Who Guidline

Policies to protect children
from the harmful impact

of food marketing
WHO guideline
Policies to protect children
from the harmful impact
of food marketing
WHO guideline
Policies to protect children from the harmful impact of food marketing: WHO guideline
ISBN 978-92-4-007541-2 (electronic version)
ISBN 978-92-4-007542-9 (print version)
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Cover illustration by Clarissa Ines
Contents
Acknowledgements v
Abbreviations vi
Glossary vii
Executive summary ix
Background ix
Objective, scope and methods ix
The evidence x
Good-practice statement and recommendation xi
Key considerations for implementation xiii
1. Introduction 1
1.1 Background 1
1.2 Scope and purpose 3
1.3 Objectives 5
1.4 Target audience 5
2. How this guideline was developed 6
2.1 Contributors to guideline development 6
2.2 Guideline development process 7
2.3 Management of conflicts of interest 11
3. Summary of evidence 13
3.1 Evidence on the nature, extent and impact of food marketing 13
3.2 Evidence on effectiveness of policies to restrict food marketing to which
children are exposed 16
3.3 Evidence on contextual factors 20
4. Good-practice statement and recommendation 22
5. Implementation considerations 27
6. Research gaps 31
6.1 Overarching research gaps 31
6.2 Considerations for design of future evaluations 32
7. Uptake, monitoring and updating of the guideline 34
References 35
iii
Annexes
Annex 1. Global calls to action and commitments related to food environment policies 43
Annex 2. WHO Secretariat 44
Annex 3. Members of the WHO Steering Committee (headquarters) 45
Annex 4. Members of the WHO NUGAG Subgroup on Policy Actions 46
Annex 5. External resource people 48
Annex 6. External peer review group 49
Annex 7. Guidance questions for the review of contextual factors 50
Annex 8. GRADE evidence profile 51
Annex 9. Summary of declarations of interests of contributors to the guideline development
process 63
Annex 10. Key characteristics of policies evaluated by studies included in the systematic
review on the effectiveness of policies to restrict food marketing to which children
are exposed 67
iv Policies to protect children from the harmful impact of food marketing: WHO guideline
Acknowledgements
This guideline was prepared by the Department of Nutrition and Food Safety (NFS) of the World Health
Organization (WHO) under the overall leadership of Francesco Branca, Director of the Department of
Nutrition and Food Safety, and with coordination by Chizuru Nishida. Katrin Engelhardt was the responsible
technical officer. The Department of Nutrition and Food Safety gratefully acknowledges the contributions
that many individuals and organizations have made to the development of this guideline.
Guideline Development Group (WHO Nutrition Guidance Expert Advisory Group (NUGAG) Subgroup
on Policy Actions): Nawal Al Hamad (Ministry of Health, Kuwait), Carukshi Arambepola (University of
Colombo, Sri Lanka), Gastón Ares (Universidad de la República, Uruguay), Sharon Friel (Australian National
University, Australia), Cho-il Kim (Seoul National University, Republic of Korea), Knut-Inge Klepp (Norwegian
Institute of Public Health, Norway), Joerg Meerpohl (University Medical Center Freiburg, Germany), Musonda
Mofu (National Food and Nutrition Commission, Zambia), Ladda Mo-suwan (Prince of Songkla University,
Thailand), Monica Muti (University of Witwatersrand, South Africa), Celeste Naude (Stellenbosch University,
South Africa), Lisa Powell (University of Illinois Chicago, United States of America), Mike Rayner (University
of Oxford, United Kingdom of Great Britain and Northern Ireland), Eva Rehfuess (Ludwig Maximilian
University Munich, Germany), Lorena Rodríguez Osiac (University of Chile, Chile), Franco Sassi (Imperial
College London, United Kingdom of Great Britain and Northern Ireland), Barbara Schneeman (University of
California at Davis, United States of America), Reema Tayyem (University of Jordan, Jordan), Alison Tedstone
(Department of Health and Social Care, United Kingdom of Great Britain and Northern Ireland), Anne Marie
Thow (University of Sydney, Australia) and Edelweiss Wentzel-Viljoen (North-West University, South Africa).
Special acknowledgements are given to Elie Akl (American University of Beirut, Lebanon) who, as a methods
expert, guided the work of the NUGAG Subgroup on Policy Actions throughout the guideline development
process and to the systematic review team, led by Emma Boyland (University of Liverpool, United Kingdom
of Great Britain and Northern Ireland).
External peer reviewer group: Huda Mustafa Al Hourani (The Hashemite University, Jordan), Gershim
Asiki (African Population Health and Research Center, Kenya), Alejandro Calvillo (El Poder del Consumidor,
Mexico), Suparna Ghosh-Jerath (Public Health Foundation of India, India), Maria João Gregório (Directorate-
General of Health, Portugal), Fiona Sing (University of Auckland, New Zealand) and Boyd Swinburn
(University of Auckland, New Zealand).
WHO Steering Committee: Melanie Bertram, Fiona Bull, David Clarke, Katrin Engelhardt, Monika Kosinska,
Benn McGrady, Chizuru Nishida, Jeremias Paul, Marcus Stahlhofer, Nicole Valentine and Angeli Vigo.
Special thanks are given to: Ruby Brooks (WHO/NFS) for supporting the preparation of this guideline;
Dorit Erichsen (WHO/NFS) for supporting the review of contextual factors; Jason Montez (WHO/NFS) and
Kathryn Robertson (WHO/Public Health Law and Policies Team) for internal review of the draft guideline;
and to Kaia Engesveen (WHO/NFS) for providing data on implementation of food marketing policies from
the Global database on the Implementation of Nutrition Action.
WHO expresses special appreciation to the following organizations and institutions, for providing financial
support for the guideline development work, including the undertaking of systematic reviews:
Ministry of Health, Labour and Welfare of the Government of Japan
Swiss Agency for Development and Cooperation
European Union
Swedish International Development Cooperation Agency
Qingdao University, Qingdao, People’s Republic of China.
v
Abbreviations
BMI body mass index

CI confidence interval
GRADE Grading of Recommendations Assessment, Development and Evaluation
HFSS foods foods high in saturated fatty acids, trans-fatty acids, free sugars and/or salt, usually highly
processed, whose consumption is associated with negative health effects
HIC high-income country
LMIC low- and middle-income country
NCD noncommunicable disease
NUGAG Nutrition Guidance Expert Advisory Group
PICO population, intervention, comparator and outcome
RCT randomized controlled trial
SES socioeconomic status
WHO World Health Organization
vi
Glossary
Children: Unless otherwise noted, as defined in the Convention on the Rights of the Child, all human beings
below the age of 18 years unless, under the law applicable to children, majority is attained earlier (1).
Exposure: The reach and frequency of a communication, message or action that constitutes marketing.
Reach is the percentage of people in a target market who are exposed to the communication, message or
action over a specified period. Frequency is a measure of how many times the average person is exposed to
the communication, message or action.
Food: Foods and non-alcoholic beverages.
Food choice: Used in this guideline to describe one of the outcomes of interest of the research questions
that the guideline addresses. It refers to the selection of one food over another (or others) from a given
selection of foods and hence is limited by the foods available.
Marketing: Any form of commercial communication, message or action that acts to advertise or otherwise
promote a product or service, or its related brand, and is designed to increase, or has the effect of increasing,
the recognition, appeal and/or consumption of products or services.
Nutrient profile model: A tool for classifying foods according to their nutritional composition for reasons
relating to preventing disease and promoting health. Nutrient profile models in the context of food
marketing help define foods to be restricted from marketing. According to the World Health Organization
region-specific nutrient profile models (2–7), marketing is to be restricted for foods that belong to a food
category with nutrient thresholds and exceed these thresholds, or belong to a food category for which all
marketing is prohibited (for which no nutrient thresholds are established). Such foods are typically high in
saturated fatty acids, trans-fatty acids, free sugars and/or salt, and are usually highly processed.
Policies: All measures to regulate marketing to which children are exposed, whether through legal
instruments mandating compliance (such as legislation and regulations), government-led measures with
which compliance is voluntary (such as codes of conduct and standards), or measures by which industry
actors voluntarily undertake to restrict marketing (such as pledges and codes). Policies do not include
action plans, strategies, programmes or initiatives.
Power: The extent to which a marketing communication, message or action achieves its communications
objectives. The power of marketing is influenced by the content of the message, especially the creative
strategies used. These strategies include graphics and visual design elements, such as cartoons and
brand equity characters; humour, fun and fantasy; movie and sports celebrities; and competitions and
entertainment events.
vii
Executive summary
Background
Unhealthy diets are a leading global public health risk, contributing to all forms of malnutrition
(i.e. undernutrition; micronutrient-related malnutrition; and overweight, obesity and diet-related
noncommunicable diseases (NCDs)). Food environments, which include food marketing, are recognized as
one of the key influences on diets. A 2009 review, for example, found that food marketing affected children’s
nutrition knowledge, food preferences and consumption patterns, and that the foods promoted by food
marketing represented a “very undesirable dietary profile, with [a] heavy emphasis on energy dense, high
fat, high salt and high sugar foods”. More recent evidence has reinforced these findings, and the advent and
growth of digital marketing have raised new concerns.
Food marketing is also increasingly recognized as a children’s rights concern. Marketing of foods high in
saturated fatty acids, trans-fatty acids, free sugars and/or salt negatively impacts several of the rights
enshrined in the Convention on the Rights of the Child, including the rights to health, adequate and nutritious
food, privacy, and freedom from exploitation. The Committee on the Rights of the Child has stated that the
marketing of such foods should be regulated.
Objective, scope and methods

In 2010, the Sixty-third World Health Assembly unanimously endorsed the World Health Organization
(WHO) Set of recommendations on the marketing of foods and non-alcoholic beverages to children, and urged
Member States to take the necessary measures to implement the set of recommendations.
In response to Member State requests, WHO developed this guideline to strengthen and streamline support
for Member States in developing and implementing new, or strengthening existing, policies to protect
children from the harmful impact of food marketing.
This guideline builds on the 2010 WHO Set of recommendations on the marketing of foods and non-alcoholic
beverages to children, and takes into consideration more recent evidence specific to children and to the
context of food marketing. The guideline’s objectives are to:
provide evidence-based recommendations and implementation considerations for policies to protect
all children from the harmful impact of food marketing;
enable evidence-informed advocacy to advance policy action to restrict food marketing to which
children are exposed;
guide future research to further strengthen the evidence base for policy action; and
contribute to the creation of healthy food environments that enable healthy dietary practices among
children.
In this guideline, policies were defined as all measures to regulate marketing to which children are
exposed, whether through legal instruments mandating compliance (such as legislation and regulations),
government-led measures with which compliance is voluntary (such as codes of conduct and standards), or
measures by which industry actors voluntarily undertake to restrict marketing (such as pledges and codes).
This guideline was developed using the procedures outlined in the WHO handbook for guideline
development. These procedures include a review of systematically gathered evidence by an international,
multidisciplinary group of experts (the Nutrition Guidance Expert Advisory Group (NUGAG) Subgroup on
ix
Policy Actions); assessment of the certainty of that evidence via Grading of Recommendations Assessment,
Development and Evaluation (GRADE); and consideration of additional decision criteria potentially relevant
for the translation of the identified evidence into recommendations.
The evidence
Nature, extent and impact of food marketing
Evidence from a narrative review showed that food marketing predominantly promoted foods high in
saturated fatty acids, trans-fatty acids, free sugars and/or salt (HFSS foods), and that food marketing was
prevalent:
in settings where children gather (e.g. schools and sports clubs);
during children’s typical television viewing times and on children’s television channels;
on digital spaces popular with young people; and
in magazines targeting children and adolescents.
A wide variety of marketing strategies that were likely to appeal to children were reported by studies, and
these were used more often when marketing HFSS foods than when marketing healthier foods. Across
studies, the most frequently marketed food categories were fast food, sugar-sweetened beverages,
chocolate and confectionery, salty and savoury snacks, sweet bakery items and snacks, breakfast cereals,
and desserts.
Evidence from a systematic review showed that exposure to food marketing likely affects children’s food
choice or intended choice, product requests or intended requests, and dietary intake.
Effectiveness of policies to restrict food marketing to which children are exposed

Evidence from a systematic review showed that policies to restrict food marketing to which children are
exposed may affect food purchasing by or for children. The evidence also showed that such policies may
have effects on wider society, such as reduced investment in television advertising of HFSS foods, and
reduced food and beverage advertising revenue on children’s channels; these changes were considered
favourable to public health.
The overall evidence on the effect of policies on children’s exposure to food marketing and the power of
food marketing was inconsistent. Analyses by policy design elements, however, showed that reductions in
children’s exposure to food marketing were more often found with:
mandatory policies;
policies designed to restrict food marketing to children, including those older than 12 years; and
policies that used a government-led nutrient profile model to determine the foods for which marketing
was to be restricted.
The analyses by policy design elements also showed that reductions in the power of food marketing were
more often found with:
mandatory policies; and
policies designed to restrict food marketing to children, including those older than 12 years.
Studies comparing voluntary policy with no policy were significantly more likely to show effects on exposure
to, and the power of, food marketing that were unfavourable to public health; this was not the case for
studies comparing mandatory policy with no policy.
Analyses on the impacts of policies on food marketing exposure and power by marketing medium showed
that most evidence was about television advertising. This evidence showed that mandatory policies were
more likely to reduce exposure to and power of television advertising relative to voluntary policies. Evidence
on the impact of policies on exposure to and power of digital food marketing was limited and only evaluated
voluntary policies. This evidence showed that voluntary policies that addressed digital food marketing did
not lead to a reduction in exposure to and power of such marketing.
x Policies to protect children from the harmful impact of food marketing: WHO guideline
Additional analyses were conducted on the impacts of policies on the use of different food marketing
techniques. Most studies evaluated voluntary policies that restricted the use of promotional characters.
These studies reported favourable effects more often than studies evaluating policies that restricted a
broader range of child-appealing persuasive techniques or animation techniques.
Contextual factors
Evidence from a review of contextual factors showed that:
policies to protect children from the harmful impacts of food marketing would be highly cost-effective
or cost-saving;
children of lower socioeconomic status (SES) in high-income countries (HICs) are more exposed to food
marketing than are children of higher SES. As a result, policies to protect children from the harmful
impacts of food marketing can be expected to reduce health inequities;
policies to protect children from the harmful impact of food marketing are in accordance with human
rights standards, whereas unregulated food marketing may jeopardize the fulfilment of the Convention
on the Rights of the Child;
in HICs, policies to protect children from the harmful impact of food marketing are largely acceptable to
the public, but industry has generally opposed government-led restrictions;
some countries have successfully implemented policies, demonstrating that policies are acceptable to
government and policy-makers and feasible to implement.
Good-practice statement and recommendation
Good-practice statement
Children of all ages should be protected from marketing of foods that are high in saturated fatty acids,
trans-fatty acids, free sugars and/or salt.
Statement rationale
The good-practice statement was formulated by the NUGAG Subgroup on Policy Actions based on several
key considerations.
Children continue to be exposed to powerful marketing of HFSS foods, consumption of which is
associated with negative health effects (8, 9). Such marketing is prevalent (including on packaging, in
settings where children gather (e.g. schools and sports clubs), during children’s viewing times and on
children’s channels, in youth magazines, and on social media) and uses many techniques appealing to
young audiences (9). Digital marketing is of growing concern because it facilitates engagement, which
can amplify the marketing message and overall impact of marketing (9).
Food marketing negatively affects children’s food choice or intended choice (odds ratio 1.77; 95%
confidence interval (CI): 1.26–2.50) and dietary intake (standardized mean difference 0.25; 95% CI: 0.15–
0.35) (10). It also affects children’s product requests to adults for marketed foods (10), and negatively
influences the development of children’s norms about food consumption (9).
Enabling children of all ages to achieve their full developmental potential is a human right and a critical
foundation for sustainable development. Children’s rights, including their rights to health, adequate
and nutritious food, privacy, and to be free from exploitation, are threatened by the marketing of HFSS
foods (11–13).
Countries that are State Parties to the Convention on the Rights of the Child have a legal obligation to
ensure that children’s rights are respected, protected and fulfilled. According to general comments on
the Convention, countries that are State Parties to the Convention should use appropriate regulation
to ensure that marketing does not have adverse impacts on children’s rights, and should make the
Executive summary xi
best interests of the child a primary consideration when regulating marketing that is addressed and
accessible to children (14, 15).
WHO recommendation
WHO suggests implementation of policies to restrict marketing of foods high in saturated fatty acids,
trans-fatty acids, free sugars and/or salt to which children are exposed, and that such policies:
¡¡ be mandatory;
¡¡ protect children of all ages;
¡¡ use a government-led nutrient profile model to classify foods to be restricted from marketing;
¡¡ be sufficiently comprehensive to minimize the risk of migration of marketing to other media, to
other spaces within the same medium or to other age groups; and
¡¡ restrict the power of food marketing to persuade.
(Conditional recommendation)
Recommendation remarks
These remarks provide context for the recommendation and are to facilitate interpretation and
implementation.
‘Children’ refers to all human beings below the age of 18, as defined by the Convention on the Rights of
the Child, unless, under the law applicable to children, majority is attained earlier.
The impact of marketing is a function of both exposure and power.
—— Exposure is the reach (percentage of people in a target market who are exposed) and frequency
(the number of times an average person is exposed) of a marketing communication, message or
action. Policies should address children’s exposure to food marketing, irrespective of timing, venue
or intended audience, and should therefore go beyond children’s media.
—— Power refers to the extent to which a marketing communication, message or action achieves its
communications objectives. Power is influenced by the creative content and strategies used. The
power of food marketing to persuade children relates to techniques appealing to children, including
promotional characters, branding, emotional appeals, games, engagement techniques, interactive
or downloadable content, and celebrity endorsements (9); these techniques impact dietary intake
(10).
Migration of marketing refers to the movement of marketing from restricted to unrestricted mediums
or spaces (e.g. if a policy restricts marketing on television but not digital marketing, digital marketing
may increase).
A nutrient profile model is a tool for classifying foods according to their nutritional composition for
reasons relating to preventing disease and promoting health. Nutrient profile models in the context of
food marketing help define foods to be restricted from marketing and should align with national dietary
guidelines.
Recommendation rationale
The recommendation was formulated by the NUGAG Subgroup on Policy Actions based on several key
considerations (below and Table 2, p. 24).
Based on evidence from a systematic review that assessed the effectiveness of policies to restrict food
marketing to which children are exposed (8), the group judged policies to have moderate desirable
effects and trivial undesirable effects and judged the overall balance between desirable and undesirable
xii Policies to protect children from the harmful impact of food marketing: WHO guideline
effects to favour the intervention. Following application of the GRADE approach (see section 2.2), the
certainty of the evidence from the systematic review was considered very low, therefore the group
made a conditional recommendation. The group noted that the relevant policy evaluations were all
observational studies, leading to lower certainty of evidence when applying the GRADE system, and that
the inconsistency of effect, which led to downgrading of the certainty of evidence for some outcomes,
was partly due to variation in policy design elements.
The group judged policies to be cost-effective, feasible and generally acceptable to government,
policy-makers and the public, but less so to industry. Further, implementation of policies supports the
realization of human rights and will probably support improved health equity.
Some policy design elements are likely to be effective in protecting children from marketing of HFSS
foods, but others are more likely to lead to unfavourable effects. The recommendation therefore
specifies elements that maximize the effectiveness of policies, as identified in the systematic review (8).
—— Of studies evaluating voluntary policies, significantly more studies showed undesirable effects than
desirable effects on exposure to, and power of, food marketing. This was not the case for studies
evaluating mandatory policies (8).
—— Of studies evaluating policies designed to restrict food marketing to children that included only
children aged 12 years or younger, significantly more studies showed undesirable effects than
evaluating policies that included children older than 12 (8).
—— Of studies evaluating policies that used a company-led nutrient profile model to define foods to
be restricted from marketing more studies showed undesirable effects than desirable effects
on exposure to food marketing. This was not the case for studies evaluating policies that used a
government-led nutrient profile model.
—— Some studies indicated that policies that were too narrow in scope (i.e. not comprehensive) may
have led to migration of marketing (e.g. from children’s television programmes to non-children’s
television programmes, from younger to older age groups) (16, 17).
—— Food marketing uses strategies that appeal to young audiences (9), and marketing using such
strategies affects food choice and dietary intake (10). Studies indicated that mandatory policies result
in reductions in use of powerful marketing strategies, such as the use of promotional characters and
other persuasive techniques that appeal to children (8).
Key considerations for implementation

