In 2019, the Mexican government instituted a new rule that took mascots like El Tigre Toño off of high-sugar foods. The food industry fought back. And now a similar fight may be coming to the United States. Abdul reflects on the role of marketing in our food environment. Then he speaks with Nick Florko, a reporter at STAT News, about Mexico’s struggle to cage the tiger.

The following is a transcript of America Dissected episode 209. The full podcast is available at Crooked Media.

Dr. Abdul El-Sayed, narrating: Infant mortality in the United States increased in 2022, the first time in two decades. The American Medical Association considers supporting single payer health care. Health care activist Ady Barkan dies of complications of ALS at 39. This is America Dissected. I’m your host, Dr. Abdul El-Sayed. [music break] Saturday morning cartoons, remember those? Among the many reasons I’m grateful to have grown up in the nineties was that hallowed Saturday morning ritual observed by millions of children like me. I’d be up at like eight before anyone else in the house. I’d turn on that tube television with 47 channels and I’d fix myself a bowl of cereal. Mom wouldn’t let me eat the sweet stuff on weekdays, but weekends? [sigh] My time. It was Cocoa Puffs or Cinnamon Toast Crunch for me. As I devoured those little sugar bombs, their commercials would intersperse my cartoons featuring either Sonny, who was, of course, Cuckoo for Cocoa Puffs or the Cinnamon Toast Crunch chefs virtually guaranteeing that they’d be a regular part of my breakfast every Saturday. All was right in the world. Only it really wasn’t. I didn’t realize it, but the millions of us were unsuspecting victims of an elaborate scheme to convince us and our parents that the main line sugar we were eating was, quote, “part of a balanced breakfast.” That scheme hinged on the industry’s ability to do a couple of basic things. Feed us cheap ingredients at marked up prices and guarantee that we’d keep buying it. It starts with the first ingredient in Cocoa Puffs, corn. Corn is artificially cheap in America, a byproduct of a decades old public policy in this country that has us subsidizing its production by factory farms. Those subsidies have helped drive the consolidation of agribusiness, displacing family farms nationwide. And those corporate farms sell directly to multinational food corporations that rely on our artificially cheap corn supplies to manufacture the very cereals I and millions of other kids were eating. But if all I was eating was subsidized Iowa corn, I probably wouldn’t be so excited to eat it. It’s that second ingredient that got me and millions of other kids hooked, the sugar. I have to admit that I’m still at almost 40 years old cuckoo for Cocoa Puffs. It’s not just the fact that there are little sugar balls. There are lots of ways to get a sugar fix, after all. It’s a fact that they embody the nostalgia of childhood. That’s because for decades, the company that sells them, General Mills, made sure that they literally became the taste of my childhood. That has nothing to do with the puffs themselves. It’s a product of the marketing that the company put into them. Cocoa Puffs have been around since 1956. Their avatar, Sonny, he’s been around since 1962. He’s gotten a couple of redesigns and some new voices. But he’s still the same old Sonny and he’s still, well, cuckoo for Cocoa Puffs. And because of Sonny, whenever I hear Cuckoo for, I think Cocoa Puffs. Chances are love him or hate him, you do, too. And that brand, that’s powerful. And the companies that have been feeding American kids like me cereal for decades have put a lot of time and effort into making sure those brands associations stick. Let’s try something. Name the avatar for each of these children’s cereals. Frosted Flakes, Froot Loops, Cap’n Crunch. Okay. That one’s literally in the name. If you named Tony the Tiger, Toucan Sam and, well, Cap’n Crunch, a.k.a. Horatio Magellan Crunch. Their marketing worked on you too. Now, look, I’m not one of those finger waggey public health people that believes there’s no room to live a little. I still enjoy a bowl of sugary cereal every once in a while. Though, my tastes have evolved a bit. Along with Cocoa Puffs I also enjoy a bowl of Reese’s puffs nowadays. And if you haven’t had one, I’m not recommending it, but I’m just saying. But when I enjoy it, I enjoy a bowl for dessert once in a while. The fact that millions of children around the country and around the world because of our country eat this stuff every morning as breakfast, that’s wild. The recommended serving of Cinnamon Toast Crunch has the equivalent of three added teaspoons of sugar. And let’s be clear, most folks don’t eat the recommended serving. They eat a lot more than that. What’s the upshot? Rates of pediatric diabetes are higher than they’ve ever been. And for that reason, in 2019, the Mexican government decided to fight back against the cereal industry. They forced manufacturers to put warning labels on products with excess sugar or fats. Worst still for the manufacturers, if their products contained a warning label, they were banned from promoting their products with their ubiquitous mascots. So that meant that Kellogg’s, manufacturers of Frosted Flakes and Froot Loops could no longer include Sam el Toucan and el Tigre Tonio on their boxes. And let’s just say they went cuckoo. I learned about Mexico’s efforts to protect the kids from marketing designed to normalize diabetes causing foods in a recent article from Nick Florko at STAT News, and I knew I had to have him on the show to share more about what Mexico did, how the manufacturers responded, and what it means for similar regulations that may be coming around the pike here in the US. Here’s my conversation with Nick Florko.

