EP92 Nutrition in the Digital Age with Dr. Marie Bragg and Amaal Alruwaily

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I AM GPH EP92 Nutrition in the Digital Age with Dr. Marie Bragg and Amaal Alruwaily
EP92 Nutrition in the Digital Age with Dr. Marie Bragg and Amaal Alruwaily

Maureen: My name is Maureen Zeufack, and you're listening to the I AM GPH podcast. In this episode, I'm joined by Dr. Marie Bragg, an assistant professor of Public Health Nutrition here at NYU GPH, and Amaal Alruwaily, a 2019 MPH graduate with a concentration in epidemiology. Amaal, who currently works as a health consultant assistant in her home country of Saudi Arabia, spent a year working in Dr. Bragg's SocioEconomic Evaluation of Dietary Decisions or SEED Program as a researcher. Both Bragg and Alruwaily worked on an extremely interesting and widely circulated study on the harmful effects of kid influencers on YouTube promoting junk foods. The study had media coverage across major news outlets, such as CNN and the New York Times, and was published in the official journal of the American Academy of Pediatrics. Hear more about the fascinating backstory behind Amaal's inspiration for this innovative study, the surprising findings from the study, as well as an interesting conversation on the intersection of health and technology and screen time in today's world. You're not going to want to miss out on this episode. 

Maureen: I'm so happy to have you guys on today.

Dr. Bragg: Thanks for having us.

Amaal: Thank you.

Maureen: So first of all, can you tell us a bit about your backgrounds and what brought you to be connected with NYU?

Dr. Bragg: I am an assistant professor at the NYU School of Global Public Health, and I joined in 2014 and have been fortunate enough to work with a lot of really talented NYU students including Amaal, who came up with this great study idea. So it's exciting to be here with her today.

Amaal: Thank you, Marie. Yeah, so I graduated with a Master of Public Health in Epidemiology from NYU back in 2019. And before that, I worked as a nutritionist at the Obesity Research Center in Saudi Arabia, and that's when I decided to pursue my Master's. And I ended up at NYU and I ended up working with Dr. Bragg at the SEED Program.

Maureen: That's fantastic. So you both were recently a part of a team that published a cross-continentally, widely circulated study on the harmful effects of kid influencers on YouTube promoting junk foods. Can you tell us a bit more about this study and the process of researching it?

Dr. Bragg: We became interested in it actually because of Amaal, and I think it's a pretty great story. Maybe if you're up for sharing it, Amaal, first on in terms of how we got to the study idea?

Amaal: Yeah, sure. So yeah, it's back, I think, in 2019, after my graduation, I was sitting with Marie, and I was discussing that I wanted to apply for a Ph.D., and I wanted to publish some papers. And she encouraged me to do my independent research. So she told me like, "Go out there. Look for a research question and come back." And my family was visiting me back from Saudi Arabia because they wanted to attend my graduation ceremony. And one day, all of us were sitting in the living room, and I saw my niece and nephews watching these children on YouTube, playing pretend and playing with toys. And I noticed that there's a lot of logos for these restaurant and food brands, and those children were consuming it. And I was like, "Oh, that's not supposed to happen. I know that these products shouldn't be promoted like that." So after they went back to Saudi, I talked with my sister. I asked her to give me more names for these channels. And I started doing kind of exploratory research in YouTube, and I saw a lot of logos in YouTube, a lot of children consuming these foods. So I went back to Marie, and I told her like, "No one talks about that. We should maybe search that question." Yeah. And I remember her face when she was shocked when she also googled the name of the children influencer, and she saw all these logos.

Dr. Bragg: Yeah, because I had never heard of kid influencers. I knew that influencers were celebrities who maybe have their own Instagram account or YouTube channel and have lots of followers, but I typically thought of fashion or sort of fitness. So when Amaal was describing it, I was sort of like, "I can't even picture what you're describing. Can you show me one of these?" And so we pulled one up, and it was four- and five-year-old kids who were either playing with McDonald's toys or consuming fast food and talking about how great it was. And so it really was shocking, and, I think, surprising. And so we both agreed on the spot that we should do the study and sort of the rest is history. So what we ended up doing was collecting a sample of 418 YouTube videos and looking at them to see how many featured foods and beverages, what kinds of brand logos were featured, and we used the Nutrient Profile Model, which is a tool to score how healthy or unhealthy your food is. And we wanted to get a sense of how many views are these kinds of videos accumulating and how unhealthy are these products being featured. So it was a fun study to do and really surprising outcomes.