In line with the good-practice statement, policies should be formulated in the best interests of children.
Their design should also consider the policy design elements specified in the recommendation. The WHO/
UNICEF publication Taking action to protect children from the harmful impact of food marketing: a child
rights-based approach provides step-by-step guidance through the four main stages of the policy cycle
(preparation; development; implementation; monitoring and evaluation).
Recommendations should be adapted to the local contexts of WHO regions and Member States.
Considerations about the local context include:
available resources, including for policy implementation, enforcement and continued monitoring for
compliance;
structures and mechanisms, including mechanisms to manage conflicts of interest and to safeguard
public health policies and enforcement mechanisms;
the policy context, including the country’s legal system and potential regulatory pathways and the
overall political economy; and
the stakeholders to consult or engage with at different stages of the policy cycle.
Other considerations include actions to reduce children’s exposure to cross-border marketing, and
restrictions on the promotion of brands (as distinct from products and services).
Executive summary xiii

Preparing for potential opposition to policies (such as that from industry) may increase policy strength
and effectiveness. The WHO/UNICEF publication Taking action to protect children from the harmful impact
of food marketing: a child rights-based approach gives guidance on anticipating opposition to policies, and
summarizes common arguments against policies. It provides counterarguments based on a child rights-
based approach and the available scientific evidence, and outlines steps to strengthen the government’s
position against legal challenges.
Policies to protect children from the harmful impact of food marketing are best implemented as part of a
comprehensive policy approach to create enabling and supportive food environments. The recommendation
in this guideline should be considered alongside other relevant WHO guidance and recommendations,
including forthcoming WHO guidelines on school food and nutrition policies, nutrition labelling policies,
and fiscal policies.
xiv Policies to protect children from the harmful impact of food marketing: WHO guideline
1. Introduction
1.1 Background
Unhealthy diets are a leading global public health risk, contributing to all forms of malnutrition (i.e.
undernutrition; micronutrient deficiencies; and overweight, obesity, and diet-related noncommunicable
diseases (NCDs)) (18, 19). Globally, 38.9 million children under the age of 5 were estimated to have overweight
or obesity in 2020 – 41% of whom lived in low- and lower-middle-income countries (20). 45.4 million were
estimated to be wasted, and 149.2 million to be stunted (20). Of children aged 5–19 in 2016, 337 million were
estimated to have overweight or obesity (18). Virtually no progress has been made in reducing the spread
of childhood overweight in two decades (20). Worldwide, dietary risks1 were responsible for 11.61% of all
disability-adjusted life years (DALYs) lost to NCDs and nearly 8 million deaths from NCDs in 2019 (21).
Every country in the world is affected by one or more forms of malnutrition. Malnutrition threatens the
survival, growth and development of children and adolescents, as well as economies and nations (22).
Combating malnutrition in all its forms is one of the greatest global health challenges (23, 24). The causes
of malnutrition are complex, and action is required on many fronts (25–28). There is wide recognition
that structural changes (i.e. changes to social, cultural, political and physical environments) are required
to promote healthy diets (29). Behaviour change interventions on their own have had limited success in
reducing disease risk factors (30). Following the work of the World Health Organization (WHO) on creating
supportive environments for health (31–33), key actions to improve diets include those that focus on the food
environment – that is, the surroundings that influence and shape consumers’ food behaviours, preferences
and values, and prompt consumer decisions (34, 35).
Governments play a leading role in addressing malnutrition in all its forms and reducing the burden of
diet-related NCDs, including through public policies that create food environments conducive to healthy
diets (36–39) and through effective regulation of private sector activities that influence health – that is,
the commercial determinants of health (33, 40). The private sector, however, continues to influence public
health policy and regulation through lobbying and other actions (40).
Food marketing (Box 1) is one commercial activity that shapes the food environment and marketing of
HFSS foods has long been recognized as having an especially harmful impact on the diets of children
(41–43). Marketing is a recognized means to promote products that are harmful to health, such as HFSS
foods (44). Arguments in defence of marketing fade when the marketed products harm health and when
marketing poses a threat to children’s rights. In 2009, a review on the extent, nature and effects of food
promotion to children found that food marketing affects children’s nutrition knowledge, food preferences
and consumption patterns, and that the foods promoted by food marketing represented a “very undesirable
dietary profile, with [a] heavy emphasis on energy dense, high fat, high salt and high sugar foods” (41). More
recent evidence has echoed these findings, showing that exposure to food marketing affects children’s food
preference, food choice and food intake in undesirable ways (45), and that food marketing continues to
be predominantly for HFSS foods (9). Numerous studies have documented the wide variety of media used
for food marketing, including television, packaging, magazines, outdoor media, digital and sponsorship
media, and promotions in and around schools (9, 41–43). The advent and growth of digital marketing has
raised new concerns, including the use of novel marketing techniques (e.g. food-themed apps, influencer
marketing, user-generated content) (46). Another concern is the collection of copious personal data from
internet users and the use of these data to target marketing to users (46).
1
“Dietary risks” includes diets that are low in whole grains, fruit, nuts and seeds, vegetables, fibre, legumes, polyunsaturated
fatty acids, calcium or milk, and/or are high in sodium, trans-fatty acids, processed meat, red meat or sugary drinks (Global
Burden of Disease risk factors).
1
Box 1. What is marketing?
The definition of marketing used in this guideline builds on that used in the 2012 WHO publication A
framework for implementing the set of recommendations on the marketing of foods and non-alcoholic
beverages to children (47), with the explicit addition of marketing of brands. The 2012 framework
refers to marketing of products and services, and states that efforts to restrict marketing need to
consider how brands are marketed (47). Marketing, in this guideline, is therefore defined as:
Any form of commercial communication, message or action that acts to advertise or otherwise promote
a product or service, or its related brand, and is designed to increase, or has the effect of increasing, the
recognition, appeal and/or consumption of products or services.
The definition of marketing in the 2012 framework is intended to be comprehensive in its coverage
(47). For example, the framework explains that examples of marketing include not only advertising,
but also product placement and branding, sponsorship, direct marketing, product design and
packaging, and point-of-sale marketing (47). “Commercial” is also intended to be broadly interpreted
to include all forms of direct and indirect promotion (47). The definition of marketing used in this
guideline should be similarly interpreted to be comprehensive in its coverage.
Fig. 1 illustrates the cascade of effects by which exposure to food marketing is likely to ultimately influence
children’s weight status and likelihood of developing diet-related NCDs (48), and highlights the commercial
drivers of food marketing.
Food marketing is also increasingly recognized as a children’s rights concern, particularly in relation to
the Convention on the Rights of the Child (12). The Convention on the Rights of the Child articulates the
rights of children, including the rights to health, adequate and nutritious food, privacy and freedom from
exploitation. Countries that are State Parties to the Convention have legal obligations to respect, protect
Fig. 1. Cascade of effects of food marketing
Investment in
marketing Company
profits
No
Exposure to compensation
marketing for extra energy
intake Sustained
energy
imbalance
Consumption
Awareness Changes in attitudes:
Normalization of products
of products
Taste preference/desire
and brands for product
Weight gain
Taste
preference
and diet-related
diseases
Responsiveness
Intention to
to cues at point purchase Purchase
of sale
Via parents/caregivers
[Parent/ [Parent/
caregiver] caregiver] agrees
influenced by to purchase
“pester power” Via
parents/
caregivers
Source: Adapted from Kelly et al. (48).
2 Policies to protect children from the harmful impact of food marketing: WHO guideline
and fulfil these rights, and are required to take immediate action to implement these obligations as a matter
of priority (12). Countries that are State Parties to the Convention are therefore obliged to take action toward
the fulfilment and realization of children’s rights. This should include actions to protect children from
marketing of HFSS foods as such marketing negatively affects children’s rights, such as the rights to health,
adequate and nutritious food, privacy and freedom from exploitation (12). The Committee on the Rights of
the Child, in a 2013 general comment on the right of the child to the enjoyment of the highest attainable
standard of health, stated that the marketing of foods that are high in fat, sugar or salt, and are energy-
dense and micronutrient-poor should be regulated (49). The general comment articulated core obligations
relating to children’s right to health, which include reviewing the national and subnational legal and policy
environment and, where necessary, amending laws and policies; providing an adequate response to the
underlying determinants of children’s health; and developing, implementing, monitoring and evaluating
policies and budgeted plans of action that constitute a human rights–based approach to fulfilling children’s
right to health (49). In a 2021 general comment on children’s rights in relation to the digital environment, the
Committee on the Rights of the Child reinforced that marketing of “unhealthy products, including certain
food and beverages” should be regulated to prevent children’s exposure to such marketing and stated that
regulations relating to the digital environment “should be compatible and keep pace with regulations in the
offline environment” (15).
Recognizing the harmful impact of food marketing on children, numerous global and regional calls to
action have been made. As part of implementation of the Global Strategy on Diet, Physical Activity and
Health (2004) (50), the World Health Assembly in May 2010 endorsed the WHO Set of recommendations on
the marketing of foods and non-alcoholic beverages to children (resolution WHA63.14) (51). The resolution
called for policies to reduce the impact on children of marketing of HFSS foods. In response to WHA63.14, a
framework was developed for implementing the WHO set of recommendations (47). Implementing policies
to restrict food marketing to which children are exposed has also been proposed in various other WHO
documents adopted by the World Health Assembly, including the Comprehensive Implementation Plan on
Maternal, Infant and Young Child Nutrition (52) in 2012, and the Global Action Plan for the Prevention and
Control of Noncommunicable Diseases 2013–20201 (53) in 2013. In 2016, the report of the WHO Commission
on Ending Childhood Obesity similarly recommended implementation of the Set of recommendations on the
marketing of foods and non-alcoholic beverages to children (54).
1.2 Scope and purpose

Despite growing evidence of the harmful impact of food marketing on children and increasing recognition of
food marketing as a children’s rights concern, as of May 2022, only 602 countries have adopted policies that
restrict food marketing to which children are exposed. Of these, one third (20 countries) have mandatory
policies. Additionally, in the second global nutrition policy review, undertaken in 2016–2017, responding
countries that had measures in place to restrict food marketing to which children are exposed reported
a mix of approaches used to define which foods are covered by such measures (55). Of 17 countries that
provided detailed information, fewer than half used nutrient profile models to define the foods covered
by the policies (55). Marketing restrictions differed not only in relation to the foods included but also the
marketing media covered – of 28 countries that provided detailed information, 93% covered television, but
only 29% covered social media (55). Overall, an important omission in existing measures was that, of the
18 countries that had defined the age of children covered by the policy, most had policies that covered
children only up to the age of 12 years (55).
In response to Member State requests, and to strengthen and streamline support for Member States in
developing and implementing new, or strengthening existing, public policies to protect children from
the harmful impact of food marketing, WHO began developing this guideline, taking new evidence into
consideration (Box 2).
1
The Seventy-second World Health Assembly extended the period of the global action plan to 2030 to ensure its alignment
with the 2030 Agenda for Sustainable Development.
2
This number was collated by WHO from the WHO Global database on the Implementation of Nutrition Action (GINA) and the
WHO Noncommunicable Disease Document Repository.
1. Introduction 3
Box 2. How does this guideline relate to other published WHO guidance on
policies to restrict food marketing to which children are exposed?
This guideline builds on the 2010 WHO Set of recommendations on the marketing of foods and non-
alcoholic beverages to children (51), endorsed by the Sixty-third World Health Assembly in May 2010
(51).
Since then, the evidence on the harmful impact of food marketing has grown; however, country action
remains limited, and children continue to be exposed to marketing for HFSS foods. New marketing
media have also evolved, most notably digital marketing, which poses a growing concern.
The development of this guideline followed a transparent process, outlined in the WHO handbook
for guideline development (56). This guideline considers a more recent evidence base than the set of
recommendations was based on, including more recent evidence on the effectiveness of policies to
restrict food marketing to which children are exposed and on the effectiveness of different policy
approaches.
The 2012 WHO publication A framework for implementing the set of recommendations on the marketing
of foods and non-alcoholic beverages to children (47) remains a useful resource for the development
and implementation of policies to protect children from the harmful impact of food marketing, noting
that evidence continues to accumulate, especially on the effectiveness of different policy approaches
and on the evolution of new marketing media and techniques.
In view of the increasing recognition of food marketing as a children’s rights concern, the 2012
framework should be used in conjunction with the 2023 WHO/United Nations Children’s Fund (UNICEF)
publication Taking action to protect children from the harmful impact of food marketing: a child rights-
based approach (57). See Chapter 5 for further details.
Because no single intervention can ensure that all aspects of the food environment support healthy diets, a
comprehensive package of policy actions is required. Therefore, guidelines are being developed for multiple
policy actions in addition to policies to protect children from the harmful impact of food marketing, including
nutrition labelling policies (58), fiscal policies (59) and school food and nutrition policies (60). Prioritization
of policies will depend on the country context.
The scope of this guideline relates to policies to protect children from the harmful impact of food marketing,
with a focus on marketing of HFSS foods. The systematic reviews undertaken to address the key questions
for the guideline (see section 2.2) excluded studies on the impacts of marketing and marketing restrictions
more broadly, and were restricted to direct evidence on food marketing and its impact on children. Although
this limits the ability to extrapolate from evidence on marketing of other products, services or brands or on
the impact of marketing on adults, the direct evidence was considered a workable subset of the evidence
for developing this guideline. Finally, this guideline is not an implementation manual. It does not describe
how countries can implement and monitor policies to protect children from the harmful impact of food
marketing, but rather recommends what measures to take. While some implementation considerations are
highlighted in Chapter 5, detailed implementation guidance can be found in the WHO/UNICEF publication
Taking action to protect children from the harmful impact of food marketing: a child rights-based approach
(57).
The WHO guidelines on policies to improve the food environment are in line with other WHO guidelines and
recommendations, including guidelines on sodium intake (61) and sugars intake (62); forthcoming guidelines
on total fat, saturated fatty acids and trans-fatty acids, polyunsaturated fatty acids, carbohydrates, use
of non-sugar sweeteners and use of low-sodium salt substitutes; and the recommendations of the WHO
Commission on Ending Childhood Obesity (54). The guidelines on policies to improve the food environment
can be used in conjunction with available tools and frameworks, including the nutrient profile models
and guidance developed by the WHO regional offices for restricting food marketing to which children are
exposed (2–7).
1.3 Objectives
Complementing global and regional guidance on restricting food marketing to which children are exposed,
and recognizing that there is considerable evidence on the impacts of marketing and marketing restrictions
outside the food context, the objectives of this guideline are to:
provide Member States with recommendations and some key implementation considerations on
policies to protect all children from the harmful impact of food marketing;
enable evidence-informed advocacy to advance policy action to restrict food marketing to which
children are exposed;
guide future research to further strengthen the evidence base for policy action to restrict food marketing
to which children are exposed; and
contribute to the creation of food environments that enable healthy dietary practices among children.
As noted above, this WHO guideline is one of several on policies to improve the food environment. The
overarching objective of these guidelines is to contribute to the achievement of healthier populations, in
line with the WHO Thirteenth General Programme of Work (2019–2023) (63). The WHO guidelines on policies
to improve the food environment will also contribute to implementation of additional calls to action relating
to nutrition and health (Annex 1).
1.4 Target audience

The guideline is intended for a wide audience involved in the development, design, implementation,
monitoring and evaluation of policies to protect children from the harmful impact of food marketing, as
well as those involved in compliance with, and advocacy for, such policies. The end users for this guideline
are thus:
national and local policy-makers and food regulators involved in developing, designing, implementing,
monitoring or evaluating policies restricting food marketing to which children are exposed;
implementers and managers of national and local health and nutrition programmes, including school
administrators, teachers and educators;
organizations (including nongovernmental organizations) and professional societies involved in
advocating for, developing and evaluating policies restricting food marketing to which children are
exposed;
health professionals, including managers of health and nutrition programmes and public health policy-
makers in all settings;
scientists and other academic actors involved in relevant research (including policy evaluation); and
representatives of the food industry, marketing/advertising agencies and related associations involved
in implementing, or complying with, policies to restrict food marketing to which children are exposed.
1. Introduction 5
2. How this guideline
was developed
This guideline was developed in accordance with the WHO process for development of evidence-informed
guidelines outlined in the WHO handbook for guideline development (56). This chapter describes the
contributors to the guideline development process and the steps taken.
2.1 Contributors to guideline development

The guideline was developed by the WHO Department of Nutrition and Food Safety and other members of
the WHO Secretariat (Annex 2), together with the contributors described below.
WHO Steering Committee

An internal steering committee (Annex 3) provided input to development of the guideline. The WHO Steering
Committee included representatives from relevant departments in WHO with an interest in the provision
of advice on food environment policies, determinants of health, health promotion, and maternal and child
health.
Guideline development group

A guideline development group (Annex 4) – the WHO Nutrition Guidance Expert Advisory Group (NUGAG)
Subgroup on Policy Actions – was convened with the main functions of determining the scope and key
questions of the guideline (including the target population, intervention, comparator and outcomes of
interest), reviewing the evidence and formulating evidence-based recommendations. The NUGAG Subgroup
on Policy Actions included experts identified through an open call for experts in 2018, and people who had
participated in previous WHO expert consultations or were members of WHO expert advisory panels. In
forming the group, the WHO Secretariat considered the need for expertise from multiple disciplinary areas,
representation from all WHO regions and a balanced gender mix. Efforts were made to include experts in
complex interventions; development and/or implementation of policies to protect children from the harmful
impact of food marketing; and systematic review, programme evaluation and Grading of Recommendations
Assessment, Development and Evaluation (GRADE) methodologies.
External resource people

Various external resource people, including methods experts and members of the systematic review teams,
attended the meetings of the NUGAG Subgroup on Policy Actions (Annex 5). The systematic review team
was led by Dr Emma Boyland, University of Liverpool. It undertook two systematic reviews (8, 10) and a
narrative review (9) to support development of the guideline.
External peer review group

Seven external peer reviewers were identified in consultation with WHO regional nutrition advisers from
all WHO regions, representing academia, civil society and government (Annex 6). The external peer review
took place between June and August 2022.
Public consultation
A public consultation on the draft guideline was held in July 2022. Stakeholders were invited to provide
comments on the overall clarity of the guideline, considerations and implications for adaptation and
implementation of the guideline, context- and setting-specific issues that may not have been captured,
6
any errors of fact and missing data. The consultation was open to everyone. Declaration of interest forms
were collected from all those submitting comments, which were assessed by the WHO Secretariat following
procedures for management of conflicts of interest (see section 2.3). The comments were reviewed and
considered in finalizing the guideline. A summary of the comments, together with WHO responses, was
posted on the WHO website.1 Comments were received from 46 individuals and organizations.
2.2 Guideline development process

Scoping of the guideline
A scoping review of existing evidence was prepared by Dr Emma Boyland, University of Liverpool. The
scoping review included a review of newly available evidence on:
the impact of food marketing to children on food behaviours and health outcomes among children; and
the impact of policies to restrict food marketing to which children are exposed on exposure to food
marketing, the power of food marketing, and food behaviours and health outcomes among children.
Formulation of key questions and prioritization of outcomes

A policy to protect children from the harmful impact of food marketing is a priority policy option for creating
food environments that contribute to healthy diets, and is implemented within complex systems (including
the food system), that are country-specific, and influenced by political, legal, economic, cultural and
ethical contexts. As proposed in the WHO handbook for guideline development, logic models can be used
during guideline planning to show interventions of interest and elements of the system in which they are
implemented to help formulate guideline questions (56). Fig. 2 shows a logic model depicting pathways
from policies to protect children from the harmful impact of food marketing to behavioural and health
outcomes. It shows country context policy inputs and considerations, including potential interactions with
other, complementary food environment policies, which can amplify the policy of interest’s impact.
Considering the scoping review and the logic model, research questions were formulated using the
population, intervention, comparator and outcome (PICO) format. Draft PICO questions were first discussed
and reviewed by the WHO Secretariat, the WHO Steering Committee and the NUGAG Subgroup on Policy
Actions. The final PICO questions were determined by the NUGAG Subgroup on Policy Actions. All potentially
important outcomes were first identified and discussed by the group, followed by an anonymous online
rating of outcomes on a scale from 1 to 9. Outcomes rated 7–9 were considered critical for decision-making,
and those rated 4–6 were considered important. Those rated 1–3 were dropped from the PICO questions.
The NUGAG Subgroup on Policy Actions noted several challenges to assessing longer-term health outcomes.
The policies under consideration may have been only recently introduced, whereas changes to outcomes
such as body weight/body mass index (BMI)/obesity and diet-related NCDs occur gradually.
There are methodological challenges in disentangling the impact of food marketing and policies to
restrict food marketing to which children are exposed from the complex array of factors that contribute
to outcomes such as body weight/BMI/obesity and diet-related NCDs.
There is a need to be realistic about the extent to which any one intervention can be expected to impact
outcomes such as body weight/BMI/obesity and diet-related NCDs on its own. Instead, policies to
restrict marketing are intended to contribute to such outcomes as part of a comprehensive package of
policy actions.
Nonetheless, the group ranked several longer-term health outcomes as important, to ensure that the
breadth and depth of current evidence were captured and considered in the guideline, and to highlight
potential research and knowledge gaps and data challenges to strengthen the evidence base for future
updates to this guideline. The selection of outcomes of interest when defining research questions should
not be based on outcomes for which evidence is known to be available, but rather should provide the
opportunity to explore the unknown and highlight data gaps.
1
Consolidated comments and responses: Public consultation on the draft WHO Guideline to protect children from the harmful
impact of food marketing.

