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  1. supermarket-aisle-blurred-background-with-laptop-computer-and-cart-on-wood-Charlie Cooke considers how and why advertising and marketing of unhealthy foods has been so successful and what can marketeers of healthy choices learn from industry practices.

    Marketing is a fundamental component of any health enterprise.

    In a free market of companies competing for customer cash and attention, the balance between what you want to say/sell with the integrity with which you wish to sell it, and the fluff claims and excitement that come with effective health marketing, will always be a teeter-totter-tip away from either complete grandiose nonsense health claims or the crumbling of your health enterprise due to insufficient customer demand for what you’re selling.

    This is why I set out to understand what it is the big dogs have been doing for all these years to gain their marketplace success, and what promoters of good health and nutrition can do to beat them at their own game.

    CONSUMER BEHAVIOUR

    Before assessing the role of marketing and advertising in food selection, however, we must first understand consumer behaviour. Fortunately, a large review of all recent data assessing food consumption in the UK was published in 2020 by RAND,1 and the primary headline under consumption trends is: ’What people consume still falls short of dietary guidelines’. This was simply subdivided as:

    • UK consumers are generally not meeting the standards recommended for a healthy diet.
    • There have been reductions in salt, sugar, and red and processed meat consumption but consumption of fruit, vegetables and fibre has shown little or no change.

    Hardly surprising for anyone who works with clients on a regular basis. However, it is promising to see some change in behaviour around processed foods. But why and how did this change take place? Of the top drivers of consumption, the highest quality and most consistent evidence demonstrates the importance of these three points:

    1. Cost
    2. Availability and convenience, and
    3. Marketing and advertising

    As the focus of this article is on food marketing, it is worth noting the following section from the RAND report:

    ‘Marketing has a significant effect on consumer choices, in particular increasing the consumption of unhealthy food, especially in children and young people. Emerging evidence suggests that social media is increasingly influencing younger segments of the population.’

    This statement was a shame to read.

    THE BASIC PRINCIPLE OF MARKETING

    When my first business, KnowHowNutrition, eventually and inevitably failed, leaving me thousands of pounds in debt and having to let go of three members of staff at the age of 19, I quickly came to the smarts that I failed at the most basic principle of marketing: putting the right product in front of the right person at the right price.

    Having this realisation, I went on to study Nutrition with Food Marketing at Newcastle University – perhaps as relevant as you could possibly get for the subject of this article. I had learned that putting the right message out to the right person was fundamental to any success, and perhaps by learning more from those who have managed to successfully market and profit from their health claims, I could perhaps have a more substantive impact on my target market.

    The above quote from consumer trend data was a shame to read because those who have come before, with their effective marketing, branding, messaging and advertising, have generated their success and profit at the cost of consumer health. Certainly their methods were successful, but marketeers of health nutrition and foods must consider which elements of the big-dog campaigns were the drivers of success in order to steal their tactics.

    I went on to scan the whole consumer food trend report for the word ‘marketing’ and found the same result scattered throughout – that marketing was substantially and significantly evidenced as being a primary driver of unhealthy food choices, and, alarmingly, this is becoming more and more relevant in children and young populations.

    ‘Marketing and advertising increases the consumption of unhealthy foods in children, adolescents and young adults.’1

    In a systematic review of persuasive marketing techniques to promote food to children on television published in 2014,2 the following methods were commonly reported as the most effective:

    • Use of premium offers
    • Use of promotional characters
    • Nutrition and health-related claims
    • The theme of taste
    • The emotional appeal of fun

    We can probably all recall many effective adverts we have seen with brightly coloured cartoon characters, multi-buy offers in the supermarket, how much ‘fun’ one can have by consuming this or that toffee – but in recent years such campaigns have become less and less frequent.

    Since the RAND report, there have been multiple developments to curb efforts in these areas of effective food marketing, with current UK legislation imposing restrictions in the permitted practices of food marketing, and government proposals (now unfortunately on hold) on limiting the use of price promotions of specified food, restriction on the price promotion of certain drinks, and the restriction on the placement of specified food.3 The Advertising Standards Agency has also taken a clear stance on preventing food companies from marketing unhealthy habits or lifestyles to children, included in their statement: ‘Advertisers are not allowed to use licensed characters in food and drink ads targeted at children.’4

    With regard to nutrition and health claims, it is cited on the UK Government website that ‘Nutrition and health claims are required to be based on scientific evidence and may only be used in commercial communications if they have been authorised following scientific assessment of substantiating evidence.’5Certainly a step forward, and yet, still, unhealthy foods are outcompeting healthy recommendations in the ether of food advice and health habits. But what is it that’s so effective about this marketing? How do these findings and regulations relate to nutrition practitioners in the marketing of our advice/products to our consumers?

