Introduction

Childhood obesity is one of the most challenging public health issues that can lead to the early onset of adult Non-Communicable Diseases (NCDs).^1-3 In 2016, almost 40 million children under 5 years of age and 340 million children and adolescents aged 5-19 years were overweight or obese throughout the world.⁴ Iran, as a developing country, is also dealing with this health problem.^{5, 6} The prevalence of overweight and obesity  were reported  9% and 8%, respectively, in Iranian children under 5 years of age,⁷ and  11% and 9% in those aged 7–18 years.⁸ The CASPIAN-IV (2011-2012) and CASPIAN-V (2015) national school based surveys revealed an association between junk foods’ consumption and excess weight in Iranian children.^{9, 10} According to CASPIAN-IV, 34%, 20%, 13%, and 2.9% of school-age students (6-18 years) had daily consumption of sweets, sweetened beverages, salty snacks, and fast foods, respectively.¹¹ Based on CASPIAN-V, 22%, 3.1%, 6.4% and 11% and of adolescent girls consumed sweets, sweetened beverages, salty snacks, fast foods respectively on a daily basis.¹² Besides, a systematic review on Iranian children revealed that sugars and sweets had the highest consumption compared with other processed foods.¹³

Pediatric obesity has been linked to exposure to marketing of unhealthy food items, and easy access to energy dense food items.^{14, 15} Children often have limited ability to control on food environment around them and living in unhealthy food environments can easily encourage them to consume low nutritional value  food items.¹⁶ Therefore, they have become a main target market for the food industry^{17, 18} and are the largest consumers of these products in Low and Middle Income Countries (LMIC).¹⁹ Children may be affected by persuasive messages conveyed through food marketing, since their cognitive development is relatively not completed.²⁰ They may even interpret advertising as factual or helpful information to choose up-to-dated products available in stores.²¹ Therefore, exploitation of children’s cognitive limitations in marketing pose ethical concerns.²² Food industries, through  applying attractive techniques such as music, visual effects, animation, gif advertising, and storytelling, influence children and adolescents’ choices.²³ Findings of systematic reviews reveal that children s’ food consumption, preferences, and attitudes can be influenced by the surrounding food advertising.^24-26

It is well accepted that controlling and regulating food marketing to children is a crucial prevention strategy for managing obesity in this age group.^{15, 27-29} In 2010, the World Health Organization (WHO) established recommendations for food marketing to children to formulate new policies and/or reinforce existing policies to decrease the impact of marketing of low nutritional value food products on children.³⁰ One of the recommended actions of the WHO Commission on Ending Childhood Obesity focused on establishing and implementing effective measures to assess the impact of existing related legislations, guidelines and regulations, and to design mechanisms to strengthen their effectiveness.²⁹ Despite WHO’s recommendations, implementation remained a challenge, with only 8% of LMIC countries regulating the food marketing to children.³¹ Iran’s health system has some actions to ban  marketing of  unhealthy food products with high levels of sugar, saturated and trans fats, and salt .³² However, despite the various attempts in this regard, Iranian’s pediatric population has not been addressed properly and explicitly in these policies and actions. Since, providing strong evidence is necessary for supporting the policies making and decisions in this regard,³³ this scoping review aimed to explore existing policy regulations relevant to food marketing in children and to assess evidence on food marketing channels targeting children in Iran, evaluating their nature, the products they promote and their effect on children.

Materials and Methods

The Arksey and O’Malley methodological framework³⁴ was applied to conduct this scoping review through the following steps:

Identifying the Research Question

The research questions of this review include the following:

• What promotional channels are used by food marketers to reach Iranian children?
• What type of food products are highly promoted to Iranian children?
• What are the most frequently used advertising techniques by food marketers to target children?
• What do we know about the impact of food marketing on Iranian children?
• Is there any violation of food regulations in Iran?
• What are food advertising regulations for children in Iran?