8
Fig. 2. Logic model depicting pathways from inputs to outcomes for policies to protect children from the harmful impact of food marketing to
behavioural and health outcomes
Country context inputs and Interventions and target populationa Outcomesa
considerations
Policies that restrict
Target group Behaviours Health outcomes
Resources, structures, mechanisms food marketing
•• Organizational structures
Design elements Pester power
•• Governance mechanisms of policies to
(including for accountability and restrict food
transparency) marketing Body weight status,
•• Available capacity Food preference body mass index
•• Target Reductions in
•• Available resources, financing population (age/ exposure to
mechanisms definition of marketing
Food choice Diet-related NCDs
•• Mechanisms to protect against children)
(including
conflicts of interest and safeguard •• Target marketing Reductions in validated surrogate
public health approaches indicators)
b power
Children Food purchases/sales
•• Enforcement mechanism •• Target food and of marketing
(0–19 years)
(including capacity to enforce), beverage (and
strategies to minimize non- approach to Dental caries
compliance define target Diet (energy, total food
foods) and/or nutrient intake,
Stakeholders nutritional quality)
•• Legal
Policy context instrument:
Unintended
•• Legal system and options for voluntary and
consequences
regulatory instruments (including mandatory
for example existing related Product change
policies on advertisement
restrictions of non-food products Complementary food environment
or on consumer protection) policies: For example: nutrition
labelling policies, fiscal policies,
•• Signatory to human rights treaties school food and nutrition policies,
•• Political economy procurement policies.
Sociodemographic, sociocultural factors, commercial drivers
NCD: noncommunicable disease

a
Interventions and outcomes shown in the figure are those prioritized by the members of the WHO Nutrition Guidance Expert Advisory Group (NUGAG) Subgroup on Policy Actions in formulating the
research question for the evidence review to inform the guideline on policies to restrict food marketing.
b
For the purposes of the logic model and systematic review, children were defined as those aged 0–19 years, as WHO defines adolescents as those aged 10–19.
The two PICO questions were as follows.
What is the effect on the outcomes of interest of exposure of children to food marketing, compared with no
marketing?
What is the effect on the outcomes of interest of implementing a policy that aims to restrict children’s
exposure to food marketing and its persuasive power, compared with not implementing a policy?
Table 1 provides details of the key questions in PICO format. As the WHO Set of recommendations on the
marketing of foods and non-alcoholic beverages to children proposed that policies could be implemented
through a variety of approaches, including statutory regulation, industry-led self-regulation and
co-regulatory mechanisms (51), the definition of policies used in the second key question included both
Table 1. Population, intervention, comparator and outcomes for key questions

Measure Key question 1 Key question 2
Population Children (0–19 years) and, for the food Children (0–19 years)
purchasing/sales or intended purchasing Disaggregation by age, sex, gender, BMI, SES,
outcome only, parents or other adults rurality, region (HICs and LMICs)
making purchases on behalf of children
0–19 years
Disaggregation by age, sex, gender, BMI,
SES, rurality, region (HICs and LMICs)
Intervention Exposure to marketing for foods All measures to regulate food marketing to
(including non-alcoholic beverages) which children are exposed, whether through
legal instruments mandating compliance
(e.g. legislation, regulations), government-
led measures with which compliance is
voluntary (e.g. codes of conduct, standards) or
measures by which industry actors voluntarily
undertake to restrict food marketing
(e.g. pledges, codes)
Disaggregation by target population, target
marketing media, approach to defining target
foods, voluntary or mandatory approach, and
degree and quality of implementation and
enforcement
Comparator Exposure to no marketing, less No policy, or different policies that aim to
marketing or less powerful marketing restrict food marketing to which children are
for foods (including non-alcoholic exposed
beverages)
Critical Food preferences Exposure to marketing
outcomes for Food choice or intended choice Power of marketing
decision-making
Food purchasing/sales or intended Food preferences
purchasing Food choice or intended choice
Dietary intake Food purchasing/sales or intended purchasing
Dietary intake
Important Product requests or intended requests Product requests or intended requests
outcomes Dental caries/erosion Dental caries/erosion
Body weight/BMI/obesity Body weight/BMI/obesity
Diet-related NCDs (or validated surrogate Diet-related NCDs (or validated surrogate
indicators) indicators)
Product changes
Unintended consequences to wider society
(e.g. revenue, jobs)
BMI: body mass index; HIC: high-income country; LMIC: low- and middle-income country; NCD: noncommunicable disease;
SES: socioeconomic status.
Note: For the key questions, children were defined as those aged 0–19; WHO defines adolescents as those aged 10–19 (64).

mandatory and voluntary measures, to ensure that the effects of all policy approaches were considered.
The second key question included disaggregation by target population, target marketing media, approach
to defining target foods, voluntary or mandatory approach, and degree and quality of implementation and
enforcement, to enable consideration of policy design elements that may affect policy effectiveness.
The nature of food marketing has evolved since a previous review, in 2009, on the impact of food marketing
(41) – on which the 2010 WHO Set of recommendations on the marketing of foods and non-alcoholic beverages
to children (51) was based. Further, the scoping review identified a growing evidence base on the impact of
food marketing. Consequently, a new systematic review on the impact of food marketing on the outcomes
of interest was commissioned. A second systematic review – to assess the evidence on the effectiveness of
implemented policies to restrict food marketing to which children are exposed, including to determine their
potential desirable and undesirable effects, and explore policy design elements – was also commissioned,
as none of the reviews identified by the scoping review adequately answered the formulated research
question.
The NUGAG Subgroup on Policy Actions requested an additional review to provide information on
contextual factors that would be considered in the formulation of the recommendations, such as resource
implications, equity and human rights, acceptability and feasibility. The contextual factors in the review
included those outlined in the WHO handbook for guideline development (Chapters 10 and 18) (56). Extra
questions were formulated to guide the review of contextual factors (Annex 7).
Evidence gathering and grading

Evidence gathered for this guideline included:
a systematic review on the impact of food marketing on children (10);
a narrative literature review on exposure to, and power of, food marketing, and their associations with
food-related attitudes, beliefs and behaviours (9);
a systematic review on the effectiveness of policies to restrict food marketing to which children are
exposed (8); and
a review of contextual factors (values, resource implications, equity and human rights, acceptability,
and feasibility) (11).
The systematic review team conducted the two systematic reviews to address the two key questions in PICO
format (Table 1). The systematic review searches were conducted in March and April 2019 and updated in
March 2020. Studies that were retrieved in the systematic review searches and were considered relevant
for the formulation of the guideline but did not meet eligibility criteria for either of the two systematic
reviews were synthesized into a narrative review on exposure to, and power of, food marketing, and their
associations with food-related attitudes, beliefs and behaviours (9). Reasons for excluding studies from the
systematic reviews included ineligible study design or absence of a comparator group (9). Opinion pieces,
studies that discussed marketing but did not report any primary data, and studies published before 2009
were excluded from the narrative review (9). The review of contextual factors was conducted by WHO and
involved literature searches for systematic reviews, primary studies and grey literature that provided
information on values, resource implications, equity and human rights, acceptability, and feasibility (11).
Detailed descriptions of the methods for each review are available in the review publications.
In line with the guideline development process, the certainty of the body of evidence for each outcome
gathered through each systematic review was assessed by the systematic review team using the GRADE
approach. GRADE provides a transparent approach to grading the certainty of evidence for each outcome
included in key questions. The certainty of evidence indicates the level of confidence that the effects of an
intervention as observed in a body of evidence (i.e. a set of scientific studies) reflect the true effects that
would occur in real-world settings.
Using the GRADE approach, there are four possible assessments for the overall certainty of the evidence for
an outcome (65):
very low (very low level of confidence in the effect estimate – the true effect is likely to be substantially
different from the effect estimate);
low (low level of confidence in the effect estimate – the true effect may be substantially different from
the effect estimate);
moderate (moderate level of confidence in the effect estimate – the true effect is likely to be close to the
effect estimate, but there is a possibility that it is substantially different); and
high (high level of confidence in the effect estimate – the true effect is likely to be close to the effect
estimate).
The starting point for assessing the overall certainty of the evidence for an outcome depends on the design of
the studies that contribute to the evidence base: evidence from observational studies starts at low certainty,
because of residual confounding, whereas evidence from randomized controlled trials (RCTs) starts at
high certainty. Most studies that assess the effectiveness of policies to restrict food marketing to which
children are exposed are observational, which means that the certainty of evidence often starts at low. The
overall certainty of evidence for each outcome in the systematic reviews was assessed by considering five
factors for potentially downgrading the certainty (risk of bias, inconsistency, indirectness, imprecision and
publication bias) as defined and used in the GRADE approach, and three factors for potentially upgrading
the certainty (large effect size, all plausible confounding would reduce the demonstrated effect, and dose–
response gradient).
For each GRADE factor for each systematic review, judgements were made by the systematic review team
leader, and discussed and cross-checked with the systematic review team. The judgements and their
rationale were recorded in a GRADE evidence profile table (see Annex 8 for the GRADE evidence profile
table for the systematic review on the effectiveness of policies to restrict food marketing to which children
are exposed).
The certainty of evidence was not assessed for the narrative review or the contextual factors review.
Formulation of the recommendations

The NUGAG Subgroup on Policy Actions discussed and assessed the evidence, drafted recommendations,
and reached consensus on the direction and strength of the recommendations using the GRADE approach.
After reviewing the ratings for the certainty of evidence for each critical and important outcome, the NUGAG
Subgroup on Policy Actions made a judgement on the overall certainty of evidence by reflecting on the
validity, precision, consistency and applicability of the measures of effect, taking into consideration the
pathway of effect of the entire body of evidence. The GRADE approach explicitly separates the process of
assessing the level of certainty in the evidence from the process of making recommendations. The latter
process takes into consideration several additional contextual factors (resource implications, equity
and human rights, acceptability and feasibility) (65). The level of certainty of evidence does not imply a
particular strength of recommendation; high certainty evidence does not necessarily mean that a strong
recommendation will be made, and a strong recommendation can be made with low or very low certainty
evidence, depending on additional considerations.
Evidence-to-decision tables were used to structure and document the discussion, and anonymous online
voting was used to arrive at an initial judgement for each factor. Following the voting, initial judgements
were discussed until the group reached consensus. Based on the evidence of effectiveness and additional
contextual factors, the NUGAG Subgroup on Policy Actions developed the recommendations and associated
remarks by consensus.
2.3 Management of conflicts of interest

According to the rules in the WHO Basic documents (66), whenever an expert or an individual provides
independent advice to WHO, including participating in WHO meetings, a declaration of interest form must
be submitted, and all declarations must be analysed. In the case of guideline development, this includes all
members of the guideline development group (for this guideline, the NUGAG Subgroup on Policy Actions),
individuals who prepare systematic reviews and evidence profiles, and any other experts (including
external peer reviewers) who participate in the process of guideline development in an individual capacity.
Declaration of interest forms were reviewed by the WHO Secretariat in consultation with the WHO Office
of Compliance, Risk Management and Ethics when finalizing the composition of the NUGAG Subgroup on

Policy Actions. Before every meeting, the members of the NUGAG Subgroup on Policy Actions, the members
of the systematic review team and other experts who would be participating in the meeting were asked to
submit their updated declaration of interest forms. In addition to distributing the declaration of interest
form, the WHO Secretariat described the declaration of interest process and provided an opportunity during
meetings for guideline development group members to declare any interests not provided in written form.
All declared interests were reviewed by the WHO Secretariat in consultation with the Office of Compliance,
Risk Management and Ethics, as necessary. A summary of declared interests and the assessment of these
interests is provided in Annex 9.
Similarly, declaration of interest forms from external peer reviewers were assessed by the WHO Secretariat,
following the procedures for management of interests outlined in the Guidelines for declaration of interests
for WHO experts (67).
3. Summary of evidence
Evidence was gathered via a systematic review of studies on the impact of food marketing on children (10), a
narrative review on food marketing exposure and power and their associations with food-related attitudes,
beliefs and behaviours (9), a systematic review on the effectiveness of policies to restrict food marketing to
which children are exposed (8), and a review of contextual factors (11). The evidence gathered was specific
to food marketing and does not include broader evidence on the impact of marketing of other products,
services or brands, or on the effectiveness of policies to restrict marketing of these. Policy-makers may
draw upon such broader evidence to further support marketing restrictions.
3.1 Evidence on the nature, extent and impact of food marketing

