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Source: http://www.doksinet The Digital Food Ecosystem Understanding the opportunities to promote healthy eating following the fourth industrial revolution A report by the Sandro Demaio Foundation for VicHealth Source: http://www.doksinet TABLE OF CONTENTS NUTRITION AND HEALTH IN MODERN AUSTRALIA 2 THE DIGITAL FOOD ECOSYSTEM 4 SUPERMARKETS AND THE FAST FOOD MARKET 4 DATA AND MACHINE LEARNING 5 TARGETED ADVERTISING 5 THE RISE OF NEW AND SOCIAL MEDIA 7 HEALTH IN THE DIGITAL AGE 9 NOVEL PARTNERSHIPS 10 ADAPTIVE PUBLIC HEALTH PROFESSIONALS 11 VICHEALTH RECOMMENDATIONS 13 CONCLUSION 15 CONTRIBUTING AUTHORS 17 REFERENCES 17 1 Source: http://www.doksinet Nutrition and Health in Modern Australia Over the past 30 years, global inequality has risen sharplyi, and continues to rise, with the richest 1% of people now possessing more wealth than the rest of the world combined ii. In Australia, both wealth and income inequality iii continue to rise at some of the

fastest rates seen globallyiv. We know that inequality and low socio-economic status (SES) have a profound impact on nutritionv, food choices, obesity (especially in children)vi and the prevalence of noncommunicable disease (NCDs), so as inequality continues to worsen, so do its downstream effects. Low disposable income and pressure on the weekly shopping budget for many Australians continue to push families towards processed, high-calorie, but often nutrient-poor foods, which are perceived as cheaper than their fresh food alternativesvii. Sedentary behaviour is also driving poorer health outcomes. Australian’s with a digital device spend on average 10 hours and 24 minutes engaging with their devices every day viii. That is more than the amount of time spent asleep, and more time glued to devices than eating, commuting, exercising and spending time with friends and family ix. When examining poor diets combined with sedentary lifestyles, it unsurprising that we are facing a national

obesity epidemicx, with almost 2 in 3 Australian adults and at least 1 in 4 children overweight or obese. We spend A$4 billion every year on health care associated with obesity in Australia.xi Individually, healthcare costs for chronic diseases such as diabetes are prohibitively expensive, with the average annual healthcare costs for an Australian with type 2 diabetes $4,025, rising to as much as $9,645 if there are accompanying micro- and macrovascular complications.xii Yet, as the number of people with overweight and obesity continues to rise, many seem to have adjusted to this as the new ‘normal’. This ignores not only the preventable nature of the disease, but also the fact that there are greater forces at play that are actively shaping this concerning and costly trend. The food industry is deeply entrenched in a model of selling highly profitable products of poor nutritional value, while leveraging their economic, political and societal influence to curb efforts at regulation.

With poor diet now a leading risk factor for disease among Australians, those companies that produce, advertise and sell food have an enormous impact on human health. Yet, leaders and sections of society fail to recognise or ignore these purposeful, market-driven actions and instead, continue to blame the overweight individual and their poor “lifestyle choices”. 2 Source: http://www.doksinet The Digital Food Ecosystem Supermarkets and the Fast Food Market With increasing income inequality and urbanisation, Australian eating habits have undergone a dramatic shift over the past three decades. Inner-city population growth has fed the market share of Australia’s two largest grocers, such that Wesfarmers and Woolworths are now ranked within the top 25 global retailersxiii. The roaring success of fast food giants – the Australian fast food market has grown by 5% between 2010-2015, and the fast-casual restaurant market has grown by 30% in the same periodxiv, compared to food retail

revenue growth of 1.1%xv– coupled with the immediate popularity of online aggregators and new-delivery companies such as MenuLog, Uber Eats, Deliveroo, and Foodora, demonstrates the prioritisation of convenience and affordability in shaping the food choices of Australians. Online food-delivery platforms now occupy a 10% ($1.5 billion) share of the fast food market and are forecast to rise to 23% ($42 billion) of the market share by 2025.xvi Traditional food systems have undergone a rapid transition of commodification, homogenisation and globalisation, largely driven by multinational food conglomerates promoting highly profitable foods, often laden with salt, sugar and fat, which rarely align with national or regional dietary guidelines. This new age of digital food ecosystems is unlikely to be different. Alto Data Analytics, who collected Twitter data in English from the US Uber Eats Market, and applied data visualisation algorithms to find the most-shared images found that donuts

