Junk food, soft drinks and sweets

Junk food, soft drinks and sweets - assessing the marketing effects on 3-13 year old children in India

Bachelor Thesis, Stockholm School of Economics

May 2011

Supervisor: Susanne Sweet

Authors: Leilei Tong 21145, Peter Ueda, 21141

Key search words:

Food marketing, children, India

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Abstract

Background: In the light of the ongoing epidemic of childhood obesity and chronic diseases globally,

marketing of energy dense foods and drinks towards children has been recognized as an important

health risk. The aim of this study was to examine the effects and extent of exposure to marketing of

such diets among 3 to 13 year old Indian children from different socioeconomic backgrounds. As an

indicator for marketing exposure children’s ability to recognize brand logos for high sugar high fat

products was used. Correlations between logo recognition and children’s food related behavior and

Body Mass Index were also examined.

Methods: 306 child-parent pairs were recruited at a pediatric clinic in southeastern India. A test

including 18 brand logos assessed the children’s brand logo recognition ability. Information about

the children’s food preferences, nutritional knowledge, weight and height was obtained. A parental

questionnaire collected information on children’s socioeconomic characteristics, eating and

pestering (influencing of parents’ purchase decisions) behaviors.

Results: The children from all socioeconomic groups demonstrated high rates of recognition – up to

80% - for many logos. Recognition rates increased with age and socioeconomic level. Poor dietary

practices and frequent pestering behaviors in purchase situations were reported. Relationships

were not found between logo recognition and food preferences, nutritional knowledge and

pestering behavior. Logo recognition level was associated with higher BMI.

Conclusions: Correlation between brand logo recognition and BMI, the frequent pestering behavior

and poor dietary habits of the children and the generally high brand awareness in all age and

socioeconomic groups implicate problematic aspects of marketing towards children in India. The

findings could contribute to the debate on the role of food marketing with respect to the increasing

rates of child obesity and chronic diseases in the country.

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Table of Contents

1 Introduction ....................................................................................................................................................................... 4

1.1 Background .............................................................................................................................................................. 5

1.2 Overall aim ............................................................................................................................................................... 8

1.3 Previous research .................................................................................................................................................. 8

1.4 Objectives ............................................................................................................................................................... 11

2 Theory ............................................................................................................................................................................... 12

2.1 Logo recognition as an indicator of marketing exposure .................................................................. 12

2.2 Indicators of socioeconomic status ............................................................................................................. 12

2.3 Preference and knowledge tests .................................................................................................................. 13

2.4 Assessing eating behavior and healthiness of diet ............................................................................... 14

2.5 Assessing pestering behavior ........................................................................................................................ 14

2.6 Body Mass Index ................................................................................................................................................. 14

3 Methodology ................................................................................................................................................................... 15

3.1 Recruitment and inclusion criteria ............................................................................................................. 15

3.2 Testing equipment ............................................................................................................................................. 15

3.3 Selection of logos ................................................................................................................................................ 15

3.4 Logo test ................................................................................................................................................................. 16

3.5 Preference and nutritional knowledge test ............................................................................................. 16

3.6 Parental questionnaire ..................................................................................................................................... 17

3.7 Study procedure .................................................................................................................................................. 18

3.8 Variables ................................................................................................................................................................. 18

3.9 Data analyses ........................................................................................................................................................ 19

4 Results ............................................................................................................................................................................... 20

5 Discussion ........................................................................................................................................................................ 25

References ................................................................................................................................................................................. 28

3

Acknowledgements

We would like to express our deep gratitude to the following persons:

All children and parents who kindly and patiently participated in this study.

Mr Viedma for your top class programming, self-deprecating humor and issue- and caffeine driven

workaholism.

Professor Sujith Chandy at the Christian Medical College for kindly welcoming us in Vellore and for

all the assistance during the field work.

Ms Rachel, Ms Vincy and Madame for your indispensable translation efforts during the field work.

Professor Cecilia Stålsby-Lundborg at Karolinska Institutet for the help with organizing this study.

Susanne Sweet for supervising our thesis and giving feedback throughout the process.

Swapan Deep at the Christian Medical College, Vellore for valuable input and information about the

local settings at the study site.

Everyone in the Pharmacology Office at CMC Vellore for your kind assistance.

The bookbinder shop owner for efficient production of parental questionnaires.

MFS & Sida for the financial support.

Maddy, Crappy and Touchy for persistently surviving and delivering despite being repeatedly

maltreated by us and by the children.

- It looks like that’s that

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1 Introduction

One prominent professor once said “the industry is like a horse. It is powerful, highly useful and

indispensable for the people in many ways, but you never ask the horse for advice when deciding

how to shape the society.”

Although the profit driven parts of the world economy have come to increasingly recognize the

importance of social responsibility and sustainability, it is frequently criticized for myopic quests for

profit and lack of consideration for negative externalities of businesses.

The adverse aspects of consumerism and the frenetic consumption that is underpinned by heavy

investments in marketing on local and global level have long been discussed in an ideological and

philosophical context. When involving health affecting products such as tobacco and alcohol

however, the debate on the negative effects of marketing has been more concrete and led to real

political countermeasures. The arguments of the advocators for state regulations on marketing and

the industry typically clash in the discourse on the free will of the individual versus the protective

paternalism of the state. For children, in contrast, there is a general consensus that they are too

young to take full responsibility for their own actions and choices. Thus, many people agree upon

protecting them from harmful influences in the society. Focal point of research and regulations on

marketing towards children has previously been on smoking and tobacco products. The accelerating

global epidemic of child obesity and chronic disease has in recent years shifted this focus towards

the marketing of junk foods, soft drinks, snacks and sweets. In many rapidly developing economies,

where lifestyle related diseases or so called “affluence diseases” are still a novel phenomenon, the

scientific evidence and monitoring of marketing of foods and drinks towards children is lagging

behind the high pace of social and economic development. India is one example of such a country

and where we chose to conduct this study. Through this thesis we hope to shed light on the Indian

children, situated in the intense crossfire of rapidly changing lifestyles, dietary habits and marketing

forces.

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1.1 Background

Marketing towards children is a much debated and controversial subject. Children are lucrative

targets for advertisers, not only for their own spending money today and in the future as adults, but

also for their ability to influence purchase decisions made by their parents. As children can be too

young to distinguish advertising from objective truth and incapable of grasping the long term

consequences of their decisions, advertising directed at young children is by its very nature

exploitative. Promotion of junk food, soft drinks and other poor dietary practices to children has

therefore been put under certain scrutiny in many countries.