The evidence summarized in this section is from two reviews: the narrative review on exposure to, and
power of, food marketing, and their associations with food-related attitudes, beliefs and behaviours (9);
and the systematic review on the impact of food marketing on children (10).
Narrative review
A total of 179 studies, published from 2009 onwards, were included in the narrative review, which found that
marketing of HFSS foods remains pervasive and persuasive across the globe (9).
As mentioned in section 2.2, articles that were retrieved in the searches for the two systematic reviews but
were not eligible for inclusion in those reviews (e.g. because of unsuitable study design or comparator) were
considered for inclusion in the narrative review. The findings should be interpreted as a thorough overview
rather than an exhaustive account of the available evidence.
The studies were grouped as those related to:
children’s exposure to food marketing;
the power of food marketing; and
associations between food marketing and eating-related attitudes, beliefs and behaviours among
children.
A total of 118 studies (43 solely on exposure and 75 on both exposure and power) provided evidence on
children’s exposure to food marketing. The majority of studies were conducted in high-income countries
(HICs) only (89 studies, compared with 26 conducted in low- and middle-income countries (LMICs) only,
and three conducted in both HICs and LMICs). Studies assessed exposure to food marketing via television,
digital media, product packaging, magazines and sports sponsorship; and in store, in schools, outdoors,
on public transport and in restaurants. Findings of studies showed that, across marketing media, food
marketing was prevalent and predominantly promoted HFSS foods.1 The proportion of food marketing that
was identified as being for HFSS foods generally ranged from 31.0% to 93.0%. The most frequently marketed
foods (as defined by the study authors) included “fast food”, sugar-sweetened beverages, chocolate and
confectionery, salty/savoury snacks, sweet bakery items and snacks, breakfast cereals, dairy products, and
desserts. The studies showed that food marketing continues to be directed at children – one study reported
1
The studies included in the narrative review used varying terms to describe, and varying criteria to define, HFSS foods.
Frequently used definitions and descriptors for such foods in reviewed studies included “unhealthy”, “foods high in fats,
sugars and/or salt (HFSS)”, “not permitted”, “less healthy”, “junk food”, “energy-dense nutrient poor (EDNP)”, “non-core”,
“ultraprocessed”, “not meeting nutritional quality standards”, “discretionary”, “high in” or “rich in” undesirable nutrients,
and “low in nutritional quality”.
13
that as many as 95.2% of television advertisements for food were child oriented – and that child-directed
marketing is generally for HFSS foods. Studies from the United Kingdom, Australia, the United States of
America and New Zealand indicated that exposure to food marketing varied by socioeconomic status (SES),
with greater exposure among those of lower SES.
A total of 100 studies (25 solely on power and 75 on both exposure and power) provided evidence on the
power of food marketing. The majority of studies were conducted in HICs only (74 studies, compared
with 23 conducted in LMICs only, and three conducted in both HICs and LMICs). Studies considered food
marketing via television, digital media, product packaging, magazines and sports sponsorship; and in store,
in schools, outdoors and in restaurants. The studies showed that, across marketing media, a wide variety
of strategies that are likely to appeal to children were used in food marketing. These included celebrity/
sports endorsements; promotional characters; product claims; promotions, gifts/incentives and tie-ins;
competitions; games; colour, visual imagery and novel designs; animation, dynamic elements and special
effects; prominent food cues; branding; product association; salient themes or contexts; persuasive
appeals; emotional appeals; health/nutrition claims and disclaimers; depiction of physical activity;
engagement techniques; interactive or downloadable content; children’s language and voices, and child-
related messages and fonts; and large portion sizes. Some of these strategies were more frequent in food
marketing directed at children than in general marketing, and in marketing of HFSS foods than in marketing
of healthier foods.
A total of 36 studies (16 studies on associations between food marketing and outcomes of interest, and
20 qualitative studies on the impact of food marketing) provided evidence on the effect of food marketing.
Of these, 22 studies were from HICs and 14 from LMICs. Studies considered food marketing via television,
video games, billboards, the internet, social media, in store and in print.
The studies on associations between food marketing and outcomes of interest covered a range of outcomes.
For example, one study showed that exposure to marketing for HFSS foods was positively associated
with descriptive norms about the consumption of such foods among adolescents. In another study, the
frequency of consumption of such foods was affected by the entertaining dimension of advertising and
the level of emotional arousal that children experienced after exposure to food marketing. Studies also
reported a positive association between frequency or level of exposure to food marketing and habitual
consumption of marketed foods. Two studies indicated that engagement with food marketing (e.g. liking,
sharing or commenting on social media posts; actively watching brand videos on YouTube) was associated
with a greater impact on consumption than exposure to food marketing on its own. One study reported a
positive correlation between the amount of time spent watching television and the prevalence of dental
caries. Another reported a significant association between commercial television viewing at time 1 and BMI
at time 2 (5 years later), which persisted after adjusting for exercise and eating while viewing television; no
association was found for non-commercial television viewing.
The qualitative studies also reported on a wide range of impacts of food marketing. For example, one study
reported that children could recognize advertised food in the supermarket, while another reported that
adolescents could identify energy drink products by brand name. Several studies identified strategies that
were likely to appeal to children in food marketing, including promotional characters, toys, playful visuals,
colourful packaging, brand imagery and fun themes. Adolescents in one study reported that product
packaging, the use of humour and the product’s projected image were important. In another study, young
adults reported that advertisements that they considered credible, entertaining, informative or relevant to
them, or that contained offers, were of more interest to them. In a different study, young adults reported
more positive feelings towards brands after exposure to brand websites and social media pages, and
particularly content related to corporate social responsibility initiatives, community involvement and
sponsorship. In multiple studies, parents reported concern about children’s exposure to food marketing
and support for regulation of such marketing. Children in one study believed that “junk food” should not
be advertised to them. In terms of the impact of food marketing, studies generally reported a belief among
participants that food marketing influenced eating and related behaviours among young people; these
included studies of children, adolescents and parents. In one of these studies, parents reported that their
children wanted to purchase food shown in advertisements; in another, children reported that they had
chosen a cereal because of a toy and regardless of its taste. Children also reported being influenced by
advertisements that their Facebook friends had liked or commented on. In contrast, in one study, parents
believed that advertising for food had no effect on preferences or requests, and children did not believe
they had learned about food from food advertising.
Systematic review
A total of 96 studies, reported in 100 records, were included in the systematic review on the impact of food
marketing on children (10). Table 1 outlines the population, intervention, comparator and outcomes that
guided the review. Because the review was an update of a previous review conducted in 2009 (41), studies
were limited to those with a publication date from January 2009 onwards. The search was conducted in April
2019 and updated in March 2020. Of the 96 included studies, 64 were RCTs and 32 were non-randomized
studies (21 experimental and 11 observational). The majority of studies were conducted in HICs; only six
took place in LMICs.
Pooled analyses were completed for three of the four critical outcomes – food preferences, food choice or
intended choice, and dietary intake – and none of the four important outcomes. For the pooled analyses,
moderator analyses assessed the possible impact on the effect sizes of study design type (RCT or non-
randomized study), marketing manipulation type (exposure or power), marketing medium (television, digital
or packaging) and risk of bias. The possible impact of different marketing techniques (e.g. promotional
characters, toys, celebrities) could not be assessed because of the small number of effect sizes for each
technique within each outcome. For food choice or intended choice and dietary intake, the possible impact
of mean age and BMI z-score of children on effect sizes was also assessed – this was not possible for food
preferences because of the small number of effect sizes. Analyses by SES, sex, gender, rurality or region
(i.e. HICs and LMICs) were not possible.
A total of 20 studies (12 RCTs and eight experimental non-randomized studies) provided evidence on
the impact of exposure to food marketing on the critical outcome of food preferences. Pooled analysis
of 14 effect sizes from 12 studies found a standardized mean difference in food preferences of 0.30 (95%
confidence interval (CI): 0.12–0.49; Z = 3.21; P = 0.001; I2 = 90.0%), indicating a significant effect of exposure
to food marketing on food preference compared with exposure to no, less or less powerful food marketing.
There was no statistical evidence that study design type, marketing manipulation type or marketing
medium significantly moderated the effect size. Eight studies lacked the required data to be included in
the pooled analysis – four of these found a significant association, two reported an association but did not
report statistical testing, one showed apparently similar preferences between the exposure and control,
and one found no significant association. According to the GRADE assessments for both the pooled analysis
and all data, there is very low certainty evidence from RCTs and very low certainty observational evidence
about the effect of food marketing on food preferences (10).
A total of 37 studies (27 RCTs and 10 experimental non-randomized studies) provided evidence on the
impact of exposure to food marketing on the critical outcome of food choice1 or intended choice. Pooled
analysis of 27 effect sizes from 27 studies found an odds ratio of 1.77 (95% CI: 1.26–2.50; Z = 3.27; P < 0.001;
I2 = 77.5%), indicating that exposure to food marketing was associated with 1.77 times the odds of choice of
the test item compared with exposure to no, less or less powerful food marketing. There was no statistical
evidence that study design type, marketing manipulation type, marketing medium, risk of bias or mean
age of children significantly moderated the effect size. Ten studies lacked the required data to be included
in the pooled analysis – six of these found a significant association, two found no significant association,
one reported greater choice of the test item in the control condition but did not report test statistics (the
authors suggested that this was due to issues with the demographic targeting of characters to children,
with liking of characters very dependent on the age and sex of children), and one reported an association
but did not report statistical testing. According to the GRADE assessments for both the pooled analysis
and all data, there is moderate certainty evidence from RCTs that food marketing likely increases choice of
marketed foods and very low certainty observational evidence about the effect of food marketing on food
choice or intended choice (10).
1
The term “food choice” is used to describe the outcome of interest. Food choice refers to selection of one food over another
(or others) from a given selection of foods and hence is limited by the foods available.
A total of 46 studies (31 RCTs and 15 non-randomized studies – seven experimental and eight observational)
provided evidence on the impact of exposure to food marketing on the critical outcome of dietary intake.
Pooled analysis of 43 effect sizes from 41 studies found a standardized mean difference in dietary intake
of 0.25 (95% CI: 0.15–0.35; Z = 4.88; P < 0.001; I2 = 76.6%), indicating a significant effect of exposure to food
marketing on dietary intake compared with no, less or less powerful food marketing. There was no statistical
evidence that study design type, marketing manipulation type, marketing medium, risk of bias, mean age of
children or mean BMI z-score significantly moderated the effect size. Five studies lacked the required data
to be included in the pooled analysis – three of these studies found a significant association, and two found
no significant association. According to the GRADE assessments for both the pooled analysis and all data,
there is moderate certainty evidence from RCTs that food marketing likely increases dietary intake slightly
and very low certainty observational evidence about the effect of food marketing on dietary intake (10).
As pooled analysis could not be completed for the important outcome of product requests or intended
requests, because of a small number of studies and lack of reporting of relevant statistics, P value
combination was used. Six studies (five RCTs and one observational non-randomized study) provided
evidence. The combination of P values was significant in all model iterations (P < 0.001), indicating an effect
of food marketing on product requests or intended requests. According to the GRADE assessment, there is
moderate certainty evidence from RCTs that food marketing likely increases product requests or intended
requests and very low certainty observational evidence about the effect of food marketing on product
requests or intended requests (10).
As a result of the limited availability of P values, vote counting by direction of effect was used for the
remaining critical outcome of food purchasing/sales or intended purchasing and the important outcomes
of dental caries/erosion and body weight/BMI/obesity. The five effect directions were clear effect of public
health harm, unclear effect of potential public health harm, no difference in effect, unclear effect of potential
public health benefit, and clear effect of public health benefit. No relevant studies were identified for the
important outcome of diet-related NCDs (or validated surrogate indicators).
Five studies (one RCT and four non-randomized studies – one experimental and three observational)
provided evidence on the impact of exposure to food marketing on the critical outcome of food purchasing/
sales or intended purchasing. Of the five studies, one reported a clear effect of public health harm, one an
unclear effect of potential public health harm, two no significant association, and one a clear effect of public
health benefit (a significantly higher proportion of orders for fruit desserts on days when fruit desserts
were promoted). According to the GRADE assessment, there is very low certainty evidence from RCTs and
very low certainty observational evidence about the effect of food marketing on food purchasing/sales or
intended purchasing (10).
Two studies (both observational non-randomized studies) provided evidence on the impact of exposure
to food marketing on the important outcome of dental caries/erosion. One study reported a clear effect of
public health harm, whereas the other study reported no significant association. According to the GRADE
assessment, there is very low certainty observational evidence about the effect of food marketing on dental
caries/erosion (10).
A single observational non-randomized study provided evidence on the impact of exposure to food
marketing on the important outcome of body weight/BMI/obesity. The study reported no significant
association. According to the GRADE assessment, there is very low certainty observational evidence about
the effect of food marketing on body weight/BMI/obesity (10).
3.2 Evidence on effectiveness of policies to restrict food marketing

to which children are exposed
A total of 44 observational studies, reported in 47 records, were included in the systematic review on the
effectiveness of policies to restrict food marketing to which children are exposed (8). Table 1 outlines
the population, intervention, comparator and outcomes that guided the review, and Annex 8 provides
the GRADE evidence profile. The search was conducted in March 2019 and updated in March 2020. The
44 included studies assessed the impact of 14 policies (including two subnational policies1 and one regional
1
Quebec (Canada) and San Francisco (United States)
policy1) implemented in 10 countries2 and one region (the European Union) (see Annex 10 for details of
included policies). Seven policies were voluntary measures. Only one study used a natural experiment
design;3 all others had cross-sectional designs. All but one of the studies were conducted in HICs; the one
study conducted in an LMIC was from Mexico.
Because of the nature of the available evidence, comparators were not consistent for all studies. Studies
were therefore considered according to five comparisons:
comparison 1 – any policy compared with no policy (includes all studies from comparisons 2 and 3);
comparison 2 – mandatory policy compared with no policy (i.e. post-implementation compared with
pre-implementation);
comparison 3 – voluntary policy compared with no policy (i.e. post-implementation compared with pre-
implementation, or signatory companies compared with non-signatory companies);
comparison 4 – mandatory policy compared with voluntary policy;4 and
comparison 5 – fully implemented mandatory policy compared with partially implemented mandatory
policy.
Pooled analysis could not be completed for any of the outcomes of interest, because of the heterogeneity in
effect measures5 and the lack of data required for computation of effect sizes. Because of the lack of effect
estimates and limited number of P values, vote counting using five effect directions was used to synthesize
results for the critical outcomes of exposure to food marketing, power of food marketing, food purchasing/
sales or intended purchasing and dietary intake, and the important outcomes of product changes and
unintended consequences to wider society by outcome of interest for the five comparisons described above.
The five effect directions were clear effect favouring the intervention, unclear effect potentially favouring
the intervention, no difference in effect, unclear effect potentially favouring the control, and clear effect
favouring the control. Fig. 3 shows the results of the vote counting for each outcome and each comparison.
No evidence was found for the critical outcomes of food preferences and food choice or intended choice,
and the important outcomes of product requests or intended requests, dental caries/erosion, body weight/
BMI/obesity and diet-related NCDs (or validated surrogate indicators).
Where possible, subgroup analyses compared findings based on the target age group, marketing medium,
approach to determining foods restricted from marketing, and marketing technique.6 As pooled analyses
could not be completed, formal sensitivity analyses were not possible – instead, results were synthesized
narratively. Because of data limitations, it was not possible to complete subgroup analyses for children by
body weight/BMI/obesity, SES, age group, sex, gender, rurality or region (i.e. HICs and LMICs).
Overall, 37 studies provided evidence on the effect of food marketing policy on the critical outcome of
exposure to food marketing. Of these, four studies reported effects clearly favouring the intervention
(i.e. considered desirable for public health), 11 reported unclear effects potentially favouring the intervention,
seven reported no effects of the intervention, 11 reported unclear effects potentially favouring the control
(i.e. considered undesirable for public health), and four reported effects clearly favouring the control. As
shown in Fig. 3, however, the distribution of studies varied between the comparisons – studies comparing
mandatory policy with no policy were more likely to report effects clearly or potentially favouring the
intervention (five out of seven studies – 71% of studies) than studies comparing voluntary policy with no
policy (eight out of 26 studies – 31% of studies). Additionally, studies comparing voluntary policy with no
1
European region
2
Australia, Canada, Chile, Germany, Mexico, Republic of Korea, Singapore, Spain, United Kingdom, United States
3
Evaluation of the Quebec Consumer Protection Act, Canada (68)
4
When mandatory policy was compared with voluntary policy, mandatory policy was considered the stronger policy because
of its mandatory nature and therefore uniform application.
5
As an example, the effect measures for the outcome of exposure to food marketing included the number of food
advertisements, the rate of food advertisements, the proportion of all advertisements that were for food, the proportion of
all advertisements that were for HFSS foods, the proportion of food advertisements that were for HFSS foods, nutritional
quality of advertised foods, gross rating points (a measure of audience size) and person-minute-views (the viewing audience
multiplied by the length of advertisements).
6
Details of the additional analyses are available in the supplementary material (Appendix D–H) to the systematic review (8),
except for the subgroup analyses of studies evaluating policies using government-led nutrient profile models and company-
led nutrient profile models, which is shown in the GRADE evidence profile (Annex 8). This analysis was conducted following
publication of the systematic review, but deemed relevant because of the clarification it provides.
Fig. 3. Harvest plot of the effects of policies to restrict food marketing to which
children are exposed
Unclear effect Unclear effect

Outcome and Clear effect Clear effect
potentially potentially
certainty of favouring the No difference favouring the
favouring the favouring the
evidence intervention control
intervention control
Exposure
(critical outcome)
㊉◯◯◯
Comparison 2 ¢ ¢¢¢¢ ¢ ¢
Comparison 3 ¢¢ ¢¢¢¢¢¢ ¢¢¢¢¢ ¢¢¢¢¢¢¢¢¢¢ ¢¢¢
Comparison 4 ¢ ¢ ¢
Comparison 5 ¢
Power (critical outcome)
㊉◯◯◯
Comparison 2 ¢ ¢¢
Comparison 3 ¢ ¢ ¢¢¢¢¢¢ ¢¢¢¢¢
Comparison 4 ¢ ¢
Purchasing
(critical outcome)
㊉㊉◯◯
Comparison 2 ¢ ¢
Comparison 3 ¢¢
Comparison 4 ¢
Diet (critical outcome)
㊉◯◯◯
Comparison 2 ¢
Product change
(important outcome)
㊉◯◯◯
Comparison 2 ¢
Comparison 3 ¢
Unintended
consequences
(important outcome)
㊉㊉◯◯
Comparison 2 ¢ ¢¢
Each block represents one study. Dark shading = high quality study. Certainty of the evidence = ㊉◯◯◯ very low;
㊉㊉◯◯ low; ㊉㊉㊉◯ moderate; ㊉㊉㊉㊉ high
Notes: Comparison 2 compared mandatory policy with no policy (i.e. post-implementation compared with pre-
implementation). Comparison 3 compared voluntary policy with no policy (i.e. post-implementation compared with pre-
implementation, or signatory companies compared with non-signatory companies). Comparison 4 compared mandatory
policy with voluntary policy. Comparison 5 compared fully implemented mandatory policy with partially implemented
mandatory policy.
policy were significantly more likely to show effects on exposure to, and the power of, food marketing that
were unfavourable to public health than effects that were favourable; this was not the case for studies
comparing mandatory policy with no policy. Of studies comparing any policy with no policy, subgroup
analyses of other policy design elements showed that some studies were more likely than others to report
effects clearly or potentially favouring the intervention.
Studies of policies designed to restrict food marketing to children including those older than 12 showed
benefits on exposure more often (six out of eight studies) than studies evaluating policies designed to
restrict food marketing to children that included only children aged 12 or younger (seven out of 25 studies).
Additionally, studies evaluating policies designed to restrict food marketing to children that included only
children aged 12 or younger were significantly more likely to report unfavourable than favourable effects
on exposure; this was not the case for studies evaluating policies designed to restrict food marketing to
children including those older than 12 years.
Studies of policies that addressed exposure to television food marketing and to packaging more often found
a beneficial impact on exposure (12 out of 29 studies and one of one studies, respectively) than did studies
of policies that addressed exposure to digital marketing (zero of three studies; all three assessed policies
were voluntary).
Studies of policies that used a government-led nutrient profile model more often found a beneficial impact
on exposure (five out of six studies) than did studies of policies that used a company-led nutrient profile
model (eight out of 25 studies). Additionally, studies evaluating policies that used a company-led nutrient
profile model were more likely to report unfavourable than favourable effects on exposure; this was not the
case for studies evaluating policies that used a government-led nutrient profile model.
Some studies reporting on exposure to marketing also provided information about the potential migration
of marketing following policy implementation. For example, a study included in the systematic review
demonstrated that after the prohibition in the United Kingdom of Great Britain and Northern Ireland of
television advertising of HFSS foods on all children’s channels and on non-children’s channels during or
around programmes “of particular appeal” to children, children’s relative exposure to television advertising
of HFSS foods did not change because of an apparent migration of such advertising to other times and
channels that children also viewed (17). Another study included in the systematic review demonstrated
that, following the implementation of a policy focused on children younger than 12 in the United States of
America, there was a decrease in in the average food and beverage television advertisements 2–11 year-olds
viewed per year, but an increase for 12–17 year-olds, suggesting migration of marketing to non-restricted
spaces (16).
A total of 18 studies provided evidence on the effect of food marketing policy on the critical outcome of
power of food marketing. Of these, three studies reported effects clearly favouring the intervention, two
reported unclear effects potentially favouring the intervention, one reported no effects of the intervention,
six reported unclear effects potentially favouring the control, and six reported effects clearly favouring the
control. As with exposure to food marketing, the distribution of studies varied between the comparisons
(Fig. 3) – studies comparing mandatory policy with no policy were far more likely to report effects clearly or
potentially favouring the intervention (three out of three studies – 100% of studies) than studies comparing
voluntary policy with no policy (one out of 13 studies – 8% of studies). Additionally, studies comparing
voluntary policy with no policy were significantly more likely to show effects on the power of food marketing
that were unfavourable to public health than effects that were favourable; this was not the case for studies
comparing mandatory policy with no policy. Of studies comparing any policy with no policy, subgroup
analyses of other policy design elements showed that some studies were more likely than others to report
effects clearly or potentially favouring the intervention.
Studies evaluating policies designed to restrict food marketing to children including those older than
12 years more often reported favourable effects on power (in three out of four studies) than studies
evaluating policies designed to restrict food marketing only to children that included only children aged 12
or younger (one out of 12 studies). Additionally, studies evaluating policies that were designed to restrict
food marketing to children that included only children aged 12 or younger were significantly more likely to
report unfavourable than favourable effects; this was not the case for studies evaluating policies designed
to restrict food marketing to children including those older than 12 years.
Studies evaluating policies (most of which were voluntary) that restricted the use of promotional characters
more often reported favourable effects on power (in three out of 10 studies) than studies evaluating
policies that restricted a broader range of child-appealing persuasive techniques (one out of five studies)
or animation techniques (zero out of one study). Most of the studies included in this analysis evaluated
voluntary policies.
Studies evaluating policies that addressed power of television food marketing or packaging were more often
reported to have favourable effects on power (in three out of 10 studies, and in one out of three studies,
respectively) than were policies that addressed power of digital marketing (zero out of three studies; all
three assessed policies were voluntary).
Five studies provided evidence on the effect of food marketing policy on the critical outcome of food
purchasing. Of these, four studies reported effects clearly favouring the intervention, and one study
reported effects clearly favouring the control.
One study provided evidence on the effect of food marketing policy on the critical outcome of dietary
intake; the study reported effects clearly favouring the intervention.
Two studies provided evidence on the effect of food marketing policy on the important outcome of product
change. Of these, one study reported no effects of the intervention, and one study reported effects clearly
favouring the control.
Three studies provided evidence on the effect of food marketing policy on the important outcome of
unintended consequences to wider society. Of these, one study reported effects clearly favouring the
intervention (a statistically significant reduction in expenditure on television advertising of HFSS foods),
and two reported unclear effects potentially favouring the intervention (a reduction in spending on
television advertising of HFSS foods, and a reduction in net food and drink advertising revenue on children’s
channels). These changes were considered favourable to public health.
3.3 Evidence on contextual factors

