Spotlight on Child & Adolescent Health: Childhood obesity

Jessamy Bagenal is joined by Dr. Eduardo J. Gomez and Pauline Mapfumo to discuss the drivers of childhood obesity, predatory industry tactics, and what steps can be taken to help bring down levels of childhood obesity.

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Transcript

This transcript was automatically generated using speech recognition technology and may differ from the original audio. In citing or otherwise referring to the contents of this podcast, please ensure that you are quoting the recorded audio rather than this transcript.

Jessamy: Hello and welcome to this episode of the Lancet Voice. This is one of four special episodes linked to our Child and Adolescent Health Spotlight for the Lancet 200 year anniversary. I'm Jessamie Bagonal and today we'll be talking about how industry impacts the things children eat. This is an area of research that has been coined the commercial determinants of health.

I'll be joined by Pauline Masurmo, a nutritionist and nutrition youth advocate from Zimbabwe, and Eduardo Gomez, associate professor in the College of Health at Ley University and author of Junk Food Politics. As always, you can find me on Twitter and LinkedIn, at jessamibaginal. I hope you enjoy the conversation.

Pauline and Ed, thanks so much for joining us today. I wonder whether you might just be able to sort of introduce yourselves and your interest in this area of kind of the commercial determinants of health, industry's influence on diet, obesity rates in young people maybe Pauline you could kick off and then over to you, Ed.

Thank you very much 

Pauline: for having me. Hi everyone. My name is Pauline Mabfumo. I am from Zimbabwe. I'm a nutritionist by profession and also a youth nutrition advocate with a specific focus and passion on child and adolescent nutrition. So this topic today is very close and dear to my heart because it's something that I really.

Work towards in my line of profession. 

Jessamy: It's 

Eduardo: lovely. Thank you. And Ed. Yes. Thank you very much. Destiny. Thank you so much for inviting me on the show. My name is Dr. Ed Gomez. the college of health at Lehigh university and the director of the Institute of health policy and politics, political scientists by training.

And determinants of health for many years. I started working on the U S and Brazil's response to obesity. Many years ago, and that started to notice now adolescent diabetes. And so that led me to question if policies aren't working, what's going on? And then I started to investigate sort of the role of industry and, and their interactions with government and society.

And that led me to my, my research that I've been doing for several years now. On my recent book, looking at the politics of corporate determinants of health and how industries work with government society to influence in our health, ultimately. And so that's what my, my interest in this subject comes from.

Jessamy: That's awesome. Thanks so much. So maybe we can just start for listeners to kind of frame it slightly. So, I mean, what do we know about the influence of big industry and commerce on young people's diet? And how does that feed into obesity levels and other non communicable diseases? Maybe, maybe Ed, you could start off with that one and then we'll hear from Pauline.

Eduardo: Yes, I think that diet industry has had a massive impact on children and other populations through several different ways. First is through marketing, certainly sort of advertising on major TV channels. Social media, for example, I think one area that has been targeted a lot are, you know, Instagram, Facebook, all these major, major popular channels and ways of communicating.

And I think that's been certainly important. Also, advertising in communities, on billboards you know, billboards near schools of of beverages and ultra processed foods. Also, at checkout points, you know, in the UK, the government's doing a good job of addressing how and when children see these ultra processed and checkout areas and counters and local convenience stores.

This is still a major problem in the U. S. and a lot of countries where children see these foods and sort of pressure parents to buy impulse, this is impulse shopping, pushing parents to buy the food away. There's a wide variety of ways that I think industry has influenced the way that children and other, other populations, especially poor populations, see these foods and, and purchase these foods.

And so I think that's something that, that certainly needs to be addressed. 

Jessamy: Pauline, would you like to add to that? 

Pauline: Yes. I definitely agree with what Ed was saying, especially on the front of marketing and how most recently the idea of using social media as a, as a platform for marketing has really affected and influenced the young people in their dietary preferences towards These commercialized over processed foods that are being produced by the different industries.

And when we're looking at people in different socio economic Structures, you find that some most of these industries are sending most of these unhealthy commodities at very low prices, very affordable prices. So these foods end up being readily available and easy and easy to consume. And it's what makes it worse is the aggressive marketing that's there for towards these foods.

