The digital presence of the leading brands in the category of Food for Special Medical Purposes

Objective: Food for Special Medical Purposes (FSMP) is a niche area in the food and healthcare industries that produces foods to meet the dietary requirements of people with specific medical conditions. These products provide specific nutrient amounts and ratios, which can be used as a supplement to a conventional diet, part of an entire medical treatment plan, or as a sole source of Nutrition. The market is expected to generate revenues of $19.67 billion in 2028. Most FSMPs products are purchased individually by patients or caregivers. Although these products are not advertised directly to the public might be bought online from pharmacies and other online shops. This research aims to evaluate the online presence of the most important brands within the FSMPs category and how the patients get to the online shops without direct-to-consumer advertisement. Methods: This exploratory qualitative research study examines the online presence of FSMP products and key brands using SEO as the main digital technique. Data sources included Romanian websites, Google SERPs, Brandmentions.com, Semrush, and Ubersuggest. Results : The findings showed that these websites received only a small amount of direct traffic, with only a few hundred monthly visits. To increase organic visibility, businesses must follow regulatory requirements, collaborate with medical experts, engage with potential clients, and exhibit their products at medical events and fairs. Content marketing is crucial for FSMP brands to engage with their target audience and deliver valuable information. Conclusions : FSMP brands cannot advertise directly to consumers. Instead, they should focus on SEO, reputable online pharmacies, e-commerce shops, and content marketing. This research applies to FSMP brands, digital marketers, and online pharmacies to effectively connect with target demographics, promote products, navigate regulatory constraints, and enhance online presence, improving accessibility and awareness.


Introduction
A specialised sector of the food and healthcare industries called "food for special medical purposes" (FSMP) creates food items to satisfy the unique nutritional needs of people with particular medical problems.These conditions may include long-term illnesses like diabetes or cancer and other illnesses that require particular dietary interventions [1][2][3].
According to the requirements of people with various medical conditions, FSMP products are designed to supply precise nutrient quantities and ratios.These items can be incorporated into a comprehensive medical treatment plan, utilised as a solitary source of Nutrition, or complement a typical diet [4,5].
FSMP are defined according with Article 2(2)(g) of the FSG Regulation [4] as follows: "food specially processed or formulated and intended for the dietary management of patients, including infants, to be used under medical supervision; it is intended for the exclusive or partial feeding of patients with a limited, impaired or disturbed capacity to take, digest, absorb, metabolise or excrete ordinary food or certain nutrients contained therein, or metabolites, or with other medically-determined nutrient requirements, whose dietary management cannot be achieved by modification of the normal diet alone".
The FSMP industry is experiencing rapid growth due to an ageing population, chronic diseases, and increased recognition of Nutrition.Patients in oncology often experience stomatitis and oral mucositis, which can lead to higher medical expenses and side effects.According to estimates, the market for foods used for special medical purposes (FSMP) is valued at $11.2 billion in 2019, $13.48 billion in 2021, and maybe $19.67 billion in 2028 or $ 19.41 billion in 2030 [6][7][8].According to local research firm Cegedim, the market for goods in this category marketed through pharmacies in Romania is worth 4.8 million RON, or approximately one million euros, yearly.[9].This does not include online sales and sales through retail units other than pharmacies (drogheries, natural shops, and ecommerce portals).
The main factors cited by the source consulted for this article are the growing knowledge of the advantages of this product category, the rise in chronic disease prevalence, the rising demand from older adults, the proliferation of new private-label producers, and the development of new distribution channels.Healthcare personnel supervise patients' medical treatment and assist them with FSMPs.However, looking into the legal obligations of pharmacies and pharmacists for dispensing FSMPs is necessary.Regulations should be followed.However, the digitalisation of healthcare systems will greatly impact future problems.Transparency can be provided via digital tools that can be used to monitor, evaluate, and control risks to food safety.
"Food for special medical purposes" (FSMP) refers to foods created for people with certain medical conditions and dietary requirements.Frequently, they can only be obtained with a professional recommendation and should only be used under medical supervision.Various national and international organisations, including the European Food Safety Authority (EFSA) and the United States Food and Drug Administration (FDA), regulate FSMPs through FSG Regulation and Codex Alimentarius [4,5].
FSMPs are divided into three categories: nutritionally complete with a standard nutrient formulation, nutritionally complete with a nutrient-adapted formulation, and nutritionally incomplete with either a standard or nutrient-adapted formulation.Products designated as FSMP should be consumable by humans and efficiently provide the intended population with nutritional support.Information on the label should include the energy value, the proteins, carbs, and fats, the vitamins and minerals present, the osmolarity and/or acid-base balance, and the source and makeup of the proteins [1].
Data extraction involved automated tools and manual review to ensure accuracy and relevance.The FSG Regulation provides precise guidelines for categorising and regulating FSMP products to guarantee their efficacy, safety, and suitability for people with certain medical conditions.Regulation (EU) 2016/128 governs the labelling, presentation, and advertising of Food for Special Medical Purposes (FSMP) products in the European Union (EU) [4,10].
Medicalisation in food advertising has increased, with claims about a particular food product's nutritional or health benefits targeting specific food groups and media genres [11].Regulation or awareness-raising is needed to prevent the negative effects of the medicalisation of food advertising on consumer behaviour and health.
Most FSMPs products are purchased individually by patients or caregivers.Although these products are not advertised directly to the public might be purchased online from pharmacies and other online shops.There is even the perception that this channel is cheaper than brick-andmortar pharmacies or shops.This research aims to evaluate the online presence of the most important brands within the FSMPs category and how the patients get to the online shops without direct-to-consumer advertisement.