came in first, followed by burgers and pizzas.xvii As the increasingly digitalised world penetrates the supermarket industry, this will in turn continue to shape consumer food choices. Online grocery shopping is already a burgeoning market, and one that is set to grow over the coming years. A 2016 report from Nielsen predicts that online consumer spending will add $2 billion of sales into the Australian grocery industry over the next 5 years, with online grocery sales growth 6 times faster than total grocery sales growth in 2016 (20.1% vs 35%) xviii The attractiveness of home delivery is clear; consumers can order food from the convenience of their home and peruse an expansive array of food options. Amazon Go’sxix new cashier-free supermarket similarly emphasizes the value consumers place on convenience and time. It remains to be seen how this venture will influence Australian consumers, but stores in the US are already seen to be prioritising ready-to-eat 4 Source:

http://www.doksinet meals. Online food services and the advent of novel supermarket initiatives such as Amazon Go will be central to the way Australians eat in five years’ time. Of course, the widespread uptake of food-to-door delivery services has the capacity to improve the eating habits of Australians should stakeholders take deliberate steps to prioritise health. An efficient online user interface could help consumers shop more efficiently and provide easy access to nutritional information to encourage healthy purchasing decisions. Data and Machine Learning The power of data and machine learning is generating wide sweeping change across all levels of industry. Shopping behaviours and patterns are being predicted by deep learning systemsxx and Google’s search algorithms are being powered by machine learningxxi. In the field of public health, IBM’s ‘Watson’ is bringing an unprecedented combination of resources and technology to cancer treatment. Watson for Oncology is a

cognitive computing system developed to provide treatment recommendations based on training it receives from published medical literature, publicly available treatment protocols, patient charts, test cases and guidelines.xxii As food systems go digital, the food industry faces an unprecedented ability to amass data on consumer food choices. In all likelihood, public health authorities will be competing with industry interests to determine how this data is used, and whether this newfound knowledge will generate positive nutrition outcomes for the Australian public. Unfortunately, industry’s prioritisation of economic efficiency and profit often comes at the expense of population health and wellbeing. What could be of concern, however, is the capacity for industry to capitalise on data driven insights to manipulate consumer food choices, from online grocery shopping and Uber Eats through to supermarket rewards schemes. Targeted Advertising Concerns regarding the significant impact of

digital food advertising have gained increasing attention in recent times, and it is probable that data-informed marketing campaigns will be even more effective at generating desired behaviour change at a population level. The capacity for the food industry to use consumer data to specifically target us as individuals presents an even more concerning prospect: the persuasive power of advertisements will be magnified by industry’s understanding of our individual food preferences, and their intimate 5 Source: http://www.doksinet understanding of which advertising campaigns have been effective in changing our behaviour in the past. Online behavioural advertising that tailors advertising to the characteristics and preferences of individual users and depends on the extensive aggregation of detailed personal and behavioural data, has led researchers to conclude that “advertisers are making it impossible to avoid online tracking”.xxiii xxiv Digital broadcasting of high sugar, salt

and fat products during sport games and the use of cartoon characters to promote unhealthy food items are already a cause of concern for public health. The digital space has the potential to amplify and accelerate many of these existing and documented challenges, providing yet another ecosystem for them to occur in. In the absence of effective regulation of digital media in many countries, children are also increasingly exposed to persuasive, individually tailored marketing techniques. Products are now being promoted through social media sites and ‘advergames’, which advertise products through video games. In Japan, McDonald’s partnered with the popular mobile-based game Pokémon Go to make their restaurants important locations in the game. xxv Research has shown that the likelihood of children consuming unhealthy food rises after they interact with these advergames, and these negative effects can increase with repeated exposure. xxvi There is little being done by way of