We attract the young people even more. Almost in going back to what it meant, what it said about the counter and they get the count, the checkout point area where you have all these sweets or these chocolates and chips displayed there sort of is like a way to lure kids into wanting to eat them more.

So I think that aggressive marketing is really like the basis for these commercial determinants. 

Jessamy: Yeah. That's helpful. I mean, it seems like such an obvious thing, particularly when you think about this sort of number of adverts that children are exposed to. I think, I think it might've been the Lancet Planetary Health or one of our journals published a study where they basically had young people wear a camera for a day and then counted the number of adverts that they were exposed to over a 24 hour period.

And it was something insane like 500 or, you know, so it seems completely obvious. But actually it's, it's a relatively early field of research, is that right, Pauline? And how does it play out in your context? Yes. And it 

Pauline: really is. As recently, I think towards the middle, low to middle income countries, you find that obesity is slowly beginning to emerge as like In nutrition issue compared to the previous years, because in the previous years we were mainly dealing with malnutrition, we're looking at cases of stunting, we're looking at cases of wasting, but now you find that obesity levels are rising within the young people and the young generation.

And that what makes it even worse is. It's still a relatively new area of research, especially when you're now looking when you're now focusing more on the commercial sides and how the industries are affecting what we do know is. There's a lot of advertisements, there's a lot of aggressive marketing, but there hasn't really been like straightforward research that digs deep into how exactly it's affecting our young generation directly.

It's mostly mentioned as like a additional factor or an additional contributor to, or like a precursor to what the result is, which is the issue of obesity that we're now dealing with. 

Jessamy: Interesting. 

Eduardo: Ed, do you want to add to that? Yes, I completely agree with Pauline. I think that there's, I think in, in, in different countries and regions in the U.

S. Because children and the population in general have been exposed to sodas and beverages and all processed foods for many years, I think the research has been around on, on advertising and regulations. But as Pauline pointed out, I think in In other countries, in, in, in emerging middle income countries, lower, lower income countries, this is a very new topic for several reasons, as Paulin pointed out, for many years the focus was on malnutrition and poverty, which is still, of course, a major issue.

But politicians and governments often have a difficult time wondering what to address, what to emphasize, and have undernutrition and overnutrition happening at, at the same time. In many countries in Indonesia, in Brazil, and so that has been a problem and because of that, not enough political attention and resources went to addressing the overnutrition problem and especially the adolescent diabetes problem that we're seeing in Mexico and China and India, a major problem in these countries.

And so because of that, in addition to the you know, the cultural issues, you know, South Africa, for example, in my book, I talk about how. Being thin was associated with having an illness and how, you know, in many countries being overweight and trying it, for example, for children, seeing that as something healthy you know, and prosperous.

These perceptions also contributed to the lack of attention to doing research on these topics. And it's just as Pauline pointed, just now, this is starting to increase, you know, activism and researchers on children and relations and diet. Is new and just starting a lot of these, you know limit countries.

Jessamy: And I mean, maybe just kind of like going into that a bit deeper, sort of taking an intersectional lens. I mean, how does poverty, racism and sexism feed into this issue? We've mentioned some of the ways already, I know, but Pauline, maybe, maybe kick off and just sort of maybe lay that out a little bit for us.

Pauline: Okay, so I would, looking at poverty, you find that Most people that are living in like an impoverished situation. We'll mostly choose foods that are readily available that are easily accessible to them. And in most cases, it might not be the most healthy, the most healthy of food. I think this is when we can bring in the idea of globalization and it has its pros and cons.

One of the cons in this case is you find that for some of our, for some of the African countries were being highly influenced by Western culture, by Western culture, which means the area, the urban areas now. are looking more towards if you are able to afford fast food, then that makes you a trendy person.

Whereas now compared to the people that are now in these in these lesser areas, let's say the rural areas, they might be in a tougher situation, but they use what they have. They pretty much eat what they have access to, and I guess in the context of Zimbabwe that would be like our indigenous foods, so which are healthier and easier on the stomach, so to speak, but then when you're looking now at the urbanized Areas now you have those very high density areas where people are living in poverty and the only foods that they can possibly that they can possibly get access to a food on like the event from the vendors and these are usually like the junk food or the over processed food and then looking in like the westernized side of things, you find that in most cases you have parents.