A total of 244 publications were included in the review of contextual factors relevant to policies to protect
children from the harmful impact of food marketing (11). The overall aim of the review was to search for,
identify, summarize and present information on the impact of contextual factors on implementation of
policies to protect children from the harmful impact of food marketing.
Fifty-eight publications provided evidence related to values. Study populations varied in their values about
body weight status. In HICs, overweight and obesity were generally perceived as a serious health problem.
Women were more likely than men to perceive overweight and obesity (especially childhood obesity) as
a serious health problem, as were people of lower SES compared with their higher SES counterparts. In
contrast, in many studies from LMICs, overweight and obesity were perceived as indicating good health or
interpreted as “normal weight”. However, in some countries that have perceived overweight and obesity
as indicating good health, values are changing, and normal-weight BMI is increasingly considered healthy.
In contrast to values about body weight status, there was no variability in values about diet-related NCDs,
or dental caries and erosion in children, which were perceived negatively in all identified studies. Limited
information was identified on the potential impact of food marketing on values or whether consumers
value “non-misleading” information.
Nine publications provided evidence related to resource implications. Evidence was identified in modelling
studies and impact assessments, from both HICs and LMICs. The expected costs of such policies, expected
health gains, expected health care cost savings and cost-effectiveness differed depending on country
context, and the design and regulatory nature of policies. All identified modelling studies, however, found
that policies to protect children from the harmful impact of food marketing would be cost-effective or cost-
saving. Studies noted that, like other interventions targeting children, policies to protect children from
the harmful impact of food marketing may take some time to have an impact. Costs included in various
studies included planning, implementation and compliance costs; savings typically included health care
cost savings. One study estimated that self-regulation would be less costly than government regulation, but
that its effects would also be less because of presumed lower compliance.
Fifty-nine publications provided evidence related to human rights and equity. Policies to protect children
from the harmful impact of food marketing are in accordance with human rights standards. The Universal
Declaration of Human Rights; the International Covenant on Economic, Social and Cultural Rights; and the
Convention on the Rights of the Child provide the legal framework for a child rights-based approach to
optimal nutrition and health. Publications included in the review outlined how unregulated food marketing
may jeopardize the fulfilment of the Convention on the Rights of the Child, including in relation to Article 24
(the right to health) and Article 17 (protection from material injurious to well-being). The Convention on the
Rights of the Child articulates the rights of children, including those to health, adequate and nutritious food,
privacy and freedom from exploitation. Countries that are State Parties to the Convention on the Rights of
the Child have legal obligations to respect, protect and fulfil these rights and are required to take immediate
action to implement these obligations as a matter of priority (12). State Parties to the Convention on the
Rights of the Child are therefore obliged to take action toward the fulfilment and realization of children’s
rights, which should include actions to protect children from marketing of less-healthy foods, which inhibits
children’s rights, such as the rights to health, adequate and nutritious food, privacy and freedom from
exploitation (12). The Committee on the Rights of the Child, in a 2013 general comment on the right of the
child to the enjoyment of the highest attainable standard of health, stated that the marketing of HFSS foods
should be regulated (49). An area of increasing focus in relation to children’s rights and food marketing is
marketing through online media. In a 2021 general comment on children’s rights in relation to the digital
environment, the Committee on the Rights of the Child noted that State Parties should “make the best
interests of the child a primary consideration when regulating advertising and marketing addressed to and
accessible to children” (15). The general comment specifically addresses food marketing to which children
are exposed by noting that State Parties “should regulate targeted or age-inappropriate advertising,
marketing and other relevant digital services to prevent children’s exposure to the promotion of unhealthy
products, including certain food and beverages, alcohol, drugs, tobacco and other nicotine products”
(15). The general comment also notes that “such regulations relating to the digital environment should be
compatible and keep pace with regulations in the offline environment” (15). Special Rapporteurs on the
right of everyone to the enjoyment of the highest attainable standard of health and the right to food have
also emphasized the need for regulation of food marketing.
Limited evidence was identified on the impact on health equity of policies to protect children from the
harmful impact of food marketing. However, research in HICs shows that children of lower SES are more
exposed to food marketing than children of higher SES, and this can lead to, or worsen, health inequities.
As such, policies to protect children from the harmful impact of food marketing can be expected to reduce
health inequities. Reflecting this, a modelling study from Australia found that restrictions on food marketing
to children on television were likely to have greater health benefits and greater health care cost savings for
children of lower SES than for those of higher SES.
A total of 118 publications provided evidence related to acceptability. The evidence showed that acceptability
of policies to protect children from the harmful impact of food marketing varied greatly by stakeholder.
The existence of policies, or national action plans that recommend implementation of policies, indicates
acceptability to government and policy-makers. For example, 40% of the 167 participating countries
in the most recent global nutrition policy review reported including the regulation of food marketing to
which children are exposed as an action area in national nutrition policies. However, few countries have
implemented comprehensive policies to restrict food marketing to which children are exposed – 42 countries
reported in the second global nutrition policy review that they have measures in place, which included
guidelines or codes (voluntary or mandatory); few measures were integrated into national law. Evidence
identified from HICs indicates that policies to protect children from the harmful impact of food marketing
are largely acceptable to the public. Women were consistently more supportive than men. Support also
varied by age, ethnicity and SES. There was a lack of evidence from LMICs. Industry generally opposed
government-led restrictions, but offered voluntary self-regulatory policies as an alternative. When initiated
by industry, such policies can be considered a strategy to prevent the introduction of strong, legally
enforceable government regulations. Limited evidence was found relating to environmental acceptability.
Thirty-two publications provided evidence related to feasibility. The existence of policies in some countries
to protect children from the harmful impact of food marketing points to their feasibility, although many
countries are yet to develop or implement such policies. Evidence identified on feasibility showed that
facilitators of the development and implementation of policies include strong political leadership,
supporting evidence, intersectoral collaboration and community support. Barriers to development and
implementation include complexity of regulatory processes, conflicting interests, a lack of financial and
human resources, industry interference, a weak evidence base, and ambiguous categorization of, or lack
of criteria for, foods for which marketing is to be restricted or banned. Facilitators of monitoring and
enforcement include clear guidelines and protocols, independent monitoring, transparency and monetary
penalties. Barriers to monitoring and enforcement include a lack of transparency and accountability,
conflicting interests in reporting of compliance, methodological difficulties, and inadequate human and
financial resources.
4. Good-practice statement
and recommendation
Good-practice statement
Children of all ages should be protected from marketing of foods that are high in saturated fatty acids,
trans-fatty acids, free sugars and/or salt.
Statement rationale
The good-practice statement was formulated by the NUGAG Subgroup on Policy Actions based on several
key considerations.
Children continue to be exposed to powerful marketing of HFSS foods, consumption of which is
associated with negative health effects (8, 9). Such marketing is prevalent (including on packaging, in
settings where children gather (e.g. schools and sports clubs), during children’s viewing times and on
children’s channels, in youth magazines, and on social media) and uses many techniques appealing to
young audiences (9). Digital marketing is of growing concern because it facilitates engagement, which
can amplify the marketing message and overall impact of marketing (9).
Food marketing negatively affects children’s food choice or intended choice (odds ratio 1.77; 95%
confidence interval (CI): 1.26–2.50) and dietary intake (standardized mean difference 0.25; 95% CI: 0.15–
0.35) (10). It also affects children’s product requests to adults for marketed foods (10), and negatively
influences the development of children’s norms about food consumption (9).
Enabling children of all ages to achieve their full developmental potential is a human right and a critical
foundation for sustainable development. Children’s rights, including their rights to health, adequate
and nutritious food, privacy, and to be free from exploitation, are threatened by the marketing of HFSS
foods (11–13).
Countries that are State Parties to the Convention on the Rights of the Child have a legal obligation to
ensure that children’s rights are respected, protected and fulfilled. According to general comments on
the Convention, countries that are State Parties to the Convention should use appropriate regulation
to ensure that marketing does not have adverse impacts on children’s rights, and should make the
best interests of the child a primary consideration when regulating marketing that is addressed and
accessible to children (14, 15).
22
WHO recommendation
WHO suggests implementation of policies to restrict marketing of foods high in saturated fatty acids,
trans-fatty acids, free sugars and/or salt to which children are exposed, and that such policies:
¡¡ be mandatory;
¡¡ protect children of all ages;
¡¡ use a government-led nutrient profile model to classify foods to be restricted from marketing;
¡¡ be sufficiently comprehensive to minimize the risk of migration of marketing to other media, to
other spaces within the same medium or to other age groups; and
¡¡ restrict the power of food marketing to persuade.
(Conditional recommendation)
Recommendation remarks
These remarks provide context for the recommendation and are to facilitate interpretation and
implementation.
‘Children’ refers to all human beings below the age of 18, as defined by the Convention on the Rights of
the Child, unless, under the law applicable to children, majority is attained earlier.
The impact of marketing is a function of both exposure and power.
—— Exposure is the reach (percentage of people in a target market who are exposed) and frequency
(the number of times an average person is exposed) of a marketing communication, message or
action. Policies should address children’s exposure to food marketing, irrespective of timing, venue
or intended audience, and should therefore go beyond children’s media.
—— Power refers to the extent to which a marketing communication, message or action achieves its
communications objectives. Power is influenced by the creative content and strategies used. The
power of food marketing to persuade children relates to techniques appealing to children, including
promotional characters, branding, emotional appeals, games, engagement techniques, interactive
or downloadable content, and celebrity endorsements (9); these techniques impact dietary intake
(10).
Migration of marketing refers to the movement of marketing from restricted to unrestricted mediums
or spaces (e.g. if a policy restricts marketing on television but not digital marketing, digital marketing
may increase).
A nutrient profile model is a tool for classifying foods according to their nutritional composition for
reasons relating to preventing disease and promoting health. Nutrient profile models in the context of
food marketing help define foods to be restricted from marketing and should align with national dietary
guidelines.
Recommendation rationale
The recommendation was formulated by the NUGAG Subgroup on Policy Actions based on several key
considerations (below and Table 2).
Based on evidence from a systematic review that assessed the effectiveness of policies to restrict food
marketing to which children are exposed (8), the group judged policies to have moderate desirable
effects and trivial undesirable effects and judged the overall balance between desirable and undesirable
effects to favour the intervention. Following application of the GRADE approach (see section 2.2), the
certainty of the evidence from the systematic review was considered very low, therefore the group
made a conditional recommendation. The group noted that the relevant policy evaluations were all
observational studies, leading to lower certainty of evidence when applying the GRADE system, and that

the inconsistency of effect, which led to downgrading of the certainty of evidence for some outcomes,
was partly due to variation in policy design elements.
The group judged policies to be cost-effective, feasible and generally acceptable to government,
policy-makers and the public, but less so to industry. Further, implementation of policies supports the
realization of human rights and will probably support improved health equity.
Some policy design elements are likely to be effective in protecting children from marketing of HFSS
foods, but others are more likely to lead to unfavourable effects. The recommendation therefore
specifies elements that maximize the effectiveness of policies, as identified in the systematic review (8).
—— Of studies evaluating voluntary policies, significantly more studies showed undesirable effects than
evaluating mandatory policies (8).
—— Of studies evaluating policies designed to restrict food marketing to children that included only
children aged 12 years or younger, significantly more studies showed undesirable effects than
evaluating policies that included children older than 12 (8).
—— Of studies evaluating policies that used a company-led nutrient profile model to define foods to
be restricted from marketing more studies showed undesirable effects than desirable effects
on exposure to food marketing. This was not the case for studies evaluating policies that used a
government-led nutrient profile model.
—— Some studies indicated that policies that were too narrow in scope (i.e. not comprehensive) may
have led to migration of marketing (e.g. from children’s television programmes to non-children’s
television programmes, from younger to older age groups) (16, 17).
—— Food marketing uses strategies that appeal to young audiences (9), and marketing using such
strategies affects food choice and dietary intake (10). Studies indicated that mandatory policies result
in reductions in use of powerful marketing strategies, such as the use of promotional characters and
other persuasive techniques that appeal to children (8).
Table 2. Additional considerations by the NUGAG Subgroup on Policy Actions to

determine the direction and strength of the recommendation
Decision criteria and
Additional considerations
judgement
Magnitude of desirable The policies included in the systematic review on the effectiveness of policies
effects of implementing to restrict food marketing to which children are exposed varied greatly in their
a policy: moderate design. When comparing any policy with no or other policies, the group judged
the magnitude of the desirable effects to be variable. Following discussions on the
results of additional comparisons and of subgroup analysis, the magnitude of the
desirable effects was judged as moderate. The group agreed that the policy design
elements that were more likely to result in effects favourable to public health
should be clearly listed in the recommendation; these included the policy approach
used, target age group, and approach to defining foods whose marketing was to be
restricted.
Most evidence is from HICs, but the group considered it unlikely that the effects
of the intervention would be substantially different in low- and middle-income
countries (LMICs).
Food environment policies are complex interventions. Many factors influence the
relevant outcomes of interest (Fig. 2). The intervention’s impact on the outcomes
of interest could be amplified if it is implemented alongside complementary food
environment policies.
judgement
Magnitude of No undesirable effects on health outcomes of implementing policies to restrict
undesirable effects of food marketing to which children are exposed were identified in the reviews.
implementing a policy:
Based on the results of the systematic review and experience in countries, the
trivial
group noted that policies that are too narrowly defined could have undesirable
effects, including:
migration of marketing to other media;
migration of marketing to other spaces within the same medium or to other age
groups; and
risk of increased marketing of brands in place of marketing of specific products.
Overall, the magnitude of the undesirable effects of implementing a policy to
restrict food marketing to which are children are exposed was judged as trivial,
if the approach to marketing restrictions is comprehensive and if policy design
uses elements identified by the additional comparisons and subgroup analyses as
favourable to public health.
Balance of desirable Based on the available evidence, country experience and discussions on the results
and undesirable of additional comparisons and of subgroup analyses, the balance of desirable and
effects: probably undesirable effects was judged to probably favour the intervention.
favours the
intervention
Overall certainty of There was a high level of heterogeneity in the evidence.
evidence: very low
The inconsistency of effect was partly due to variation in policy design elements
(i.e. the policy approach, target age group and approach to defining foods to be
restricted from marketing).
The relevant policy evaluations were all observational studies, leading to lower
certainty of evidence when applying the GRADE system.
Cost-effectiveness: Evidence was based on modelling studies and showed the intervention was cost-
favours the effective.
intervention
Resources required: The costs should be considered in the context of, and relative to, total government
moderate costs expenditure on health and preventive health.
Both one-off costs (e.g. policy drafting and enactment) and ongoing costs
(e.g. monitoring and enforcement) should be considered.
The costs considered should be costs to government and not costs to other actors
(e.g. industry).
Country experience showed that some countries may previously have
underestimated the resources required.
Impact of policy Research, mainly from HICs, shows that children of lower SES are more exposed to
implementation on food marketing than children of higher SES, which can lead to, or worsen, health
equity: probably inequities.
increased
Low-agency public health interventions (i.e. public health interventions that do not
rely on, or rely less on, the conscious actions of individuals) are likely to increase
health equity.
Impact of policy Children’s rights are an important consideration for country action to restrict
implementation marketing. New marketing media and techniques, particularly digital marketing,
on human rights: are of increasing concern.
increased
Current safeguarding mechanisms permitting advertising in the digital space
(e.g. age-appropriate videos on social media platforms) are unlikely to work in
practice.
Additional challenges arise with increased digital marketing, including respecting
the right to privacy.

judgement
People’s values related The group noted the importance of valuing children’s health, the need to protect
to the outcomes of the health of the vulnerable, and the role of governments in enabling decision-
policy implementation: making that protects health.
probably no important
uncertainty or
variability
Acceptability of the Generally, policies are acceptable to government, policy-makers and the public,
policy to key actors: but less so to industry.
varies
Acceptability to industry depends on the type of policy proposed. Industry
generally prefers voluntary to mandatory policies.
Acceptability to government may vary between ministries. This could relate to
industry being a core stakeholder for some ministries (e.g. industry, commerce and
communications), and to concerns about potential economic impacts on related
sectors.
Most evidence is from HICs. It is unclear whether acceptability would be different in
LMICs.
Feasibility of Countries that have successfully implemented policies have shown that policies
implementing the can be implemented, and that well-designed policies do not pose substantive trade
policy: yes concerns.
The nutrient profile models developed by the WHO regional offices can be adapted
by countries; they help identify foods to be restricted from marketing and may
increase feasibility.
Industry influence may be a barrier to implementation of effective policies.
Providing clear guidance to countries may remove fears of complexity and increase
feasibility.
HIC: high-income country; LMIC: low- and middle-income country; SES: socioeconomic status.
5. Implementation
considerations
This chapter is not intended to provide an exhaustive list of implementation considerations. Instead, it aims
to highlight some key considerations. These considerations:
emerged from the systematic review on the effectiveness of policies to restrict food marketing to which
children are exposed (8);
were mentioned by the NUGAG Subgroup on Policy Actions in the development of this guideline; and/or
come from existing implementation resources – particularly the 2023 WHO/UNICEF publication Taking
action to protect children from the harmful impact of food marketing: a child rights-based approach
(57) and the 2012 WHO publication A framework for implementing the set of recommendations on the
marketing of foods and non-alcoholic beverages to children (47).
The WHO/UNICEF publication Taking action to protect children from the harmful impact of food marketing:
a child rights-based approach provides step-by-step guidance through the four main stages in the policy
cycle (preparation; development; implementation; and monitoring and evaluation) – integrating both a
public health lens and a child rights lens – as summarized in Table 3 (57). In line with this guideline’s good-
practice statement, policies should be formulated in the best interests of children, and apply the policy
design elements specified in this guideline’s recommendation.
During the preparation stage, it is important to consider the country context. This includes the country’s:
nutritional situation;
cultural context;
locally available foods;
dietary customs;
available resources and capacities;
existing governance structures and mechanisms (including mechanisms to identify and manage
conflicts of interest and to safeguard public health policies and enforcement mechanisms);
policy context (relevant legal and policy frameworks, potential regulatory pathways and the overall
political economy); and
stakeholders with an interest in the policy outcome and whether, or at what stage, they may be engaged
in the policy process to optimise policy effectiveness and implementation while protecting public health
objectives (see Fig. 2).
The review of contextual factors highlighted factors that may facilitate the development and implementation
of policies to protect children from the harmful impact of food marketing. These include strong political
leadership, supporting evidence, community support, intersectoral collaboration, and mechanisms
to protect the public interest and avoid conflict of interest (11). Factors that hinder development and
implementation include complex regulatory processes, conflicts of interest, lack of financial and human
resources, industry interference, a weak evidence base, and ambiguous categorization of (or a lack of
criteria for categorization of) foods for which marketing is to be restricted or banned (11).
Given that marketing and regulatory landscapes are complex, a situation analysis of both is a useful tool for
policy development (47). Reviewing existing laws and policies is important to identify gaps, and potential
regulatory pathways and mechanisms for the implementation of marketing restrictions. Potentially relevant
27
Table 3. Steps involved in each main stage of the policy cycle for policies to protect
children from the harmful impact of food marketing (adapted from 57)
Preparation Development Implementation Monitoring and evaluation
Gather information Agree on the Finalize the Establish a framework
on the health and intended instrument instrument and to monitor and
nutrition situation in to implement the implementation plans evaluate policy impact
the country policy measure, the – define methods,
Set up the
objective(s) and indicators and data
Collect information on monitoring and
scope; define the needs
exposure and power enforcement system
key components of
of marketing (including protocol Monitor the extent of
the restrictions and
development) implementation of,
Review existing laws ensure alignment with
and compliance with,
and policies and other policies and Build capacity to
the instrument
identify potential laws implement, monitor
legal entry points for and enforce Leverage the
Conduct a child rights
reform Convention on the
impact assessment of Raise public
Rights of the Child
Identify the lead policy options awareness
reporting cycle for
government authority/
Consult the public on Apply meaningful additional evaluation
agency
the proposed policy sanctions for purposes and involve
Identify key options violations national human rights
stakeholders institutions
Consider, and prepare
Advocate for political to defend, possible Communicate results
buy-in, form a steering legal challenges of evaluation
committee, and against the policy
Revise and revisit
anticipate opposition
Plan for compliance
Manage conflicts of monitoring and
interest enforcement
Engage with Plan for monitoring
children, civil society and evaluation
organizations and
Allocate budget
academia throughout
to support
the process
implementation,
monitoring,
enforcement and
evaluation
controls and agencies to include in a regulatory landscape situation analysis vary between countries, but
could include:
public health policies, legislation and institutions;
media controls and regulating authorities;
child protection legislation and agencies;
regulation and enforcement agencies relevant to food labelling, composition and distribution;
regulations and institutions relevant to consumer protection and consumer rights;
planning and zoning controls on food retailing, catering and outdoor marketing; and
school regulations and education authorities (47).
To implement the recommendation in this guideline, countries may choose to strengthen existing policies
and/or develop and implement new policies.
During the preparation stage, it is also important for policy developers to anticipate opposition (57). The
2023 WHO/UNICEF publication Taking action to protect children from the harmful impact of food marketing:
a child rights-based approach lists common arguments and legal challenges against policies to protect
children from the harmful impact of food marketing. It provides counterarguments based on a child rights-
based approach and the available scientific evidence, and gives steps to strengthen the government’s legal
position in the event of challenge (57). Clear, transparent and robust conflict of interest guidelines and
mechanisms that cover all stages of the policy cycle should also be adopted during the preparation stage
(57).
During the development stage, when a government is deciding on key design issues, some factors should be
borne in mind to maximize effectiveness. These include:
the instrument to be used to implement restrictions on food marketing to which children are exposed;
the regulatory objectives;
the scope and definitions of the key components of the policy (57);
the policy design elements specified by the recommendation in this guideline (i.e. taking a mandatory
approach, protecting children of all ages, using a government-led nutrient profile model, being
sufficiently comprehensive, restricting the power of food marketing to persuade).
The nutrient profile models for regulating food marketing to which children are exposed developed by the
WHO regional offices (2–7) provide an existing tool that countries can use.
As highlighted by the 2012 WHO report A framework for implementing the set of recommendations on the
marketing of foods and non-alcoholic beverages to children, efforts to restrict marketing must consider how
brands are marketed (47). If brand marketing is not included within a policy’s scope, a possible unintended
consequence may be an increase in brand advertising and sponsorship by brands synonymous with
less-healthy products (in place of marketing for the products themselves) (57). Possible approaches that
countries could use to restrict brand marketing include classifying brands as permitted or not permitted
based on whether their top-selling products are classified as healthy or unhealthy (47) and restricting
marketing of brands that are synonymous with less-healthy products (69).
When agreeing on the scope and defining the key components of a policy, an additional key consideration is
the incorporation of provisions for cross-border marketing (i.e. marketing via material that is produced in one
country and sold, shared, downloaded or consumed in others) (57). Cross-border marketing presents some
challenges to national policies. However, government lawyers can help policy-makers to find entry points
for incorporating and enforcing such provisions within domestic jurisdictions (57). Recommendation 8 of the
2010 WHO Set of recommendations on the marketing of foods and non-alcoholic beverages to children noted
that, to ensure significant impact of national actions, effective international collaboration is essential (51).
Also important is regional collaboration, in which cross-border marketing is shared between neighbouring
countries or those with close cultural and commercial ties.
During the development stage, the resources required for policies to protect children from the harmful
impact of food marketing should be considered. Like other interventions targeting children, policies to
protect children from the harmful impact of food marketing may take considerable time to have an impact
on population health (11). Long-term political commitment to such policies – including resource allocation
for enforcement, and continued monitoring for compliance and achievement of objectives – is therefore
needed if policies are to be effective. Such commitment should be across all relevant ministries, because
policy implementation may involve ministries other than health (e.g. food regulators, consumer affairs,
media and communications, trade).
During the implementation stage, a monitoring and enforcement system should be established to assist
in identifying violations and enforcing compliance (57). The enforcement system should be both proactive
(acting on infringements identified through monitoring) and reactive (open to receiving notification of
possible infringements) (57) and apply enforceable sanctions that are sufficiently meaningful to deter non-
compliance. The monitoring for compliance during the implementation stage should be accompanied by
monitoring and evaluation of the policy impact during the monitoring and evaluation stage (57). Additional
information on considerations for evaluation design is provided in section 6.2.
Finally, a comprehensive policy approach is needed to create enabling and supportive food environments.
The recommendation in this guideline should be considered together with those in other WHO guidelines on
5. Implementation considerations 29
policies to improve the food environment, including WHO guidelines on school food and nutrition policies
(60), nutrition labelling policies (58) and fiscal policies (59). Also relevant for improving the food environment
and promoting healthy diets are the WHO guideline on school health services (70); the global standards
for health-promoting schools (71); WHO guidelines on sodium intake (61) and sugars intake (62); and the
recommendations of the WHO Commission on Ending Childhood Obesity (54). WHO guidelines on total fat,
saturated fatty acids and trans-fatty acids, polyunsaturated fatty acids, carbohydrates, use of non-sugar
sweeteners and use of low-sodium salt substitutes are all forthcoming.
More detailed guidance on the implementation of policies to protect children from the harmful impact of
food marketing should be consulted before implementing the recommendation in this guideline. Selected
existing global and regional implementation resources are listed in Box 3.
Box 3. Resources for development and implementation of policies to