Dr. Abdul El-Sayed: Can you introduce yourself for the tape?

Nick Florko: Sure. My name is Nick Florko and I’m the reporter on the Commercial Determinants of Health at STAT.

Dr. Abdul El-Sayed: So I um I wanted to reach out and talk to you because I have mixed feelings about Tony the Tiger or El Tigre Tonio, as uh as he’s called in Mexico. And on the one hand, he was like the character of Saturday morning cartoons and like, you know, when I was five, they really were great. And the problem is, is that I’m like a lot older than that now. And um I I very much understand that they’re not that great. And uh and and that’s why regulators are trying to do something about it. So I want to step back here and just give give some context. Um. Can you talk a little bit about labeling laws? Like what do they do? Why do they exist uh and and do they actually work?

Nick Florko: Sure. Um. So in the US, right, we really only have one true sort of food labeling law when it comes to nutrition, which is the nutrition facts label, which is what you see like on the back of a package of food. Um. It’s interesting that actually has only existed since the 1990s. Um. And I have to admit, I was a young kid back then, but my understanding is that was actually created really in response to consumers growing interest in nutrition and the subsequent rise of food companies making nutritional claims about their products and really the confusion that that created for consumers. Uh. You know, in preparation for this, I was looking back at some history, and the former head of the federal health department in 1990 gave this quote, which I have to read, “the grocery store has become a Tower of Babel, and consumers need to be linguists, scientists, and mind readers to understand the many labels they see.” So that’s where we were just you know three decades ago. Um. And to your question of do food labels work? Uh the research that I’ve seen says, yes, they do. I mean, there’s this new experiment going on, which I’m sure we’re going to talk about, which is uh adding a warning label to the front of a food package. The idea being the consumer is making a split second decision, trying to decide, should I buy this cereal or this cereal? They see a warning on the front of one of them and says, hey, there’s excess sugar. They might not buy it. They might go to another one. We’re still gathering data on sort of the actual impacts of that. But that’s sort of the new frontier in food labeling and what a bunch of countries around the world are doing and what the US is actually toying with doing as well.

Dr. Abdul El-Sayed: So I want to talk a little bit about that because, you know, when we’re talking about about food labeling, particularly when you’re talking about the warnings, you’re talking about high uh macronutrient dense, uh micronutrient poor foods that are highly processed in um or super processed in the in the language of of one of our previous guest here. And you’re talking about stuff that one should not be thinking about eating all too often as a as a part of a regular diet. Um. And there are a lot of countries that have gone far further, far faster than we have. To give us context, though, in order to you know to think about labeling as a as a public health intervention, you have to understand how the corporations that manufacture these foods try to market themselves. Can you give us some some context about that? What is the way they market? How do they try and push themselves into the eyes and ultimately into the guts of consumers, particularly our youngest consumers?

Nick Florko: Yeah. I mean, you already mentioned it at the start to be honest. El Tigre Tonio as it’s known in, he’s known in Mexico or Tony the Tiger here in the US. Um. I mean that’s a big way that food companies do market their products is is using mascots sort of making sure that those mascots get in front of of younger people. And there’s there’s really interesting research actually coming out, sort of looking at what the long term impact of things like that are. Um. So, for example, I mean, there’s there’s a study that showed that if you have a positive association with um, you know, a mascot on a unhealthy food as a kid, you’re more likely to sort of have a biased view of of how healthy that food is as an adult. Um. And what we really know is that when you try to take away those sorts of marketing tactics from food companies, they will fight pretty darn hard to keep them. I’m happy to go into it. But the experience in Mexico with them trying to ban mascots on their products is really one clear example of sort of what happens when you try to take away Tony the Tiger.

Dr. Abdul El-Sayed: And I want to get to that, um but it’s actually kind of crazy when I think about the foods that were pushed as like breakfast when I was a kid. I don’t know if they still exist now, but like, to me, the craziest one was Cookie Crisp. Like the notion that very small cookies that are in bite sizes that you can then mix with milk should be like eaten for breakfast, and that the industry got away with marketing small cookies as breakfast made absolutely zero sense to me. But I can think about all of these breakfast cereals that are extremely high in sugar, very low in protein, and were marketed as a part of a balanced breakfast. I think that was the term they always used. Um. Can you explain you know, you talked a little bit about the connection between childhood and adulthood. Um. Can you explain you know particularly why breakfast became this way to, like, really jam kids full of sugar at the beginning of a day and like, why breakfast cereals tend to be so marketed in this particular way?