Working two or three jobs to sustain the livelihood of the offenders. Therefore you then have young, young children being left alone without. Proper meals without being offered proper meal, properly cooked meals. And they end up turning to the first food places that are easily accessible, easily available, and with the foods that are being sold, it quite affordable prices.

And those factors together sort of just contribute to that one particular problem or other. They create the line in which the problem falls in. And then moving to the sexism part, I think. As Ed mentioned earlier, you find that in certain African countries being thin is considered as unhealthy, whereas being bigger, on the bigger side, or being obese is a sign that you are living lavishly, you're being well taken care of and that's usually applies to women and children mostly, which became an issue because you didn't find that you find most women being obese or suffering from diabetes or some have heart condition.

And that issue is quite, is like a deep, is like a deep issue to deal with now because it's also tied in with the culture of that specific region. Therefore it makes it a bit hard to try and deal with. 

Jessamy: Yep. That makes total sense. And I guess You know, being able to sort of, it might not even just be by country, but actually by, you know, region, location, there's cultural differences that when you're thinking about policies and regulations, difficult to track down.

And what about the racism side, 

Pauline: Pauline, maybe? The racism side it's, it's a bit tricky because it differs per country and per region, so to speak, but you find that I think racism Mainly towards the western side of things, depending on the society or the type of area that you're living in.

I think you're then looking at location. That's maybe the, the big thing, where you, where you're living. What services are being offered there and the advantageous to you. Are they similar to those of people that are living maybe in like the uptown of the country you live in? Because you find that the services that are offered there will never be the same as the services that are offered on the other side of town.

And I think we've seen many cases of many cases like these being shown on the news or on different social media platforms where people complain of. An equal treatment and an equal services, and you still find that there are people that are not being treated for certain nutrition, nutrition ailments, you can find that someone says I'm severely malnourished or I do not have access to the food that you are prescribing me to eat, and nothing is done about it.

So it then becomes a situation where Is this happening because of where I live or is it that where I live is connected to the color of my skin or to my ethnicity and the other, the other side is also linked to that. So it's a lot, I think with racism, it's a lot of interconnecting factors that are, that are contributing to it as a standalone, as a standalone point.

I don't really think it would be strong enough to use as like Proper determinant of the resulting levels that we're observing today. 

Jessamy: Interesting. Big structural problems there. Ed, do you wanna add on to that? Yes. Thank you. I agree with Pauline 

Eduardo: on Oliver points. 

Jessamy: Nice that you both agree with each other so much.

Let's go. There's, 

Eduardo: I guess I think that in terms of race, it is certainly clear, especially in the us where. You know, the, you know, African American, Latino, indigenous communities are disproportionately exposed to these ultra high, cheap, ultra processed foods. And this takes a long, especially in what we call food deserts.

Every country has this urban areas that have, don't, don't have grocery stores where you can buy health, you know, fresh products. Where, where where, you know, especially in certain, for example, in the area that I live in, if you want to go get some healthy foods, you have to travel a long distance.

Whereas in the city, small city areas in the urban areas, these kinds of grocery stores are not available. Why is that? Because in many, in many cities in the U. S. and, and in other countries as well you know, major food stores that sell products that are more expensive do, don't want to invest in these urban communities because they know demand will be less, especially if there are foods comparatively cheaper in the location.

So I think that that's been a problem. And at this point, yes, so poverty, as Paulina point out when you have families that have dual in the time that's needed to, to purchase foods, to cook food, it's extremely, extremely difficult. This is something that's happening globally and contributing in Indonesia when I did my research there, you know, we found that there was a lot of, because of the dual incomes and because parents are often out of the household.

As Pauline mentioned, children had to eat you know, ultra processed foods at home, parents were outside of the household, they were actually eating outside, so you had the double burden of nutrition over and under nutrition within households because parents were eating outside while they were working, and kids at home were not having access to to nourish, you know, healthy cooked foods at home.

So I do think that the, you know, the dual incomes those that work two jobs makes it extremely difficult to have access to health care in addition to the lack of investments in communities. One thing that the U. S. is seeing a lot is the dollar stores. Dollar stores are stores that market themselves.