Material and methods
This study adopts an exploratory qualitative research design to comprehensively examine the online presence of FSMP products and key brands.We evaluated the hypothesis that SEO is the main digital technique to get the brands known online.
The data collection assumed the following procedure.Selection of data sources to ensure a comprehensive dataset, multiple reputable sources were selected for data collection: -the websites of key brands available in the Romanian language or from Romania.
-Google: Data from Google's search engine results pages (SERPs) was used to assess the visibility and ranking of FSMP brands.SERPs usually display seven to ten links to websites relevant to the user's query, with paid ads taking up prime views at the top.Organic results are further down [12].Google's market share of over 85% suggests that data for other search engines will remain the same for paid and organic visibility [13].The top 10 search results account for 96% of traffic, illustrating the importance of the first page results [14].-Brandmentions.comprovides insights into brand visibility, sentiment analysis, and context of FSMP brand discussions across various online platforms.-Semrush was used to gather data on backlinks, keywords, and competitor analysis to understand FSMP brand link profiles, keyword strategies, and competitor positioning [15].Close variants can be used to reach customers looking for products or services without compiling long lists of keywords [16].-Ubersuggest was used to identify relevant keywords and search volumes associated with FSMP products, extracting data for key brands in the Romanian territory and language [17].Criteria for brand selection: a list of FSMP brands was compiled based on a previous qualitative study performed by authors [18] and information acquired searching for the FSMP category with main search engines, and we ended up with six brands (Fresubin, Nutridrink, Medidrink, Nutricomp, Recover Nutrition and Resource 2.0).
Data extraction involved automated tools and manual review to ensure accuracy and relevance.
Data analysis involved qualitative and quantitative analysis.
-Quantitative analysis involved descriptive statistics and metrics in examining FSMP brands' search engine rankings, social media engagement, and website traffic.-Qualitative analysis interpreted and understood contextual aspects of FSMP brands' online presence.Content analysis of textual data, including social media posts, online discussions, and website content, utilised thematic analysis techniques to identify recurring themes, sentiment patterns, and consumer perceptions.Ethical considerations were prioritised, adhering to platforms' terms of service, privacy policies, and data usage and privacy guidelines.