Maureen: That's amazing how you kind of stumbled across this idea in sort of a familial sense, and that kind of just became this whole phenomenon. That's fascinating. So what were you guys' roles on the team, and what was the experience of executing this line of investigation?

Dr. Bragg: Amaal is really the brains behind the operation. So a lot of credit goes to her for sort of the data collection and coming up with a lot of the methods. And I think hearing from Amaal on how she approached that is interesting not only because it sort of showcases the independent research that our really talented MPH students are capable of, but it also shows how simple the study was, which I think is part of why it got a lot of attention because everybody could relate to it because it was pretty simple. So yeah, it'd be great to hear from you, Amaal, in terms of how you approached it.

Amaal: Yeah, sure. So before I started the study, I was working with Dr. Bragg for a year and a half at the SEED Program, and there we do a lot of content analysis for the racially targeted marketing. So from my experience with the content analysis to the website, for McDonald's website and other, like Twitter accounts, I started developing this sense of how critically to approach a YouTube channel or any content on YouTube or Twitter. So that's how when I started watching these videos, I started thinking like, "How should we rank those children without being biased just towards one child?" or, "How to define it well?" That's why we use Socialbakers because it was used in multiple content analyses for YouTube channels. From there, I decided to see what type of channels were targeted to children and family-friendly. And that's why I ranked them, and we excluded a lot of channels that their content wasn't really family-friendly, and also it was under the entertainment section. And then when I decided to do 50 videos, I wanted to have the videos that featured food in the thumbnail, and the thumbnail is the still image that the influencers put to describe their videos. So when you go into YouTube, and then you see these still pictures that you know immediately what this video is going to talk about. So I decided that this is kind of how I choose the videos that have featured food. And then I decided to choose the other 50 videos as a control for the most viewed videos just to compare. All of these skills, honestly, I just developed from working with Dr. Bragg because we do a lot of content analysis at her program. So yeah, that's kind of how we start.

Dr. Bragg: And I think that using publicly available tools was really important because anybody could replicate our methods. They could do them themselves and see the phenomenon for themselves. And so the Socialbakers tool that Amaal is describing is publicly available, and you can just go and search and say that you want to find these sorts of videos. And so getting to the final sample of 179 videos that featured food or drinks, it was pretty straightforward to do. And even if you just go to YouTube and do a search for the channel name, the kid influencer's name, and the brand name, like McDonald's, you get a lot of results. So the methods were really nice, and there's simplicity for being able to capture this phenomenon.

Maureen: And Marie, you touched on this a little bit before about the relatability aspect of this. What do you both ultimately think was the reason why the study was able to pick up so much attraction in the way that it did, and why did it connect to people so much?

Dr. Bragg: I've wondered, whether you're a parent or you have nieces and nephews, or just a human person who knows about YouTube, you can relate to this idea of the persuasive nature of influencers. And then there's something, I think, and I'd be interested, Amaal, to hear what you think about this because I don't think we've chatted about it, but I think there is an element of this practice being a little bit scary because we're talking about toddlers promoting junk food brands in a country where we have really suffered from high rates of obesity and chronic diseases that come from poor nutrition. And we know that when kids see food advertisements, they end up eating more than kids who see non-food advertisements. And so I think there was a little bit of the shock factor that probably contributed to some of the attention. And if you search for some of these videos, the visual nature of it is just pretty compelling. But what do you think, Amaal?

Amaal: To me, I think, also, I agree with what Marie was saying. It's just the type of content that they were advertising is kind of shocking. And also, I think that the culture now with the children, they always rely on YouTube channels or social media to distract the children so the parents can attend other work, especially with the pandemic now. So I think when parents think that it's not really harmful, it's just a child playing with a toy, and then knowing that, no, they're marketing these unhealthy behaviors and unhealthy habits, that's what kind of was shocking in that moment, like, "Okay, well, now I cannot just give it to my child and go and do other work." And also, I don't know if you see that, but before the pandemic, when I was walking down the street, I always noticed that children are on their tablets and watching YouTube channels. And I don't know, maybe it's biased because I was doing the study, but it was obvious, just hearing the type of the music and also the sound. So that's why I was like... I think parents are like, "We're more concerned." They're like, "Okay, well, this is not really a healthy outlet for my child to have." So I think that's why people got excited about the study.