Branding and marketing of foods with large amounts of sugar, salt and fat tend to be profitable as

those ingredients are cheap but palatable. Excessive consumption of such foods and drinks - poor in

nutrition and rich in calories – has been shown to be harmful for a child’s development and health.1,2

Childhood obesity is one problem associated to adverse dietary habits, negatively affecting the

child’s cognitive development3 and significantly increasing the risk of chronic diseases such as

diabetes in childhood4 as well as later in life.5,6 The problem of overweight and obesity in childhood

is growing all over the world and particularly in the developing countries. According to the World

Health Organization (WHO) more than 42 million children five years old or younger are overweight

today, of which the majority - about 35 million - resides in the developing world7. Childhood obesity

is part of the rising burden of chronic lifestyle-related diseases globally.8 These groups of diseases –

including diabetes, heart disease, obesity and cancers – are the leading cause of death and disability

worldwide and have in common that they are largely preventable if lifestyle factors such as diet,

exercise and smoking are controlled. Previously regarded as a problem of high-income countries,

the chronic diseases are now increasing at an unprecedented rate in the developing world. Killing

35 million people annually and projected to account for 7 of every 10 death in the world by 2020,

the burden of chronic diseases is a pressing global challenge.9

Varying advertising regulations in the world

In the light of the ongoing epidemic of chronic diseases and childhood obesity, food and drink

advertising directed at children has been the target for heated debate. The WHO declares that

exposure to marketing of adverse dietary practices in early age represents an important health risk

as unhealthy consumption patterns start in childhood and build up throughout life. Outlining a set of

internationally endorsed recommendations on the marketing of food and non-alcoholic beverages

to children, the WHO is urging its member states to immediately take action against such

exposure.10 In USA - where 30 % of the calories in the average child’s diet derive from sweets, soft

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drinks, salty snacks and fast food and the child obesity problem is daunting - the intense and

pervasive food advertising towards children has been denounced by the Obama administration

calling for increased self-regulatory efforts from the industry.11 However, concerned that 50% of the

ad time during children’s television shows promotes foods high in fat, sugar and salt and that the

average American toddler is exposed to over 1000 fast food ads per year12 only through television,

public health authorities and experts advocate instead more state regulatory measures.13 The vested

interests of for-profit enterprises to sell large amounts of highly profitable and easily branded foods

will impede initiatives of self-regulation or promotion of healthier products, they mean, as no one

will get rich from marketing broccoli.

More than 50 countries have introduced bills to curb food marketing and advertising aimed at

children in order to prevent poor child health and obesity. In the European Union, Audiovisual

Media Services Directive regulates advertising to minors and states among other things that in TV

services [...content which is likely to impair minors must be ensured, by selecting the time of the

broadcast…, that minors in the area of transmission will not normally hear or see such broadcasts]14.

In Sweden, TV advertising aimed at children below 12 years is illegal15. Restrictions or bans on

television advertisements targeting children are concentrated to high income and European

countries, whereas middle and low income countries often lack these legislations or in law

enforcement.16 Although guidelines and self-regulatory measures exist in middle and low income

countries, incentives to liberalize and stimulate these economies has led to increased food

advertising and marketing viewed by children, as has happened in India and China.17 These

countries also bear the burden of growing chronic diseases and would thus potentially benefit more

from advertising regulations.

The consequences of the growing chronic disease burden in India

Along with its economic development, India is experiencing an accelerating epidemic of chronic

diseases underpinned by the rapid introduction of lifestyle-related risk factors including unhealthy

diets, physical inactivity and smoking. Accounting for more than 30 % of all deaths, cardiovascular

diseases are now the leading cause of death in the country with the prevalence of coronary heart

disease rising four-fold over the last 40 years.18 India is already the “the diabetes capital of the

world” with its 32 million diabetics, a number that is projected to rise to nearly 70 million in 2025.19

However, India suffers from a double burden of significant prevalence of both over- and

underweight simultaneously. In general, the trend is that overweight is more common in urban

areas whereas underweight is widespread in rural settings.

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Apart from the debilitating effects on the quality of life of the individuals affected, the chronic

lifestyle related diseases cause great macroeconomic losses. The WHO estimates that in many

developing regions, up to 5% of the economic growth will be lost from heart disease, stroke, and

diabetes and its associated medical costs and labor units lost due to early deaths. 20The chronic

diseases were long neglected by Indian authorities, righteously focusing on addressing problems

such as maternal health care and infectious diseases, as lifestyle-related disease was considered as

problems of the upper class. It has become apparent however, that chronic diseases affects the

whole Indian socioeconomic spectrum, imposing huge challenges on the country’s already crippled

health care system. 21The public health implications of the chronic disease burden are thus

staggering - in terms of individual suffering, early deaths and soaring health care costs - and call for

immediate and effective action.

Concurrently, the marketing environment surrounding children in India is changing rapidly. The

level of marketing exposure for children is increasing at a high pace driven by economic

development, deregulations and changing media habits. The biggest window to the world for Indian

children is television. The number of television channels specifically for children grew from one in

2002 to six today, and is expected to grow further as broadcasters exploit the untapped market

constituting 20% of the youth in the world. According to newspaper reports, advertising spend in

children’s media was US$ 19 million in 2005, growing at a rate of 15–30% annually. Of the

commercials shown during children’s programming it is observed that roughly half are for food,

mostly promoting processed packaged foods, soft drinks, snacks and junk foods.22 Multinational

food companies eager to penetrate the emerging Indian markets are intensifying their presence,

using a persuasive array of techniques. Through advertisements with direct appeal of celebrity and

cartoon character endorsements they make considerable efforts to associate their brands with a

desirable modern lifestyle.23 The sedentary lifestyle and poor eating habits associated with

television watching compound the problem of child obesity, especially in some urban areas where

more than 20 % of the children have been shown to be obese or overweight.24 In addition, the

increasing promotion efforts in-store, in print, at schools and through other media, let alone the

advent of internet, have further diversified the marketing channels aimed at children and

complicated the mapping of them. 25

The information and Broadcasting Ministry is the regulatory body for all broadcast media in India.

Regulations for misleading advertisement to children are included in the India Cable Television

Networks Act, but the implementation is insufficiently monitored and infringements reported to be

8

common.26 As a response to criticism from public authorities, consumer organizations and the

international community, some self-regulatory initiatives have been launched by the industry.

Companies including Coca-Cola India, Kellogg’s, Nestlé and Mars India recently declared that they

will not advertise food that does not fulfill specific nutrition criteria to children under 12 years of

age or engage in campaigns in primary schools. The pledge has however been criticized for its many

loopholes and lack of clarity regarding the prospects of a successful implementation.27

1.2 Overall aim

Literature on the degree of exposure and effects of marketing towards children in India is relatively

scarce compared to that of the western world. By investigating marketing exposure and potentially

associated food-related behavior for Indian children, we aimed to shed light on the role of food

marketing with respect to the increasing rates of child obesity and chronic disease in the country.