    EFFECTIVE MARKETING OF HEALTHY FOOD PRODUCTS USING STANDARD FOOD INDUSTRY PRACTICE

    Fortunately for granola-warriors like me, many of the food marketing restrictions are only in place against ‘specified food’. I went through the luxury of reading this list, and was not surprised to see that specified restricted foods generally consist of some form of potato- or flour-based confectionary with or without excessive amounts of fats/sugars in their formulation.3

    This means that as long as foods fall outside of the 13 categories of specified foods, then the restrictions do not stand. Therefore, health-food marketeers are able to use the effective strategies of fun-association, science-backed health claims, great taste and healthy lifestyle promotion. This would even be permissible for advertising standards, as the promotion would not be categorised as promoting unhealthy behaviours or lifestyle. We could even have a catch-phrasing character if we wanted! The joys of being on the good-side!

    I am not trying to advise a specific marketing campaign for bananas or to tell you what to tell your clients, but instead to bring attention to some very useful research demonstrating the effective marketing practices that have been used historically for unhealthy foods, the efforts made to prevent their success, and the open window for healthy lifestyle ambassadors to jump through by using their own methods against them – as long as the government obesity strategy legislation doesn’t stay on the back-burner for too long.

    The free market is a competitive world, so I think it’s about time we start trying to beat the processed-food-conglomerates at their own game.

    CGR Cooke, ANutr

    Charlie has qualifications in nutrition
    and a history in fitness, varying from coaching boxing
    to international marketing.

     References

    1      Rand.org. 2020. Food consumption in the UK: Trends, attitudes and drivers. [online] Available at: <https://www.rand.org/content/dam/rand/pubs/research_reports/RR4300/RR4379/RAND_RR4379.pdf> [Accessed 16 May 2022].

    2      Jenkin, G., Madhvani, N., Signal, L. and Bowers, S., 2014. A systematic review of persuasive marketing techniques to promote food to children on television. Obesity Reviews, 15(4), pp.281-293.

    3      Legislation.gov.uk. 2022. The Food (Promotion and Placement) (England) Regulations 2021. [online] Available at: <https://www.legislation.gov.uk/ukdsi/2021/9780348226195> [Accessed 16 May 2022].

    4      ASA. Practice, A., 2022. Food, drink and supplements. [online] Asa.org.uk. Available at: <https://www.asa.org.uk/topic/food_drink_and_supplements.html> [Accessed 16 May 2022].

    5      GOV.UK. 2022. Nutrition and health claims: guidance to compliance with Regulation (EC) 1924/2006. [online] Available at: <https://www.gov.uk/government/publications/nutrition-and-health-claims-guidance-to-compliance-with-regulation-ec-1924-2006-on-nutrition-and-health-claims-made-on-foods/nutrition-and-health-claims-guidance-to-compliance-with-regulation-ec-19242006#:~:text=Nutrition%20and%20health%20claims%20are,scientific%20assessment%20of%20substantiating%20evidence.> [Accessed 16 May 2022].

     

  2. pregnancy-&amp;-nutritionThe number of people following a vegan diet is increasing in the UK and has been reported as comprising 1.21% of the population. This is a significant rise when compared with 0.25% reporting to be following a vegan diet in 2014.1

    This year (2022), Ipsos for the Vegan Society also found that almost half of British adults polled reported using plant milks and 58% reported including ‘at least one plant-based meat alternative’ in their diet.1 Sales of vegan alternative food products are also on the increase, with Aldi reporting a 500% increase in sales in January 2022 compared with 2021 – and they expect a continued increase as they expand their range in response to demand.1

    In line with this, the percentage of women of childbearing age who are adopting a vegan or more plant-based diet will likely be on the rise.

    POSITIVES AND NEGATIVES OF A VEGAN DIET IN PREGNANCY

    Pregnancy is a critical time for both mother and child, providing a window of opportunity to lay foundations for healthy growth in the child and protecting the mother’s health. This increased intake of plant foods has the potential to have a positive effect on health. However, if swapping meat and dairy out for heavily processed and non-fortified alternatives, expectant mothers may be putting themselves and their child at risk of malnutrition.