protect children from the harmful impact of food marketing
Global
¡¡ A child rights-based approach to food marketing: a guide for policy makers (12)
¡¡ A framework for implementing the set of recommendations on the marketing of foods and non-
alcoholic beverages to children (47)
¡¡ Implementing policies to restrict food marketing: a review of contextual factors (11)
¡¡ Protecting children from the harmful impact of food marketing: policy brief (72)
¡¡ Taking action to protect children from the harmful impact of food marketing: a child rights-based
approach (57)
Regional
¡¡ Monitoring and restricting digital marketing of unhealthy products to children and adolescents:
report based on the expert meeting on monitoring of digital marketing of unhealthy products to
children and adolescents, Moscow, Russian Federation, June 2018 (73)
¡¡ Regional action framework on protecting children from the harmful impact of food marketing in the
Western Pacific (74)
¡¡ Tackling food marketing to children in a digital world: trans-disciplinary perspectives – children’s
rights, evidence of impact, methodological challenges, regulatory options and policy implications
for the WHO European Region (46)
Nutrient profile models

¡¡ Nutrient profile model for the marketing of food and non-alcoholic beverages to children in the WHO
Eastern Mediterranean Region (2)
¡¡ Nutrient profile model for the WHO African Region: a tool for implementing WHO recommendations
on the marketing of foods and non-alcoholic beverages to children (30)
¡¡ Pan American Health Organization nutrient profile model (7)
¡¡ WHO nutrient profile model for South-East Asia Region (4)
¡¡ WHO nutrient profile model for the Western Pacific Region: a tool to protect children from food
marketing (5)
¡¡ WHO Regional Office for Europe nutrient profile model; 2nd edition (6)
6. Research gaps
Based on the results of the systematic reviews, the narrative review, the review of contextual factors, the
discussions of the NUGAG Subgroup on Policy Actions, and input received during peer review and the public
consultation, a number of research gaps and considerations were identified. They reflect understudied
thematic areas and geographic locations, as well as methodological issues. These will be important when
updating this guideline, and for further advocacy and action to protect all children from the harmful impact
of food marketing.
As noted previously, the evidence on which this guideline is based is specific to food marketing. Accordingly,
it does not include evidence on the broader question of the impact of marketing, or on the broader question
of the effectiveness of policies to restrict marketing. It is inherent in the search strategy and selection
criteria used in the systematic reviews that broader evidence on marketing and evidence specific to adults
is excluded from the evidence underpinning the guideline. This evidence is also not used for purposes of
triangulation or checking the conclusions drawn against the broader body of evidence on the impacts of
marketing and marketing restrictions.
6.1 Overarching research gaps

Overall, most research was from HICs. High-quality studies from LMICs would improve the representativeness
of evidence underlying this guideline and provide additional information on contextual factors that may
affect the implementation of policies to protect children from the harmful impact of food marketing.
Impact of food marketing

Much of the research identified in the systematic review on the impact of food marketing on children
focused on proximal outcomes (e.g. food preferences, food choice or intended choice, dietary intake); few
suitable studies were available for more distal outcomes (e.g. dental caries/erosion, body weight/BMI/
obesity, diet-related NCDs) (10). Long-term studies that consider the impact of food marketing on more
distal outcomes would be valuable when updating this guideline. Given the substantial methodological
challenges – for example, disentangling the impact of food marketing from the complex array of other
factors that contribute to outcomes such as body weight/BMI/obesity and diet-related NCDs that develop
gradually over time – high-quality studies on proximal outcomes will remain valuable. As well, most studies
on the impact of food marketing on dietary intake focused on the impact of acute exposure to marketing on
acute dietary intake; studies that consider the sustained effects of food marketing on dietary intake would
also be valuable.
Much of the research on the impact of food marketing to date has focused on food marketing via television.
As the marketing landscape continues to evolve, additional research could improve understanding of
the impact of food marketing via other marketing media (e.g. outdoor advertising, digital marketing,
sponsorship), as well as of the combined effect of different types of marketing.
Additional studies on the impact of brand marketing – including on possible brand spillover and health
halo effects – would be beneficial in closing loopholes in some policies to restrict food marketing to which
children are exposed that permit the marketing of brands (as distinct from products and services).
The potential impact of food marketing on adults, including those who are caregivers and who purchase
food for children, was outside the scope of this guideline. However, research in this area may be important
when updating this guideline.
31
Effectiveness of policies
As with the systematic review on the impact of food marketing on children, much of the research identified
in the systematic review on the effectiveness of policies to restrict food marketing to which children are
exposed focused on proximal outcomes (e.g. exposure to marketing, power of marketing); no suitable
studies were available for more distal outcomes (e.g. dental caries/erosion, body weight/BMI/obesity, diet-
related NCDs) (8).
Studies on the effectiveness of policies on more distal outcomes would be valuable when updating this
guideline. The same methodological challenges discussed above apply, as well as a need to be realistic
about the extent to which any one intervention can be expected to affect these outcomes on its own.
Studies included in the systematic review reported on the effect of policies on exposure to, or power of,
food marketing via a single marketing medium only (e.g. television, packaging). To ensure the effectiveness
of policies and mitigate unintended consequences, there is a need for studies that monitor the possible
migration of food marketing within one medium (e.g. from child-focused to family-focused television
content) or to other marketing media (e.g. outdoor advertising, sponsorship). Current research on the
impact of policies largely focuses on changes to food marketing on children’s television programmes,
or marketing of food products of appeal to children – changes to overall exposure to food marketing are
a knowledge gap. The use of indirect evidence on policies to restrict marketing of products or services
beyond food could also be explored to further support policy actions to protect children from the harmful
impact of food marketing.
Comparative studies that include multiple countries would be beneficial when updating this guideline.
Information on the scope of current national policies and whether they cover cross-border food marketing
would also be useful.
Contextual factors
Although the review of contextual factors found evidence that children of lower SES are more exposed
to food marketing than children of higher SES, it found few studies that directly examined the impact on
health equity of policies to protect children from the harmful impact of food marketing (11). Future studies
should therefore include data disaggregated by characteristics such as SES, sex, gender and rurality (see
section 6.2).
During the discussions of the NUGAG Subgroup on Policy Actions, an expert noted that, in some countries,
there may be concerns that prohibition of sponsorship of children’s sport might reduce children’s opportunity
to play sport. The review of contextual factors found some evidence relating to this. For example, an
impact assessment of a draft policy that included restrictions on sponsorship of children’s events noted a
possible “public outcry” if events stopped as a result of funding limitations due to restrictions on marketing
(11). Further research on the acceptability and feasibility of restrictions on sports sponsorship would be
beneficial.
6.2 Considerations for design of future evaluations

For many of the outcomes of interest in the systematic reviews on the impact of food marketing on children
(10) and the effectiveness of policies to restrict food marketing to which children are exposed (8), the
certainty of the evidence was low or very low. Following application of the GRADE approach (see section
2.2), the certainty of the evidence was often downgraded because of a serious or very serious risk of bias in
the included studies, or serious or very serious inconsistency of effect. The certainty of the evidence could
be improved by ensuring that future studies address common issues related to risk of bias – for example,
for studies on the impact of food marketing on children, not providing information on non-respondents
or not controlling for confounding factors. The inconsistency of effect for studies on the effectiveness of
policies to restrict food marketing to which children are exposed also reflects differences in study design,
sampling approach and effect measure. Use of standardized monitoring procedures could potentially
reduce the inconsistency of effect between studies and thereby improve the certainty of the evidence. A
diverse array of tools has been used in research that assesses the extent of policy implementation, and
implementation processes for food environment policies (75). Although guidance on appropriate study
designs and methods for policy evaluation remains limited, results from current research projects can be
used to strengthen policy evaluations (76). Potential standardized monitoring procedures include those
proposed by the WHO Regional Office for Europe (77) and the International Network for Food and Obesity/
Non-communicable Diseases Research, Monitoring and Action Support (INFORMAS) (78). As the use of
digital marketing (including programmatic advertising and user-generated content) increases, tools for
monitoring such marketing, such as the CLICK tool for monitoring digital food marketing developed by the
WHO Regional Office for Europe (73) should also be considered.
A number of studies in the systematic review on the effectiveness of policies to restrict food marketing to
which children are exposed lacked effect estimates and/or P values. This prevented pooled analysis; instead,
vote counting based on direction of effect was used, which provided no information on the magnitude of
effect and did not account for differences in the relative size of included studies. Future studies should
include effect estimates and P values.
In both systematic reviews, analyses by SES, sex, gender and rurality were not possible, because data on
these characteristics were either reported by too few studies for each outcome or not reported by exposure
groupings. Where possible, future studies should include data disaggregated by these characteristics to
enable analysis of the impact on health equity of food marketing and of policies to protect children from its
harmful impact.
Other considerations for the design and reporting of future evaluations of policies to restrict food marketing
to which children are exposed include a need for more detailed information on policies (e.g. enforcement
mechanisms); this would allow more detailed examination of policy design elements that may impact
effectiveness.
Implementation research addresses both policy implementation processes and relevant contextual factors
(79). Integrating implementation research into policy and programmatic decision-making processes
from the start can support collaboration between policy implementers and researchers to ensure that
such research is useful (79). Qualitative comparative analysis can provide further insights into regulatory
governance conditions that lead to food environment policies that can improve population nutrition
outcomes (80). Systems thinking can be useful in generating robust evidence about which policies are the
most effective. This applies to the policy-making process, problem identification and policy analysis and,
after a policy is implemented, policy evaluation (81).
6. Research gaps 33
7. Uptake, monitoring and
updating of the guideline
This guideline will be disseminated to Member States through the networks of WHO regional offices and
country offices, WHO collaborating centres, United Nations partner agencies and civil society agencies,
relevant nutrition webpages on the WHO website1 and the electronic mailing lists of the WHO Department
of Nutrition and Food Safety, among others. The guideline will also be disseminated at relevant global,
regional and national meetings. Specifically, it will be used to support policy dialogues being held as part
of the WHO’s work to accelerate action to stop obesity. The guideline is an important part of the technical
package to support implementation of the recommendations for the prevention and management of
obesity over the life course, and related targets adopted by the 75th World Health Assembly.2
The impact of this guideline can be evaluated by assessing its adoption and adaptation across countries.
Evaluation at the global level will be through the periodically conducted Global Nutrition Policy Review
and the WHO NCD Country Capacity Survey, published through the WHO Global database on the
Implementation of Nutrition Action (GINA)3 and will also consider independent researcher input. GINA
is a centralized platform developed by the WHO Department of Nutrition and Food Safety for sharing
information on nutrition actions in public health practice implemented around the world. GINA currently
contains information on thousands of policies (including legislation), nutrition actions and programmes
in more than 190 countries. It includes data and information from many sources, including the first and
second WHO global nutrition policy reviews conducted in 2009–2010 and 2016–2017, respectively (55, 82). By
providing programmatic implementation details, specific country adaptations and lessons learned, GINA
serves as a platform for monitoring and evaluating how policy guidelines are being translated and adapted
in various countries. The WHO NCD Country Capacity Survey is a global survey of all Member States that
provides a periodic assessment of national capacity for NCD prevention and control, including in several
nutrition-related areas.
In line with the WHO handbook for guideline development (56), the recommendation in this guideline will be
regularly updated, based on new data and information. The WHO Department of Nutrition and Food Safety
will be responsible for coordinating updates of the guideline, following the formal procedure described in
the WHO handbook for guideline development (56). When the guideline is due for review, WHO will welcome
suggestions for additional questions that could be addressed in the guideline.
If there are concerns that the guideline’s recommendation may no longer be valid, the Department of
Nutrition and Food Safety will communicate this information, together with plans to update the guideline, to
relevant actors via announcements on the Department of Nutrition and Food Safety website and electronic
mailing lists, as well as communicating directly with actors, as necessary.
1
http://www.who.int/nutrition/en/
2
https://apps.who.int/gb/ebwha/pdf_files/WHA75/A75_10Add6-en.pdf
3
https://extranet.who.int/nutrition/gina/en/home
34
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Annexes
41
Annex 1.
Global calls to action and commitments
related to food environment policies
The WHO guidelines on policies to improve the food environment will contribute to implementation of a
number of calls to action relating to nutrition and health, including:
the Comprehensive Implementation Plan on Maternal, Infant and Young Child Nutrition;
the Global Action Plan for the Prevention and Control of Noncommunicable Diseases 2013–2030;
the Political Declaration of the High-level Meeting of the United Nations General Assembly on the
Prevention and Control of Non-communicable Diseases held in New York in September 2011 and the
outcome document (A/RES/68/300) of the High-level Meeting of the United Nations General Assembly
on the Prevention and Control of Non-communicable Diseases held in New York in July 2014;
the recommendations of the Commission on Ending Childhood Obesity established by the WHO
Director-General in May 2014;
the commitments of the Rome Declaration on Nutrition and recommended actions in the Framework
for Action, which recommends a set of policy options and strategies to promote diversified, safe and
healthy diets at all stages of life; these were adopted by the Second International Conference on
Nutrition in 2014 and endorsed by the 136th session of the WHO Executive Board (in January 2015) and
the Sixty-eighth World Health Assembly (in May 2015), which called on Member States to implement the
commitment of the Rome Declaration on Nutrition across multiple sectors;
the goals of the United Nations Decade of Action on Nutrition (2016–2025), declared by the United
Nations General Assembly in April 2016, which include increased action at the national, regional and
global levels to achieve the commitments of the Rome Declaration on Nutrition by implementing policy
options included in the Framework for Action and evidence-informed programme actions;
the acceleration plan to stop obesity adopted at the Seventy-fifth World Health Assembly in May 2022,
together with the intermediate outcome and process targets; and
the 2030 Agenda on Sustainable Development and the Sustainable Development Goals, particularly
Goal 2 (“zero hunger”) and Goal 3, Target 4 (“reduce by one third premature mortality from non-
communicable diseases through prevention and treatment”).
43
Annex 2.
WHO Secretariat
Headquarters Regional Office for the Eastern

Mediterranean
Dr Francesco Branca
Director, Department of Nutrition and Food Safety Dr Ayoub Al-Jawaldeh
Regional Adviser for Nutrition
Dr Chizuru Nishida
Unit Head, Safe, Healthy and Sustainable Diet Unit, Regional Office for Europe
Department of Nutrition and Food Safety
Dr Joao Breda
Dr Katrin Engelhardt Head, WHO Athens Quality of Care and Patient
Scientist, Safe, Healthy and Sustainable Diet Unit, Safety Office & Special Adviser for the Regional
Department of Nutrition and Food Safety Director
Ms Ruby Brooks Dr Kremlin Wickramasinghe
Consultant, Safe, Healthy and Sustainable Diet Acting Head, WHO European Office for Prevention
Unit, Department of Nutrition and Food Safety and Control of NCDs
Ms Dorit Erichsen Ms Clare Farrand
Consultant, Safe, Healthy and Sustainable Diet Technical Officer, WHO European Office for
Unit, Department of Nutrition and Food Safety Prevention and Control of NCDs
Ms Emma Kennedy Ms Julianne Williams
Assistant to Unit Head, Safe, Healthy and Technical Officer
Sustainable Diet Unit, Department of Nutrition and WHO European Office for Prevention and Control
Food Safety of NCDs
Regional offices Ms Olga Zhiteneva
Regional Office for Africa Technical Officer, WHO European Office for
Prevention and Control of NCDs
Dr Adelheid Onyango
Director, Universal Health Coverage/Healthier Ms Holly Rippin
Populations Cluster Consultant, WHO European Office for Prevention
and Control of NCDs
Dr Hana Bekele
Medical Officer – Nutrition, Universal Health Regional Office for South-East Asia
Coverage/Healthier Populations Cluster
Dr Angela de Silva
Regional Office for the Americas Regional Adviser for Nutrition
Dr Fabio Da Silva Gomes Regional Office for the Western Pacific

Adviser, Nutrition and Physical Activity
Dr Juliawati Untoro
Mr Leo Nederveen Technical Lead – Nutrition, Division of Healthy
Adviser, Food, Nutrition and Physical Activity in Environments and Populations
Schools
Dr Ying Cui
Technical Officer of Sodium Reduction and Health
Promotion, Disease Control, WHO China Country
Office
44
Annex 3.
Members of the WHO Steering Committee (headquarters)
Dr Melanie Bertram Dr Benn McGrady