1.3 Previous research

Adverse health effects of marketing junk foods, snacks and soft drinks

Previous studies suggest a significant influence of food and drink marketing on children’s

consumption, purchase and purchase-related behavior. 28,29,30 These effects appear to be translated

into less healthy diets which eventually increase risk for obesity and lifestyle related chronic

diseases. The conclusion is drawn in several reviews of available literature31,32 and constitutes the

fundaments of the WHO’s policy document “Global recommendations on marketing of foods and

non-alcoholic beverages to children”.33 It is of importance to mention that not all studies point to the

same conclusion. Many studies have not showed the effects found in the above mentioned literature.

In this kind of research however, it is not possible to attain an indisputable level of proof and studies

in different settings reassessing suggested effects need to be conducted continuously. In the

following sections a review of previous literature is made on how food and drink promotion affects

health of children. The focus is on the marketing effects on children’s food preferences, eating

behavior, nutritional knowledge and pestering behavior.

Effects on children’s preferences, eating and purchasing behavior

A number of studies have found significant advertising effects on children’s preferences and also on

what they choose to eat and purchase. Seemingly, the effects are considerable both in terms of

which brand children choose within the same product category34 and between different product

categories.35 The effects appear to be especially pronounced for sugared and salty food adverts

compared to other type of foods.36

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Numerous studies have shown that advertising also can influence what children purchase and eat.

One study found that advertising on vending machines affected the purchase decision of secondary

school pupils37 and another showed that exposure to food promotion reduced children’s likelihood

of selecting fruit or fruit juice, compared to a sweet for a daily snack.38,39 Boys who were exposed to

food promotion in an experiment were also shown to increase their calorific consumption from a

tray of snack foods compared to their unexposed peers.40,41

As for the marketing effects on product preferences in India, a qualitative study from the southern

part of the country investigating adolescent girls’ knowledge about food safety found that the brand

awareness among the interviewed was strong. Reputable brands were considered more reliable and

safe than non-branded products.42 However, few studies have assessed the effects of food marketing

and branding on children’s preferences and consumption behavior in an Indian setting.

Effects on children’s nutritional knowledge

Another suggested mechanism of how marketing affects children’s food choices towards an

unhealthy diet is that exposure to advertisements associating food products to health and well-

being distorts the child’s perception of which type of food is good for health and which is not.

Studies on this hypothesis however, do not provide convincing evidence for such effects. In three

studies – two experimental43,44 and one cross-sectional45 – food promotion had no impact on

children’s perception of the nutritional value of different food products. Other studies using more

detailed knowledge measures have shown certain effects.46 47 For instance, seeing soft drink and

cereal advertisements reduced primary school children’s accuracy for correctly determining

whether or not certain products contained real fruits.48,49

A group of reports have pointed at the Indian children’s poor nutritional knowledge.50 Large scale

education measures in primary schools in southern India aiming to improve the children’s

nutritional awareness have been launched and proved efficient.51 Researchers and authorities call

for increased efforts to improve health knowledge and awareness as measures to mitigate the

chronic disease burden. The link between exposure to marketing and affected nutritional

knowledge was not explored in these studies.

Effects on pestering power and influencing parents’ purchasing decision

Existing literature provide evidence that exposure to advertising increase children’s pestering

behavior, i.e. their efforts to influence their parents’ purchase decisions. In two experiments in

natural settings, children exposed to advertising prior to entering a supermarket with their parents

increased their nagging frequency and demand for advertised products compared to unexposed

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control groups.52,53 Not surprisingly, the likelihood of parents giving in to the children’s demands

has been shown to depend on the intensity of the nagging which also causes parent-child conflicts in

purchase situations.54 Furthermore, marketing efforts aimed to induce pestering towards parents

increasingly takes the approach of instilling into the children the idea of knowing better than their

parents about which products to buy.55 These sophisticated advertising methods are hypothesized

to make the children more confident and independent consumers and further complicating the

situation for parents wanting to choose healthy food products for their children.56,57

Pestering power of Indian children is increasingly recognized by the marketing forces. A survey

carried out by the cartoon network “New Generation” revealed that 29% of the responding parents

to 4-6 year olds experienced pestering behavior from their children. 31 % of the same parents

admitted that they asked their children for advice regarding which products to buy. Several studies

confirm the picture of Indian children being particularly important decision makers in family

purchase decisions.58

Brand logo recognition in previous studies

Brand logo recognition has in several studies been used as a measure of exposure to marketing

activities. A high level of logo recognition among children has been shown in previous research

conducted in the United States59,60 and in the United Kingdom61. In the first study from 199162,

children between age three and six displayed high recognition rates for unhealthy brands of food

and drinks, e.g. recognition of McDonald’s at 81.7%, Burger King at 79.9%, Domino’s Pizza at 78.2%,

Coca Cola at 76.0% among other brands. The highest recognition rate was of Disney Channel at

91.7%. 30% of the three year olds recognized the Old Joe logo of Camel cigarettes and for six year

old children the rate was as high as 91.3%.

Logo recognition rate can be affected by other factors not directly related to marketing exposure.

Unsurprisingly, recognition rate increased with the age of the respondent in all three studies with

different target age groups: 3-6 year olds63, 4-6 year olds64 and 4-8 year olds65. This finding is in line

with other research of when brand perceptions are formed66 and how marketing affects children67.

In a report from the US, children considered to be overweight showed higher recognition for fast

food restaurant logos than for other food logos. In the same study, parents' psycho-social and socio-

demographic characteristics also influenced what kind of food logos were recognized by their

children. Children belonging to families of lower socioeconomic status recognized other logos than

fast food logos to a lower degree and fast food logos to a higher degree than the average child.68

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Children with parents showing lower barriers to promoting a healthy lifestyle recognized other

logos to a higher degree. The authors argue that the reasons could be that families in the US

belonging to lower social-economic status serve more fast food to their children, live in areas where

such marketing is more apparent, or that the higher recognition rate is due to more television

watching and thus higher exposure to TV commercials.69

The previous study that looked into the relationship between eating behavior and brand awareness

could however not find any significant causality between poor diets and brand awareness among

children as children with higher brand recognition rates did not have less healthy preference and

lower knowledge of food70. Thus, they implied that regulations on food advertising to children alone

were not likely to resolve the problem of unhealthy eating habits.