    Nutritional advice differs across the world. In the UK and many other countries, a well-planned vegan diet is not contraindicated for pregnancy or breastfeeding. However, in Germany, it is not recommended without sufficient nutritional support.2

    Positives

    • The positives of increased plant food intake are well documented and may well confer additional benefits to pregnant women. These may include a potentially reduced risk of preeclampsia (PE) in those following a vegan or vegetarian diet, linked with increased fibre and fruit and vegetable intake.3,4 However, PE is a complex and multifactorial condition and so further research is warranted.
    • Research has also highlighted the reduced risk factors for gestational diabetes in those consuming a more plant-based diet,5 although a recent Cochrane review highlights the need for more quality research.6

    Concerns

    • Those following a vegan diet may be at an increased risk of deficiency from certain nutrients, which could in turn have a negative impact on both maternal and foetal health. These deficiencies include: iron, vitamin B12, iodine, calcium, omega-3 fatty acids, zinc and vitamin D.
    • B12 is of particular concern as it’s vital in foetal development and the only reliable dietary sources are from animal products or fortified foods.
    • Iron deficiency during pregnancy has been associated with low birth weight and neonatal anaemia,7 and maternal B12 status is also noted to be a key determinant of neonatal and infant B12 status – itself an independent risk factor for neural tube defects (NTDs).8
    • A 2021 systematic review also highlighted a risk of increased NTDs, lower birth weights and other adverse outcomes with B12 deficiency and noted a potential benefit of B12 supplementation in those in countries where animal products can be scarce and so B12 intake is low (high risk of a low-B12 intake areas).9 A recent study from the University of Bristol drew links between adverse maternal and infant health outcomes and low B12 intake in pregnant women. Speech and mathematical abilities in later life of the child may also be affected, though they report that more longitudinal studies are needed.10
    • A recent observational study has also highlighted incidences of lower birth weights for children of vegan mothers and a higher chance of small for gestational age (SGA) babies when compared to omnivores.11
    • Links have also been made that suggest an increase in self-reported postnatal depression in vegetarian mothers, potentially due to micronutrient deficiencies.12

    Table 1: UK recommended intake for some key nutrients in pregnancy for vegans

    Nutrient

    RDA

    Vegan sources

    Calcium

    700mg/day

    • Fortified milk/yoghurt/spreads and other dairy alternatives. It’s always worth reminding pts that organic versions aren’t fortified and some popular versions like Rude health are also not always fortified.
    • Calcium set tofu, not set with nigari. Check the label
    • Green leafy vegetables
    • Pulses
    • Calcium fortified breads and cereals
    • Dried fruit13

     

    Iodine

    200μg/day

    (usual adult RDA 140μg/day)

    • No official UK recommendations for supplementation of iodine in pregnancy, though intake is vital for baby’s brain development.
    • The only reliable vegan sources of iodine are fortified plant milks and supplements containing <150μg/day potassium iodide or potassium iodate.
    • Seaweed-based supplements are not recommended and excessive supplementation can be harmful.14

     

    Omega-3 fatty acids

    No official UK RDA but two portions of fish (one oily) per week guidelines = ~450mg EPA and DHA/day

    • Omega-3 fortified vegan foods and supplements.
    • Rapeseed oil
    • Walnuts
    • Chia seeds
    • Ground linseeds15

     

    Iron

    14.8mg/day

    • Fortified foods, including breakfast cereals
    • Dried fruit, including apricots and dates
    • Beans and pulses
    • Dark green veg16

     

    Vitamin B12

    1.5μg/day

    • The only reliable vegan sources are fortified foods and supplements.
    • Fortified foods: eat fortified foods at least twice a day, aiming for 3mcg of vitamin B12 17
    • Supplements: at least 10mcg daily or at least 2000mcg weekly.

    NB excessive supplementation with B12 can be harmful17

    In addition to this, all pregnant women in the UK are advised to consider supplementation with the following:

    • 400μg/day folic acid, prior to conception and up to 12 weeks into pregnancy
    • 10μg/day vitamin D daily

    SUMMARY

    In summary, there is currently limited heterogenous research available that looks into the outcomes of a vegan diet in pregnancy. All of those following a vegan or plant-based diet are at risk of micronutrient deficiency without careful planning and in pregnant women this could potentially affect the health of mother and child.

    There is a sea change happening in the world of food and amongst heightened environmental and health concerns and much needed changes to agriculture, it doesn’t look like it is going anywhere soon.

    Reasons for choosing to follow a vegan diet are variable and individual, ranging from religious and moral reasons to health and environmental concerns. Those who choose to follow these diets should be supported to follow them in the safest way. As nutrition healthcare professionals we need to be well-equipped to help support clients during their pregnancies who wish to follow a vegan or more plant-based diet, especially in the midst of an unimaginably large number of self-styled nutrition ‘experts’ and influencers.

