Fitness Industry and Social Media Dangers

Could The Fitness Industry Be More Harmful Then Helpful?

Introduction

Health can be defined as “the state of being free from illness and injury”. However looking further into the word “health” gives you synonyms such as “well-being; fitness; good condition; good shape”. These words generate concepts regarding the relationship of the fitness industry to the sense of well being and good health. Since the First World War the focus on physical fitness has been a primary focus of the Health status and conversation around health issues in Canada and the United States.

In Canada Health Canada and The Canadian Food Inspection Agency, and The Food and Drug Administration in the United States, are responsible for the nutritional labels on the food we consume. These labels along with the appropriate food guidelines of nutritional intake are supposed to be the gold standard for an individual to maintain a level of healthy eating one aspect of a healthy lifestyle. With a healthy diet, exercise, and adequate sleep, should in theory, enable a very healthy and long life. But what if the foods, the substances being consumed, aren’t exactly what they said they were? Or what if something marketed with one health goal, losing weight, actually destroyed and damaged your kidneys in the process?

In the Health Consumables Market the issue is whether Canada and the United States’ fitness industry’s have become counterproductive to the maintenance of health. One major issue are the regulations and guidelines for nutritional information on products that are directly correlated with the fitness industry, such as protein, Branch-Chain-Amino-Acids, creatine and fat loss products are too relaxed and often go untested^[1]. An even greater detriment to the fitness industry is that the people who promote these various fitness supplements on their social media platforms create unrealistic body images and thus further health issues. Body issues and eating disorders further fuel the unregulated supplement industry creating a cyclical beast that may promote health in some but in turn does the opposite in others.

What is needed to tame this beast are tighter regulations and standards for supplement products and a system to control the promotion of these “Instagram stars” and their products. Could the fitness industry ever become an industry worth believing in?

CURRENT SUPPLEMENT REGULATIONS

Currently supplements and health products are governed by Health Canada. The Food and Drug Regulations operate on a “test if needed” basis rather than on a mandatory food-testing basis. The Food and Drug Regulations have a voluntary submission requirement. The company submits their nutritional label and product information to Health Canada and they ensure it follows the nutritional guidelines of what is allowed in products^[2]. If a product makes a claim of either nutrition content or disease risk reduction then the product itself will be submitted for testing to the Canadian Food Inspection Agency (CFIA)^[3]. Once submitted to the CFIA they will determine whether the claim of a nutrient value is present in the product so that the label is reporting the correct health contents. Disease reduction is also monitored and measured by CFIA to see if the product claims are accurate i.e. “Cheerios reduces heart disease”^[4]. When determining the safety and the health claims of each product there are a number of critical issues:

• Industry is responsible for ensuring that nutrition labelling and claims are compliant with the Food and Drug Regulations and that label values accurately reflect the nutrient content of the product.
• A suitable compliance test for the accuracy of declared nutrient values must take into consideration the inherent variability of nutrients in foods and the variability of the laboratory method using appropriate statistical analysis.
• The CFIA compliance action will take into consideration not only laboratory results, but also the health risk to the public, economic loss to consumers, past compliance history of the product and the company’s quality control over the manufacturing and labelling processes.^[5]

Interestingly CFIA and health Canada exempt some foods from this rigorous process and the requirement of having to submit their product for health claims review. Exceptions include meal replacements, nutritional supplements, mineral nutrients and/or amino acids.

The United States reviews are conducted by a sub-section of the Food and Drug Administration entitled Center for Food Safety and Applied Nutrition (CFSAN). CFSAN operates very similarly to the Canadian equivalent, CFIA, in that the majority of testing is done on a random not mandatory basis.  The manufacturers are asked to submit the product test results as outlined in the “Manufacturer’s Responsibility” criteria:

“FDA’s continuing policy since the 1970s assigns the manufacturer the responsibility for assuring the validity of a product label’s stated nutrient values. Accordingly, the source of the data used to calculate nutrition label values is the prerogative of the manufacturer, but FDA’s policy recommends that the nutrient values for labeling be based on product composition, as determined by laboratory analysis of each nutrient. FDA continues to recommend the use of the Official Methods of the Association of Official Analytical Chemists International (AOAC), with non-AOAC Official Methods used only in the absence of appropriate AOAC validated methods. For each product that is included in a nutrition-labeling database submitted to FDA, the agency requests that the developer include a table identifying proposed analytical methods that were used in the analysis of each nutrient, with accompanying information containing validation of the method used by the onsite or commercial laboratory for the matrix of interest.”^[6]

However the FDA’s regulations allow for a choice by each manufacturer to use the non-AOAC Official Methods that gives them the ability to “prepare” their numbers.