A dollar and under, and these are emerging in a lot of rural areas where a lot of the poor lives. And and so that's, that's another issue that's sort of you know, we always think that food deserts are in urban areas, but it's also in rural areas in very big countries like the US Brazil where you have where you have these companies that are part of, you know, these specialty companies that are focusing on cheap products.

And so I completely agree. With, with doc, with all the issues that Polly raised and, and these are major issues in poverty and race. 

Jessamy: Thanks, ed. I mean, moving on to sort of the types of policies to, to regulate this. We, we mentioned how difficult it can be, but often also that is used by industry.

The fact that it's too difficult or too complex, that's a, a common narrative that's used by industry to prevent progress and change. Ed, I know a lot of your book is about this. I've just finished it. It's great. Maybe you could walk us through some of the sort of types of policies that have been used to regulate the influence of industry on diet and junk food.

Where it's happening and, and sort of what's going on. Sure, yes, just me. Thank you. Well there have been a variety 

Eduardo: of policies. I think that a lot of the lessons that were taken from tobacco industry to begin with, you know, we all know tobacco was the first major industry where we started to see the commercial determinants of health and policy surrounding that.

And so, but when it comes to to soda and ultra processed foods, in terms of prevention several different policies have been created, for example, improving food labels. This is something that has been a very problematic in a lot of countries. Chile, for example, has been an innovator in the Americas with respect to adding black octagons on food labels that are foods high in sugar, salt, and fat.

And many countries have adopted, in the Americas, have started to adopt these high black black octagon labels. And, and then also improving the quality of information. Mexico has recently improved their labels on the quality and effectiveness of providing information. But in many countries, it's still a big problem providing truthful information, reporting levels of sugar, added sugars and a lot of the countries that I discuss in my book, that's the major problem.

So labeling has been one. The biggest problem has been marketing and sales. Some countries such as Mexico, Chile have been doing a good job and trying to limit what children see on TVs. But most countries don't have, in, in, in low and middle income countries, don't have any regulations on this. In China, for example, the major television show CCTV, still has advertisements.

Researchers find towards children on, on these, you know, sodium ultraprocessed food products. Some countries have not even started working in those areas. I think marketing has been the weakest area in terms of the policy areas that have been addressed. Sales has also been a challenge limiting sales in schools.

Countries have new guidelines. Mexico, for example, has their guidelines. In many countries are starting to address this issue, but the problem has been enforcement. How do you get schools to implement what the national guidelines say? That's been a major problem. When there's federal regulations, but local local preferences and lack of accountability and holding local school boards accountable for what they're selling in schools is a major issue.

So marketing, you have sales, but then the soda taxes, right? The soda taxes. Has been probably the most popular globally in terms of attention. And Mexico was the first country at the national level to introduce a soda and chocolate tax, and a lot of evidence has suggested it's been very effective in sort of decreasing or contributing to a decline in consumption of these products, but in several other countries we've seen taxes.

South Africa, India has introducing taxes. Many other countries are introducing taxes. And so waitress would say, and I would argue as well that that is probably been the most, the easiest for industries to accept because they've been able to negotiate the tax rate. They still know that, that their power comes from marketing and sales.

And so marketing and sales is an area that, that these industries are focusing on. I would argue the taxes, not as much because I think there's an awareness that people still consume their products even with the tax and the tax has not contributed to an increase in price. That's that's that, that makes it impossible, for example, bottled water is still more expensive in a lot of countries than, than, than sodas that have a tax.

And so I think that that's sort of the, the state right now. I think that countries are now starting to realize that marketing and sales is important, but but have started to adopt the tax idea first and have been less effective, less committed to marketing and sales. 

Jessamy: Thanks, Ed. Pauline? 

Pauline: I definitely agree with everything you mentioned.

I think the one point that he raised that really stuck out to me was the issue of enforcement. There are certain drives towards policies like that where I think, if I'm to give an example, you look at the Food Labeling and Food Standards Act here in Zimbabwe. It's there and it does protect it's, it's meant to protect they use the clients.

