Children’s Reaction to Depictions of Healthy Foods in Fast-Food Television Advertisements

Importance  Since 2009, quick-service restaurant chains, or fast-food companies, have agreed to depict healthy foods in their advertising targeted at children.

Objective  To determine how children interpreted depictions of milk and apples in television advertisements for children’s meals by McDonald’s and Burger King (BK) restaurants.

Design, Setting, and Participants  Descriptive qualitative study in a rural pediatric practice setting in Northern New England. A convenience sample of 99 children (age range, 3-7 years) was shown depictions of healthy foods in fast-food advertisements that aired from July 1, 2010, through June 30, 2011. The images from McDonald’s and BK showed milk and apples. Children were asked what they saw and not prompted to respond specifically to any aspect of the images.

Exposure  Two still images drawn from advertisements for healthy meals at McDonald’s and BK.

Main Outcomes and Measures  Children’s responses were independently content coded to food category by 2 researchers.

Results  Among the 99 children participating, only 51 (52%) and 69 (70%) correctly identified milk from the McDonald’s and BK images, respectively, with a significantly greater percentage correct (P = .02 for both) among older children. The children’s recall of apples was significantly different by restaurant, with 79 (80%) mentioning apples when describing the McDonald’s image and only 10 (10%) for the BK image (P < .001). The percentage correct was not associated with age in either case. Conversely, although french fries were not featured in either image, 80 children (81%) recalled french fries after viewing the BK advertisement.

Conclusions and Relevance  Of the 4 healthy food images, only depiction of apples by McDonald’s was communicated adequately to the target audience. Representations of milk were inadequately communicated to preliterate children. Televised depictions of apple slices by BK misled the children in this study, although no action was taken by government or self-regulatory bodies.

In 2009, US quick-service restaurant chains (ie, fast-food restaurants) spent $154 million on television marketing to children aged 2 to 11 years.¹ Exposure to food advertisements alters eating choices and behaviors,² and obese children may be more susceptible to food advertising.^3,4 Food marketing must not be false, deceptive, or unfair under applicable federal and state laws. The industry-sponsored Children’s Advertising Review Unit (CARU), administered by the Council of Better Business Bureaus, also oversees marketing guidelines for advertising aimed at children. To ensure that advertising is not deceptive, CARU guidelines⁵ state that “The ‘net impression’ of the entire advertisement…must not be misleading to the children to whom it is directed, and whether an advertisement leaves a misleading impression should be determined by assessing how reasonable children in the intended audience would interpret the message.”

Since 2006, industry has also sponsored the Children’s Food and Beverage Advertising Initiative, also administered by the Council of Better Business Bureaus, whereby companies pledge that food advertising to children will feature only foods that meet certain nutritional criteria.⁶ In 2010, McDonald’s⁷ and Burger King (BK)⁸ began to advertise milk and apple slices as healthy food options. We reviewed all fast-food advertisements aired by McDonald’s and BK from July 1, 2010, through June 30, 2011, and were concerned with the depiction of apple slices (Fresh Apple Fries) by BK. Whereas the product was sold packaged in a cellophane bag, children’s BK advertisements depicted the apple slices in a container that resembled one used for french fries. The aim of this descriptive, qualitative study is to describe how children interpreted depictions of healthy foods in television advertisements by McDonald’s and BK aired during the study period.

A convenience sample of children aged 3 to 7 years was recruited by telephone from an academic general pediatrics clinic in rural New Hampshire; health insurance status was used to enrich the sample to about 40% of participants with Medicaid coverage. We targeted the age range to represent the ages of children to whom these companies target their meals. The participation rate was 46.1%, giving us a final sample of 99 children who viewed each advertisement. The study was approved by the Committee for the Protection of Human Subjects at Dartmouth. Written informed consent was obtained from the parents.

We obtained all fast-food advertisements from McDonald’s and BK that aired nationally during the study period (n = 258). These advertisements were divided by company and reviewed to determine whether they advertised children’s meals (McDonald’s Happy Meals or BK Kids’ Meals). Still images were used because the food imagery is fleeting in real time. We captured the images used in the study (Figure 1 and Figure 2) from 2 of the 62 McDonald’s and 30 BK children’s advertisements at broadcast resolution. The images represent how the healthy food products were typically depicted during the study period.

Children were shown each of the images depicted in Figures 1 and 2 in sequence and asked, “What do you see in this picture?” They were prompted to discuss until they had nothing more to say about the picture. They were not prompted to comment specifically on any of the food items if they failed to mention one of them. Their responses were videotaped, and the audio portion of the tape was transcribed. The words in the transcription were coded into product categories for each of the healthy food products (eg, apples or milk) and for any mention of french fries. Transcriptions were categorized by 2 reviewers (including A.M.B.), the responses were compared, and any disagreement was resolved by a third reviewer (J.D.S.).