The manufacturer must also comply with Title 21 of the Code of Federal Regulations, which breaks down consumables into different classes of nutrients according to the FDA^[7]. There are three different classes of nutrients:

Class I: are those added in fortified or fabricated foods, these nutrients are vitamins, minerals, protein, dietary fibre, or potassium^[8]. Class I nutrients must be present at 100% or more of the value declared on the label; in other words, the nutrient content identified by the laboratory analysis must be at least equal to the label value^[9].

Class II: are vitamins, minerals, protein, total carbohydrate, dietary fibre, other carbohydrate, polyunsaturated and monounsaturated fat, or potassium that occur naturally in a food product^[10]Class II nutrientsmust be present at 80% or more of the value declared on the label^[11].

Class III: nutrients include calories, sugars, total fat, saturated fat, cholesterol, and sodium^[12]. However, for products such as fruit drinks; juices; and confectioneries; that have sugar content of 90 percent or more of total carbohydrate. To prevent labeling anomalies due in part to rounding, FDA treats total carbohydrate as a Class III nutrient instead of a Class II nutrient^[13]. For foods with label declarations of Class III nutrients, the ratio between the amount obtained by laboratory analysis and the amount declared on the product label in the Nutrition Facts panel must be 120% or less. The label is considered to be out of compliance if the nutrient content of a composite of the product is greater than 20% above the value declared on the label^[14].

For example, if a laboratory analysis found 8 g of total fat/serving in a product that stated that it contained 6 g of total fat/serving, the ratio between the laboratory value and the label value would be (8 / 6) x 100 = 133%, and the product label would be considered to be out of compliance.

Like the CFIA the FDA have dietary supplements under a different category legislated under the Dietary Supplement Health and Education Act 1994(DSHEA)^[15]. These supplements are required to follow these rules outlined below:

“Federal law requires that every dietary supplement be labeled as such, either with the term “dietary supplement” or with a term that substitutes a description of the product’s dietary ingredient(s) for the word “dietary” (e.g., “herbal supplement” or “calcium supplement”).

Federal law does not require dietary supplements to be proven safe to FDA’s satisfaction before they are marketed.

For most claims made in the labeling of dietary supplements, the law does not require the manufacturer or seller to prove to FDA’s satisfaction that the claim is accurate or truthful before it appears on the product.

In general, FDA’s role with a dietary supplement product begins after the product enters the marketplace. That is usually the agency’s first opportunity to take action against a product that presents a significant or unreasonable risk of illness or injury, or that is otherwise adulterated or misbranded.

Dietary supplement firms must report to FDA any serious adverse events that are reported to them by consumers or health care professionals.

Dietary supplement manufacturers do not have to get the agency’s approval before producing or selling these products.

It is not legal to market a dietary supplement product as a treatment or cure for a specific disease, or to alleviate the symptoms of a disease.

There are limitations to FDA oversight of claims in dietary supplement labeling. For example, FDA reviews substantiation for claims as resources permit”[16].

The regulations from the DSHEA actually allow companies to manipulate and alter their product and nutritional labels to secure granting and limit investigation by the FDA or CFSAN. It also creates a system where CFSAN and the FDA are required to go out of their way to find new-to- market products in order to start an investigation process if needed. The FDA states it is committed to working with all interested parties in order to achieve reliable nutrition labeling as economically as possible[17]. The agency acknowledges that following all of the recommendations/guidelines in their manual could pose economic hardships. Therefore, in certain instances, FDA may accept a proposal to “develop a database” over several years to help defer costs[18]. By deferring the testing even longer this can only add to the problem at hand.

Although limited in the previously mentioned areas of inspection, the Canadian and United States systems have a number of successful and positive parameters. Health Canada and the Food and Drug Administration both have independent testing bodies. The CFIA and CFSAN both have good, unbiased structures for testing and the type of tests they use are considered industry gold standards. They also have correctly identified the differences in regular “grocery store” food and what would be considered food from the “supplement” or “fitness” industry.

