that media can have for the development of child and

adolescents.

Media advertisement is an area where government/industry regulation should

accept best practices of advertising foods for children, which is currently poorly
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regulated (Nutrition Australia, 2009). Approximately 30% of non-program content during

children's television viewing hours in Australia and New Zealand is for food.

The majority of this food is of questionable nutritional value, as deduced from the

results found in many countries. Such advertising is directed at influencing the food

preferences of children, and it has been shown to be effective. The consistency of food

messages provided through television advertising with current dietary recommendations is

poor. Children need to be protected from commercial influences, particularly those that have

the potential to adversely impact on their present or future health.

A review by Spettigue and Henderson (2004) highlights the need for media literacy

and media activism to help change the current normative body discontent of women in the

Western world. The literature on gambling in youth on the internet was reviewed to explore:

(1) the role of the media in providing a social context for the development of eating disorders,

(2) the role of the media in the etiology of eating disorder pathology, (3) the ways in which

the media is used by patients suffering from eating disorders, and (4) the role that awareness

of the media can have in the treatment and prevention of eating disorders.

This study concluded as “the mass media surrounds us with images of the “thin ideal”

for females, an ideal that has become increasingly thin since the 1950’s and thus increasingly

unrealistic for most girls and women”. The messages and images that focus on the value of

appearances and thinness for females have a significant negative impact on body satisfaction,

weight preoccupation, eating patterns, and the emotional well-being of women in western

culture. Research has demonstrated that the media contributes to the development and

maintenance of eating disorders.

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Prevention and treatment of eating disorders should therefore include media

literacy, activism, and advocacy. “The associations which have been found between

eating disorders and the media, it would be prudent for professionals and the public to

advocate for more positive and self-esteem building messages to be conveyed to

females by the media” (Spettigue & Henderson, 2004).

Non-Core Food Ads

In an extensive global study, it was revealed that, children were exposed to

high volumes of television advertising for unhealthy foods, featuring child-oriented

persuasive techniques (Bridget, et al 2010). To compare television food advertising to

children in several countries a massive collaborative study was conducted by 13

research groups in Australia, Asia, Western Europe, and North and South America.

Each group recorded programming for 2 weekdays and 2 weekend days between 6:00

and 22:00 hours, for the most watched 3 channels by children.

The Researchers classified food advertisements as core (nutrient dense, low in

energy), noncore (high in undesirable nutrients or energy, as defined by dietary

standards), or miscellaneous. They also categorized thematic content (promotional

characters and premiums). Food advertisements composed 11% to 29% of

advertisements. Noncore foods were featured in 53% to 87% of food advertisements,

and the rate of noncore food advertising was higher during children’s peak viewing

times.
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This study significantly observed that, most food advertisements containing

persuasive marketing were for noncore products. Because of the proven connections between

food advertising, preferences, and consumption, findings of the study lend support to calls for

regulation of food advertising during children’s peak viewing times.

Global Pledge

The International Food & Beverage Alliance (IFBA) which comprises top brands

such as Mondelez (Oreo), Nestlé, McDonald’s, Coca-Cola, PepsiCo, Kellogg’s, Mars,

Unilever and Ferrero recently took a global pledge to stop advertising and promotional

activities targeted towards kids below 12 years of age (Collin Furtado, 2014). Representatives

of the eleven member companies signed on a letter delivered to the World Health

Organization Director-General Dr Chan, which outlined a set of enhanced global

commitments with regards to health and wellness strategies they expect to follow in the

coming years.

ASCI’s Regulations on Advertisements

The Advertising Standards Council of India (ASCI) - in partnership with the

government of India - is all set to crack down on advertisers promising slimmer waists,

smarter children and other assorted ways to immortality through claims about products made

in their advertisements (Malay Desai, 2015).

Now, with ASCI’s partnership with the Department of Consumer Affairs (DoCA), the

latter will redirect complaints it receives to ASCI, to avoid duplication of processing. The tie-

up has prioritized six sectors of tracking complaints, and ‘agriculture and food’ is among
 83

them. What this means is that the government will build a coalition of watchdogs to

combat misleading advertisements and consequent unfair trade practices.

One crucial factor is that if ads are found to be misleading with exaggerated

claims in packaging or communication and proven to be fraudulent, the penalty is just

Rs 10 lakh. This pittance of a penalty isn’t discouragement enough for big advertisers

to stop making outwardly promises on their packaging. The penalty must be raised if

the brand’s sales are national and run into crores of rupees (Malay Desai, 2015).
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