Delivery Expert, Delivery for Impacts Unit, Unit Head, Public Health Law and Policies Unit,
Department of Data, Analytics and Delivery for Department of Health Promotion
Impact
Dr Chizuru Nishida
Dr Fiona Bull Unit Head, Safe, Healthy and Sustainable Diet Unit,
Unit Head, Physical Activity Unit, Department of Department of Nutrition and Food Safety
Health Promotion
Mr Jeremias Paul
Mr David Clarke Unit Head, Health Taxes Unit, Department of
Team Leader, UHC and Health Systems Law Unit, Health Promotion
Department of Health Systems Governance and
Mr Marcus Stahlhofer
Financing
Technical Officer, Epidemiology, Monitoring
Dr Katrin Engelhardt and Evaluation Unit, Department of Maternal,
Scientist, Safe, Healthy and Sustainable Diet Unit, Newborn, Child and Adolescent Health
Dr Nicole Valentine
Ms Monika Kosinska Technical Officer, Equity and Health Unit,
Technical Officer, Economic and Commercial Department of Social Determinants of Health
Determinants of Health Unit, Department of Social
Ms Angeli Vigo
Determinants of Health
Technical Officer, Economic Evaluation and
Analysis Unit, Department of Health Systems
Governance and Financing
45
Annex 4.
Members of the WHO NUGAG Subgroup on Policy Actions
Dr Nawal Al Hamad Professor Joerg Meerpohl

Deputy Director-General, Community Nutrition Director, Freiburg GRADE Center
Promotion Sector Co-Director of Cochrane Germany
Public Authority for Food and Nutrition University Medical Center Freiburg
State of Kuwait Germany
Professor Carukshi Arambepola Dr Musonda Mofu
Professor, Community Medicine Executive Director, National Food and Nutrition
Department of Community Medicine Commission
Faculty of Medicine Zambia
University of Colombo
Dr Ladda Mo-suwan
Sri Lanka
Associate Professor, Department of Pediatrics
Professor Gastón Ares Prince of Songkla University
Associate Professor, Sensometrics and Consumer Thailand
Science
Ms Monica Muti
Facultad de Química
Manager, Nutrition Intervention
Universidad de la República
Ministry of Health and Child Welfare
Montevideo
Zimbabwe, and
Uruguay
PhD Student, University of Witwatersrand
Professor Sharon Friel South Africa
Director, School of Regulation and Global
Professor Celeste Naude
Governance (RegNet)
Associate Professor, Centre for Evidence-based
and Professor of Health Equity
Health Care
Australian National University
Co-Director, Cochrane Nutrition
Australia
Division of Epidemiology and Biostatistics
Dr Cho-il Kim Faculty of Medicine and Health Sciences
Visiting Professor, Department of Food and Stellenbosch University
Nutrition South Africa
College of Human Ecology
Professor Lisa Powell
Seoul National University
Distinguished Professor and Director, Health Policy
Republic of Korea
and Administration
(Former Executive Director, Korea Health Industry
School of Public Health
Development Institute)
University of Illinois Chicago
Dr Knut-Inge Klepp United States of America
Executive Director, Management and Staff for
Professor Mike Rayner
Mental and Physical Health
Professor, Population Health
Norwegian Institute of Public Health
Nuffield Department of Public Health
Norway
University of Oxford
United Kingdom of Great Britain and Northern
Ireland
46
Professor Eva Rehfuess Dr Alison Tedstone
Chair, Public Health and Health Services Research Chief Nutritionist, Public Health England (2013–
Ludwig Maximilian University Munich 2022)
Germany Department of Health and Social Care
Professor Lorena Rodríguez Osiac
Ireland
Professor, School of Public Health
University of Chile Associate Professor Anne Marie Thow
Chile Associate Professor, Public Policy and Health
Menzies Centre for Health Policy and Economics
Professor Franco Sassi
School of Public Health
Professor and Chair, International Health Policy
University of Sydney
and Economics
Australia
Imperial College London
United Kingdom of Great Britain and Northern Professor Edelweiss Wentzel-Viljoen
Ireland Extraordinary Professor, Nutrition, Center of
Excellence for Nutrition
Professor Barbara Schneeman
North-West University
Professor Emerita, Departments of Nutrition/Food
South Africa
Science and Technology
University of California at Davis
United States of America
Professor Reema Tayyem
Professor, Nutrition
University of Jordan
Jordan, and
Qatar University
Qatar
Annex 4. Members of the WHO NUGAG Subgroup on Policy Actions 47

Annex 5.
External resource people
Systematic review team Methods experts

Dr Angela Boland Professor Elie Akl1
Liverpool Reviews and Implementation Group Professor, Department of Internal Medicine
University of Liverpool Associate Professor of Epidemiology and
United Kingdom of Great Britain and Northern Population Health
Ireland Department of Epidemiology and Population
Health
Professor Emma Boyland
Faculty of Medicine
Professor, Food Marketing and Child Health
American University of Beirut
Department of Psychology
Lebanon
University of Liverpool
United Kingdom of Great Britain and Northern Dr Damian Francis2
Ireland Co-Director, Cochrane Caribbean
Caribbean Institute for Health Research
Ms Juliet Hounsome
University of the West Indies
Liverpool Reviews and Implementation Group
Jamaica
Ireland
Dr Andrew Jones
Ireland
Dr Michelle Maden
Liverpool Reviews and Implementation Group
Ireland
Dr Lauren McGale
Postdoctoral Research Associate
Ireland
1
Served as methods expert from the second meeting of
the WHO NUGAG Subgroup on Policy Actions in December
2019.
2
Participated in the first meeting of the WHO NUGAG
Subgroup on Policy Actions as methods expert.
48
Annex 6.
External peer review group
Dr Huda Mustafa Al Hourani Dr Maria João Gregório

Associate Professor, Department of Clinical Director, National Healthy Eating Promotion
Nutrition and Dietetics Program
Faculty of Applied Medical Sciences Directorate-General of Health
The Hashemite University Portugal
Jordan
Ms Fiona Sing
Dr Gershim Asiki PhD student
Research Scientist University of Auckland
African Population Health and Research Center New Zealand
Kenya
Professor Boyd Swinburn
Mr Alejandro Calvillo Professor of Population Nutrition and Global
Director Health
El Poder del Consumidor University of Auckland
Mexico New Zealand
Dr Suparna Ghosh-Jerath
Professor and Head, Community Nutrition
Indian Institute of Public Health Delhi
Public Health Foundation of India
India
49
Annex 7.
Guidance questions for the review of contextual factors
Factor Guidance questions
What are the values people affected by the intervention assign to the
Values
intervention health outcomes?
What is the value for money of the intervention in terms of cost–benefit ratio/
cost-effectiveness/cost utility, including the impact on national/global health
Resource
care costs in the short term and long term, and the impact on government
implications
revenue (including the use of additional revenue; and issues of non-
compliance, inflation, black market or cross-border trade)?
What is the impact of the intervention on (health) (in)equality and/or (health)

(in)equity, including food and nutrition security (unequal and/or unfair access
to food)?
Equity Is the intervention sensitive to sex, gender, age, ethnicity, religion, culture,
language, sexual orientation/gender identity, disability status, education,
socioeconomic status, place of residence (including issues of social stigma,
household expenditure, financial regressivity, and jobs/employment)?
Is the intervention in accordance with human rights standards, and what is

Human rights the impact of the intervention on human rights (including the ability to make a
competent, informed and voluntary decision)?
Is the intervention acceptable to governments and policy-makers, the public

and consumers, and industry?
Acceptability Is the intervention acceptable to, and in agreement with, existing cultural and
religious norms and beliefs?
Is the intervention aligned with environmental goals and considerations?
What is the feasibility of developing and implementing the intervention

(including barriers and facilitators)?
What is the feasibility of monitoring and enforcement of the intervention
Feasibility (including barriers and facilitators)?
Does the intervention have an impact on change within existing health or
food systems (including resulting in additional interventions to improve the
nutrition and health of populations)?
50
Annex 8.
GRADE evidence profile
PICO: What is the effect in children on the outcomes of interest of implementing a policy to restrict food marketing to children, compared with implementing no policy – or a
different policy?
Population: Children
Intervention: All policies that aim to restrict food marketing to children, comprising mandatory, legally enforceable measures (including statutory approaches, regulations,
legislation or orders used by a jurisdiction’s legal system) and voluntary measures (including self-regulatory measures, pledges or codes), but excluding action plans, strategies,
programmes and initiatives
Comparison: Varied by intervention. For voluntary measures, the comparison was before implementation of the measure or by non-signatory companies after implementation
of the measure; for mandatory policies, the comparison was marketing activity under a previous voluntary measure, at the point of partial implementation of the mandatory
policy, or before implementation of the policy.
Characteristics of studies
No. of Other Impact Certainty Importance
Study design Risk of bias Inconsistency Indirectness Imprecision
studies considerations
Exposure to marketing
37 Observa Not Very seriousa Not serious Not serious None Overall, the evidence is very uncertain about the ㊉◯◯◯ Critical
tional serious effect of implementing any food marketing policies on Very low
studies exposure to food marketing.
4 studies (2 assessing mandatory policies (1 comparing
mandatory policy with no policy (1) and 1 comparing
mandatory policy with voluntary measure (2)), and 2
comparing voluntary measure with no measure (3, 4)
reported a clear effect favouring the intervention
(i.e. significantly lower exposure to food marketing
with policy; no effect sizes provided).
51
52
11 studies (5 comparing mandatory policy with no
policy and 6 comparing voluntary measure with no
measure (5–15)) reported an unclear effect potentially
favouring the intervention (i.e. narratively reported
lower exposure to food marketing with policy). Only 1
of the 11 studies reported an effect size : Hebden 2011
(7) reported a significant IRR of 0.73 (95% CI: 0.60–0.88)
for change in non-core fast food advertising pre–post
policy, but mean frequency was 1.0 advertisements/
hour at both time points, and the reduction was
relative to all fast food advertising (which had
increased) only.
7 studies (5 of which compared voluntary measure
with no measure (16–22)) reported no effect. Adams
2012 (16) reported a non-significant OR of 1.05
(99% CI: 0.99–1.12) for person-minute views of food
advertisements pre- vs post-mandatory policy, and
King 2011 (18) reported a non-significant IRR of 1.05
(95% CI: 0.84–1.17) for average number of non-core
food advertisements per hour pre- vs post-voluntary
measure.
with no voluntary measure (23–33))reported an unclear
effect potentially favouring the control (i.e. narratively
reported lower exposure to food marketing).
4 studies (1 comparing a mandatory policy with a
voluntary measure (34); and 3 comparing voluntary
measures with no voluntary measure (35–37))reported
a clear effect favouring the control (i.e. significantly
lower exposure to food marketing in the comparison
group). Potvin Kent 2018 (36) reported a significant
OR of 2.53 (95% CI: 2.52–2.53) for the analysis of the
volume of food advertisements for less-healthy items
between signatory and non-signatory companies.
The effect on marketing varied when comparing the
predefined policy design elements. Data allowed
several focused comparisons and subgroup analyses.
Results of these additional analyses indicated that
studies were more likely to report effects clearly or
potentially favouring the intervention when evaluating
Annex 8. GRADE evidence profile

the following.
Mandatory policies (5/7 studies) relative to
voluntary measures (8/26 studies). A significantly
greater proportion of studies evaluating voluntary
measures showed undesirable effects for public
health than showed desirable effects; this was
not the case for mandatory policies. Few studies
directly compared mandatory policies with
voluntary measures (1/3 favoured the intervention
but this was non-significant). The single study
exploring different stages of mandatory
policy implementation indicated that greater
implementation may result in more desirable
effects.
Policies designed to restrict food marketing
to children >12 years (6/8 studies favoured or
potentially favoured the intervention) relative to
those ≤12 years (7/25 studies).
Exposure to television food advertising
(12/29 studies) or product packaging (1/1 – a single
study) relative to those assessing exposure via
digital media (0/3).
Policies using a government-led nutrient profile
model to classify foods (5/6) compared with
company-specific models (8/25).
53
54
Additional analyses on the approach used to
classify foods to which the restrictions apply (not in
Appendix D (16)):
For studies of policies that used government-led
nutrient profile models (n = 6).
One study clearly favoured the intervention (50.0%
[95% CI: 9.5% to 90.5%], P = 1.00), four studies
potentially favoured the intervention (80.0% [95% CI:
29.9% to 99.0%], P =0.371), and five studies clearly or
potentially favoured the intervention (83.3%. [95% CI:
36.5% to 99.1%], P =0.221).
For studies of policies that used company-led
models (n = 25).
Two studies clearly favoured the intervention (10.5%
[95% CI: 1.8% to 34.5%], P = 0.001), six potentially
favoured the intervention (26.1% [95% CI: 11.1%
to 48.7%], P = 0.037), and eight studies clearly or
potentially favoured the intervention (32.0% [95% CI:
15.7% to 53.6%], P = 0.110).
Power of marketing
18 Observa Not Very seriousb Not serious Not serious None The evidence is very uncertain about the effect of food ㊉◯◯◯ Critical
tional serious marketing policies on power of food marketing. Very low
studies
3 studies (2 assessing mandatory policies, the first
comparing policy with no policy and the second
comparing mandatory policy with voluntary measure,
and 1 comparing voluntary measure with no voluntary
measure (10, 19, 21)) reported a clear effect favouring
the intervention (i.e. significantly less powerful food
marketing with policy).
2 studies (comparing mandatory policy with no
policy (11, 12)) reported an unclear effect potentially
favouring the intervention (i.e. narratively reported
less powerful food marketing with policy).
1 study reported no effect (38).

6 studies (all of which compared voluntary measure
with no measure (18, 22, 23, 25, 32, 39)) reported
an unclear effect potentially favouring the control
(i.e. narratively reported less powerful food marketing).
with no measure (20, 33–35, 37, 40)) reported a clear
effect favouring the control (i.e. significantly less
powerful food marketing). Of all studies reporting on
this outcome, only Effertz 2012 (37) provided an effect
size, a significant OR of 4.188 reflecting a reduction
post- vs pre-voluntary measure in propensity for non-
core food advertisements containing a promotional
character.
Data allowed several focused comparisons and
subgroup analyses. Results of these additional
analyses indicated that studies were more likely to
report effects clearly or potentially favouring the
intervention when evaluating the following.
Mandatory policies (3/3 studies) relative to
voluntary measures (1/3 studies). A significantly
greater proportion of studies evaluating voluntary
measures showed undesirable effects for public
health than showed desirable effects; this was not
the case for mandatory policies. Only 2 studies
directly compared mandatory policies with
voluntary measures (1/2 favoured the intervention,
but this was non-significant), and no study explored
55
different stages of policy implementation.
56
Policies designed to restrict food marketing
to children >12 years (3/4 studies favoured or
potentially favoured the intervention) relative to
those ≤12 years (1/12 studies).
Effectiveness of policies to restrict use of
promotional characters (3/10 studies) relative to
those assessing use of a broader range of child-
appealing persuasive techniques (1/5 studies) or
animation techniques (0/1 study).
Power of television food advertising (3/10 studies)
relative to power of marketing via digital media
(0/3 studies) or product packaging (1/3 studies).
Purchasing/sales or intended purchasing
5 Observa Not Not serious Not serious Not serious None The evidence suggests that food marketing policies ㊉㊉◯◯ Critical
tional serious may result in a reduction in food purchasing. Low
studies
4 studies (2 reporting on mandatory policies (41,
42); and 2 reporting on voluntary measures (3, 4))
reported a clear effect favouring the intervention
(i.e. significantly lower food purchasing with policy/
measure). Dhar 2011 (41) reported a difference-in-
difference estimate of –0.102 (indicating that the ban
led to a decrease in purchase propensity by 10.2%).
Huang 2013 (3) reported a change in relative purchase
frequency (%) of –2.486 (±0.684); P < 0.01.
Favouring the intervention, Dhar 2011 (41) reported
that the policy led to a 10.2% reduction in fast food
purchase propensity, Huang 2013 (3) reported a
2.486% reduction in purchasing of a confectionery
item, Silva 2015 (42) reported a reduction on HFSS
expenditure per capita per quarter of £6.2 for foods
and £2.7 for drinks, and Lwin 2020 (4) reported that
volume of unhealthy food in household pantries
decreased from 721.65 to 526.16; all studies reported
statistically significant P values (<0.05, <0.01 or <0.001).
1 study evaluating a United States city ordinance
reported a clear effect favouring the control
(i.e. significantly lower food purchasing) (43).

Purchasing of child meals (not meeting nutritional
criteria set by the ordinance) significantly increased
with the policy (from 35.8% to 47.3%; P = 0.01).
3 studies were high quality; all clearly favoured
the intervention. 2 studies were moderate quality;
1 clearly favoured the intervention, and 1 clearly
favoured the control.
No subgroup analyses were possible for this outcome.
Food choice or intended choice
0 None of the studies reported this outcome. NA Critical
Dietary intake
1 Observa Seriousc Not serious Not serious Not serious None The evidence is very uncertain about the effect of ㊉◯◯◯ Critical
tional study food marketing policies on dietary intake. Very low
1 study (comparing voluntary measure with no
measure) reported a clear effect favouring the
intervention: self-reported potato chip consumption
was significantly lower (1.97 vs 1.91; P = 0.03) post-
voluntary measure (4).
Food preferences
0 None of the studies reported this outcome. NA Critical
Body weight/BMI/obesity
0 None of the studies reported this outcome. NA Important
57
58
Product requests or intended requests
Diet-related NCDs (or validated surrogate indicators)
Dental caries/erosion
Product changes
2 Observa Not Seriousd Seriouse Seriousf None The evidence is very uncertain about the effect of ㊉◯◯◯ Important
tional serious food marketing policies on product change. Very low
studies
1 study (comparing voluntary measures vs no
measure) reported a clear effect favouring the control:
mean sugar content was significantly higher (8.7 g vs
6.6 g; P < 0.05) for breakfast cereals from signatory
companies (vs non-signatory companies) of the
voluntary measure (39).
1 study reported no effect, as there was no significant
difference (P = 0.08) in the average price of children’s
brand breakfast cereals between jurisdictions with
and without a mandatory policy in place (44).
Unintended consequences to wider society (e.g. revenue, jobs)
3 Observa Not Not serious Not serious Not serious None The evidence suggests that food marketing policies ㊉㊉◯◯ Important
tional serious may result in unintended consequences that are Low
studies favourable to public health.
1 study (comparing mandatory policy with no policy)