The Fitness Industry

The fitness industry is an ever-changing entity that has continued to evolve over the past several decades. Following the First World War, especially in Canada, physical fitness started to become an area of focus of government. In the 1950’s in North America the fitness focus was on rhythmic exercises, jumping jacks, calisthenics and the “Five Basic Exercises” (stretching, sit-ups, back extensions, push-ups, running in place) the first type of circuit training^[19]. The hula-hoop was the main trend in fitness selling over 100 million units in the United States. The 1960’s brought us massage belts and diet trends. The massage belts were supposed to massage away fat in unwanted areas, and eating “healthier” meant drinking diet soda and artificial sugar^[20]. The 70’s brought into the fitness industry jazzercise and bodybuilding. Both of these trends would last longer than the decade due to the enigmatic figure behind it, Arnold Schwarzenegger one of the most decorated bodybuilders of all-time^[21]. The addition to the 80’s fitness culture was Jane Fonda and her aerobics videos^[22]. The 1990’s fitness trends included: Taebo; boot camps; and extremely popular -celebrity workout videos ^[23]. The boot camp and fitness video trends have definitely stood the test of time as they still are still widely used by fitness participants worldwide. The 21st century heralded in a new attitude of “Staying fit” including: Pilates, kickboxing and weightlifting exercises for women^[24]. The focus switched to heart rate to determine the effectiveness of a workout ^[25].

The trends of the fitness industry today focus on: High Intensity Interval Training (HIIT); the use of social media; and the “super-hero body”. HIIT programs consist of workouts under the brand of Cross Fit, which is quickly becoming one of the fastest growing fitness trends. It emphasizes strength components interspersed with sprints and long bouts of cardiovascular fitness. Along with intense training like HIIT the industry has started to incorporate and profit from the use of social media. There are YouTube fitness bloggers and now most recently “Instagram Stars”. Both use social media and have become one of the primary sources of income for today’s fitness personality. Blockbuster movies have created the “ideal” body image modelled after the “ incredibly- in-shape” superheroes such as Superman, Thor, Wonder Woman and Captain America.

The presence of social media in the fitness industry although a new phenomena in the last decade, has really exploded in the last 5 years. The creation of highly viewed YouTube content used to reap monetary rewards for the creators, which is why fitness professionals created content on this platform. Now however, it has evolved into something much more. As the fitness industry grows instead of a part-time hobby it has become a lucrative occupation. A individual involved in this industry can include: competing in their respective fields (bodybuilding, weightlifting, Cross Fit, etc.); personal training; online coaching; selling workout plans, nutrition; in person training; sponsors (which can be promoted through their respective social media platforms); and personal business endeavours (clothing lines, supplement brands, operating own gym). All of these add revenue to the individual and are often cyclically attached, so one generates customers for the other. Like with anything the more that see you and your accomplishments the more profitable you can become which is why a person’s social media platforms have become so important in building one’s brand.

As mentioned these fitness personalities usually have supplement sponsors as most of these athletes are in the top one percent of all people in terms of body aesthetics and performance. When you are in the top one percent of athletes the nutrition and supplementation you take can give you the slight advantage you need to be just that much better than your opponent creating the dependence on these sponsors by all athletes in this industry. However, as is the case in this primarily unregulated industry they are “playing” with their health and careers. It is hard to believe that an individual who cares so much about their body would put so little research into what they are taking and more importantly what they are promoting.

Fitness Industry Supplements

The most often-used supplement for any athlete is protein powder. Having a protein powder supplement allows an individual to increase their protein intake while not upping the rest of the macros (protein, fats, and carbohydrates) in their daily consumption. However, in a recent 2010 study done, by Consumer Reports not-for-profit magazine run by U.S. Consumer Union, of the top 15 brands in the industry^[26] found at least one product from each brand tested contained detectable amounts of toxic substances.  The toxic substances included cadmium, arsenic, lead and/or mercury. The three most toxic brands contained heavy metal poisoning over the safe allowable amount^[27]. These named companies fought back against the report by taking their product line to NSF a non-profit International non-governmental organization, which conducted their own tests. These products passed NSF’s American National Standard for Nutrition/Dietary Supplements testing but Consumer Reports counters that there is significant variation between samples in a product line and one passed test doesn’t mean every product is safe. The major concern is that prolonged exposure to heavy metal toxicity can cause body toxicity, which can result in further medical issues down the road^[28].

The National Science Foundation is an independent subsidiary of the World Health Organization reports there are still many issues with these testing processes. NSF International has legitimate testing which some companies submitted to for independent testing, but they only scored adequately which is also concerning. T Consumer Reports states that the testing of one product doesn’t mean that all the others would be adequate.