Nick Florko: I think one of the ways that that folks got away with putting so much sugar, frankly, in breakfast cereals is “sugar science,” quote unquote, has been hotly debated for for decades. And we now know that industry played a big role in that. Um. So there was documents uncovered a few years back that found that in the 1960s, food companies were intentionally funding research that downplayed the role of of sugar in coronary heart disease and purposely focused the debate on fat. Um. And we still see a lot of these arguments happening today of added sugar is not the problem. Excess any macronutrient is the problem. Why are we focusing on added sugar when we’re not focusing on total sugar like [?] sugar you’d find in fruit? What we’ve seen is like decades of this debate over whether sugar is good or bad, and we’ve ended up in this country with a with looser restrictions around around sugar than other potentially unhealthy substances, like if you look, for example, at sodium, at least in the US, there’s a voluntary goal for manufacturers to lower their sodium in food. It’s voluntary, but it exists. That doesn’t even exist for sugar. Um. So we are just like when we think about what we should be limiting in our diet. Sugar has sort of been like the last issue to be addressed.

Dr. Abdul El-Sayed: Hmm. I really appreciate that you start at the, you know, the science debate level. Right? If you can make something controversial that uh really on its face should not be, you can tie up any effort to regulate it simply by pointing to what ends up being somewhat bunk science to to to substantiate your point. There’s a difference of opinion here. And, you know, that’s a playbook that a lot of the Covid deniers uh used far later on. Um. I I want to now turn to the Mexico example. Right? And uh we can talk about El Tigre Tonio here. Um. So the Mexican government decides to take a stand against what is largely American corporations selling um straight sugar to kids, in effect, and they take this stand in 2019. Can you tell us what they did?

Nick Florko: Yeah. Uh. Essentially they required warning labels on the front of packages that look like stop signs um that say excess sugar. [laugh] If a food has excess sugar there’s a warning label on it that says excess sugar. If there’s if there’s excess sodium, it says excess sodium, if there’s excess fat, it says excess fat. It honestly sounds really simple, um but it ended up prompting a multi-year just all out brawl with uh with food companies and especially the folks that were pushing food, you know, ultra processed foods with lots of sugar.

Dr. Abdul El-Sayed: And and where does uh Tony the Tiger or El Tigre Tonio come in?

Nick Florko: [laughing] Well, interestingly, one of the pieces of the Mexico law was that if you have a warning label on your product, you can’t also use a mascot or any sort of cartoon. And the idea being here that you don’t want kids getting attracted to this food uh that is potentially unhealthy for them just because they’re seeing a mascot that they like and they’ve seen commercials. What we saw was that there was just food companies got very, very creative. Specifically, Kellogg got really creative in figuring out ways to get around uh that requirement. Uh. My favorite is that they it might it’s sort of the one I like to focus on is that they basically launched this campaign in Mexico that translated to Always With You. Where these mascots were featured in all different forms of media. So, Tony the Tiger was curating Spotify playlists. He was on [laughter] commercials alongside soccer announcers. And then, I mean, my favorite and I think the one that really has just stuck with me the most is that essentially Kellogg paid to have a drone show above Mexico City where they use drones to sort of draw all the characters in the sky. Um. So the goal, of course, of all of this is to sort of not erase the mascots from consumer memory and to keep using them, even if they can’t actually use them on certain food packages.

Dr. Abdul El-Sayed: You know it’s an interesting approach here because it’s one thing to have a mascot. It’s another to have a mascot that tries to sell the good when by definition, you can’t associate the mascot with the good. And what that tells you is that they have so burnt in what that mascot stands for through decades and decades and decades of marketing that even when they cannot put Tony the Tiger or Toucan Sam in this in the same case on their packaging for the good that those mascots are associated with, they believe that they can continue to sell their product simply by making you think about Tony the Tiger and Toucan Sam.

Nick Florko: It really speaks to the uh the impact that these mascots must actually have on sort of their their bottom lines. And well I’m sure we’ll talk about sort of the US and what the US is considering. But the US doesn’t have or isn’t isn’t considering a sort of ban on mascots. At least public information suggests that at this point they’re not considering a ban on mascots. And it sort of raises the question of like was Mexico sort of on to something here? Um. Is this something that actually could have a potential public health impact if the food companies are just so aggressively trying to fight and so openly trying to fight it?

Dr. Abdul El-Sayed: Yeah, I mean, there’s there’s sort of a principle here where if you’re trying to regulate an industry that you know has a set of externalities that include obesity, diabetes, heart disease, etc., or in the in the tobacco case, uh lung cancer, heart disease and stroke, you kind of want to hit them where it hurts and they’ll tell you where it hurts by how how loudly they scream. And so, you know, you wouldn’t necessarily think that punching them in the mascot would have such a huge impact. But if their response is to go, like, absolutely, truly apeshit or in this case tiger shit to to put their mascot everywhere, it tells you that there’s something really deep about their marketing and that the ability to associate your food with a cartoon character really does create, you know, a level of almost loyalty that that increases the probability that kids are and then adults are going to continue to buy this good. And so, you know, it must be effective if they’re that upset about it.

Nick Florko: Yeah. I mean, I have to admit that. I mean, I went to Mexico for this story, but I didn’t have the foresight to actually go there to report the story. I was sort of just had the privilege to be there. And I had known about this policy and sort of honestly had sort of just wondered like, you know, what is the big impact going to be? How big of a deal is this? Like I had heard the U.S. was doing something similar and uh it was really eye opening how quickly talking to advocates in uh in the country, sort of how aggressively the food companies fought this and how big of a deal it was for them. Because it doesn’t it sounds pretty basic and uh not super controversial to add a little bit of information about, uh you know, a food’s health effects on the front of a label and maybe it restricts the marketing, but it really, really has prompted a response.