For each food item (apples, milk, or french fries/fries), any recall was defined as 1 or more item-specific words used when describing the advertisement stills. We used the McNemar test to compare the likelihood of any recall of each item by restaurant type; the McNemar test considers the agreement across 2 measures on the same participant (ie, any recall per item across restaurants). The proportion of children with any recall of apples or milk was also computed stratified by age. Least squares linear regression models were used to test for a linear trend in the rates of any recall by increasing age; Wald test P values of less than .10 were considered evidence of a significant trend.

Table 1 gives the characteristics of the children in the study sample. We included a nearly equal number of boys and girls, and 89% of the sample was non-Hispanic white. More than one-third of the sample had Medicaid coverage, 28% lived in rental housing, and 35% were from families with annual incomes of less than $50 000. All but 17% of the children’s mothers attained educational levels greater than a high school diploma.

Table 2 shows children’s responses to the food items depicted in the images. Images for each restaurant contained milk (Figures 1 and 2), yet only 52% of the children made reference to milk when describing the McDonald’s image, and 70% mentioned milk when describing the BK image (McNemar test, P = .004). Each image also contained apples; however, the children’s recall of apples was significantly different by restaurant. Although 80% of the children mentioned apples when describing the McDonald’s image, only 10% of children mentioned apples when describing the BK image (McNemar test, P < .001). Conversely, although french fries were not featured in either image, 81% of the children recalled french fries after viewing the BK image, a significantly higher level of recall compared with the McDonald’s image (McNemar test, P < .001).

Table 3 presents the rates of recall for milk and apples for each restaurant by age. Older children were significantly more likely to have any recall of milk for McDonald’s and BK (for both, P = .02 for linear trend). With respect to any recall of apples, the test of trend did not reach statistical significance. Similarly, any recall of french fries after seeing the BK image was consistently high for all ages, with no significant linear trend (data not shown; P = .25).

Qualitative data illustrated a higher level of confusion among children when interpreting the BK image, specifically with respect to the presentation of the apples. The following exchange is an example:

Child: And I see some…are those apple slices?

Researcher: I can’t tell you…you just have to say what you think they are.

Child: I think they’re french fries.

The study is the first, to our knowledge, to assess actual children’s perceptions of fast-food advertising depictions against self-regulatory guidelines governing how members market products (CARU) and the types of food they market to children (Children’s Food and Beverage Advertising Initiative). McDonald’s and BK had pledged via the Children’s Food and Beverage Advertising Initiative to market milk and apples as healthier options to children in their advertising during the period advertisement images were sampled, and both companies briefly depicted images of these healthy foods in all their television advertisements. Of the 4 healthy food depictions, only the presentation of apple slices by McDonald’s was adequate because the image was recognized as an apple product by most of the target audience, regardless of age. The other 3 presentations represented poor communication to the target audience or outright deception.

In determining deception under CARU, the advertiser’s intent is not dispositive. The important question is whether the “net impression of the entire advertisement”⁵ appears deceptive and whether children are deceived. Apple slices in the BK image were presented deceptively in the shape of french fries, packaged in a french fry container, and labeled Fresh Apple Fries. Children’s confusion of apples with french fries in the BK television image, which applied across all ages, could be considered deceptive under industry standards.

Although we are not surprised that many children failed to recall apples after viewing this image, this apparent deception was not addressed by the CARU oversight process (CARU did call on BK to make other changes to its advertising during the study period; that action addressed the company’s toy promotion practices and not the misleading depiction of its apple product⁹). By 2012, Burger King was selling Apple Slices rather than Fresh Apple Fries.

The presentation of milk merits a somewhat different interpretation. Regarding the presentation, both containers displayed the word milk, so judging the image as deceptive would be difficult. However, many children (almost half for the McDonald’s depiction) failed to recognize the beverage as milk. In comparing companies, not surprisingly, more children mentioned milk in the BK advertisements because the container pictured is white, like milk itself, whereas the container is blue with a clown picture in the McDonald’s advertisement. This finding brings up one consideration: make the container look like the product. Moreover, the fact that more school-aged children, who can read, correctly identified the drink suggests that the presentation of the product did not consider the younger segment of the target population adequately. Companies, their advertising firms, and regulators of the Council of Better Business Bureaus need to keep in mind the extreme youth of this market segment, with many in the target population unable to read even simple words like milk. Food companies should emphasize the words milk and apples in the audio track of all television advertisements to make the visual reference explicit to nonreaders. Future evaluations of Children’s Food and Beverage Advertising Initiative pledge compliance should take into consideration not just whether advertisements contain images of foods meeting specified nutrition criteria but also whether or not the targeted children can identify them as such. Pediatric groups should be vocal about their criticism of examples of lax oversight by the Council of Better Business Bureaus on children’s food advertising.