Results
The investigation begins by examining the websites held by major brand manufacturers or their official e-commerce sites or distributors for the Romanian language/country.The SaaS Platform Ubersuggest is then utilised to obtain traffic data and the keywords that created this traffic.The results are displayed in Table 1, which reveals that these websites had little direct traffic.A few hundred of visits per month suggest marketing actions do not help the traffic and are rather focused on users looking at a particular purpose (i.e. to get details about a product or a situation well known).
The keywords that generated the traffic consist of a variety of expressions used by consumers when searching for products to help them solve certain health problems (cancer, allergy, malnutrition, cachexia, etc.), a combination of words that involved the brand's name or a combination of words that imply brand name and a pharmacy chain brand.
As these are assets classified as owned media and FSPMs should not advertise directly to consumers, we also investigated whether access to marketing information is restrict-ed to professional users and determined that there is no standard approach.Some brands ask about professional/ non-professional capacity, while others do not filter access.
Based on data from Ubersuggets shown in Figure 1, 8.3%, respectively 17.64% of people's searches for Fresubin or Nutridrink (the most searched brands within the FSMPs category) are generated by CPC type.This suggests that someone is promoting such keywords.
Figure 2 presents various keyword variants that internet users use to search for key brands in this category.This information is useful in identifying the actual words that users search for on Google, which can then be utilised in setting up effective marketing strategies.
Table 2 presents the concept of paid visibility, which involves paying for adverts to be displayed in search results  for particular keywords that users search for.In the case of Google, the advertising platform is called Google Ads.Businesses can create ads targeting keywords related to their special supplements and bid on those keywords.The ads will be displayed at the top or bottom of the SERPs, with a small "Ad" icon indicating they are paid placements.B using paid advertising, businesses can quickly boost their visibility on search results pages, even if their organic SEO efforts have yet to bring them to the top positions.
Take note that Table 3 highlights the degree of organic visibility, a crucial metric that gauges the level of ease in which a product or website can be discovered on search engines like Google without the need for paid advertising.To improve organic visibility, website owners use search engine optimisation (SEO) techniques.In simpler terms, SEO is a set of strategies that help make a website more attractive to search engines by improving its content, structure, and user experience.By optimising their websites, business owners can increase the chances of their special supplements appearing higher in the search results when potential customers search for relevant keywords.The higher a website ranks on the SERPs, the more likely it is to be clicked on and visited by users.
Most of the results for Fresubin that are shown on the 1st page of results are generated by online pharmacies/stores.There is the brand page of Fresubin which has generated a lot of relevant content, but the other results that rank high in the SERPS are of the most popular online pharmacies and relevant websites in this niche like alimentespeciale.ro.
Most of the results for Nutridrink that are shown in the 1st page of results are generated by online pharmacies/ stores.Nutrient.ro-is the distributor for Romania -which has listed most of the information about this brand, and nutricia-med.ro is the brand page generated by Nestle.Other than that, the other results that rank high in the SERPS are of the most popular online pharmacies and relevant websites on this niche alimentespeciale.roand one result from emag.ro which doesn't have this product listed but they have generated a page based on the searches on their website.
Most of the results of Medidrink are again generated by online pharmacies.This time, the results are not just from the top pharmacies, but also from some that are not so well known, such as onlinefarmacia.ro,axafarm.roor farmaciasmart.ro.Medifood.ro is the manufacturer/distributor's website -owned by Thorus Pharma which is bidding  through their own online shop ( store.thoruspharma.eu).
In the case of Nutricomp, the BBraun websites are owned by the manufacturer/distributor in Romania.It is logical for it to show up since it has most of the relevant content about the product/brand.Other results are from top pharmacies and emag.ro.
For Recover Nutrition the only relevant listing comes from onconnect.ro-which is the Romanian distributor of this product.Other results that show up, are for products with similar/containing words, so data isn't relevant for this particular product, but rather for the keyword.
For the brand Resource 2.0 the top results are from the manufacturer/distributor website -nestle.roand nestlehealthscience.com.The others are from top online pharmacies / relevant stores for these products.
We used the Brandmentions.comtool to track the presence of important brands on social media and the internet.Table 4 displays our findings, which showed that only Fresubin and Nutridrink had a small number of mentions.Despite this, these mentions resulted in thousands of interactions but had limited reach.Additionally, we discovered the power of social media, where 147 mentions generated 1200 interactions and were viewed by 43,800 users.
After analysing the social media channels used by brands in the FSMP industry, we observed that Twitter is mainly utilised for brief comments, while Facebook and Instagram are more prevalent on Brandmentions.com.However, we found that mentions of Fresubin and Nutricomp are relatively scarce on the web, as shown in Figure 3.