1.4 Objectives

There are to our knowledge no previous studies examining children’s exposure to food and drink

marketing in India by measuring brand logo recognition rates and how it is correlated to child

socioeconomic characteristics, BMI, eating habits, food preferences, nutritional knowledge and

pestering behavior. Thus, this study aimed to explore these subjects in an Indian context by

examining the following:

(1) logo recognition of fast food, snacks, sugared sweets and soft drinks brands in children aged 3 to

13 years in India,

(2) the relation between logo recognition by children and their age and socioeconomic

characteristics,

(3) children’s food preferences, nutritional knowledge, reported pestering behavior, reported eating

behavior and parents’ nutritional knowledge,

(4) the relations between the logo recognition by children and their food preferences, nutritional

knowledge, reported pestering behavior, reported eating habits and BMI.

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2 Theory

The theoretical framework of this study can be visualized as figure 1. The model is based on the

links described in previous literature mentioned in the section above. The links that were

investigated in our study are shown as solid blue arrows in the figure. The dashed red arrows are

relations tested in previous research that were not tested in this study.

Figure 1: Schematic map over the underlying theoretical framework based on previous research

2.1 Logo recognition as an indicator of marketing exposure

Advertisement recognition was established and tested as a reliable indicator of marketing exposure

several decades ago. It has been used as a basic method of advertisement testing for printed ads and,

later on when television became widespread, for TV ads. Scores on a recognition test generally do

not decline over time, indicating that recognition is an indicator of promotional exposure that is

remembered.71 Recognition can be tested in different ways. As for children, the ability of matching a

brand logo to a corresponding product category has often been used. This serves as an indication

that the subject has both seen and remembered an advertisement.72,73,74 The same method was used

in this study.

2.2 Indicators of socioeconomic status

The aim of testing how socioeconomic status affects marketing exposure is to relate socioeconomic

status to eating behavior and BMI, as an indicator of future health issues such as development of

chronic diseases. Many studies have been conducted on the correlation of socioeconomic status and

Socioeconomic

status

Marketing

exposure

Food

preferences

Nutritional

knowledge

Pestering

behavior

Eating

behavior BMI

Link tested in this study

Link not tested in this study

13

various health problems, such as cardiovascular diseases, cancers, malnutrition etc. However, most

of the research uses different indicators for socioeconomic status, usually occupation, income or

wealth measures, educational level, urban or rural residence etc.75,76,77,78 The studies also differ in

the use of individual measurements or composite indices.

Some pros and cons of using individual measurements or composite indices are discussed in these

studies. Since possible variables explaining socioeconomic status often interrelate, it might seem

appropriate to use some composite measurement. However, different variables, such as wealth or

educational level, represent different driving forces behind lifestyle and health issues.79 A study

from 1988 that is still heavily cited today conclude that it is difficult to choose appropriate

indicators and that no consensus exist for which indicators that should be subject for standardized

use. Of course, a possible explanation is the differing fields of research making different indicators

the best one, if such an indicator would exist. However, nine criteria for selecting measures are

presented and it is argued that using individual indicators provide more information and flexibility,

as the individual indicators can later be combined if necessary.80

Thus, individual indicators of socioeconomic status were used in this study. These indicators include

income, occupation, educational level for both parents, land ownership and type of residence. Cutoff

points for high or low level in each of the indicators were based on data from the National Family

Health Survey, India, from 2005-2006 and India Human Development Survey from 2010 presenting

overall means and percentile means of income, education, occupation and area of residence. The

indicators were then combined to a composite core for more convenient usage.

2.3 Preference and knowledge tests

In a previous study81, food preference and nutritional knowledge among children was tested using a

procedure developed and validated by Calfas et al.82 According to this method, pairs of photos

showing various food items were shown to the children. For each pair, the child would select the

item that was preferred during the preference test or the item that was believed to be more

nutritional during the knowledge test. As this test has been shown to have high test-retest reliability

and validity, the method was used in this study. Naturally, adjustments were made to suit the Indian

context. For the parents, a similar test was presented in text.

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2.4 Assessing eating behavior and healthiness of diet

The links between obesity and its related health problems and high consumption levels of sweets,

chips, junk food and soft drinks are well established.83 Apparently, the brands tested for in this

study also belong to these groups of foods. In previous research, intake of such products at once per

day or more has been defined as unhealthy and contributing to overweight and obesity in children.84

The questions in this study were outlined to detect such dietary patterns.

2.5 Assessing pestering behavior

As mentioned earlier, marketing seems to induce children into pestering their parents in purchase

situations in order to get the products advertised. Parents in their function as gate-keepers can

either resist the nagging or give in to the requests. The questions on pestering behavior employed in

this report sought to cover these points and also the recently observed trend - described in the

previous section - of sophisticated marketing strategies aiming to make children independent and

confident consumers.

2.6 Body Mass Index

Body Mass Index, which gives a measure of the weight in relation to height, is widely used to classify

healthy body weight as well as under- and overweight. BMI has been criticized as it does not take

into consideration the body composition differences between ethnicities and where on the body the

fat is accumulated. Adjusting for these factors better predicts for health hazards than only using

weight and height. Due to its convenience however, the measure is widely adopted as a health

indicator. Regarding children, no general cutoffs define underweight or overweight. Instead, BMI-

for-age growth charts have been outlined indicating normal ranges corresponding to the child’s

age.85 It is evident however that the more the child weighs, the higher is its BMI. Accordingly, we

used cutoff points86 outlined with respect to the child’s age and gender to categorize children as

under- or overweight.

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3 Methodology

3.1 Recruitment and inclusion criteria

The study was conducted at the pediatric clinic of Christian Medical College (CMC) Hospital in

Vellore, Tamil Nadu in southeastern India. CMC is one of India’s largest hospitals with both private

and publicly funded health services. Ethical consent was obtained from the ethical vetting board of

the hospital prior to launching the data gathering.

306 children aged 3-13 years and their parents, visiting the hospital for various reasons, e.g. health

checkups, metabolic diseases or vaccine boosts, were recruited. Children who were considered too

sick to participate were not included. In some cases accompanying siblings that fit the age interval

also took part in the study.

The children visiting the clinic came from different age groups and socioeconomic backgrounds and

the study site thus provided an efficient means of recruiting a diverse study population consistent

with the purpose of the research. Parental consent was obtained for each child included in the study.

Translators assisted in cases when participants could speak Tamil or Hindi but not English. Children

not speaking any of these languages were not included.

3.2 Testing equipment

For the brand logo test, preference test and the child’s nutritional knowledge test, an application

was programmed on a tablet computer (Kendo M7) running Android 2.1. Paper-based

questionnaires in either English or Tamil were used for obtaining information from parents. A

digital weight scale and measuring tape was used to measure weight and height of the child.

3.3 Selection of logos

18 logos were selected from the product categories fast food, soft drinks, sweets and snacks. All the

brands have marketing directed towards children and are potential parts of children's dietary

consumption. Choice of logotypes was based on presence on the Indian market and popularity

among local kids as well as diversity in terms of product categories, marketing strategies and

countries of origin. Commercials from Indian TV were probed and a number of Vellore inhabitants

were consulted in the process of choosing the logotypes.