Maureen: What might you say were the most surprising findings of the study? And was there anything that this study only confirmed something that you already believed?

Dr. Bragg: I think what surprised me was just how many brand appearances there were and how few appearances there were for poor little broccoli and bananas and apples. And so it wasn't even something where we were saying like, "Look at the mix of stuff here, and we're concerned that there's a portion of it that's junk food." It was junk food by a landslide. And it wasn't just that it was a burger. It was a burger with the fast-food logo placed right in front of the camera. And so I think the sheer volume of that was what surprised me most, at least.

Amaal: Yeah. To me, when I was doing the awareness gathering videos, I went back like five years or... It was a lot of videos. So for me, I started noticing the pattern that with time, the influencers are starting putting these logos on the thumbnail. So it's kind of, I don't know, maybe knowing that, oh, the thumbnails or having these logos could attract more views or more clicks. So that was kind of shocking to me. We didn’t research that in this paper, but it was an observation that I noticed. So yeah, so knowing that people will go and watch something about these products or these foods.

Maureen: So we often discuss the link between the use of technology and sedentary behaviors. So in a technology-driven world, does this mean that we should be more concerned with how we're spending our screen time and what content we're consuming?

Dr. Bragg: It's an excellent point. And we know from the American Academy of Pediatrics that the recommendations are to have children on screens as little as possible. I think for kids under two, they sort of make an exception for when you're FaceTiming grandparents that that is something that is interactive and maybe is enriching the children's relationship with their relatives. But for other screen time, especially where it's passive, it can be concerning because of the sedentary behavior but also potentially because of the content that's in it. Our study focused on junk food, but there's also concerns about images of violence or the idea that YouTube has autoplay. And so a parent may start them with one video, but what the kid ends up on, may be totally different. And so I do think there's a lot to be said about not only limiting screen time but being really purposeful on the content that's in it and to hold technology companies accountable for putting safeguards in place that help children really only have access to things that are appropriate for children.

Amaal: Yeah. And also, it's really important to control what the children see because previously, we used to... As children or as kids, we used to watch TV, and it's more controlled, the content that is out there in the TV and the type of advertisement. So now it was having this freedom to put anything you want on social media, and the child having access to that is really kind of dangerous not only because of the food content, also as Marie said, there's a lot of risky behaviors that is being promoted on YouTube, Snapchat, Twitter. So I think it needs to be controlled from the parents.

Maureen: In what ways do you think that the COVID-19 pandemic has exacerbated this issue?

Amaal: Yeah, so, well, I think because the stay home orders and people are just staying and having nothing else to do. We spend more times watching YouTube channels, screens, and seeing other people's living life, so seeing these influencers doing what you want to do sometimes. So I think it gives more view... It was an outlet for us to watch it. And the other part of it is that parents, because they work from home now, and it's hard for them to work and maintain their children, they use it as a way to distract their children sometimes. And also, in our study, we mentioned that a lot of parents let their children under the age of seven watch YouTube channels. So I think if you do the study now, I think this number will increase significantly.

Dr. Bragg: And whenever I think of this question about the pandemic and screen time, I think about my own kids. I have a four-year-old and a two-year-old. And even as someone who researches this topic and someone who has had the great opportunities and fortunate to pursue higher education and to have resources to understand sort of what's at stake with technology, even in our house, we've been so exhausted at points that we are like, "You know what? I have to make lunch here. So here's Sesame Street on YouTube, and please just sit and watch it, and give me five minutes of peace and time to make us lunch." And like Amaal is saying, it's sort of something I didn't think that I would have to rely on. But in the pandemic when you're sort of quarantined, there's not a lot of help from grandparents. Or when school is shut down and both parents have a Zoom call and the kids are at home, or when parents have to go into work as a bus driver or a shift worker or a nurse and they have to figure out what to do with child care, I think it's easy for us, all us parents, to turn to these videos because they're sort of digital babysitters in a pinch and free digital babysitters in a pinch. And so I think it's really important to be mindful that for a lot of parents, it's sort of getting through this year in particular. But also, even outside of the pandemic, if we think about parents who are grappling with the choice to keep their kids inside and keep them safe versus sending them out to a playground where they don't know if they're going to be safe, we have to keep that in mind when thinking about the role that screen time plays because sometimes it is the safer option for parents. And we need to be thinking about the structural factors that contribute to that instead of just shaming parents for keeping their kids inside on screens versus sending them outside to play.