Identifying Relevant Studies                     

We searched English and Persian (Farsi) articles, reports, dissertations, and documents from international electronic databases, including Web of Science, PubMed, Scopus, Google scholar, and the Iranian databases, including Iranian Research Institute for Information Science and Technology (www.Irandoc.ac.ir), Scientific Information Database (SID: www.sid.ir), Magiran (www.magiran.com), and Civilica (www.civilica.com). The search was performed using the following keywords: market*, advertis*, tv, televis*, media, magaz*, commerc*, regula*, polic*, govern*, bann*, barrier*, food*, nut*, diet*, beverag*, unhealth*, health*, child*, kids, young*, youth*, adolec*, teenag*, school*, and Iran*. Relevant journal articles, congress/conference articles, dissertations, reports, or policy briefs published from January 1978 to December 2020 were included. Hand searching among the included articles’ references and google engine were performed to identify additional data sources.

Study Selection            

First, duplicate studies were identified by EndNote™ (version X7) software and removed. Studies were screened by reviewing the titles and abstracts. We included all studies/documents related to food marketing in Iran, focused on 2-17-year-old children. Since there is no food marketing regulation in Iran with direct focus on children, we included all related regulations to explore how they have addressed children. The following documents were excluded from this review: conference and poster abstracts, letters, general reviews, and practice guideline papers. In addition, studies that did not consider children were left out for the review. If sufficient information was not available from the title and abstract, the full text was read. The full text of the selected studies were then read to determine if they were eligible. The selection process was performed independently by two authors (MA and NO). Any disagreement between them was resolved by discussion until a consensus was reached.

Charting the Data

The studies and documents were categorized into three groups based on their content: 1) Studies on characteristics of food advertisements targeted at children in Iran, 2) Studies on the effect of food marketing on children in Iran, and 3) food marketing Regulations on (with reference to children) in Iran. The following information was extracted from each study: author, publication year, target group, media used for marketing, appeals/techniques for marketing, food(s) advertised, report of violation of Iran’s regulations, objective(s) of the study, place of study, effect(s) of marketing on children. Title of regulation, date of publication/approval, target group and content were extracted from regulations.

Collating, Summarizing, and Reporting Results

The relevant content of included studies and documents were extracted in duplicates by three authors (MA, NO and MB) and entered into data sheets. The final report was prepared according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) guideline.³⁵

Results

A total of 23 documents, including nine peer-reviewed articles, four dissertations, two project reports, one full-text article from a congress proceeding and seven government publications/documents met eligibility criteria and were included in this review (Figure 1).

Figure 1: PRISMA Flow Diagram for the Study Selection Process. Click here to view Figure

Characteristics of Food Advertisements Targeted at Children

Eight studies identified reported on food advertisements in the country.^36-43 Characteristics of these studies are presented in Table 1. All of the studies are on advertisements targeted at children and/or adolescents.^36-43 Seven out of eight studies had focused merely on television and one on children’s magazines.⁴² The main type(s) of foods advertised with reference to children included: Salty snacks, e.g. cheese puffs,^{36-38, 41, 43} chips,^{38, 41} cheese fish snacks, puffed corn,³⁸ as well as sweet snacks such as ice creams,^{37, 38, 43} cakes/biscuits/cookies and candies,^{36, 37, 41} beverages/drinks/soft drinks/fruit juices,^{36, 37, 40, 41} dried fruits and fruit rolls,^{40, 42} and chocolates.^{37, 43} The majority were foods with poor nutritional values.^{36-38, 41, 43} Most reported violation of food marketing regulations in the studied documents included using an obese child/actor, either as the consumer or presenter of the product(s).^{36-38, 43} In one study, it was shown that half of the nutritional messages conveyed through the advertisements were scientifically untrue or misleading.³⁶ Another study reported that more than one quarter of Islamic Republic of Iran Broadcasting (IRIB)’s advertisements were “misleading”³⁶ and the main value(s) conveyed to the audience who were mainly children and adolescents, were negative values, e.g. aggressiveness, greed, etc..³⁸ Marketing techniques that were commonly used in advertising food products targeted at children in Iran were as follows:

Appeals

The most frequent appeals used in food ads included: “stimulation of hunger/thirst,^36-40 “attributed quality/high quality”,^{36, 38, 40} “stimulating curiosity”,^{37, 39} “attention to health and nutrition”,^36-39 “entertainment/laughter/ happiness/emotional attractiveness”,^37-39 “novelty”,^{37, 40}“highlighting and exaggeration”,^{39, 43} and appeals namely “scientific credit”, “energy boosting”, “energetic”, “superiority over other products”, “exceptional”, “must be remembered”, “miraculous function”, “magic”, “passion for the product”, “appealing to cartoon characters” and “dream world”. Appeals aimed to stimulate and provoke emotions and influence children’s subconscious minds to convey their message, and to attract the attention and gain trust of their young audience.³⁸