So to speak from like adulteration of films and making sure that food stuffs are labeled appropriately in the, whilst following the standards as prescribed in the guideline. However, there is not, there is the enforcement is not as strong. Therefore, you don't exactly see a positive effect of these measures that are being put in place and into speaking like a sort of informal manner.

Junk food is still food. So with that line of thought, you can't really say we can come up with, well, we need to come up with policies that will inhibit people from consuming junk food, but you can put, make control measures in place to help decrease the intake of the, of the over processed foods that we're speaking of.

And I think that's where the issue of marketing comes into play and how disaggressive marketing is being controlled. But the problem is in the low to middle income countries context, there is no such those measures haven't been seen yet. Maybe they're still in the works, but they haven't really been put forward.

In the manner that they should be given the rising rates and numbers that were beginning to observe in these. Obesity rates and in these in the double version of malnutrition that we're, that we've been observing in the past few years. And yeah, I think, I think that that would mainly be my issue with policy, mainly controlling marketing, because that is the number one driving force when you've been looking at industry and how it's feeding into the society.

Jessamy: Thanks both. I mean, do we have any examples of kind of real progress or best practice, Pauline, 

Pauline: maybe 

Jessamy: you can start with that 

Pauline: one. I think one that I've noticed, that I've noticed that it's an indirect solution, but it's trying to introduce the idea of nutrition education into the school curriculums.

That way, instead of trying to curb the. Long the big giant, which is industry and commercialization of food and marketing, you then educate young people starting from a young age so that their perceptions start being shaped as they grow up. And they can, and empowering them to be able to make their, to make educated decisions that will, that will potentially benefit them and help them as they grow into adults.

That's what I've seen. I think I've, I've been seeing towards, was it 20, in late 2020, I remember attending a workshop where we were trying to draft school nutrition guidelines. For Zimbabwean schools, and I think I've also heard talks of this initiative also being done in other parts of the world, which shows that nutrition education seems to be a point, a key point in addressing this issue.

Jessamy: Definitely. Ed? 

Eduardo: Yes, I agree. And I think that he In terms of what has worked I think, I think in the Americas, Chile and Mexico have been great examples. As I mentioned earlier, Mexico with the soda taxes, I think that's been very effective in reducing preferences to consume products. But Chile, I think has been very, very interesting and very good examples.

The black labels on food labels, as I mentioned, there have been evidence showing that Children are becoming much more aware of of these labels and associating them with unhealthy products. I see articles where children are starting to tell their parents that they don't want to consume those foods with the black octagon labels on it.

And so that, that's very interesting because you do see children learning and seeing images. Chile has also gotten rid of any kinds of cartoons on boxes. For serials, for example, something that the U. S. hasn't even, you know, started to address. Chile has also had very good TV advertising regulations and prohibiting the marketing of products to children.

And there has been evidence suggesting that that has contributed as well to a decline in overweight, obesity amongst children. So I do think I would argue that Chile is one of the countries that has seen some remarkable success in addition to Mexico in, in, in, in sort of you know, showing evidence that these policies can work but as Pauline pointed out, I think that you know, the marketing is still the, the area that no, I mean, with the exception of, of, of Chile that I mentioned, other, most countries have not really addressed this issue and taxes are sort of seen the most popular.

But I think there there are some, is a lot of, some evidence suggesting that, you know, these policies really can work and then we have to ask why, why is it working in Chile and not these other countries? So what are the, and I think a lot of it has to do with politics and, and, and the role of industry and, and a lot of complex factors that are not the same in, in, in countries.

Jessamy: So it's kind of, I mean, what I'm hearing is sort of about using all of the different levers of policy, you know, education, knowledge, as well as the subsidies and the incentives, and then the big kind of challenge is this marketing aspect. What, what do we need in, in the next five to 10 years to, to really be able to make progress so that it translates from just a successful policy to actually being able to reduce the number of children with obesity and non communicable diseases.

Eduardo: I think that Margaret Chan in 2016, the former director of the World Health Organization, really, really hit the, hit, hit, you know, made a great point, is that progress won't be made until political leaders take on the interest, powerful industries. And I think that political will, presidential will, especially as I talk about in my book, that has been lacking having the confidence to take on the street through these marketing regulations, not searing political retaliation from these major corporations.