Maureen: And how do we counter this narrative of unhealthy habits? What can be done to mitigate the impacts of these easily accessible videos or advertisements, and who do you think is a part of this change?

Dr. Bragg: We've had a follow-up conversation with some different groups who are involved in this. And I think there are things that the food industry can do. It was unclear from our study whether food companies were paying for a lot of these because there weren't disclosures on many of them that said ad or sponsored. And so one thing that I would like to see is that even for these videos where it wasn't sponsored, companies should... because a lot of these food and beverage companies have pledges that say, "We won't market to kids under age 12." And so, but instead of saying, "You know what? These influencers are posting these videos without our permission. And we're not paying them to do it, so it's not really our problem." I would encourage them to reach out to those influencers and say, "You know what? We actually have this pledge that says that we're not going to target kids under 12 with some of these products. And so we're actually going to ask you to pull these videos down because even though we didn't pay for them, they're inconsistent with the spirit of what we're trying to do with reducing food marketing to kids." And then hopefully the FTC can do more to sort of encourage and enforce these disclosures so that we can better understand what percentage of these videos are sponsored.

Amaal: I think also putting it out there and speaking up about it makes influencers more aware about this issue. So I would assume that maybe influencers didn't know that these could harm kids. And so in the future, when they see these studies and these numbers, they will understand that "Oh, maybe we should be more responsible [about] what we give our audience and create more healthy habits for them."

Maureen: Marie, you were quoted as having said, "We need a digital environment that supports healthy eating instead of discouraging it." So in your opinion, as well as in yours, Amaal, how do we, as a society, parents, caretakers, brands, move towards this? What does that future look like?

Dr. Bragg: It's such an interesting question because we're really lagging behind in terms of public health policies. We're really lagging behind where we were with TV. So on TV, there's something called host selling, which means you can have SpongeBob on the cartoon and then switch to a commercial where SpongeBob is selling your junk food. So there's a prohibition of host selling where the character in the show is selling stuff or selling it in the show. But we don't have that kind of stuff on digital media, and so we really need to catch up to the current technology landscape and become more innovative. And there have been a couple of policy efforts aimed at doing that, and one of them is the KIDS Act, which was proposed by two senators, Senator Blumenthal and Senator Markey, which will probably have to be reintroduced in the next year. But they are specifically targeting some of that technology in saying, specifically, the autoplay feature that makes the videos continuously play but also influencer videos. And right now, the KIDS act only focuses on tobacco and illicit drugs and alcohol and some of those kinds of products. And it doesn't include food, but it would be great to see it expand to food because that would go a long way with creating a healthier digital environment.

Amaal: Yeah. I think the same idea is, also, influencers need to understand how much they have an impact on their audience. So creating that it's cool to eat something healthy, it's really important because those children, they see those idols that they look up to or they want to live their life. So it's nice to see them also consuming these healthy foods and consume these healthy habits as well. So I think that's how you create a really healthy digital environment.

Maureen: Yeah, exactly. You made a great point because young kids are especially impressionable. So if you flip the script, it can also have a different outcome.

Amaal: It's funny. I always talk about my niece and nephews, but recently, they came and they brought also this sweet from a local restaurant that apparently they knew from a Saudi influencer here. So I'm like, "Okay, that's what I'm talking about. There’s something about it. It's happening here too." And they also adopt the healthy habits that these influencers do. One of the influencers was doing karate, so my nephew was excited to register for karate class. So it's just kids. They just want to live the life that they see.