Dr. Abdul El-Sayed, narrating: We’ll be back with more of my conversation with Nick Florko after this break.

Dr. Abdul El-Sayed: One of the other things that they did was they started to use artificial sweeteners so they could get by the the sugar regulation. Can you speak to their use of of of allulose in particular to try and get past this?

Nick Florko: Yeah, um it’s funny. I discovered this by actually sort of walking through a Wal-Mart in Mexico City um and I looked at a package and saw a box of cereal and it was reformulated. It still had Tony the Tiger on it, or actually in this case, it was Toucan Sam and the label said it had one gram of added sugar. And the first time I I saw this, I sort of went home and I I mulled it. And I was just sort of like, how could a Froot Loop have that little sugar without just tasting completely different? I mean I should have–

Dr. Abdul El-Sayed: It’s just one fruit loop in the whole thing.

Nick Florko: Yeah, [laughter] right. And I I should have just went home I should have went and bought it in that moment. Um. But I was so confident that there must be this new version because actually Mexico has a rule that if a product uses an artificial sweetener, it also has to include a warning on the package that it has an artificial sweetener and this one didn’t. So I was totally confused. And eventually I went back to that Wal-Mart and looked even closer. And what I found was that the product listed [?] or allulose as an ingredient. Um. And Allulose is a is a sugar free sweetener. Um. But it’s one of the few that’s technically not considered by Mexico as an artificial sweetener. And there’s reporting to suggest that, you know, the food industry did sort of lobby the the Mexican government to not have allulose classified as an artificial sweetener. And so Kellogg’s basically found a way to sell its product you know without an added sugar warning by reformulating it. But then they were also able to avoid the warning that was meant to uh warn consumers about the the reformulation. And I think the other interesting thing here, since we already talked about mascots is that by doing this, they’re also able to keep their mascots in the stores because that new product doesn’t have any warnings on it, which means Toucan Sam can be on the package. So essentially, when you walk around the grocery store aisle, you see you know the warning label version, which is a plain box, and then you see the one with Toucan Sam, the reformulated. And that means that the mascots are getting into the into the grocery stores and into the cereal shelves just as much and kids are seeing it. So you know it’s a really it sort of it benefits them in multiple ways.

Dr. Abdul El-Sayed: Wow. So they went as far as to lobby the government to leave one of these artificial sweeteners off so they could put it in their cereal so that they could keep putting their mascots on their cereal. Like that’s I mean, that’s like a that is a long game. That it just takes a lot of foresight.

Nick Florko: I mean, I should say uh I don’t know if we have that clear of a line all the way through at this exact moment. Like I would you have to see sort of exactly when they lobbied around Allulose. But um yeah, I mean, there’s some skilled lawyers in figuring out you know what product they could use to avoid having to have the warnings and and still be able to sell their you know their product.

Dr. Abdul El-Sayed: See, the crazy thing is these are children’s cereals. And the reason non-sugar sweeteners work is because these are molecules that continue to bind to your sugar receptors on your tongue but are not picked up in your small intestine and digested. Allulose is technically a rare sugar. It’s not a sugar alcohol, it’s what’s called a monosaccharide. Um. But your your tongue, your tongue recognizes it, so you taste the sweetness, albeit with more uh what we call avidity meanings it meaning it binds a lot stronger to your tongue. That’s why a lot of these sweeteners taste saccharine like they’re they just artificially sweet. Like not as not like sugar, which is just the right um taste for our our uh taste buds. But your gut doesn’t recognize them. So they they flow on into your large intestine. But here’s the thing about it. In your large intestine, because they are undigested molecules, they pull water into your colon and they cause diarrhea. And so you can imagine, right, like I remember when I was a kid and I used to eat these sugar sweetened cereals, I wouldn’t just have a bowl. I’d have like three or four bowls. So you can imagine a bunch of kids, unfortunate children who saw Tony the Tiger, Toucan Sam, decided to buy this sugar or like push their parents to buy the sugar, ate three bowls and then just had diarrhea for the rest of the day. And it’s just like it’s like an awful thing that these these manufacturers know is going to happen. Like they they know that’s going to happen. And there’s like no indication that this is any different than the usual cereal, except for it looks like the cereal used to look.

Nick Florko: So the US doesn’t have a restrict or a requirement to warn about artificial sweeteners on their packages. But interestingly enough, the group that’s pushing for more disclosures of or add of artificial sweeteners is the sugar industry, uh and they’re petitioning the FDA to require companies to sort of more clearly state when a product has an artificial sweetener and to block companies from from claiming that their products are lower in sugar without also noting they have artificial sweeteners. But the reason I bring this up is because on the Allulose front, they’ve actually specifically petitioned the FDA to require companies that use Allulose to have a warning that says it may cause a laxative effect.