effective regulation to protect children from this practice, and governments have a duty to protect in the best interests of the childxxvii. New provisions in a code adopted by Ireland’s Department of Healthxxviii, is a small step towards a regulatory approach to digital advertising. The code states that ‘marketing communications for HFSS [high fat, sugar, salt] food by means of social media shall not target children under the age of 15.” However, the code is voluntary and lacks effective enforcement. In the Nordics, a new initiative from the Nordic governments to develop a joint monitoring protocol that covers digital marketing may go some way to addressing this challenge and will make an important contribution to the public health knowledge base.xxix As recommended by the WHO “tackling food marketing to children in a digital world: transdisciplinary approaches” report, a starting point at a national level could be to map the regulatory landscape so that the strengths and

gaps of the existing legislation (from health, child welfare, children and family, to food legislation) are better understood and the most appropriate entry points for modified, updated or new legislation are identified. xxx Of course, big data has the potential to generate much needed insight into consumer behaviours for public health researchers and drive positive change in our understanding of the behavioural economics of food choicesxxxi. Public health professionals must refocus their efforts on the digital food ecosystem, and the complex systems of data and technologies that underpin it, and with this, the research and funding to effectively engage in the space. 6 Source: http://www.doksinet It is imperative for the health of Australians, that the power of big data is harnessed by sectors of the food industry that will promote healthy eating, by governments and by public health itself. The challenge for health authorities will be in curbing the effects of increasing investment

by the fast food industry in translating big data into profitable, but unhealthy eating preferences for Australians. The Rise of New and Social Media The effective transmission of health information is central to promoting and maintaining good health. Today, the delivery and receipt of health information has been transformed by an evolving technological landscape. The advent of new media and digital platforms has meant that health information has become more accessible, however, there is a growing challenge to ensure its quality is not diluted. It is also important that approaches to public health are responsive to changes in the way healthcare information is consumed and sensitive to its consequences on health and social inequality. Traditionally, the dissemination of health information has been the domain of health professionals and public health bodies, but this is quickly changing – and public health organisations are lagging behind the big corporates in the degree,

effectiveness and creativeness with which they are engaging on novel platforms. Additionally, as the threat of erosion of old world media quality continues – due to its increasing reliance on private sector funds and advertising, and subsequent lack of funds for long-form investigative journalism – society is left vulnerable to system challenges and pernicious threats. As oldworld media continues to decline in influence and attempts to shape-shift in order to stay relevant, social media fast increases its aggressive stronghold on our attention. People now receive perhaps the majority of their both actively and passively sought health information via social media – meaning that health and public health organisations must increase and improve their presence on these platforms if they want to remain relevant and effective. As people’s attention span shortens, we must adapt to deliver health messages in formats that people are able and enthusiastic to digest. More and more,

individuals are relying less on primary and secondary healthcare providers for health information and turning to the internet. The scale of such mediums offers an insight into their powerful potential to improve health education and health advocacy: Facebook has over 2 billion active users while each day over 1 billion hours of video content is seen on Youtube.xxxii Facebook is the all-pervasive ‘homepage of the internet’, which, despite being exposed to data privacy challenges, still draws hours of people’s attention each day as they scroll their 7 Source: http://www.doksinet newsfeeds. Facebook has substantially reduced the penetration of unpaid page posts, so in order to engage effectively, organisations must adopt creative approaches in order to draw organic appeal, and/or dedicate significant budget to increasing exposure. Facebook, along with others, are using complex information-gathering approaches e.g drawing information from always-listening devices and apps such as

Siri, ‘Ok, Google’, Google Home and Alexa, to increase their ability for targeted advertising. Alexa uses your voice recordings and other information, including from third-party services, to answer your questions and fulfil your requests. All the while, this information is stored and processed on the Cloud, and shared and linked to Amazon. The data, for the most part then stays with Amazon and its subsidiaries. However, they also maintain the potential to deliver personalised health and nutrition coaching and could be used for effective public health campaigns, targeting, for example, those with diabetes or the LGBTQI community. As data processing and bandwidth capabilities increase, video has become a ubiquitous and ever-popular medium – both within Facebook and Instagram, as well as on Snapchat and Youtube in particular. ‘Youtubers’ have from tens of thousands to millions of followers who watch their oft-posted videos. However, this would also give public health messages an