16

Table 1: List of chosen brand logos and their respective product categories

3.4 Logo test

The logo matching test was fashioned after the procedure used by Fischer et al and Arredondo et al.

In this study however, the test was completely digital as the application on tablet computers was

used. A logo appeared on the screen and the child was instructed to touch the right picture out of 12

product category pictures also displayed on the screen. The number of correctly answered

questions gave the logo recognition score of the child. As there were18 logos, the highest score was

18 and the lowest was 0.

3.5 Preference and nutritional knowledge test

The tests assessing the children’s food preferences and nutritional knowledge were modeled

according to a scale developed and validated by Calfas et al, and also used in previous research by

Kopelman et al. Ten matched pairs were used, each consisting of one health neutral and one health

negative product of similar categories. For each pair, the child was asked to indicate which one he or

she preferred and the number of times the child chose the healthier alternative summed up to the

preference score.

Brand Product category

Parle Biscuits

Centerfresh Chewing gum

Boost Chocolate drink and brown soft drink

Maaza Orange soft drink

Pepsi Brown soft drink

KitKat Chocolate

Lay’s Chips

Cadbury Chocolate

Mirinda Orange soft drink

Domino’s Pizza

Gems Candy

KFC Fried chicken and burgers

McDonald’s Burgers

Tiger Biscuits

Coca Cola Brown soft drink

Oreo Biscuits

20-20 Biscuits

Rasna Orange soft drink

17

The same pictures then appeared again on the screen in the same order. This time the child was

asked to indicate which alternative in each pair that was the healthier choice. The sum of correct

answers gave the nutritional knowledge score. The pairs of foods used for the preference and

nutritional knowledge test are displayed in table 2.

Alternative 1 Alternative 2

Cola Juice

Chips Nuts

Mango Candy

Chocolate Fruits

Cookies Banana chips

Korma rice Pizza

French fries Rice

Burgers Chapati

Fast food Homemade food

Milk Chocolate drink

Table 2: Pairs of alternatives used in the child’s preference and nutritional knowledge tests, as well as parents’ nutritional knowledge test

3.6 Parental questionnaire

In the parental questionnaire, questions covering each parent’s educational level and occupation,

family income, house type and land ownership were asked to determine the socioeconomic status

by a score system combining the different socioeconomic factors. The eating behavior of the child

was determined by a score calculated from a number of questions on how often (answers grouped

as once a day or more/once a week or more/less than once a week) the child consumed unhealthy

foods, such as chips, biscuits, chocolates, soft drinks and deep fried food. Pestering behavior was

assessed with a score from questions answered on a four item Likert scale. Parents were asked to

indicate the frequency of certain pestering behaviors such as if the child tried to influence them in

purchase situations and if it demanded advertised products, with “always”, “often”, “rarely” or

“never”.

In the questionnaire the parents were also given a nutritional knowledge test, similar to the one

given to the children but also with the option of indicating that they did not know the right answer.

The same matched pairs were used (table 2) and the number of correctly answered questions

summed up to the parents’ nutritional knowledge score.

18

3.7 Study procedure

Children matching the inclusion criteria were approached in the waiting room of the hospital ward.

The aims and procedure of the study were explained to the parents and parental consent as well as

the child's ascent/consent was asked for. If obtained, the study proceeded with tests of the child's

brand logo recognition ability, food preference and nutritional knowledge. The parents were asked

to fill in the questionnaire on demographic information, the child’s eating habits and the parents’

nutritional knowledge. The standardized operational procedure is described below.

1. A pre-test matching game designed on the tablet computer to test if the child could

understand the concept of matching one thing to another was conducted. The child was

asked to match an apple to fruits, a bike to vehicles, a monkey to animals and so on. If the

child failed at this stage, it would not continue the test and was omitted from the study.

2. The child was asked to take the logo recognition test. Test conductors, parents or translator

were only allowed to explain the game but not help in the matching procedure. The child

was given praise during the whole test, no matter how well it performed.

3. The preference test was explained to the child and conducted.

4. The nutritional knowledge test was explained to the child and conducted.

5. The parental questionnaire was filled in by the parent. Further explanations were given in

cases when parents did not understand the question. In cases parents were not able to read,

a translator assisted in reading and filling in the questionnaires.

6. Weight and height of the child were measured.

The tests are all conducted anonymously, although the answers from all study parts were linked. All

participants were given time to ask questions before and during the testing to facilitate the

procedure. The tests were also conducted in a patient and relaxed manner as to not aggravate the

participants or anyone in the same room, considering the sensitive environment of the hospital.

After finishing, the child received a small gift as a token of appreciation for participating in the study.

3.8 Variables

Demographic data: Information on the age, gender and ethnicity of the child.

Socioeconomic status (1-3): Socioeconomic status was calculated using each parent’s educational

level, family income, house type and land ownership. A score was given for each part and summed

to a SES (Socioeconomic status) score of maximum twelve. The samples with a SES score lower than

19

seven, corresponding to approximately one third of the total sample size, were put in SES group one.

The samples with SES score lower than ten, also corresponding to approximately one third of the

total sample, were put in SES group two, and so on. A higher SES group indicated a higher SES.

Brand logo recognition score (0-18): The number of correctly recognized brand logos by the child.

Food preference (0-10): The number of times the child preferred the healthier alternative in the

matched pairs.

Child’s nutritional knowledge score (0-10): The number of times the child identified the healthier

alternative in the matched pairs.

Parents’ nutritional knowledge score (0-10): The number of times the parents identified the healthier

alternative in the matched pairs. “Don’t know” was regarded as a wrong answer.

Pestering behavior score (1-4): The average score on the questions on pestering behavior answered

by the parents, where a lower number indicated higher pestering behavior.

Eating behavior (1-3): The average score of the questions on how often the child consumed

unhealthy foods, where a lower number indicated more frequent consumption.

Body Mass Index: Body Mass Index (BMI) was calculated as the weight in kilograms divided by the

square of the height in meters. Underweight and overweight was defined from charts used in

outlined in previous research taking into account the gender and age of the child.

3.9 Data analyses

Given the objectives of this study, ANOVA tests were used to examine if any significant differences

existed for different SES groups in terms of brand logo recognition, pestering behavior, child’s

nutritional knowledge, parents’ nutritional knowledge and BMI. T-tests were then used to confirm

any significant mean difference between the highest and lowest SES groups for the previously

mentioned outcome variables. All tests were performed on a 95% significance level. To find

explaining or independent variables for brand logo recognition, pestering behavior, child’s

nutritional knowledge and BMI, linear regression analysis was employed at 95% significance level.