Messages/Claims

The message that was most frequently used to advert a food product was “taste”,^{36, 37, 40} followed by “quality”,^{36, 40} “delight”,³⁷ “relaxing”³⁷ and “novelty”.^{37, 40} Most of the food advertisements expressed at least one nutritional message (either explicitly or implicitly).^{36, 37, 40} Some had gone far enough to describe the consumption of the food advertised as a factor to fulfill ones dreams.³⁸

Techniques to Convey Message

Simultaneous application of language and picture for emphasis and depiction of famous cartoon characters (e.g. Batman) and using animation or a combination of animations, computer, and live action were common techniques used for conveying message(s).^{37, 38} Using prose, verse, or a combination of both, or narration style without text were common;³⁹ however, in some food commercials, messages were silent and exclusively pictorial.⁴⁰

Music

Rhythmic music was used in most advertisements.^36-38 Rhythm of music reported were larghetto,³⁹ happy and regular.⁴³

Setting/Location

The most frequent locations in food advertisements were park, garden, seaside, amusement places,³⁶ and /or home environment.^{37, 39}

Social/Cultural values

Social values depicted in advertisements included family connectedness, security and tranquility of friendship, work and physical activity, ethnic, local and/or national values. Cultural symbols were depicted in one content analysis.³⁹

Narrator/Deliverer/Presenter

In many cases men or boys presenters were featured in advertisements.³⁷  Presenting of thirty percent of the food ads were done by individuals who were eating the products while presenting.⁴⁰ The presenters in 43% of the advertisements were alone, in 50% were accompanied by their peers and only in 7% were with their parents.³⁶

Table 1: Studies on Characteristics of Food Marketing to Children in Iran.

NA: Not applicable

Effect(s) of Food Marketing on Children

Ten studies assessed the food marketing effect(s) of on children in Iran.^{36, 40, 44-51} Table 2 presents foremost characteristics of the included studies in this category. The main approaches used to evaluate the effect of food advertisement on Iranian children were through asking children to recall any advertisements seen and liked, interviewing the child and/or caregiver assessing  the number of times the child had requested the advertised food product(s),^{36, 40, 45} and evaluating the child’s food intake.^{44-49, 51} A significant relationship was found between food advertisements recalled by children and the number of times those foods were requested from their parents.⁴⁵ Also, the numbers of time advertisements watched and the frequency of consumption of the advertised food product were significantly associated.⁴⁸ The most common commercial food items recalled and/or consumed by children and adolescents were for chips and cheese puffs, which were also the most widely advertised food products.^{48, 52}

Table 2: Studies on the effect of Food Marketing Targeted at Children in Iran.

Regulations on Food Marketing to Children in Iran

Table 3 presents the list of regulations on food marketing in Iran, their approval date, target group(s), and main content. All of regulations focused on food marketing on TV and radio and targeted the public.

Table 3: Regulations on Food Marketing in Iran.

In Iran, soft drinks were the first food products which advertisements were banned in 2004.⁶⁰ Later, article 37 in the 5th national development plan (2011-2016), banned the advertising of health-threatening goods and services,⁵⁶ and the Ministry of Health became responsible for determining and updating the list of health-threatening products on an annual basis. Since then, this list has been updated and expanded and now includes 19 unhealthy food products , e.g. sausages, ham, processed pizza cheese, chips, edible ice products, toffee and candy.⁵⁹ After 2016, this Article was adopted as a permanent section within the development plans.⁵⁸

Despite these efforts, very few rules in Iran have directly or indirectly referred to what can be advertised to children and on the methodology of promotion. For instance, note F, article 7 of the Law on “Protection of Consumers’ Rights”⁵⁴ has prohibited featuring of children in the advertisements of goods. According to this law, untruth advertising that misleads the consumers (which can include children) has been forbidden. The only policy document that has specifically focused on food product advertisements to children is “The Set of Production Criteria for Television and Radio Advertising”⁵⁷. According to this bylaw, food products cannot be advertised during children’s programs, and the use of obese children or portraying individuals while overeating or eating a food product greedily in food advertising is banned. Several violations of this bylaw on television have been reported,⁵⁷ which can be due to the fact that  this document is just an internal bylaw within the Iran department of Broadcasting commercial and has no legal validity.⁶¹