Dr. Abdul El-Sayed: [laughter] You can’t make this shit up. [laughter]

Nick Florko: It’s pretty remarkable the infighting you see in the food industry. Yeah.

Dr. Abdul El-Sayed: Wow like [laugh] I’m just at this point, I’m really just like my heart goes out to these poor kids in Mexico who are just like, Yo, what happened today? I was just busy minding, I was eating my cereal watching my cartoons, and I don’t know what happened. [laugh] Um. I want to ask you, you know, obviously, this battle is still ongoing. Where do you think this ends up? Where are the the legal teams for Kellogg um and the Mexican government going next? What what do you think this evolves into? Do you feel like they’ll be able to repeal some of these laws? Do you feel like they’ll just, you know, put up with it? Where does this go next?

Nick Florko: So I’m not a lawyer, but I will say in the Mexican case, things are looking pretty good actually. Um. So the food industry threw everything at challenging this legally as well. I mean, the Mexican legal system is is different than the U.S. system. So these numbers you know wouldn’t be the same if it was in the U.S. But there is like estimates of 70 to 100 lawsuits filed against this. Um. And a bunch of those have already made it up to sort of their appeals level courts. And those courts actually do put out sort of um draft opinions before they decide on what they’re going to do. And those seem to suggest that they are going to uphold the law. And the Mexican regulators that have been behind this have been really steadfast in, you know, throughout the regulatory process that the food companies have you know tried to make tweaks along the edges to this. And they’ve been um you know very skeptical of those and really push forward with what they were they were intending to do. Honestly, the bigger legal uh fight might be here in the U.S., because the US is considering a similar food labeling policy, one that’s a little bit weaker, to be honest. But here in the U.S., I mean, even when I talk to the most enthusiastic supporters of this, they acknowledge that our rules around sort of when the government can regulate a corporation’s speech, they’re going to be a problem. And the food companies are already sort of making very thinly veiled threats around like potentially suing over any sort of mandatory front of package labeling here in the U.S. I mean, that’s really where the fight’s going to be. In Mexico, it’s actually looking pretty good. I mean, it’s survived thus far. And um I mean, there’s no indication at this point that you know it’s going to be thrown out.

Dr. Abdul El-Sayed: Can you tell us a little bit more about what’s being proposed here in the U.S.?

Nick Florko: Yeah. Happy to. Um. So it’s in very early stages first of all. The FDA is currently at the stage where they are studying the sorts of labels that they might use. So they’re not even in sort of like the formal proposal stage. Um. But basically what they’re thinking about is less uh maybe striking warnings than in Mexico. So not like the stop sign that says excess sugar or excess fat, but something relatively similar. So like some of the designs they’re they’re testing kind of look like stoplights where it would be like, you know, green food, you know, low in low in sugar, red food, high in sugar. Um. And so they’re deciding above, I think it’s six labels right now, sort of which one they’re thinking about. Um. And but the the policy won’t include sort of things, at least thus far it hasn’t included things like artificial sweetener warnings. It’s also um they’re not thinking about this as sort of a warning. Um. You know, folks have said like you need to be putting warning labels on products and essentially they’re saying, no, we’re going to say the products are high in sugar or high in fat. We’re not going to warn around it. And then it’s not going to include things like mascot bans, for example, at least not yet. I mean, like I said, it’s really early stages. Anything could change. But all indications suggest that they’re going to go with something a bit simpler that essentially just says, hey, this food is high in sugar.

Dr. Abdul El-Sayed: And what’s what is the timeline on this that’s been considered?

Nick Florko: Oh, that’s a good question. It’s always dangerous to try to predict FDA regulatory timelines or any regulatory timelines. Um. What I can say is that uh I believe at this point they should be actually doing the formal studying now. Uh. When I talked to the FDA commissioner, he did say to me that this was something that he wanted to do during his last stint in the administration because he was also the FDA commissioner in the Obama administration. Uh. And he so he feels really passionate about this like it’s pretty clear. Um. And this is also part of a larger strategy that the Biden White House is pushing because they had this large summit on nutrition and health a few months ago. And so, I mean, this overall is clearly a priority. I don’t think this is the sort of thing that’s going to get slow walked at the agency. But I mean, it’s going to be a slow process like I mean, the way this works is they’re going to do these studies. They’re going to review the studies. They’re going to put out a proposed rule. They’re going to take comment from the food industry. They’re going to get so many comments you won’t believe. They’re going to have to go through them all really carefully and address them all because they’re going to bring up brought up in litigation eventually. Then they’re going to finalize it, and then there’s going to be you know probably an implementation period, which could be you know it could be months, it could be years. So, I mean, it’s it’s going to be a while is the short answer.

Dr. Abdul El-Sayed: Hmm. And you talked a little bit about how the industry is gearing up here. Obviously, we’re a much bigger market. And, um you know, we are the we’re the home of a lot of these these large corporations. Kellogg is based not 100 miles from from from where I’m sitting right here in Michigan. Um. You know, in so many ways, as you talked about, our public policy tends to be a lot more sympathetic to large corporations and a lot more sympathetic on on speech grounds. What I’m hearing you say is that they would have to put a warning label on their product, which of course has a lot of precedent in the setting of tobacco. Um. Can you talk a little bit about how that precedent applies or maybe doesn’t apply here?