Durbin-Watson, collinearity and residual analysis were used to check the quality of the results. One-

way ANOVA tests and linear regression in SPSS version 19.0 software package were used for the

data analyses.

20

4 Results

Population characteristics

306 parent-child pairs took part in the study. Population characteristics are presented in figure 2

and table 3-5. Subjects ranged in age from 3 to 13 years and average age was 7.6 years (SD=2.8).

177 or 57.8% of them were boys.

Figure 2: Age distribution of sample

Gender Frequency Percent

Boy 177 57.8

Girl 127 41.5

Total 304 99.3

Table 3: Gender distribution of sample

The majority of the children (233) were Hindu. 33 were Christian, 28 Muslim and 12 belonged to

other religions or did not report any religion. Large differences were observed between family

incomes, ranging from 0 to 250 000 rupees per month. Median value was 8000 rupees.

Monthly income(rupees) Frequency Percent

<3500 79 25.8

3500-9000 76 24.8

9000-20000 74 24.2

>20000 67 21.9

Total 296 96.7

Table 4: Income distribution of sample

Of the subjects’ parents the majority of the mothers and fathers had more than eight years of

education (77% and 82% respectively). 32.4% of the mothers and 41.2% of the fathers had an

educational record equivalent to a graduate degree or higher.

22

29 30 31 32 34 34

31

21 18

11

0

5

10

15

20

25

30

35

40

3 4 5 6 7 8 9 10 11 12 13

Age

Number of children by age

21

Mother Father

Education Frequency Percent Frequency Percent

None 34 11.1 27 8.8

1-7 years 36 11.8 28 9.2

8-12 years 137 44.8 125 40.8

Graduate or higher 99 32.4 126 41.2

Total 306 100.0 306 100.0

Table 5: Educational record distribution per parent

Eating behavior, pestering and nutritional knowledge

258 children completed the logo quiz, the preference test and the nutritional knowledge test.

Overall children demonstrated a good nutritional knowledge when specifying which foods were

“healthy” or “unhealthy”. Conversely, their preferences were more oriented towards the unhealthy

options. 80% of the children scored six or more in the knowledge test compared to 31% in the

preference test.

According to the parental questionnaires pestering behavior was common in the study population.

Parents stated on the four item Likert scale that their children “always” or “often” tried to influence

them in purchase situations (56%), succeeded in doing so (47%) and demanded specific brands and

products(42%).

High consumption of snacks, sugared sweets and soft drinks was also reported. A large proportion

of the children consumed biscuits (80%), chips (38%), chocolates/sweets (52%) and soft drinks

(24%) at least once per day.

Figure 3: Eating behavior of total population per food category

38%

80%

52%

26% 24%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Chips Biscuits Chocolates Deep friedfoods

Softdrinks

Eating behavior

% once a day or more

% once a week or more

% less than once a week

22

Brand logo scores and its predictive factors

The average brand logo score was 54% (SD=16%). No differences were found between genders

(p=0.462). Not surprisingly, age was associated with a higher brand logo score (B=0.783, p=0.000).

Children 3-4 years of age scored on average 43% right compared to 69% for 11-13 year old children.

No significant differences were found between 3-4 year old children and 5-6 year old children, or

for 9-10 year old children and 11-13 year old children.

Figure 4: Brand logo recognition rate per age group

Comparison of socioeconomic groups

74 of the children were categorized as belonging to the low socioeconomic (SES) group. 124 were

placed in the middle and 96 in the high SES group. Age (p=0.680) and gender (0.585) were equally

distributed between the groups. Children in the high SES group scored significantly better on the

brand logo test compared to children from the low SES group (p=0.003). High SES children had also

higher scores in the nutritional knowledge test (p=0.001) and the reported pestering behavior

(p=0.013) as well as higher BMI (p=0.009) compared to the low SES group. 2% of the children in the

low SES group were overweight compared to 19% in the high SES group. Interestingly, 18 % of the

high SES children were underweight. The proportion for the low SES group was 26%. Parents from

the high SES group had better nutritional knowledge scores compared to the low SES group.

(p=0.000)

43% 44%

58%

70% 69%

0%

10%

20%

30%

40%

50%

60%

70%

80%

3-4 5-6 7-8 9-10 11-13

Age group

Brand logo score by age group

23

Low SES Medium SES High SES

Factors Mean Std. Dev. Mean Std. Dev. Mean Std. Dev.

Age (3-13) 7.6 2.7 7.7 2.9 7.4 2.8

Brand logo score (0-18) 8.9 4.3 10.4 4.5 11.5** 4.2

Child's nutritional knowledge score (0-10) 6.9 2.1 7.2 2.2 8.1** 1.9

Pestering score (1-4) 2.6 .7 2.4 .7 2.3* .6

Eating behavior score (1-3) 2.2 .5 2.4 .4 2.3 .4

Preference score (0-10) 4.5 1.9 4.5 2.0 4.5 2.2

Parents’ nutritional knowledge score (0-12) 7.5 3.1 8.2 3.0 9.2** 2.6

Hours watching TV per day 2.5 .7 2.5 .8 2.6 .8

BMI 14.4 1.9 15.3 3.0 16.1** 3.9

Percentage underweight 26% - 24% - 18% -

Percentage overweight 2% - 11% - 19% -

Table 6: Comparison between different SES groups on demographics, behavior and outcome variables * Difference between high and low SES groups with p-value <0.05

** Difference between high and low SES groups with p-value < 0.01

Recognition rate by logo

The mean recognition rates for all logos are shown in figure 5. Boost (80%), Maaza (77%), Lays

(73%), Gems (71%), Pepsi (70%) and Coca Cola (67%) had the highest recognition rates among the

brand logos. Random guessing alone would yield a recognition rate of 8.3%, corresponding to one

out of twelve possible answers.

Figure 5: Logo recognition rate for the different brands

The recognition level by age group of the six most recognized brands is shown in figure 6. For these

brands, children 3-4 years old displayed a recognition rate ranging from 29% to 45% and children

11-13 years old displayed a recognition rate ranging from 80%-86%.

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

Recognition rate by logo

24

Figure 6: Logo recognition score for the most well-known brands per age group

Brand logo recognition in relation to BMI, pestering and eating behavior, food preference

and knowledge

When adjusted for SES group, age and gender, the ability to recognize the brand logos was not

associated with eating behavior, food knowledge and pestering behavior. Brand logo score was

associated to a higher BMI (p=0.049) in a regression model specifying brand logo score, gender, age

and SES group as independent variables. As BMI and brand recognition could be suspected to co-

vary with TV watching this variable was subsequently adjusted for. The p-value for the effect of

brand logo recognition on BMI was then pushed just above the level for statistical significance

(0.063).