Discussion
Fresubin, Nutridrink, Medidrink, Recover Nutrition, Nutricomp, or Resource 2.0 are essential FSMP-specific products for patients with specific medical conditions.However, it can be challenging to advertise these products there because direct-to-consumer advertising is restricted in some nations, including Romania.As a result, brands use a variety of tactics and methods to increase their visibility and sell their products [19].When promoting Food for Special Medical Purposes (FSMPs) to the general public, it is important to adhere to regulatory guidelines that prohibit advertising to the general public.
One of the most effective strategies FSMP businesses use is working with medical professionals like doctors and dietitians.These medical experts are crucial in assisting people in acquiring FSMP suggestions depending on their health conditions and nutritional needs.We imagine brands like Fresubin and Nutridrink actively engage healthcare professionals to advertise their goods through conferences, seminars, and workshops.They provide information on their products' nutritional value and how they might help people with specific medical conditions.Advertising for functional foods that emphasises taste or nutrition claims is more likely to be read and appreciated by consumers [20].Such mentions should observe the provisions of Regulation 2016/128 regarding the information requirements for FSMP [10].
Another strategy used by these brands is online marketing.Due to the expansion of digital platforms, brands  are now promoting their goods via social media, online forums, and health-related websites.These platforms allow businesses to communicate with potential customers and inform them of their products' benefits and nutritional value [21,22].Additionally, Fresubin and Nutridrink have websites that provide comprehensive information on their products, their work, and which medical conditions they are suitable for.FSMP brands also participate in medical events and fairs.These events give companies a chance to showcase their products to a bigger audience, which may include patients, healthcare professionals, and caregivers.Brands like those mentioned in this paper frequently participate in medical events in Romania to promote their products and share information about their advantages.
Another tactic used by these brands is word-of-mouth advertising.People who have used FSMP products and reaped their benefits can advise others experiencing similar medical problems to use them.For example, companies that sell FSMPs brands may work with advocacy and patient support organisations to promote their products to patients and caregivers.These groups provide a forum for patients to share their stories and promote the products they have found to be effective.Within the bounds of the law, social media can serve this purpose as it is widely regarded as an efficient means of communication and education [23,24].

Conclusions
The Food for Special Medical Purposes (FSMP) category specialises in the healthcare and nutrition industries.These products are designed to meet the dietary needs of individuals with medical conditions like metabolic disorders, digestive issues, and nutritional deficiencies.In Romania, FSMP brands face strict regulations, including a ban on direct-to-consumer advertising.This makes it necessary to develop innovative strategies to establish a strong digital presence and engage with potential customers.The following strategies are recommended: Search engine optimisation (SEO) of FSMP brands' websites and digital content can increase organic visibility and position in search results.With this strategy, they can connect with consumers actively looking for data related to their medical conditions, dietary requirements, or FSMP products.In addition, since FSMP brands are prohibited from engaging in direct consumer advertising, they can benefit from using long-tail keywords and informative content to address frequently asked questions and concerns.This tactic could elevate the company's standing in the market and establish it as a reliable resource for consumers and medical professionals.
FSMP brands can increase sales by making their products more accessible to their customers through reputable online pharmacies and e-commerce shops.Our findings show that many people who search use a shopping portal or online pharmacy like www.alimentespeciale.ro to find the needed products.In addition, FSMP brands can work together with these sites to produce instructional materials, like articles, videos, and blog posts, that can help new customers learn more about the features and benefits of the products they sell.The goal of this type of indirect advertising is to increase both brand recognition and customer loyalty.
Given the limitations of traditional forms of advertising, content marketing is especially important for FSMP brands looking to connect with their demographic.FSMP brands can become industry leaders by providing their target audiences with high-quality, informative content tailored to their needs and problems.Blog posts, articles, white papers, webinars, and videos addressing conditions-specific dietary needs, scientific research on FSMP products, and expert advice on managing a wide range of medical conditions are good examples of effective content formats.
By connecting with medical professionals on social media, FSMPs can strengthen their online identities.FSMP brands can attract the professional public who are interested in their products and the conditions they treat by sharing useful and informative content on social media sites like Facebook, Twitter, and LinkedIn.In addition, FSMP brands can expand their audience by forming partnerships with influencers like doctors and patients.Potential customers will have more faith in FSMP products after hearing from these influencers about their positive experiences with the brand.However, this channel is limited due to the law regulation which does not allow FSMP to be promoted directly to the general public and the use of this channel is debatable despite being very efficient [25].
In countries like Romania or other European Union territories where direct-to-consumer advertising is forbidden, FSMP brands like Fresubin and Nutridrink use a variety of marketing strategies to get the word out about their products.These companies partner with medical professionals, conduct web marketing, participate in medical conferences, and host medical events to increase brand awareness and sales.Companies that specialise in marketing products to people with specific medical conditions can help those people get the nutritional support they need to manage their health better.
This research is highly applicable to FSMP brands, digital marketers in the healthcare industry, and online pharmacies.They can implement these strategies to effectively connect with their target demographic and promote FSMP products while navigating the constraints of regulatory requirements.Moreover, by enhancing their online presence, these entities can help to improve accessibility and awareness of FSMPs, thereby better serving patients who require these specialised nutritional products for managing their health conditions.

Table 1 :
Manufacturer's or official distributor's websites in Romania-URLs, monthly traffic, keywords to generate traffic; *monthly traffic is based on Ubersuggest data for Romanian language/country -platform accessed onJune 3, 2023

Table 4 .
Social media and web presence of key FSMP brands (Source: Brandmentions.com)