Nick Florko: That’s a good question. So the un– the understanding that I have is essentially the fact that these labels can be considered an– the issue is that they’re if they’re sort of interpretive, uh as I understand it, so the food industry is essentially arguing that they can’t be forced to say something that uh is not sort of uh you know indisputable fact, essentially. That’s how I sort of understand what their arguments that they’ve thrown at thus far has been um. In terms of the the connection to tobacco warning labels. I mean, I’ll just note that those have also been repeatedly challenged in litigation. I mean, so, you know, in both cases, these sorts of things, any time you get into you know compelled speech, you almost always in the US get a lawsuit and it gets fought out. Um. The other interesting thing I’ll just say is that the policy argument here is is kind of interesting because the food companies are essentially arguing we’re already doing this and there’s a less burdensome way that we can do this ourselves, um which I think will eventually sort of feed into their legal argument. But essentially, you’ve probably if any you’ve been to the grocery store, you’ve probably seen that some foods do have some sort of information on the front of them that says this has this much sugar, this has this many calories. Um. That’s what the food industry calls facts up front. It was their voluntary effort to sort of uh address this issue. There’s a lot of differences, though, between those labels and what we actually see in terms of what the FDA is studying, um because those labels for example, will say like five grams of added sugar or five grams of total sugar, and it won’t say high in sugar, for example. So the average consumer looking at that isn’t getting anything to sort of interpret is this good or is this bad? They’re just getting the same information that they saw on the back, on the front. Um. And basically the food companies argue that like, hey, we can do this. You can’t demand us to do this thing where you say, you know, you set a guardrail on or a guideline on what is high amounts of sugar, and then we have to put it on our food because you think our food is high in sugar.

Dr. Abdul El-Sayed: Mm hmm. You know, it’s an interesting question right now, but what actually drives a lot of the consumption and I happen to be one that says that, you know, as far as food labeling unto itself is better than not food labeling. When I think about the value of food labeling versus a lot of the agricultural policy around subsidies, for example, that disproportionately dropped the price of sugar. Right. A lot of the sugar we’re talking about isn’t actually sugar. It’s high fructose corn syrup. And that corn syrup comes out of corn that is highly subsidized in the American marketplace. And, you know, you think about the ways that that drives the economics of being able to put sugar everywhere and make a lot of money off of it. I wonder how valuable it is relative to other things. And at the same time, I think about is this is an example of the industry just being willing to push back as hard as it possibly can on any regulation? Or is it the industry really believing that this is going to take a hit relative to some other policies? Or is it the fact that in the United States we’ve just been so piss poor at regulating the food industry at all in a positive way? You know, you cover the commercial determinants of health and I’d love to hear your thoughts on the kind of public policy we should be seeing if we truly, really wanted to reduce the burden of diabetes, for example, in our society. What would we be doing to regulate the foods? [?] Is it this is it something else? Is it some combination of some of these policies?

Nick Florko: So, I mean, I’ll say is that any good reporter, that I’m not in the business of making policy recommendations but sort of reporting on their impacts. Um. So with that framing, I’ll say in terms of what we know sort of has shown some potential benefits, like one of the policies that I think is worth bringing up that has generated quite a lot of controversy in this country is um the so-called tax on sugar sweetened beverages to dissuade consumption. So the so-called soda tax and we’ve seen those enacted on a local level with some some you know pretty encouraging results. There was a study that came out of Oakland, for example, um that found that sugar sweetened beverage purchases declined by more than a quarter in Oakland after the tax versus a neighboring city that didn’t have a tax. Uh. One of the other really interesting policies that we’re seeing tried, but I don’t think we really have great results on yet um is simply just banning the sale of sugary products to kids. Uh. The state of Oaxaca in Mexico has actually tried that, um and it’s actually pretty funny to contrast that to sort of what we see here in the US, because you know covering the commercial determinants of health, I often end up covering these sort of food fights for lack of a better term. Um. And you know one of the things that the USDA is considering right now is simply uh limiting the amount of of chocolate milk that can be served in schools. So they’re considering either banning chocolate milk in elementary school or allowing schools to sell chocolate milk so long as they sell a low sugar version. Uh. And if you’re you know concerned about like added sugar, a policy like that makes sense because there’s a good amount of added sugar in chocolate milk. But you wouldn’t believe the level of vitriol that uh sort of has has come out of that regulation. I mean, I would never have thought about that when talking about chocolate milk. So like you can’t get something like a chocolate milk restriction here in the US for elementary school kids. Uh. You know, it’s hard to imagine sort of a policy like banning the sale of all uh you know sweet products to kids, but it’s definitely like an experiment that I’m really watching right now because it is, you know, relatively uh innovative.