The alarming truth of these results of high metal toxicity is consumers don’t seem to care continuing to buy the products. Statistics show that in 2012 the supplement industry had revenue of roughly $32 billion US and the industry is trending to grow to about $60 billion US by 2021^[29]. According to a registered United Kingdom dietician Maeve Hanan there are some benefits to the consumption of protein supplements. Such benefits include helping athletes hit increased protein requirement goals, it is also highly convenient, and it can often be cost efficient as most athletes get their protein supplements through sponsors^[30]. However according to Hanan there are far more cons than pros to consuming this form of protein. She includes: an investigation done by UK Medicines and Healthcare Regulatory Agencies where eighty four tested brands contained dangerous ingredients including steroids, stimulants and hormones that can cause kidney failures, seizures and heart problems^[31]. There is also evidence that the prolonged use of protein can cause osteoporosis and several gastrointestinal diseases^[32]. As well, Hanan found that the supplement may not actually contain the level of protein advertised, a product said to be containing seventy percent protein in fact had only seven percent^[33]. It appears that the issues Maeve Hanan unearthed in protein supplements could be addressed with better testing by the regulating governments.

Protein supplements are not the only supplements that fitness professionals take to build muscle. BCAA’s or Branch Chain Amino Acids have also become a go-to for many of the top one-percenters in the industry. These BCAA’s while promoted as a key fitness component for a healthier life, like protein supplements there are negative side effects that aren’t publicly acknowledged by the athletes and the companies promoting these products. In a study by Luigi et al. it was shown that decreased BCAA consumption improved metabolic health^[34]. While improving the metabolic health of the test subjects it also showed to decrease Body Mass Index (BMI) and decrease fat mass of an individual, a goal of the “fitness personality” low body fat percentage^[35]. Although the BCAA’s in this study was dietary BCAA’s found in food, it still applies here. Companies in this industry promote products like BCAA without doing the research needed to prove their effectiveness., The consumer continues to purchase due to the aesthetically appealing people promoting the product are seen as “believable”. Beautiful people are trustworthier, right?

The product that could potentially be the biggest sham and the most harmful to health, are weight loss products. One of the biggest brands in the weight loss industry is Hydroxycut. In 2008 there was a study of Hydroxycut by the World Journal of Gastroenterology analyzing its toxicity. They performed a case study with two confirmed users of Hydroxycut and the symptoms they showed when admitted to hospital. They compiled the results from the two current cases and from the previous literature written about the product and found that there was a correlation between prolonged use of Hydroxycut and heptatoxicity^[36]. Both of these test subjects and previous cases exhibited that the prolonged use of this product eventually lead to hepatitis and other liver health issues. The absence of testing of the product that falls under the supplementation guidelines led to negative health implications. Although governments have guidelines, they allow products to avoid testing until after they are on market, which is often too late.

Social Media and The Fitness Industry

One of the leading researchers in Health Law and particularly this area of Fitness and Social Media is Professor Timothy Caulfield. Professor Caulfield has written numerous books on this subject including The Cure For Everything: Untangling The Twisted Messages About Health Fitness and Happiness and Is Gwenyth Paltrow Wrong About Everything. Both of these books discuss the popular health trends, whether they are diet or fitness trends, and how celebrities promote these. Some of the trends consumers have been following even though there is no scientific evidence of their efficacy. These include:  Juice Cleanses, Colon Cleanses and Gluten Free diets. While juicing has no negative side effects it has also been shown to do no good as it is not a more effective way to get the nutrition from fruits and vegetables and does not flush toxins from the body^[37]. Now a trend like colon cleanses while they may make you feel lighter they can actually be quite harmful to the body by causing nausea vomiting and even infection^[38]. Going gluten free is a trend that has really taken off but again no scientific proof that eliminating gluten has any health benefits, while actually some studies have shown that going gluten free can actually lead to weight gain^[39]. So why would consumers buy into these fads if there is no scientific proof behind them? The answer is simple because celebrities promote them, and the consumers have no reason not to believe them.

Celebrity endorsement might just be the biggest negative in the fitness industry. If there are fitness icons or personalities who promote an untested product it causes the same issue as the diet trend promotions. However in the case of health products promoted by these fitness personalities it is much more harmful due to the elevated heavy metal present in the products. The promotion of these unregulated products is also tied into the celebrity’s unrealistic bodies. Many people forget that these people have full-time jobs devoted to looking amazing. These celebrities are seen as the definition of being healthy and attractive so if one doesn’t look like them can create serious body image issues.