opportunity to gain wider, and/or targeted exposure – such as Youtuber-now-pop singer Troye Sivan’s Durex-sponsored series on safe sex: Let’s Talk About Sexxxxiii. In this case, his sex education videos, delivered to a young audience, have attracted more than 5 million views so far. As Netflix and other online TV and video services proliferate, we must also consider their ramifications and opportunities for public health. Whereas brands used to look only to conventional ‘celebrities’ to sponsor, now media such as Instagram have enabled brands to partner with Instagram ‘celebrities’ to disseminate their messages and align their brand image to the ardent followers that these ‘celebrities’ draw. Not only this, but through various techniques, Instagram furthers the democratisation of free speech – anyone can have a platform – but this means that a proliferation of health information comes in very diverse quality from variably trustworthy sources – from athletes to

pop stars to “wellness gurus”. For example, the British food writer and blogger Ella Mills has amassed over 1.3 million followers on Instagram alone, and has leveraged her social media following to sell close to half a million cookbooks, despite not having qualifications in nutrition or the health sciences. The democratisation of information has meant there is no longer an arbiter of truth. Therefore, whilst the potential of technology to revolutionise how we access health information is readily apparent, the challenge to prevent misinformation remains. We must also consider the way that online media are used to augment and expand ‘realworld’ experiences – from KFC’s cricket hashtag #theHCGxxxiv where they encourage cricketgoing kids to share stories of home cricket, and to wear KFC buckets on their heads, to the National Gallery of Victoria’s Triennial exhibitionxxxv, whose social-media-friendly exhibits 8 Source: http://www.doksinet generated unprecedented amounts

of online exposure and social advertising, in turn leading to record crowds. As public health organisations we must not only be cognisant of the ways in which businesses are integrating physical and online experiences but also seek to use such techniques creatively ourselves. Research has shown that less than 3% of advergames used by the food industry educate children about health and nutritional issuesxxxvi, and indeed, social media and gaming are under-explored platforms for public health organisations to disseminate health promoting messages. Aspiring public health social campaigns include ‘Movember’ of the Movember Foundation and ‘Know Your Lemons’ by Worldwide Breast Cancer. Movember focuses on the oftenunder-recognised issue of men’s health Their annual social media campaign creates both a visual identity to the wider campaign, but also stimulates organic conversations around men’s health issues with the simple question ‘why are you growing a moustache?’ From its

humble beginnings in 1999, Movember has since raised $710 million worldwide and there have been more than 5,542,507 Mo Bros and Mo Sistas participating. The ‘Know Your Lemons’ campaign by Worldwide Breast Cancer is also visually-based, with an image illustrating twelve warning signs of breast cancer through lemons in an egg carton. The image has been viewed more than 3 million times and has been shared on Facebook more than 40,000 times. It has also been featured by media outlets all over the world In addition to the aforementioned initiatives and platforms, public health engagement could include podcasting. In Australia, both the frequency of listening and time spent listening to podcasts has increased year on year. More than half of adult Australians having tried podcasting, with that number increasing to 76% among 25-34-year olds.xxxvii Similarly, engagement on streaming apps such as Strava, Nike+, Garmin, Fitbit, hold the potential to encourage and promote physical activity,

while commonly used dating apps such as Tinder and Bumble could provide new platforms to engage young Australians. Public health strategies must seek to adapt and capitalise on the technological revolution affecting healthcare while remaining committed to dissolving health inequality. Planned health promotion activities must be conscious of a population, which increasingly favours a digital environment. As these platforms compound their constancy, penetration and addictiveness with their ability to capitalise on information gathering and analyse big data, they will only gain a greater stronghold on our attentions and our lives. If we want evidencebased, sensible health information to reach consumers, we must engage far more actively and effectively in the social media world before we are left any further behind. To achieve this, VicHealth could further develop its current brand as a recognised, evidencebased and authoritative body, to establish itself as an organisation that works