    At this time, it appears that well-planned vegan diets can be safe for pregnancy and breastfeeding, but attention needs to be paid at all times to some key nutrients. These nutrients and key sources are highlighted in Table 1.

    Jessica English, RD 

    Jess is a self-employed, private practice dietitian with interests in IBS,
    maternal and child health, and public health.

    Instagram: @meals.for.motherhood

    Website: www.mealsformotherhood.com 

    References

    1. The Vegan Society: Worldwide growth of veganism – Veganism in the UK, available online: https://www.vegansociety.com/news/media/statistics/worldwide#:~:text=The%20number%20of%20vegans%20in,150%2C000%20(0.25%25)%20in%202014. (accessed 18/04/2022)
    2. Koletzko B, Bauer CP, Bung P, Cremer M, Flothkötter M, Hellmers C, Kersting M, Krawinkel M, Przyrembel H, Rasenack R, Schäfer T, Vetter K, Wahn U, Weissenborn A, Wöckel A: German National Consensus Recommendations on Nutrition and Lifestyle in Pregnancy by the ‘Healthy Start - Young Family Network'. Ann Nutr Metab 2013
    3. Frederick IO, Williams MA, Dashow E, Kestin M, Zhang C, Leisenring WM. Dietary fibre, potassium, magnesium and calcium in relation to the risk of preeclampsia. J Reprod Med. 2005
    4. Chunfang Qiu, Kara B Coughlin, Ihunnaya O Frederick, Tanya K Sorensen, Michelle A Williams, Dietary Fibre Intake in Early Pregnancy and Risk of Subsequent Preeclampsia, American Journal of Hypertension, Volume 21, Issue 8, August 2008
    5. Streuling I, Beyerlein A, Rosenfeld E, Schukat B, von Kries R. Weight gain and dietary intake during pregnancy in industrialized countries – a systematic review of observational studies. J Perinat Med. 2011
    6. AMA. Tieu J, Shepherd E, Middleton P, Crowther CA. Dietary advice interventions in pregnancy for preventing gestational diabetes mellitus. Cochrane Database Syst Rev. 2017
    7. Sebastiani G, Herranz Barbero A, Borrás-Novell C, et al. The Effects of Vegetarian and Vegan Diet during Pregnancy on the Health of Mothers and Offspring. Nutrients. 2019
    8. Molloy AM. Should vitamin B12 status be considered in assessing risk of neural tube defects?. Ann N Y Acad Sci. 2018
    9. Behere RV, Deshmukh AS, Otiv S, Gupte MD, Yajnik CS. Maternal Vitamin B12 Status During Pregnancy and Its Association With Outcomes of Pregnancy and Health of the Offspring: A Systematic Review and Implications for Policy in India. Front Endocrinol (Lausanne). 2021
    10. Jean Golding, Steven Gregory, Rosie Clark, Yasmin Iles-Caven, Genette Ellis, Caroline M Taylor, Joseph Hibbeln, Maternal prenatal vitamin B12 intake is associated with speech development and mathematical abilities in childhood. Nutrition Research, 2021
    11. Avnon T, Paz Dubinsky E, Lavie I, Ben-Mayor Bashi T, Anbar R, Yogev Y. The impact of a vegan diet on pregnancy outcomes. J Perinatol. 2021
    12. Hogg-Kollars S, Mortimore D, Snow S. Nutrition health issues in self-reported postpartum depression. Gastroenterol Hepatol Bed Bench. 2011
    13. BDA. Calcium Food Fact Sheet - available online at: https://www.bda.uk.com/resourceDetail/printPdf/?resource=calcium (accessed 17/04/2022)
    14. BDA. Iodine Food Fact Sheet - available online at: https://www.bda.uk.com/resource/iodine (accessed 18/04/2022)
    15. BDA. Omega-3 Food Fact Sheet - available online at: https://www.bda.uk.com/uploads/assets/e8fa989a-6845-4864-a87427c78b5d65d7/Omega-3-food-fact-sheet.pdf (accessed 18/04/2022)
    16. BDA. Iron Food Fact Sheet - available online at: (accessed 18/04/2022) https://www.bda.uk.com/resource/iron-rich-foods-iron-deficiency.html
    17. BDA. Other Sources of B12: A practical guide for dietitians - available online at: https://www.bda.uk.com/uploads/assets/5378b751-58bd-4e85-b15b360d8165a3f8/Practical-guide-other-sources-of-B12.pdf (accessed 19/04/2022)