reported a clear effect favouring the intervention:
television HFSS food advertising expenditure
significantly decreased (19.4%; P < 0.01) post-
government policy (42).
2 studies (comparing mandatory policy with no
policy) reported unclear effects potentially favouring
the intervention: the total EDNP food advertising
budget decreased from pre- to post-mandatory policy
($420 000 to $2 000; Kim 2013 (8)), and there was a 26%
reduction in net television food advertising revenue
pre- to post-mandatory policy (11).
EDNP: energy-dense, nutrient-poor; IRR: incidence rate ratio; NA: not applicable; OR: odds ratio.
a
The direction of effect varied considerably across the included studies: 4 reported a clear effect favouring the intervention, 11 reported an unclear effect potentially favouring the intervention, 7 reported
no effect, 11 reported an unclear effect potentially favouring the control and 4 reported a clear effect favouring the control. We therefore judged the evidence for this outcome to have very serious
inconsistency and downgraded the certainty of evidence once for inconsistency.
b
The direction of effect varied considerably across the included studies: 3 reported a clear effect favouring the intervention, 2 reported an unclear effect potentially favouring the intervention, 1 reported
no effect, 6 reported an unclear effect potentially favouring the control and 6 reported a clear effect favouring the control. We therefore judged the evidence for this outcome to have very serious
inconsistency and downgraded the certainty of evidence once for inconsistency.
c
Based on two studies of only moderate quality due to methodological limitations (comparability of samples, outcome assessment).
d
The effect varied across the two studies: 1 reported a clear effect favouring the control, 1 reported no effect.
e
One of two studies used an indirect measure of marketing policy impact (cereal price).
f
Based on just two studies, but one study included data on 17 brands in 6 provinces and the other included 66 cereal brands (so substantial number of data points overall). Therefore deemed ‘serious’
rather than ‘very serious’ imprecision.
59
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Annex 9.
Summary of declarations of interests of contributors to
the guideline development process
NUGAG Subgroup
on Policy Actions Interests declared/identified Assessment
member
Nawal Al Hamad No interests declared Not applicable
Carukshi No interests declared Not applicable
Arambepola
Gastón Ares Declared receiving funding from Conaprole (a Declarations were not deemed to
Uruguayan dairy company) for a joint research constitute a risk to the guideline
project (2015–2017) with the university for the development process given the
development of guidelines to reduce the sugar topic covered by the research
content of dairy products targeted at children (i.e. the development of guidelines
to reduce the sugar content
of dairy products targeted at
children) was not related to the
topic of the guideline
Sharon Friel Declared receiving a research grant from the Declarations were not deemed to
National Health and Medical Research Council of constitute any conflict of interest
Australia (NHMRC) to fund the Centre of Research for her role in the NUGAG Subgroup
Excellence on Social Determinants of Health on Policy Actions given the topics
Equity (CRE), which ran from 2015 until 2020. The covered by the funding
goal of the CRE was to provide evidence on how
to navigate the political and policy processes
more effectively to operationalize the social
determinants of health and health inequity. Also
declared receiving a grant from NHMRC for the
Australian Prevention Partnership Centre Food
Project on systems approaches to healthy and
equitable eating
Cho-il Kim No interests declared Not applicable
Knut-Inge Klepp Declared that his institution (National Institute of Declarations were not deemed to
Public Health, Norway) paid for his participation in constitute any conflict of interest
the first meeting of the NUGAG Subgroup on Policy for his role in the NUGAG Subgroup
Actions on Policy Actions given the source
of the funding
Joerg Meerpohl No interests declared Not applicable
Musonda Mofu No interests declared Not applicable
Ladda Mo-suwan Declared presenting at the Pre-Congress of the Participation in annual meetings
20th Annual meeting of the Pediatric Association of Wyeth and Abbott on infant
in January 2019, on “Nutritional status and and young child nutrition and
dietary intake of young children in Thailand”. their coverage of her expenses to
Further declared participating in annual meetings participate, which was made to
of Wyeth and Abbott on infant and young child her university, were not deemed
nutrition in 2016, 2017 and 2018, but no income nor to constitute a risk to the guideline
honorariums were paid. The meeting invitations development process given the
were extended through her university (Prince of focus of the meetings
Songkla University, Medical Faculty, Thailand) by
Wyeth and Abbott, which covered expenses to
participate in these annual meetings.
63
NUGAG Subgroup
member
Monica Muti No interests declared Not applicable
Celeste Naude No interests declared Not applicable
Lisa Powell Declared receiving funds from WHO to travel and Declarations were not deemed to
speak at a WHO/Pan American Health Organization constitute any conflict of interest
meeting in 2016; for participation at a meeting on for her role in the NUGAG Subgroup
fiscal policies held in Bridgetown, Barbados; for on Policy Actions given the source
participation at the expert consultation in 2017; of the funding
and for a country visit to support analysis for the
Maldives. Also declared that the University of
Illinois, Chicago, where she is employed, received
an academic research grant from Bloomberg
Philanthropies
Mike Rayner No interests declared Not applicable
Eva Rehfuess No interests declared Not applicable
Lorena Rodríguez No interests declared Not applicable
Osiac
Franco Sassi No interests declared Not applicable
Barbara Declared that: Each engagement was assessed
Schneeman in the context of the topic of this
until the end of 2012 (retired in January
guideline. Declared interests
2013), she was employed by the United
– i.e. engagements whether as
States Food and Drug Administration (FDA),
consultant, presenter, speaker,
which is interested in scientific input for the
member of science advisory
development of nutrition recommendations;
group with indicated companies
as the head of the US delegate to the Codex – have been on topics related
committees on food labelling and on nutrition to regulatory issues in the
and foods for special dietary uses (CCNFSDU), United States of America, and
she presented the US positions in these Codex included providing information
forums (up to 2012); and advice on FDA’s labelling
regulations including on updates
she was employed by the US Agency for
to the Nutrition Facts panel,
International Development as higher education
on health claims and on other
coordinator from 2015 to 2016, where she
FDA requirements for labelling
worked with the higher education community
purposes to industry. Other
to increase engagement with USAID;
engagements have not involved
she was a member of advisory committee at the topic of this guideline
Monsanto discussing the role of agriculture in and were not considered to
addressing climate change and improving food pose a risk for the guideline
and nutrition security (2014 to 2017), and at the development. Engagement on
McCormick Science Institute reviewing research the science advisory committee
proposals on spices and herbs (2014 to 2021); for Monsanto was on issues
related to agriculture’s role in
she was a temporary adviser for Ocean Spray
addressing climate change and
on health claim petitions that are submitted to
food security. Engagement on
US FDA related to cranberries (2014 to 2015);
the advisory committee for the
for General Mills on US labelling requirements
McCormick Science Institute
for nutrition declarations (2014 to 2016, and
included tasks to review research
2018); for DSM on Codex Alimentarius processes
proposals submitted for funding
(2014 to 2015); for Hampton Creek on labelling
by the institute. Studies include
standards for mayonnaise (2014 to 2015); and
evaluation of the use of spices
for a Washington DC law firm on labelling of
and herbs to support consumers
genetically modified foods (2014 to 2015);
adjust, e.g. to recommendation on
NUGAG Subgroup
member
she was a member of the National Academies of reducing intake of added sodium
Sciences, Engineering, and Medicine (NASEM) and sugars. The focus of these
and member/chair of the Dietary Guidelines engagements was not considered
Advisory Committee, involved in reviewing the to pose a risk for the guideline
evidence in developing the national dietary development. Regarding her
guidelines for the US, Dietary Guidelines for membership on the US Dietary
Americans; as such, she Guidelines Advisory Committee,
the work was done for a national
—— was nominated to the Dietary Guidelines
authority and therefore was not
Advisory Committee of the USA by
considered a conflict of interest.
representatives from the North American
Regarding her nomination to the
Branch of the International Life Sciences
US Dietary Guidelines Advisory
Institute; the American Beverage
Committee by industry groups,
Association; American Bakers Association,
there is no relationship or
Grain Chain; Grocery Manufacturers
affiliation between nominator and
Association; USA Dry Pea & Lentil Council,
nominee.
American Pulse Association
It was therefore considered that
—— received honorariums for presentations
these declared interests do not
on the process to develop the Dietary
constitute any conflict of interest
Guidelines for Americans and policies for
for the work being undertaken by
food labelling in the US at various scientific
the NUGAG Subgroup on Policy
meetings organized by PMK Assoc. (IFT &
Actions
AOCS), McCormick Institute, Fiber Assoc-
Japan, and Mushroom Council;
she was a Member Board of Trustees of the
International Food Information Council
(IFIC), which ensures that IFIC upholds its
responsibilities as a 501(c)(3) non-profit (2021);
she was a government liaison for the
International Life Science Institute North
America, and evaluated research and organized
webinars on the microbiome (2018);
she presented a webinar – for which she
received no remuneration – to the International
Dairy Foods Association on the work of the 2020
Dietary Guideline Advisory Committee (2020)
Reema Tayyem No interests declared Not applicable
Alison Tedstone No interests declared Not applicable
Anne Marie Thow Declared receiving funding from WHO for Declarations were not deemed to
consultancies to analyse trade, fiscal and nutrition constitute any conflict of interest
policies, and to support nutrition policies in Pacific for her role in the NUGAG Subgroup
Island countries in 2015 and 2017. Further declared on Policy Actions given the source
receiving funding from the Food and Agriculture of the funding
Organization of the United Nations and the
Asian Development Bank, through her university
(University of Sydney) for consulting.
Edelweiss Declared receiving funding from the South African Declarations were not deemed to
Wentzel-Viljoen Medical Research Council during 2014–2016 for constitute any conflict of interest
research on salt reduction and hypertension. for her role in the NUGAG Subgroup
Further declared being a Board member of the on Policy Actions given the source
Heart and Stroke Foundation of South Africa. of and topic covered by the funding
Methods expert Interests declared Action taken

Elie Akl No interests declared Not applicable
Damian Francis No interests declared Not applicable
Annex 9. Summary of declarations of interests of contributors to the guideline development process 65

Systematic review
Interests declared Action taken
team
Kathryn Angus No interests declared Not applicable
Angela Boland No interests declared Not applicable
Systematic review
team
Emma Boyland Declared receiving research support, including Declarations were not deemed to
grants, collaborations, sponsorships and other constitute any conflict of interest
funding, from Cancer Research UK and the for her role in the systematic
Wellcome Trust. Further declared that, in the review team given the source of the
past 3 years, as part of a regulatory, legislative funding
or judicial process, she provided expert opinion
or testimony, relating to food marketing policies.
Provided public statements and positions to
the UK Government Health Select Committee
Childhood Obesity Inquiry in 2015 and 2018
Juliet Hounsome No interests declared Not applicable
Andrew Jones No interests declared Not applicable
Michelle Maden No interests declared Not applicable
Lauren McGale Declared being employed as a research assistant During Lauren McGale’s employ
on the SWITCH study at the University of Liverpool, ment as a research assistant with
which was funded by the American Beverage the University of Liverpool on a
Association. Declared that this funding was study (Switch trial) funded by the
awarded to the university. She was not part of American Beverage Association
the funding application and was not a named (ABA), she recruited participants
investigator. Her role (which ended in 2020) and collected data (running probe
involved recruiting participants and collecting days). Lauren McGale was not part
data. of the funding application, did not
receive an honorarium from ABA
and is not a named investigator.
As such her involvement in the
Switch trial was not considered a
risk to the guideline development
process.
External peer
reviewers
Huda Mustafa Al No interests declared Not applicable
Hourani
Gershim Asiki Declared having received a research grant from Declarations were not deemed to
the International Development Research Centre constitute any conflict of interest
(IDRC)–Canada in 2019 to conduct research on for his role as an external peer
the food environment and benchmarking policies reviewer given the source of
for three east African countries (Kenya, Tanzania funding and topics covered
and Uganda); and on mapping food promotion to
children in schools, in food retail outlets and on
TV/radio in Kenya. Declared receiving additional
funds from IDRC for development of four food
environment policies in Kenya, working closely
with the Kenyan Ministry of Health.
Alejandro Calvillo No interests declared Not applicable
Suparna Ghosh- No interests declared Not applicable
Jerath
Maria João No interests declared Not applicable
Gregório
Fiona Sing No interests declared Not applicable
Boyd Swinburn No interests declared Not applicable
Declared interests were discussed with the Office of Compliance, Risk Management and Ethics (CRE)/WHO.
Annex 10.
Key characteristics of policies evaluated by studies included in the systematic review on the
effectiveness of policies to restrict food marketing to which children are exposed
The following table provides the key characteristics of the policies evaluated by studies included in the systematic review on policies to restrict food marketing to which children
are exposed (1). Some of the policies and/or their characteristics may no longer be current.
Targeted products Exposure Power

Jurisdiction Restricted How are child-directed
Definition of Target Criteria/
Policy name (date Policy type communications, communications, media, How are marketing techniques
child in policy foods and model used to
implemented) channels and advertisements and settings defined and restricted?
beverages define
settings defined?
Australian Australia Mandatory 6–13 years All foods and Not reported TV Placement: programmes and Regulates (does not prohibit)
Children’s (1984) drinks advertisements shown during use of promotions, popular
Television designated “C” programmes characters and premium
Standards (those specifically produced for offers promoted to children
children 6–13 years of age) in advertisements for food:
“If a premium is offered, any
reference to the premium must
be incidental to the main product
or service advertised”. Premiums
are defined as anything offered
with or without additional cost
that is intended to induce the
purchase of an advertised product
or service.
67
68
beverages define
settings defined?
Australian Australia Voluntary <14 years Those not Defined set TV, radio, Medium that is directed primarily Not reported
Food and (August representing of nutrition newspaper, to children and/or where children
Grocery 2009) healthier criteria for magazines, represent 35% or more of the
Council’s choices assessing outdoor audience of the medium. In
Australian as per children’s billboards and relation to television, media
Quick established meals posters, emails, directed primarily to children
Service scientific or interactive include all “C” (children’s) and
Restaurant Australian games, cinema, “P” (preschool children’s) rated
Industry Government internet sites programmes and other rated
Initiative standards programmes that are directed
primarily to children through
their themes, visuals and
language.
Canadian Canada Voluntary <12 years Non– Uniform TV, radio, print, Audience and placement: Licensed characters, celebrities,
Children’s (introduced “healthier nutrition internet company-owned websites/ movie tie-ins, use of products
Food and 2007, fully dietary criteria: microsites primarily directed in interactive games, product
Beverage implement- choices” company- to children <12 years; video/ placement
Advertising ed by 2008) specific computer games rated “Early
Initiative nutrition Childhood (EC)”; DVDs of movies
standards rated “G” whose primary content
is primarily directed to children
<12 years, and other DVDs whose
content is primarily directed to
children <12 years; mobile media
(phones, tablets, personal digital
devices) where advertising on
those media is primarily directed
to children <12 years
beverages define
settings defined?
Chile Food Chile (2016, Mandatory <14 years “High in” Uniform TV, websites, Time, placement, audience, Prohibits, in any marketing for
Labelling updated products nutrition schools, and setting: all TV broadcast regulated products, use of the
and 2018) criteria: packaging from 6:00 hours to 22:00 following: celebrities, characters,
Advertising thresholds hours. Outside these hours, TV cartoons (including brand equity);
Regulation set by the broadcast on devoted children’s toys; stickers; animations;
(“Super 8 Chilean channels, during programmes children’s music; people/animals
Law”) Ministry of targeting children, or when child that capture children’s interest;
Health audience is >20% (except during fantastic statements about
sports, cultural, artistic or charity product or its effects; situations
events, if certain criteria are representing children’s daily
met). Also included are websites life; children’s expressions or
targeting children or those with language; interactive contests,
child audience of >20%; and games or applications; or “hooks”
preschools, primary schools and unrelated to the product itself
secondary schools.
EU Pledge European Voluntary <12 years Those Company- TV, radio, Audience, placement and Prohibits advertising of products
Union (EU; primarily specific cinema, print, setting: no advertising to media that do not meet common
introduced directed nutrition outdoor audiences with >35% of children nutrition criteria to children
2007, to children standards marketing, <12 years (from 2012; previously under 12 years old
uniform under 12 internet, mobile 50%), except for products that
nutrition that do apps, social meet nutrition criteria (company-
criteria not meet networking specific). No communication
adopted specific websites, related to products in primary
Annex 10. Key characteristics of policies evaluated by studies included in the systematic review
2014) nutrition influencer schools, except where specifically
criteria marketing, requested by, or agreed with,
interactive the school administration for
games, schools educational purposes. Since
2012, internet advertising
has been extended to include
company-owned websites,
in addition to third-party
advertising.
69
70
beverages define
settings defined?
Mexican self- Mexico Voluntary <12 years No specific Not reported TV, radio Audience, placement and Does not prohibit use of
regulation (2009) targets setting: applies to schedules persuasive techniques
but, to be and programmes predominantly
(Código de
permitted, aimed at children (without
Autorregu-
advertise- further speciﬁcation).
lación de
ments must
Publicidad Defined as child directed if the
“promote
de Alimentos product or packaging and/or the
healthy life-
y Bebidas advertisement (through themes
style habits,
No Alcohóli- related to fantasy, mystery or
based on a
cas dirigida adventure, or use of colourful
proper diet
al Público characters and gifts) aims to
and active
Infantil) appeal to children, and/or when
lifestyle”
an advertisement is broadcast on
children’s programming, or when
a child audience reaches a pre-
established minimum level.
Quebec Quebec, Mandatory <13 years Those Any product All commercial Audience: child directed when Use of characters or themes
Consumer Canada designed consumed advertising children make up >15% of designed to elicit the interest of
Protection (1980) for primary primarily by directed at audience children
Act appeal to children children
children
San San Mandatory Not reported Those not Uniform Fast food Settings: applies to all fast food Free toys or incentives (games,
Francisco Francisco, meeting nutrition restaurants in restaurants trading cards or other consumer
Healthy USA nutrition criteria San Francisco products)
Food (December criteria
Incentives 2011)
Ordinance
beverages define
settings defined?
Special Act Republic Mandatory 4–18 years Food Uniform TV Not reported Not reported
on Safety of Korea products nutrition
Management (September favoured criteria:
of Children’s 2010) by children determined
Dietary Life as snacks by Korean
or meal Food and
substitutes Drug Admin-
that do not istration
satisfy the
nutrition
criteria
UK content UK (April Mandatory <16 years Those high UK Food TV Placement and audience: Promotional offers, nutritional
and 2007 – in fats, sugar Standards broadcasting during children’s and health claims, licensed
scheduling January or salt Agency programmes or when proportion characters, celebrities;
(Ofcom) 2009) Nutrient of viewers aged 4–15 is 20% techniques regulated by UK Code
restrictions Profiling higher than in the general of Broadcast Advertising that are
Model population calculated to appeal to children
aged 4–16
Annex 10 references
1. Boyland E, McGale L, Maden M, Hounsome J, Boland A, Jones A. Systematic review of the effect of policies to restrict the marketing of foods and non-alcoholic beverages
to which children are exposed. Obes Rev. 2022;23:e13447. doi: 10.1111/obr.13447.
Annex 10. Key characteristics of policies evaluated by studies included in the systematic review
71
For more information, please contact:
World Health Organization
20 Avenue Appia
1211 Geneva 27
Switzerland
Email: nutrition@who.int
https://www.who.int/teams/nutrition-and-food-safety

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Policies to protect children

from the harmful impact

BMI body mass index

Objective, scope and methods

Effectiveness of policies to restrict food marketing to which children are exposed

Good-practice statement and recommendation

Key considerations for implementation

Executive summary xiii

Fig. 1. Cascade of effects of food marketing

Source: Adapted from Kelly et al. (48).

1.2 Scope and purpose

1.4 Target audience

2.1 Contributors to guideline development

WHO Steering Committee

Guideline development group

External resource people

External peer review group

2.2 Guideline development process

Formulation of key questions and prioritization of outcomes

2. How this guideline was developed 7

Sociodemographic, sociocultural factors, commercial drivers

NCD: noncommunicable disease

Table 1. Population, intervention, comparator and outcomes for key questions

2. How this guideline was developed 9

Evidence gathering and grading

Formulation of the recommendations

2.3 Management of conflicts of interest

2. How this guideline was developed 11

3.1 Evidence on the nature, extent and impact of food marketing

3.2 Evidence on effectiveness of policies to restrict food marketing

Unclear effect Unclear effect

3.3 Evidence on contextual factors

4. Good-practice statement and recommendation 23

Table 2. Additional considerations by the NUGAG Subgroup on Policy Actions to

4. Good-practice statement and recommendation 25

Box 3. Resources for development and implementation of policies to

Nutrient profile models

6.1 Overarching research gaps

Impact of food marketing

6.2 Considerations for design of future evaluations

Headquarters Regional Office for the Eastern

Dr Fabio Da Silva Gomes Regional Office for the Western Pacific

Dr Melanie Bertram Dr Benn McGrady

Dr Nawal Al Hamad Professor Joerg Meerpohl

Annex 4. Members of the WHO NUGAG Subgroup on Policy Actions 47

Systematic review team Methods experts

Dr Huda Mustafa Al Hourani Dr Maria João Gregório

Factor Guidance questions

 What is the impact of the intervention on (health) (in)equality and/or (health)

 Is the intervention in accordance with human rights standards, and what is

 Is the intervention acceptable to governments and policy-makers, the public

 What is the feasibility of developing and implementing the intervention

Annex 8. GRADE evidence profile

Annex 8. GRADE evidence profile

Annex 8. GRADE evidence profile

Annex 8. GRADE evidence profile

Annex 8. GRADE evidence profile 61

Methods expert Interests declared Action taken

Annex 9. Summary of declarations of interests of contributors to the guideline development process 65

What is the impact of the intervention on (health) (in)equality and/or (health)

Is the intervention in accordance with human rights standards, and what is

Is the intervention acceptable to governments and policy-makers, the public

What is the feasibility of developing and implementing the intervention