On the other hand, the public campaigns are bottom-up strategies that can be used for protecting children against exposure to unhealthy product advertisements.³² In 2019, the virtual campaign by Iranian parents through social networks on removing ads from the Iran in a children’s TV channel “Pooya” led to restricting broadcasting of advertisements on it.⁶² In addition to the national television broadcasting, children can be affected by other media platforms, e.g., social media, satellites, webpages, and smartphone applications. Advertisements that are broadcasted on satellite networks over which the government has no control have been reported as a challenge faced in Iran.⁶³

Controlling advertisements within the child care and education facilities was also identified in the included studies. In Iran, any marketing means and advertisement in kindergartens, schools, and spaces specified for children are banned based on note Ch, article 12 in “the Regulation on the Establishment and Monitoring of the Work and Activity of Advertising Centers”, and article 9 of the Policies and Regulations Governing on Environmental Advertising.^{53, 55} Although these are general rules that apply to all types of goods and products, they have also been used for food and beverage products. However, studies in different provinces, including Kerman and Tabriz, and Tehran reported the presence of advertisement of sweets, candies, fast foods, soft drinks, fast foods restaurant and supermarkets within the schools ^{64, 65}, the presence of food products advertisements in the canteens through the promotional facilities and/or presence of equipment donated by food industries.⁶⁶ Finally, poor monitoring scheme to control food advertising status was identified as an additional challenge in implementing the advertising restriction policy.^{32, 67}

Discussion

This scoping review aimed to introduce the existing policies and regulation on food and beverages marketing targeted at children in Iran and to provide evidence on the status and effects of food and beverage marketing on children in the country. Regulating and controlling advertisements in the mass media and educational facilities in Iran has been enforced for the last 30 years. However, concern on marketing unhealthy food products through clear regulations was first documented in 2011.³² Based on the present review, almost all the existing food marketing regulations in Iran are directed at the general public with no or very little reference to children.^32,61 There are few regulations on advertising directed at children, e.g., forbiddance of featuring children ⁵⁴ or displaying obese children in the products advertisements.⁵⁷ However, most of these regulations have no legal validity and their implementation is not well supported.⁶¹

Based on the present review, a high proportion of the existing food advertisements in Iran, specifically those targeted at children, are promoting unhealthy or nutritionally questionable food products. The most frequently advertised foods and beverages reported were those with added sugar, namely beverages, cakes, and chocolates and salty snacks e.g. cheese puffs and chips; the majority of which exceed the WHO Regional Office for Eastern Mediterranean region nutrient profiling model’s threshold criteria for energy, sugar, fat, and/or sodium.⁶⁸ Similar findings have been reported in other countries.^69-71

Emotional and rational appeals were the most frequently used techniques to encourage young customers to buy the advertised food products. The proportion of emotional appeals was higher than logical appeals, probably due to the fact that children are more susceptible to the emotional contents of the advertisements, as also reported by other researchers.^71-73 The message that was mostly used to promote food products was “taste” implying that food marketers recognize it as a driving motivation for food choices in children, compared to nutrition or health related concerns.

Overall, the reviewed studies indicated that exposure to food advertising can influence attitude, preference and dietary practices of children and have an effect on their food choice and consumption.^{15, 36, 40, 44-51, 74} There was relatively clear evidence that exposure to food advertisements increase energy intake in children and this effect can be greater in the obese children.⁷⁵ In the present review, TV was the main media studied with regard to children food advertisements and the time in recording the advertisements was mainly when children programs were broadcasted, because of larger number of child viewers^76-81. However, studies in  Slovenia⁸⁰ and the UK⁸² revealed that when restriction of ads was implemented during children’s programmes only, the frequency of advertisements for not permitted foods increased in the prime-time hours. Therefore, in order to efficiently protect children, food marketing restriction should be applied not only during children’s programs, but during peak child viewing times as well.⁸⁰ We did not find any studies on prime time advertisements directed at children in Iran.