Dr. Abdul El-Sayed: You know it frustrates me as as someone who is very much in the business of trying to make policy recommendations. I find that the industry is very good at chameleon-ing when it comes to different value sets. So for example, they would say that a ban violates the freedom of choice that we value so highly in America. How could you ban anything from anyone? Right in this country we believe that everyone has the freedom to choose and that uh we can educate, but we cannot ban. And then when it comes to something like food labeling, which is entirely about saying we are not going to take any option off the table, we are just going to educate consumers about what options are less and more healthy. Then it becomes an entire fight about freedom of speech, right? So it’s like the freedom of choice versus the freedom of speech. And what tends to really be the case is that these companies do not want to have to bear any of the costs of the externalities that they put out in the world. And I know that’s a fancy economics term, but it basically means when, you know, you sell a product, the consequences of which bear out on society in some pretty important but not direct ways that you should have to bear the cost of those outcomes. And that means some sort of regulation to force you uh to engage in. And what’s worst of all is that our taxpayer dollars, not only are we not regulating, but we’re actually subsidizing um the production of a lot of these goods. You know, as you think about where the American mind is on these things, which of these arguments do you think makes the most sense? You know, do you think that there’s sort of a um an easier time to make an argument about freedom of choice with like clear education and compelled speech? Or um are are are you know, is the average American more willing to support something where there’s a ban? I have you know, I have my I have my my my opinions on this, but I’d love to hear yours or someone who is closer to this evidence.

Nick Florko: You know, I’m sort of making an educated guess here, but my my thought from covering these these issues would be that, you know, a policy that just gives consumers more information is a lot less likely to be controversial. Like any time I’ve ever covered anything that resembles a ban or limits choice in the US, it uh it generates some backlash. But I mean, I haven’t seen besides the food companies, right. I haven’t seen the same level of backlash to something like including more information on the front of a food package that says, hey, this is unhealthy. The question. Right. And probably the question more for you then for us for me is which one of those is actually more effective from a public health perspective? Like, I can I can tell you which one is probably more helpful just from a political messaging perspective. But the question of which one actually works the best, I don’t know if I have a good answer to that. That’s a harder question.

Dr. Abdul El-Sayed: Yeah, I think your I would tend to agree with you about where the average American would sit. I think people get real uncomfortable with the idea that somebody takes away a choice of theirs. But I think people are more nonplused about the idea that you’re going to give them more information. Right and I mean, and it really just comes down to the question of giving you something versus taking something away.

Nick Florko: But look at the New York fight over over big sodas. I mean, you remember that from a few years ago.

Dr. Abdul El-Sayed: I do.

Nick Florko: I mean, that sort of tells you everything you need to know about how the public sometimes responds to these sorts of restrictions.

Dr. Abdul El-Sayed: Yeah, I think the the question of of efficacy to me, I’ve just really been a big supporter of the idea that we should fundamentally rethink our food subsidy policy. You know, I think I think there’s there’s so many opportunities to support farmers that does not mean growing mono crops that end up turning into either sugar or gasoline or fattening up an animal. Right. Um. And so many of the crops that we do subsidize tend to promote uh corporate farming. They tend to promote these mono crops, and um they tend not to promote the kind of diversity of farming that we really, um I think need to have and would really like to have and most importantly, could benefit our health in a pretty profound way. And then I think, you know, once you do that, then there’s the the question of trying to guide somebody uh around choice making. I also think that, you know, even in science curricula, we don’t do a really good job mapping the basic science that we teach folks to choices that they can make every day. Right. So like, you know, similarly with math, you want to explain why math is important, to explain compounding and investment. Right. But like we don’t really do that. So we tell you about how compounding works in like complete abstraction, but we don’t explain why compounding is probably the single most important thing that should dictate how you store your money, right? Um. Similarly, we’ll tell you a lot about the Krebs cycle, um but we don’t really explain how that then maps to um, you know, what you’re eating and help you make good decisions. So I really think that it’s not just, you know, red for bad or green for good. It’s also like, let’s give folks a little bit more ownership of the choices that they make um and do so by really trying to orient baseline curricula early on to some of these really big important choices that people are making every day. I really appreciate you joining us um to share a bit more about your reporting uh and uh and the effort to to defang and El Tigre Tonio in uh in Mexico. Our guest today was Nicholas Florko. He is a health reporter for STAT where he covers commercial determinants of health. Nick, we really appreciate your time. Thank you.

Nick Florko: Of course. Thanks for having me.