alongside other public health and social media voices in a more collaborative, design-focused and emotive manner. Employing a strengths-based approach, rather than a deficits-based 9 Source: http://www.doksinet approach, will be important, given our broken and ‘guilt-based’ relationship with food. VicHealth should be able to provide the public with a vision of what a healthy relationship to food looks like, and social media is a perfect avenue through which to do this given that social media shapes our cultural norms, expectations and aspirations. Health in the Digital Age Novel Partnerships Innovative partnerships will be central to achieving positive health outcomes in the future. A coordinated and proactive effort is required between a number of key stakeholders including the government, healthcare professionals and private industry. Together these groups have the opportunity to collaborate and drive innovation in areas such as education, research, and digital food

ecosystems. A finely nuanced relationship between government and private industry must be developed in order to capitalise on key opportunities within the food industry – these opportunities centre on leveraging social media, digital food ecosystems and ‘big data’ to drive positive health outcomes - yet do not extend to private sector sitting at the policy table. There is an opportunity to build relationships with key social media organisations in order to leverage their influence and develop a shared partnership agenda – central to this will be public investment in health promotion activities which work intimately alongside new digital platforms. Furthermore, the contemporary food environment is increasingly being transformed by the technological revolution. The food environment can be understood as the political, socioeconomic and commercial sphere of influence, which affects our food choices Simply possessing the right knowledge is not enough if the environment and digital

food ecosystems around you pose structural barriers to positive health behaviours. Commercial interests are typically and at best agnostic towards healthcare outcomes. However, given the growing impact that commercial organisations have on our food choices, it is important that the government work with, rather than against, private industry in order to achieve positive food and nutrition goals. This might manifest in the form of productive relationships between public health authorities and online digital food platforms, including online food delivery platforms and food retailers, with the intention of increasing the availability of healthy food. Similarly, public investment in actionable research should be an imperative. As private corporations look to ‘big-data’ in order to drive increased efficiency, it is equally important 10 Source: http://www.doksinet to examine its potential applications to promote positive health outcomes. Within the food and nutrition industry, this

may relate to gaining a better understanding of consumer behaviour through photo-recognition technologies or deep learning as well as developing ways to actively influence the digital and analogue choice architectures that individuals face. Ultimately the implementation of research requires multi-stakeholder collaboration – innovative food partnerships between academics, the government and private industry will permit a unified approach to health promotion. Adaptive Public Health Professionals The way governments think about health systems is changing almost as rapidly as the changing needs, perspectives and preferences of citizens in relation to their own health and wellbeing. This presents a challenge and an opportunity for a radical rethink of the way public health professionals are trained and a realignment of their responsibilities and scope of practice to better meet these shifting demands. The basic model of health professional education, with its focus on treating diseases

grounded in biomedical sciences and siloed disciplines is long overdue for an update. A Lancet Commission, chaired by the Dean of Harvard Medical School and President of the China Medical Board set out to argue that the current model of health professional education has failed to serve the needs and interests of patients and populations. xxxviii The Lancet commission makes a compelling case for updating medical education, with proposed reforms including a more multidisciplinary approach; better integration of technology to enhance data collection and access to evidence; and an increased focus on socioemotional skills like leadership and communication. The sentiment remains for all health and public health professionals engaged in and responsible for shaping health and policy. In the coming decades, technological, political and social changes will place even more demands on health professionals, as governments struggle to finance increasingly costly healthcare systems all while the

complexity of patient care, including the proportion of people living with a chronic disease, increases. If public health professionals can be trained to adapt and respond to these changing needs, both our health systems and citizens will be better for it. The major paradigm shift required in health education is a change from focusing on one disease or patient, to understanding the complex interplay of systems and factors that affect human health. Effective health prevention starts with understanding the root causes of diseases. Understanding that a child with obesity is not an individual with a disease seeking treatment from a health professional, so much as they are a person manifesting the interrelated effects that their physical and social environment, socioeconomic status, and geography have had on them. As a testament to this fact, recent concerted efforts by the City of Amsterdam at employing a whole systems approach – such as building more cycling 11 Source:

http://www.doksinet lanes, banning junk food advertising to children in both digital and physical spaces, regular health check-ups in schools and subsidised gym memberships – has seen a 10% reduction in the prevalence of obesity.xxxix Understanding how complex systems work will require a new generation of health professionals equipped with 21st century skills - a hybrid practitioner in coordination (science, policy, civil society), communication and high-level networking. They will also need socioemotional skills that are unlikely to be performed by a machine, including leadership, communication, creative problem-solving and empathy. To this they will need to further add those skills that will be essential for making system-level public health interventions and communicating their messages to the public: political science, understanding the legislative process and the role of lobbying and advocacy; media and public relations, including new media, social media and science

communication; and a range of other interdisciplinary skills in specific topic areas like behavioural economics and broader fields like social sciences. Since the list is so long, educational institutions will likely need to rethink the way such content is delivered, focusing on teaching metacognitive skills and outsourcing some classroom learning to experiential platforms like augmented reality/virtual reality to more rapidly embed learning and behaviours. This disruptive change will not be easy but given the slow pace of transformation in health education we have seen over the centuries, it also needs to start as soon as possible if we ever hope to keep up. 12 Source: http://www.doksinet VicHealth Recommendations The VicHealth Action Agenda sets out to promote innovative initiatives in nutrition to achieve the target of 200,000 more Victorians adopting a healthier diet by 2023, while remaining immersed in the world of digital technology. The following recommendations seek to

encourage VicHealth to be a leader, catalyst and early adopter of the opportunities presented by the digital food ecosystem, while mitigating the possible threats. 1) VicHealth seeks to meaningfully collaborate with major food grocery retailers and online food delivery platforms, through partners including the Sandro Demaio Foundation and the George Institute for Global Health, to help consumers shop more healthily, efficiently and provide easy access to timely, engaging, simple and evidence-based nutritional information to encourage and nudge healthy purchasing decisions. 2) VicHealth examines, through research and analysis, the ways in which businesses are integrating physical and online experiences, and then examine the opportunity to creatively utilise the techniques presented to promote health. For example, exploring advergames to disseminate health promoting messages to children. 3) VicHealth works to protect the public from unqualified or under-qualified information (including

on social media) regarding health and nutrition – through a mix of regulatory and partnership approaches. eg Work with an ‘VicHealth endorsed’ cross-section of bloggers and social media influencers to improve and deliver messages (similar to the BUPA blogger awards). Yet also work alongside governments to develop and implement laws to protect. 4) VicHealth invests in ‘big-data’ research and analytics to examine the potential application to promote positive health outcomes. 5) VicHealth advocates and sets out statutory regulatory recommendations around the protection of children from digital food marketing and other risks posed through the emerging digital food ecosystem. 6) VicHealth meets with food innovators including food-to-door delivery services to explore options and opportunities to improve the eating habits of Australians. 7) VicHealth supports and invests in research in the digital advertising space, particularly advertising to children, to assess the influence of

digital advertising on food consumption and brand association. 8) VicHealth drives and delivers health messages through social media in formats that people are able and enthusiastic to digest, including through trusted partner and influencer platforms. 9) VicHealth champions a radical rethink of the way public health professionals are trained and a realignment of their responsibilities and scope of practice to better meet these changing demands. VicHealth could partner on this with networks and 13 Source: http://www.doksinet organisations including the Public Health Association of Australia, the Royal Australasian Faculty of Public Health Medicine, the Sandro Demaio Foundation, the University of Melbourne, The George Institute and the Victorian State Government. 10) VicHealth supports and drives the training of a new generation of health professionals equipped with 21st century skills - a hybrid practitioner in coordination (science, policy, civil society), communication and

high-level networking. 14 Source: http://www.doksinet Conclusion The era of the digital food ecosystem has dawned. This new technological transformation has the potential to be a risk or a critical opportunity for public health – particularly so for the health of vulnerable groups, including children and young families. To ensure this inevitable and profound shift represents one that unlocks and protects the wellbeing of populations, the methodologies and modalities of public health itself must change. So to, the face of those that embody the sector and profession This report outlines key recommendations for both VicHealth and the public health community, with a focus on the critical need to address the epidemic of obesity and related malnutrition and NCDs, across Australia. “Together, let’s shape a future that works for all by putting people first, empowering them and constantly reminding ourselves that all of these new technologies are first and foremost tools made by

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