Despite a number of clear but implicit references in the existing laws and regulations on banning persuasive marketing techniques that involves children or their favorite characters, ^{54, 57} review of studies on the characteristics of food advertisements in Iran, indicated the application of several unauthorized techniques to persuade and attract children or young customers. ^36-43

The slow progress in regulating and controlling unhealthy food marketing targeted at children by the government is not limited to Iran and has been raised as an international issue.^{24, 83} Based on a recent review of food marketing policies in 22 countries by Kelly et al., the current regulatory restrictions have not been able to create a more desirable food advertising environment for children compared to countries that did not apply such regulations.⁸⁴ In order to overcome weaknesses of these policies, some governments have applied multi-sector legal marketing structures to better regulate the unhealthy foods advertising and marketing for children. These policies involve all key stakeholders in the child-health advocacy, consider incentives for industry and the private sector to promote healthy food products and create healthy food environments. For instance, Chile adopted in 2015 the most comprehensive marketing restriction law in the world to date.⁸⁵ This law prohibits the marketing and advertising of foods and beverages that are high in sugar, sodium, saturated fats, and energy to children and adolescents aged 14 and younger. This regulation, forbade unhealthy food sale and promotion at schools,⁸⁶ as well as persuasive marketing strategies children advertisements on TV.⁸⁷

To improve the impact of the enacted policies, efforts should be made to monitor all forms of food marketing in broadcast media, social media, and digital marketing platforms.^{88, 89} While the existing restrictive laws on food marketing to children through the TV and radio stations in Iran are poorly implemented, there is also no controlling mechanism on food advertisements broadcasted through satellite TV stations, webpages, smartphone applications, magazines and newspapers. Although all types of health-threatening advertisements in all media are banned by newly-developed laws for the general population,³² there is a need to define exact platforms of marketing limitations with a focus on children.⁸⁰  Furthermore, the food labelling policy of food products in Iran has no clear and direct reference on marketing schemes used on the food labels and packages that address children.⁹⁰

Regulating marketing of unhealthy food items can provide an opportunity for the food industry to enhance its products’ quality. For example, in South Korea, the prohibition of unhealthy food advertising directed at children on TV motivated about 50% of food companies to reformulate their food products.⁹¹ Governmental policies should address strategies to increase social responsibility initiatives of the food industry.⁹² Kelly et. al. indicated that applying voluntary practice codes food industry has been ineffective for responsible food marketing targeted at children .⁸⁴ Surprisingly, they showed higher rates of unhealthy foods products ads in the countries with industry self‐regulatory codes for food marketing to children.⁸⁴

Constant monitoring and evaluation of food marketing is needed to assay policy implementation trends and their impact in order to propose any essential modifications. Development of vigorous scientific criteria are also needed to objectively determine food restrictions for marketing to children. In this regard, using a standardized protocol such as  INFORMAS protocol⁹³ and international or regional tools, e.g., the Nutrient Profile model of the WHO Regional Office,⁶⁸ may be beneficial. Table 4 presents a summary of recommendations considering the current status of food marketing policies in Iran with respect to WHO recommendations.

Table 4: Current Status of Food Marketing Policies for Children in Iran Compared to the WHO Recommendations⁹⁴, Recommendations for their Improvement.

Based on our knowledge, this study is the first scoping review that presents characteristics and effects of food advertisements targeted at children in Iran and reviews the existing regulations on food marketing targeted at children and adolescents in this country. The findings of this study provide scientific evidence for policymakers to develop and improve food marketing policies for children. There are several limitations in this scoping review. The quality of included studies and literature was not evaluated. Thus, intrinsic quality of studies have been ignored. Besides, publication bias may also affect the study results (due to unpublished results of food marketing assessment on children).

Conclusions

This scoping review provides evidence and recommendation(s) to the policy-makers and practitioners about controlling children’s exposure to unhealthy food advertisements. Through this review, the current status of food marketing in Iran and shortcomings of existing regulations were presented and discussed as a case study. The need for regulations with clear reference to children and focusing on systematic monitoring of effective implementation was emphasized. Besides, key factors in the policy success, including improving inter-sectoral collaboration (between the health sector and the media, advertisement centers, food producers, and consumers) and making food industries more socially accountable, particularly for children s’ health were emphasized.

Acknowledgments

The authors gratefully acknowledge support from the WHO office in the Eastern Mediterranean region. We also thank Jana Jabbour for the English editing of the manuscript.

Funding Sources

This research received no external funding.

Conflict of Interest

The authors declared no potential conflicts of interest in regards to the research, authorship and publication of this article.

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