I think that's the first thing. Second is you know, giving access activists and researchers, giving them access to government policymaking institutions. Where are these policies are being made? That was one of the biggest finding in my books and in my research is that you have these national policy committees on nutrition and obesity for children.

But if you look at the details of who's on those committees, you will see that industry is overrepresented and there are not enough opportunities for activists or researchers to really have a voice in that. And finally, providing more information to citizens. The more they're aware of these industry tactics of the lack of political will, the more they can hold their politicians accountable, the local and federal level.

And so I think a lot of citizens don't know what's going on behind the scenes in terms of policy, of the ways industries are getting away with regulations, the more awareness, the better. And I think holding politicians more accountable, I think these are the three things I think that will really help make a difference.

Jessamy: Thanks Ed, and you, you do articulate that very well in your book about this kind of, you know, particularly in, in like Mexico's case of, of, you know, the sort of groundbreaking policies, but that actually they never are really able to make the big impact cause there isn't that presidential. Perhaps as they were also thinking about economic growth, they were also thinking about, Oh, you know, great.

We can have these industries come on and they can sell lots of things and it fits into other aspects of their agenda. As you say, you know, that sort of classic playbook of the commercial determinants of health, of industry funding academics, to, you know, provide research, to get onto those task force groups, to really try and sort of shape the narrative and sway policy.

Pauline: I think in addition to what Ed said, I would also include empowering the people because essentially all the beneficiaries of all of these interventions that we're trying to come up with, or that we're trying to have put, be put in place is for the public. And I think empowering the public is one of the most essential points to follow.

Sort of in line with the SDGs, if I'm to speak in that line of thoughts. With with a specific focus now, if I didn't veer in on to focus on the young people, I would say, yes, we have initiatives and steps being made to try and help or assist the young people, but I also didn't think that they should also be offered a place at that table with these solutions are being created.

That way, if we then come, we're coming up with policies that are supposed to protect the young people. We include the young people that are supposed to benefit from these policies and really solve the problem directly. Instead of going round, as was said, as was mentioned by Ed, that you find that there are these Associations that are there and you try and look at the people that are that are included in those conversations and some of them are people that don't really know who are not well versed in the situations or the current situations that the young people are going through.

In some of the factors that some of the factors that they come across that then leads them to where they are now. So I think empowering them by including them in these policy creation processes and also just educating them enough to be self sufficient and to be innovative enough to be able to take matters into their own hand.

I think the issue of nutrition being something that you can do in the in your own backyard. By having, by simply creating your own garden skills like that, having trained skill sets and training them, empowering them with the required skills to help them establish themselves and also be self sufficient, but also with the additional support from protective policies.

I think that would be my suggestion in this case. 

Eduardo: Well, more than ever, this is an area where, you know, as a political scientist, I have to advocate that. Activists. Researchers and people working in politics and sociology really need to come together to, to really investigate how industries are still having this influence.

I think that as a political scientist, I've noticed that there's been a disconnect with the academic literature and the policy literature and the academic literature is really providing some new questions and insights that activists. And learn from and I think that more than ever, we really need to have this unity in, in thought about how industries are having so much influence and what needs to be done.

And I think that that's sort of really important and, and going forward. And but I think all the issues that we raise, you know, in terms of poverty, in terms of marketing, sales, and all these things, but also what Pauline just said about empowering individuals. I think that is, that is major.

And I think that You know you know, in many different ways and powering them in many different ways. And so that's, that's what we need to do next. But yeah, I think those are like concluding thoughts. 

Pauline: Thank you, Pauline. Anything to add? I would say I agree with it on the idea of us coming together.

I think this issue is a structural issue and, and also systemic in another, if you look at it from another perspective. And with that, with that being said, I think a multisectoral approach is really needed because one sector alone can't solve the issue at hand, you'll be solving, it's like chipping off at parts of the problem, instead of just coming together and creating.

One good blow that can then just solve everything. I think that would be my concluding cutaway.

Gavin: Thanks so much for joining us for this episode of The Lancet Voice. This podcast will be marking The Lancet's 200th anniversary throughout 2023 by focusing on the spotlights with lots of different guest hosts from across The Lancet group. Remember to subscribe if you haven't already, and we'll see you back here soon.

Thanks so much for listening.