A second consideration for criticism is the networks that air food advertisements to children. About one-third of network programming through cable involves advertising content, and much of it is for food products. A 2008 study¹⁰ found that food advertising accounted for about half of the commercial messages on children’s programs and that most of these advertisements were for high-calorie foods with low levels of nutrients. In response to public pressure to constrain food advertising aimed at children, some—although not all—channels have altered their policies. In 2012, Disney announced a set of nutritional standards for all products advertised on its channels, radio stations, and web sites.¹¹ One year later, in response to a request from 4 US senators to adopt similar standards, Nickelodeon, a Viacom-owned network, refused, stating, “We believe strongly that we must leave the science of nutrition to the experts.”¹² Pediatricians could contribute to market pressure on networks by guiding parents away from networks that fail to take responsibility for advertising content. With the V-chip and other current options, parents easily can block networks, like Nickelodeon, that refuse to comply with minimal nutritional standards for their food advertising.

Finally, the case can be made that all advertising aimed at young children is misleading because they are not developmentally capable of understanding what advertising is and what it aims to persuade them to do.¹³ Pediatricians’ developmental expertise gives them a deep understanding of this argument. Given that, pediatricians may wish to have a discussion with parents about options for avoiding advertising exposure during health maintenance visits. Parents who wish to restrict all access to food advertising on television may eliminate all exposure to television advertising. Pediatricians should be familiar with these alternatives and how to access them. A good way to help ensure that they do would be to develop a practical resource through the American Academy of Pediatrics based on its existing policy on children, adolescents, and advertising.¹⁴ Finally, this diversity of commercial-free offerings also represents an opportunity for media researchers to conduct randomized trials to assess the impact of eliminating commercial content from children’s entertainment programming. Similar trials have been successfully completed to test other alterations in programming content,¹⁵ demonstrating the feasibility of such research.

One important feature of this study is its simplicity. We assessed children’s net recall of fast-food television advertisements by using representative images selected from a current advertising pool for 2 companies that frequently advertise fast food to children. Children viewed each advertising image, which allowed us to make appropriate statistical comparisons between the interpretations of each image. Further, we allowed children to describe each image on their own and did not bias their response by asking them a series of predefined questions (eg, Were apples presented in that image?). Simplicity limits the scope of the study; we did not assess multiple images, which would have ensured representativeness and may have provided insight into how the placement of each item (eg, apples in the center of the image vs apples in the right corner) might affect recall. We also did not order the image presentation randomly (order effects could explain why a higher proportion of children identify the milk correctly on the BK image, which was presented after the McDonald’s image) and did not include any audio tracks for children to listen to. However, an evaluation of 92 contemporary children’s fast-food advertisements from this period¹⁶ found that apples were mentioned in the audio track only 10% of the time and milk only 1% of the time.

This study assessed whether television advertisements by McDonald’s and BK seeking to depict healthy foods were interpreted correctly by members of the targeted audience. The study found that children frequently misinterpreted the image of apples in the BK image as french fries, suggesting that this advertisement would be considered deceptive under industry standards. Depictions of milk during the study period were also inadequate. The industry’s self-regulatory regime failed to take corrective action in the form of a recommendation or a complaint against either advertiser. Continued failures at self-regulation would suggest the need for government oversight for children’s advertising or legal action under consumer protection law.

Accepted for Publication: November 20, 2013.

Corresponding Author: James D. Sargent, MD, Department of Pediatrics, Geisel School of Medicine at Dartmouth, One Medical Center Dr, Lebanon, NH 03756 (james.d.sargent@dartmouth.edu).

Published Online: March 31, 2014. doi:10.1001/jamapediatrics.2014.140.

Author Contributions: Dr Sargent had full access to all the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Study concept and design: Bernhardt, Wilking, Gottlieb, Sargent.

Acquisition, analysis, or interpretation of data: Bernhardt, Gottlieb, Emond, Sargent.

Drafting of the manuscript: Wilking, Sargent.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: Emond, Sargent.

Obtained funding: Bernhardt, Sargent.

Administrative, technical, or material support: Bernhardt.

Study supervision: Sargent.

Legal and policy interpretation: Wilking, Gottlieb.

Manuscript development: Gottlieb.

Conflict of Interest Disclosures: None reported.

Funding/Support: This study was supported by grant 69552 from the Robert Wood Johnson Healthy Eating Research Program and by the Prouty Scholar’s Program at the Norris Cotton Cancer Center.

Role of the Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.