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

boost maaza pepsi lays gems cocacola

Recognition rate for the most well-known brands

3-4

5-6

7-8

9-10

11-13

25

5 Discussion

In this study we found an overall high recognition rate among 3-13 year old Indian children for

many brands of products containing large amounts of sugar, salt and fat. The brand recognition –an

indicator for marketing exposure – was slightly higher in the high socioeconomic group compared

to the low. The high SES group also had a considerable proportion (18%) of overweight children.

Although recognition rates increased with age, many of the brands were well recognized in lower

age groups also. These findings imply that Indian children of a wide range of socioeconomic groups -

in particular from the higher - are from a young age exposed to marketing of foods and drinks of

which excessive consumption leads to adverse health effects. Consistent with previous research87,

the reported pestering behavior indicates that children are affected by the advertising and influence

their parents in purchase decisions. Furthermore, a large proportion of the children were reported

to consume snacks, biscuits, sweets or soft drinks at least once per day. Such dietary patterns have

been defined as poor eating habits predisposing for obesity and related health problems.88 Given the

accelerating epidemic of chronic diseases in India and the increasing availability – both in terms of

distribution channels and purchasing power – of fatty and sugary foods and drinks, it is warranted

to regard marketing of such products towards children as problematic. The observations from this

study augment the body of evidence regarding the degree of exposure to marketing activities

affecting children from different age and socioeconomic groups. Our report could thus contribute to

the ongoing debate on regulations on the marketing of food and drink products towards children in

India.

Just as a previous study from the UK using a similar design, this study did not demonstrate a

sizeable relationship between logo recognition and the children’s reported eating behavior, food

knowledge and preferences. Thus, this study did not provide evidence for a direct causal link

between food advertising and poor food related behaviors. The methodology used in this study and

its rough sensitivity should however be taken into consideration when discussing these results.

There was a significant association between logo recognition and BMI. This correlation remained

however just below the size for statistical significance when adjusting for a potentially confounding

factor, namely hours of TV watched per day. This implicates that the effect on BMI by marketing

exposure is partly attributed to TV watching and its associated risk factors such as physical

inactivity and snack consumption. As shown in other parts of the world89 however, the correlation

hints about a potentially independent effect of marketing exposure on BMI also in an Indian setting.

26

Children participating in this study showed a relatively good ability to specify which type of food is

considered healthy. This could partly be explained by the educational efforts launched in schools in

southern India to improve nutritional knowledge among children. Also coherent with previous

studies is that the children displayed a considerable discrepancy between the food alternative they

regarded as healthy and the alternative they preferred.

To gauge effects of marketing on children is notoriously difficult. Logo recognition is one way in

which exposure to marketing can be quantified but entails a number of problems. Firstly, we have

the potential confounders. One is the IQ and another is the educational background of the children.

It is very plausible that children with a high IQ and better education possibilities scored higher on

both the brand logo and the nutritional knowledge test, as their ability to grasp concepts and learn

the test procedure was higher than their less privileged peers. However, measures were taken to

minimize such confounding effects. All tests constituted solely of pictures on a digital device that

was navigated by touching the screen and did not involve reading or writing. The picture based

sampling solution also helped mitigating the language problems that are inevitable in the

linguistically dispersed India. Additionally, all children had to pass a training version of the

matching game before undertaking the logo test. Those who did not pass were excluded.

Furthermore, there is an obvious arbitrariness to the selection of logos and product categories.

Focusing on products generally considered as components of an unhealthy diet, we tried to include

a wide range of brands – both domestic and international - which we expected to have high

recognition rates in the study region. As seen in the logo test, not all brands were widely recognized.

In particular, multinational fast food chains such as McDonald’s (30%) and Dominos (35%) received

low proportions of correct guesses. This was not entirely unexpected as the study site – Vellore – is

a small Indian city without any presence from international fast food chains. Reportedly, these

multinationals are also not advertising frequently on local TV in the region. Although they were still

recognized by one in three children, this could explain their relatively low recognition rates

compared to other brands. It is thus of note that the logo test was not composed as to maximize the

total brand recognition rate by the study population. There were certainly brands with higher

recognition that were omitted. Larger variances in recognition scores given by the higher difficulty

level of some brands however, was thought to allow for easier detection of associations with food

preferences, nutritional knowledge and other parameters examined in the study.

Regarding the generalizability of the findings the study site and its relatively small city size should

be considered. It is possible that the results would have been more pronounced if the study was

27

conducted in a larger city with a more intense marketing environment and a larger share of the

study population belonging to an urban middle class. The results could thus possibly be interpreted

as underestimating the marketing exposure and its effects if applied to more urban settings. In

addition, as the study was conducted in the southern part of the country, the generalizability of the

results in other parts of India should be discussed.

It also has to be acknowledged that the study site was not optimal in terms of maximizing the

children’s test performances. Children visiting the hospital ward - either as patients themselves or

accompanying their patient siblings - could be more stressed than usual thus decreasing their

accuracy when tested in this study. Additionally the possible bias in the recruitment of the study

population that the hospital setting introduced can be discussed.

On the other hand, the study site provided us with the possibility to obtain information from both

the parent and the child at the same time. It also gave access to a study population with a wide range

of family incomes, parental education and other socioeconomic factors. This would not have been

possible if conducting the research in other settings, e.g. schools.

In conclusion, this study elucidates some problematic aspects of the current situation regarding

marketing of foods and drinks in India by describing the degree of exposure and its effects on

children from different age and socioeconomic groups. More information is however desirable e.g.

on how marketing of foods interact with local dietary habits, cultural factors and values determining

children’s eating behavior and other risk factors for chronic disease. Further examination of the

particular conditions with respect to this topic in modern India is needed to enhance health

promotion measures from early age and the combating of chronic diseases in the country.

28

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obesity: a prospective, observational analysis. The Lancet 2001;357:505–8. 84


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Appendix

Linear regressions

Dependent: Brand logo

score

Unstandardized Coefficients

Standardized Coefficients

t Sig. 95.0% Confidence Interval for B

Collinearity Statistics

B Std. Error

Beta Lower Bound

Upper Bound Tolerance VIF

(Constant) 7,325 1,495 4,901 ,000 4,380 10,270 age ,208 ,104 ,130 1,996 ,047 ,003 ,413 ,992 1,008 gender -,377 ,584 -,042 -,646 ,519 -1,527 ,773 ,999 1,001 SES group 1,056 ,387 ,177 2,726 ,007 ,293 1,819 ,993 1,007

Dependent: Eating

behavior score





B Std. Error

Beta Lower Bound

Upper Bound

Tolerance

VIF

(Constant) 2,353 ,166 14,163 ,000 2,026 2,680

age -,020 ,011 -,121 -1,811 ,071 -,042 ,002 ,975 1,025 gender -,008 ,062 -,008 -,126 ,900 -,130 ,114 ,997 1,003 SES group ,038 ,042 ,061 ,903 ,368 -,045 ,120 ,963 1,038

