Background

Obesity is a prevalent, costly and severe health concern among adolescents.1 Although the incidence of overweight and obesity among children and adolescents in countries such as the United States, France and Sweden seems to have plateaued in recent years, rates remain high.2 It is important to focus on adolescents as the probabilities of an obese child to develop into an obese adult are much higher than for a healthy weight child.3 One potent environmental factor influencing the rise in obesity is the pervasive presence of food and beverage marketing to young people.4 Today, much of the food marketing relies on social media, and adolescents are heavy users of social media. In countries such as the USA and Sweden, more than 70% of adolescents at ages 13–17 use a social media site on a daily basis.5, 6 Food marketing in social media works through a range of mechanisms, and the sight of food elicits a variety of brain responses related to preparation for food intake, desire to eat and cognitive processes such as hedonic evaluation.7 Food advertisements is powerful as brain reactivity to visual food cues has been shown to predict future weight gain in adolescents 8 and to predict snack consumption.9

Persuasive food marketing in social media

Snack and beverage companies are utilizing a wide range of sophisticated social media marketing techniques targeting adolescent consumers.10 Previous studies analyzing television advertisements seen by children showed that these promoted unhealthy foods,11 and the same seems to be true in social media. In a study on Instagram, a widely used media-sharing application, almost half of the food-related images shared by Scandinavian adolescent users contained references to food and beverage brands.12 The foods were mostly high in calories but low in nutrients and normally presented with positive descriptions. The results indicate that these uploaders were not aware, or simply agreed with the persuasive intent of food manufacturers. The impact of incorporated campaigns, which underline commercial messages across numerous platforms, and of social media, which engage individually with potential consumers, is likely to be greater than that of traditional marketing.13 When meeting and treating adolescent patients with obesity, it is therefore important that clinicians are aware of these new and emerging advertising techniques.

Recommendations for action

With this background, I wish to present a window of opportunity to create a new framework for social media marketing to youth. Much of the current work to limit exposure to high-calorie low-nutrient food advertising centers around restricting advertisements during children’s television programs.14 An updated framework will need to include the full spectrum of advertising and marketing practices across all media platforms. Social media marketing needs to be regulated, such that corporations are constrained to market unhealthy brands directly to minors. But a key role will also be played by clinicians, such as dietitians, nutritionists, nurses and physicians working with adolescents undergoing treatment for obesity. As social media’s influence over adolescents is not likely to decline in the near future, we also need to learn from it and make better use of it. I propose three ways in which this can be done, with the clinic as base:

First, clinicians should assess the dietary influences their adolescent patients engage with in social media. Are the patients or their parents following any blogs, online forums or patient-led organization online that provides nutritional recommendations contradicting the ones we provide from the clinic? Social media is a growing influence when it comes to non-conventional dietary regimes, that can be potentially harmful,15 and online dietary resources are used by a range of patient groups.16, 17 These assessments should preferably be incorporated into the structured patient talks as we bring up overall nutritional issues and problems. By engaging in these matters and raise our own awareness, clinicians will understand their patients’ health information needs better, and will also be able to meet their patients with applicable arguments in regard to specific sites and recommendations. One example is the low-carb high-fat diet that has been popular in the Nordic countries for some years and has been subject to national and international public health concern.18 The diet promoters have made effective use of social media to establish their authority.15 If patients are following this diet, it is important that clinicians talk about it in regard to specific health concerns characterizing the dietary regime, such as the drastic restriction of total carbohydrates and largely unrestricted intakes of saturated fats.19 Long-term risks can be difficult to grasp for adolescents, which is why clinicians should explain the mechanisms by which their diet can raise the risk for atherosclerosis and cardiovascular disease. It is also vital that clinicians elucidate how online diet promoters frame their arguments and what evidence base they are using in doing so. It is common that diet promoters in social media use anecdotal evidence (for example, weight-loss success stories) and powerful personal narratives20 that can be appealing and tempting for adolescents struggling with obesity. But clinicians need to clarify why and how anecdotal evidence is not scientifically credible.

Second, we also need to make adolescents aware of how they themselves contribute to the promotion of high-calorie low-nutrient food items and how they are exposed to online advertisements unwarily regarding unhealthy foods. Food marketing often targets children and adolescents, as they are more receptive and as it is harder for them to distinguish advertising claims from the truth.21 Therefore it is important that we emphasize the adolescents’ ability to comprehend and assess health information from online sources; that is, that we consider and encourage their eHealth literacy skills. An important concept in our clinical practice is to educate and guide our patients in how to independently and autonomously manage and handle their dietary habits in everyday life. Instructing our patients on how food and beverage companies operate online is important, and previous studies have showed that children who recognize the persuasive intent of commercial messages are more critical towards advertisements, for instance by developing counter-argumentation.22 Clinicians can assist in deconstructing food advertisement to inform adolescents what the aim of advertising is and how manufacturers try to affect them in various ways: for example, by using an illustrative advertisement (for example, billboards, online ads) and asking the adolescents if they can identify marketing techniques in these, such as animation, filming tricks or the use of celebrities. It is also important to explain and exemplify that when the adolescents see friends share images of, for example, Coca-Cola bottles in their Instagram accounts,12 Coca-Cola aims to make money and that the company want the adolescents to identify with their brand, to form a personal relationship. Online materials aimed to improve media and advertising literacy among adolescents and how they can cope with persuasion in media are available in, for example, English23 and Swedish.24 Clinicians could use this material or develop and tailor their own educational materials and workshops to explain how persuasive marketing operate in this day and age. The information should be adapted according to the patients' age and skill level.25

Lastly, we could use social media proactively in our clinical practice. For example, it can be to inspire adolescents to eat and cook at home, as cooking meals at home is associated with consumption of a healthier diet.26 Social media applications can be used to encourage adolescents to photograph and share their endeavors in the kitchen with clinic staff for feedback. We can also create a hashtag (#)—which in social media functions as a label and as a searchable keyword—that is specific for the clinic, wherein patients can tag their images of health meal ideas. Other patients can easily access these images by searching on Twitter or Instagram for the tag and get inspiring meal idseas from others in the same situation. Social reinforcement and social modeling are important aspects to consider in influences of adolescents' food habits.27, 28 Another more focused and potentially more time-consuming strategy is to create a private group on Facebook that is moderated from the clinic. Social networks can provide obese patients social support through online communities, and enable peer support, as well as individualized interactions and the exchange of personal data and recommendations between patients and providers.29 The adolescents would need to get the invitation for the group from the clinic, to assure privacy and to only allow patients from the clinic as members, as it can be sensitive to share and disclose to peers.

Social media have considerable potential as tools in the clinical practice, but they require careful application to achieve their desired outcomes. It is important to be sensitive and aware of the individual needs of patients, and to respect privacy issues. Clinicians need to delve into this online landscape, however, in order to be aware of the nutritional risks associated with these emerging new media and potentially misleading and misguiding information that their patients are exposed to, or voluntarily engage in. It is also important that clinicians see the potential in harnessing these new media as they are bound to increase in influence over pediatric patients.