Maureen: So my final question is, where do you see the opportunities for this line of research at the intersection of technology and nutrition headed in the future? What sort of trends or movements in the industry should future public health practitioners be paying attention to?

Dr. Bragg: I'm very curious to hear what Amaal has to say, given that she came up with this fantastic study idea, and so she has a very creative mind for these kinds of things.

Amaal: Okay, thank you. Well, I always have this interest in social media maybe because I kind of grew up with it or just knowing that the new generation, they will be growing up with this kind of exposure. It's not just you in the house. It's also millions of people through Twitter or Snapchat. So I think, in the future, we need to pay more attention to what type of claims that the influencers put in their content. So even if they claim that this is healthy habits or healthy foods, what type of food that they're putting out there and what type of behaviors that they are putting, so all of these, public health practitioner needs to pay attention to because it's a fact. Influencers have an impact on children and adults. If they recommend a product, people will go and try it and buy it. So I think as public health practitioners, we need to pay attention to that, what type of content they're putting out there and how these platforms are using the influencers or just their algorithm to attract more people to them.

Dr. Bragg: I'd be interested in learning more about the age at which children begin to understand that the influencer is trying to sell them something. And so when I had my four-year-old and two-year-old watch one of these videos after we did the study, they were locked onto the screen. And normally, they're really responsive to me, but I was asking them a couple of questions while they were watching. I said, "What do you think of this?" And it was like I wasn't even there. They didn't even hear me and didn't respond to me, and they were sort of laughing along and just really mesmerized by the screen. And then at the end, when I turned it off, the four-year-old said, "Mom, I think we should get that thing that was in there." And I said, "What was it?" And he said, "I don't know, but I really want it." And it was the McDonald's drive-through toy that you can sort of make a pretend hamburger, and there's a hat and stuff like that. And I said, "What do you think those kids were trying to do?" And he said, "They were playing with toys." For a four-year-old, there's no connecting the dots between the promotion of this versus a fellow kid playing with a toy. And so I'd be interested in understanding that because if young kids, even kids up to six years old or seven years old or eight or nine... If they're having trouble understanding the promotional nature of this, then that makes room for some policy changes because we know kids... For TV, kids younger than age eight have trouble figuring out the commercials are trying to sell them. But after age eight, they sort of get it. They get when they see an ad that is trying to get them to buy something. But we don't know if that's true on YouTube, especially when these videos show it in such a sort of fun, organic and stealthy way where it just looks like it's happening naturally. And so to me, that's another big research question to tackle.

Amaal: Yeah. I don't think children understand that those influencers are kind of acting, or it's not organic, as you said. I think they feel that they're watching this child living their life. It's just like, "Oh, yeah. I'm seeing him playing with his parents and playing pretend. It's just like I do with my parents." So I think it's hard for them to distinguish that it's kind of a prompt.

Dr. Bragg: It's a great point. They don't know that some of these kids are the highest-paid influencers on YouTube. They don't know that some of these kids are earning millions and millions of dollars a year for advertisements and endorsements.

Amaal: Yeah, it is interesting because one of the kid influencers, they had a billboard on Times Square. So it's crazy.

Maureen: So are there any final thoughts on this study or this topic that you'd like to close on or share with our viewers before we close out?

Dr. Bragg: I think one other interesting topic that Amaal referenced is this idea of influencers in a variety of countries because the ones that we studied happened to be in the US. But we spoke to a journalist in India who had kid influencers in India that were doing challenge videos where siblings would try to answer questions, and the one who got it right might get the actual treat, and the one who didn't get it right would just get a toy version of the treat. And so I think there could be some interesting cultural factors to start thinking about and to capture sort of the actual global reach of this. If we look at local influencers in a variety of countries, the phenomenon might actually be a lot- It is likely a lot bigger than we even imagine.

Amaal: Yeah, that's true. As I said, my nephews here in Saudi, in New York, they were doing the same thing, and they were watching American influencers and also Saudi influencers. So it's happening everywhere, and it's an easy way to access this target population.

Maureen: Well, that's a great note to close on, opening that door to the global scope of this. And it was such a pleasure to have you on the show today.

Amaal: Thank you. It's my pleasure.

Dr. Bragg: Thank you for having us.