Brand logo score

,001 ,007 ,007 ,106 ,916 -,013 ,015 ,955 1,047

Dependent: Preference score



t Sig. 95.0% Confidence

Interval for B


B Std. Error

Beta Lower Bound

Upper Bound

Tolerance VIF

(Constant) 3,773 ,791 4,773 ,000 2,215 5,332 age ,131 ,055 ,163 2,364 ,019 ,022 ,240 ,976 1,024 gender ,027 ,295 ,006 ,091 ,928 -,554 ,608 ,996 1,004 SES group -,051 ,199 -,018 -,259 ,796 -,444 ,341 ,971 1,030 Brand logo score -,020 ,034 -,043 -,611 ,542 -,087 ,046 ,951 1,052

Dependent: Child' nutritional

Knowledge





B Std. Error

Beta Lower Bound

Upper Bound

Tolerance VIF

(Constant) 3,825 ,698 5,479 ,000 2,449 5,201 age ,328 ,049 ,413 6,740 ,000 ,232 ,424 ,978 1,022 gender -,394 ,259 -,092 -1,519 ,130 -,905 ,117 ,996 1,004 SES group ,671 ,174 ,237 3,855 ,000 ,328 1,015 ,970 1,030

Brand logo score ,014 ,029 ,029 ,474 ,636 -,044 ,072 ,952 1,050

1

Dependent: Pestering score





B Std. Error

Beta Lower Bound

Upper Bound

Tolerance VIF

(Constant) 2,478 ,234 10,596 ,000 2,017 2,939 age ,015 ,016 ,062 ,930 ,353 -,016 ,046 ,970 1,031 gender ,133 ,087 ,101 1,536 ,126 -,038 ,304 ,995 1,005 SES group -,159 ,058 -,183 -2,736 ,007 -,273 -,044 ,959 1,043 Brand logo score

,003 ,010 ,023 ,343 ,732 -,016 ,023 ,950 1,052

Dependent: BMI





B Std. Error

Beta Lower Bound Upper Bound

Tolerance VIF

(Constant) 12,053 1,149 10,495 ,000 9,789 14,317 age ,368 ,077 ,309 4,765 ,000 ,216 ,520 ,973 1,027 gender -,767 ,425 -,116 -1,804 ,073 -1,606 ,071 ,994 1,006 SES group ,894 ,284 ,204 3,144 ,002 ,334 1,455 ,968 1,033 Brand logo score

-,019 ,049 -,025 -,385 ,701 -,114 ,077 ,949 1,054

Dependent: BMI





B Std. Error

Beta Lower Bound Upper Bound

Tolerance VIF

(Constant) 12,389 1,396 8,877 ,000 9,640 15,139 age ,333 ,070 ,287 4,736 ,000 ,195 ,472 ,985 1,016 gender -,748 ,392 -,115 -1,908 ,058 -1,520 ,024 ,997 1,003 SES group ,894 ,260 ,208 3,441 ,001 ,382 1,407 ,995 1,005 Eating behavior score

-,130 ,428 -,018 -,303 ,762 -,973 ,714 ,984 1,016

2

Examples of brand logos used in the study.

Examples of product categories used in the study.

Parental questionnaire

Information retrieved from this questionnaire will be handled completely anonymously and

cannot be traced back to You or Your child. You are free to withdraw from participation at any

point for any reason. Thank You for Your participation.

1. Child’s birth date: _________

2. Gender: male female

3

3. Home district: _________

4. Vegetarian Non-vegetarian

5. Religion: _________

6. Number of siblings: _________

Media habits

7. How many hours per day does your child watch TV?

0h 1-2h 3-4h > 4h

8. How many hours per day does your child use Internet?

0h 1-2h 3-4h > 4h

Influence of advertisement

9. Does your child try to influence you when buying foods/snacks/drinks/candies?

Almost always Often Rarely Almost never

10. Does your child succeed in influencing you when buying foods/snacks/drinks/candies?


11. Do you have conflicts with your child when buying foods/snacks/drinks/candies?


12. Does your child show independence and confidence when choosing

food/snacks/drinks/sweets products?


4

13. Is your child influenced by advertisements on TV?


14. Does your child demand specific brands or products that he or she has seen advertised?


Eating habits

15. Does your child eat breakfast every day?

Yes No

16. School type ? Government school Private school

17. What type of lunch does your child eat during school days?

Mid-day scheme Pack lunch box Buys food at school: _________

18. How many times per day does your child consume fruits and vegetables?

0 1-2 3-4 5 or more

Approximately how often does your child eat: 19. Chips? More than once a day Once a day More than once a week Once a week Less than once a week 20. Biscuits? More than once a day Once a day More than once a week Once a week Less than once a week

5

21. Chocolates/Candies/Toffies? More than once a day Once a day More than once a week Once a week Less than once a week 22. Deep fried food? (e.g. pakoda, bhajji) More than once a day Once a day More than once a week Once a week Less than once a week 23. Soft drinks? More than once a day Once a day More than once a week Once a week Less than once a week 24. Milk or milk products More than once a day Once a day

More than once a week Once a week Less than once a week

25. Staple diet at home: _____________

26. What do you purchase for your child to eat?

What the family eat – staple diet Special food: _________

27. Which of the two alternatives do you consider better for your child’s health?

27.a Coca cola Fruit juice Don’t know

27 b Chips Nuts Don’t know

6

27 c Mango Candy Don’t know

27 d Chocolate Fruits Don’t know

27 e Rice Chips Don’t know

27 f Korma Pizza Don’t know

27 g Burger Chapati Don’t know

27 h Milk Chocolate drink Don’t know

27 I Fast food Homemade food Don’t know

27 j Biscuits Dried bananas Don’t know

28 a How do you consider the impact of fatty food on your child’s health?

It is good and should be eaten as much as possible

It is not good for health to consume large amounts of sugar and fat

Don’t know

28 b How do you consider the impact of sugary food on your child’s health? It is good and should be eaten as much as possible It is not good for health to consume large amounts of sugar and fat Don’t know 29. Education (mother)

None Class number: _______ Graduation

30. Education (father)

None Class number: _______ Graduation

30. Occupation (father): _____________

31. Occupation (mother): _____________

7

32. Total family income (monthly): _____________

33. Land ownership:

Yes No

34. House type:

Kutcha1 Pucca2 Mansion3 Apartment

Thank you for your participation

To be filled in by the investigator

35. Weight:

36. Height:

37. Birth weight:

1 Non-cemented house

2 Brick house = government builds

3 Big house with terrace

Documents

Junk food, soft drinks and sweets