Dr. Abdul El-Sayed, narrating: As usual here’s what I’m watching right now. Infant mortality, literally a measure of the number of babies who died before their first birthdays increased in 2022. That’s the first increase in decades. We’ve done a couple of episodes on infant mortality here. And that’s because in America, more babies die per capita than in 53 other countries in the world. Our infant mortality rates are higher than they are in Latvia and Bosnia and Herzegovina. Infant mortality is a complex outcome, a measure of a number of factors that affect a womb before a fetus is ever conceived. The health of the person carrying the fetus, the circumstances affecting the birth and the environment that shapes the infant’s life for the first year. All of this is shaped by circumstances that are a lot bigger than simply health care. Remember, these numbers are for 2022, meaning these infants were most likely conceived in 2021. And if you remember, 2021 was the single most deadly year of the COVID 19 pandemic. But COVID deaths are the tip of the iceberg. It’a also all the ways COVID shaped the mental and physical health of folks leading up to pregnancy. That includes everything from isolation, diet and physical activity, access to in-person health care. It also includes the readiness to get pregnant in the first place. Remember, COVID created a, quote, “baby bump,” which means that a lot of folks who would have been able to avoid pregnancy, ended up getting pregnant. And getting pregnant when you don’t want to be pregnant implies that by definition you aren’t in your best place to carry a pregnancy to term or care for the infant after they’re born. Which brings me to the question of choice of when, where, and with whom to carry a pregnancy. Quote, “Pro-Life” folks think they really are, quote, “saving lives” by denying abortion access. What they don’t really realize is that when people can’t control their own fertility, it creates circumstances where they’re forced to carry a pregnancy and care for an infant when they don’t feel prepared to do so. Those circumstances are terrible for the health of the parent and for the health of the infant. And sadly, I worry that because of the fall of Roe v Wade, we’re going to see these numbers simply continue to climb. For a long time, the American Medical Association has claimed to speak for physicians despite falling completely out of step with where physicians are today. In the past, physicians mainly worked for physician owned practices. They owned their own businesses and usually contracted with hospitals that used to be actual nonprofits, focused mainly on providing health care to the local communities rather than maximizing their bottom lines. Look, I wish we lived in a world where all physicians cared simply for the best for their patients and not money or autonomy. But that’s simply not the world we live in. So it made sense, at least economically, that physicians in the past might not support single payer health care in that world. But let me remind you how much health care has changed over the past two decades. Rather than truly nonprofit hospitals of yore, today’s hospitals might as well be for profits if they aren’t already. And they’ve been buying up physician practices left and right. As of 2019, the median physician no longer worked for a physician own practice. Instead, they worked for a large health care system. And guess what else changed? The median physician also supported single payer health care or Medicare for all, which makes it all the more confusing that the AMA still opposes single payer health care. But that all might change. See, some heroes have been organizing within the AMA to shift its positions, and they might just move the organization. But the last time the AMA’s House of Delegates debated the question was in 2019 and that effort to shift the tide and force the AMA to support single payer health care was led only by the medical student section. They failed by just 6%. But this time they’ll be joined by a coalition of practicing doctors from New England. We’ll keep you posted. Finally, the world lost a giant this past week. Ady Barkan was an activist, organizer and leading voice for the health care system we deserve. He was also my friend and my brother in that work. Ady campaigned for me in Michigan when I ran for office. He wrote the foreword to my first book, Healing Politics. He died of complications from ALS at 39 years old. He leaves behind two children, Carl and Willow and his incredible wife, Rachel, who will continue his legacy. You can donate to support his young family. We’ll leave the link in the show notes. Ady’s was a vivacity, born out of a righteous fight for the rest of us. When he was diagnosed with ALS. He could have resigned to spend the rest of his days with his family. Nobody would have blamed him. Instead, he used the final moments of life to remind us how much life was actually worth and what it meant to protect it. I loved Ady for his passion, his grit, his joy, his wit. But most of all, because he loved all of us. I want to leave you today with inspiration from Ady’s interview way back in 2019, when I asked him what the solution to our health care brokenness should be.

The first most important solution is Medicare for All. The solution is building a society where every single person, rich or poor, has access to excellent quality medical care. Because we believe that healing shouldn’t just be available to CEOs. The solution is a society where we believe fundamentally that health care is a human right and not a commodity like a car. No more getting on the phone trying to convince your insurance company to cover something. It’s all covered. This is personal for me. One of the things I’ve come to deeply understand over the course of this diagnosis is that our time here is the most precious resource we have. Should we really be spending the limited amount of time we have on the earth on the phone with Aetna? Why does it have to be that way?

Dr. Abdul El-Sayed, narrating: I’ve been asking myself that question too. That’s it for today. On your way out, don’t forget to rate and review the show. It really does go a long way. Also, if you love the show and want to rep us, I hope you’ll drop by the Crooked Store for some America Dissected merch. [music break] America Dissected is product of Crooked Media. Our producer is Austin Fisher. Our associate producers are Tara Terpstra and Emma Illick-Frank. Vasilis Fotopoulos mixes and masters the show. Production Support from Ari Schwartz. Our theme song is by Taka Yasuzawa and Alex Sugiura. Our executive producers are Leo Duran, Sarah Geismer, Michael Martinez and me, Dr. Abdul El-Sayed. Your host. Also a very special thanks to Michael Martinez, for whom this will be his last show with Crooked Media. Thanks, Mike. Good luck with your next endeavor. [music break] This show is for general information and entertainment purposes only. It’s not intended to provide specific health care or medical advice and should not be construed as providing health care or medical advice. Please consult your physician with any questions related to your own health. The views expressed in this podcast reflect those of the host and his guests and do not necessarily represent the views and opinions of Wayne County, Michigan, or its Department of Health, Human and Veterans Services.