Instagram is quickly becoming the most popular form of social media. This app has been noted to sharing over 40 billion photos since its creation with about 80 million a day^[40]. The purpose of the app is to curate and edit photos and posts with how we want the public to “view” that particular user. This creates a potentially dangerous atmosphere to those who may be susceptible to an eating disorder. Users need to be educated that users of Instagram may utilize filters, angles and lighting to look as desirable as possible distorting the real image^[41]. This not only creates a false reality for the followers of that user but for that user themselves^[42]. According to Crystal who is a Masters Level Registered Dietician and a Certified Intuitive Eating Counselor there are certain things to monitor when using Instagram in order to protect against negative self-image, eating disorder, or body issues:

• What Kind of accounts are you following?
• Are you preoccupied with food and or/fitness on Instagram in a way that is obsessive or unhealthy?
• Do you find yourself following certain diet trends or dieting recommendations because of someone or something you found on Instagram?^[43]

 Instagram personalities not only promote or influence diet trends they also endorse unregulated supplement products, which can add to unhealthy choices.

In response Instagram has been tagged with “creating its own eating disorder”.  According to University College London states that Instagram is the leading cause of Orthorexia Nervosa^[44]. Orthorexia Nervosa is an illness focused on an obsession with eating healthy. Symptoms can include: eating excessive fruits and vegetables; cutting out certain food groups; and excessively exercising^[45]. While this may seem like just healthy lifestyle choices this illness is related to the severity of the dietary restrictions, leading to malnutrition and social isolation^[46]. The reasons given for the Instagram connection is the people followed expose the follower to a extreme health pictures, and social media personalities are seen as authority’s on health and appearance^[47].

The Supplementation of the Regulations

There are clear issues today that stem from the growth of the fitness industry, but there doesn’t have to be. In the United States and Canada there exists already a structure to properly test all of the supplements that go to market, before the product is released. It is clear that the methods of testing and the standards for this industry are sound, but just not fully implemented. However there should be a complete ban on products leading to heavy metal poisoning.  The amount of testing for each product would increase significantly industry standard of 10 there will need to be an increase of jobs to accommodate for the amount on tests for each product and the amount of lead case workers. Government may consider a number of issues when considering implementing changes: the creation of government jobs versus the lost jobs from supplement companies who can’t comply with new proposed industry standards; the inevitable burden of unhealthy citizens versus a healthier country with healthier citizens.

Companies like BioTrust seem to be one of the industry standards for the production of healthy products. Tim Skwiat and Shawn Wells directors at BioTrust endorse:

• Right way: the right people who are formulators (use the right ingredients that work the best rather than look good)
• Cost of ingredient and the product will be higher because they do studies on the ingredients (healthy human studies, in peer reviewed journals)
• Take the stuff that we know works and make a product from that.
• Ingredients are natural (no soy product)
• Ingredient testing (they never stop testing and letting the product out of their hands)[48]

While changing the regulations and possibly the growth of a company like BioTrust will help change the supplementation industry for the better, there doesn’t seem to be a simple fix for the social media issue.

There has been extensive research on the relationship to food restrictions at a young age and developing an eating disorder or becoming overweight later in life. According to a study done by Eisenberg & Neumark-Sztanier a survey of adolescents in grades 7–12, 30% of girls and 25% of boys reported teasing by peers about their weight. Such teasing has been found to persist in the home as well – 29% of girls and 16% of boys reported having been teased by a family member about their weight[49]. Neumark-Sztainer also co-wrote a paper on the effect of this teasing on the children which increases their chances of 1.5 to develop a form of an eating disorder[50]. These trends however are not limited to children being teased it also stems into the perceived norms from social culture or mainstream media. According to a study by Abramovitz & Birch children learn (unhealthy) mainstream attitudes towards food and weight at a very young age, this study looked at five-year-old girls and a significant proportion of girls associated a diet with food restriction, weight-loss and thinness[51]. There needs to be more education from the governments around food and healthy ways for kids to eat, which is simply without rigid structure. The rigidity adds to the desire to get attractive or stay thin with extra presence from mainstream culture or social media (Instagram) which encourages the excessive use of supplementation which ends up often making the individual even more unhealthy. This has become a very cyclical and overwhelming problem which needs to be addressed by the governing bodies. If the new structure can’t be implemented then simple education could go a very long way. There needs to be a priority of everyone in the “industry” to instead of coercing people to get fit, get them healthy instead.

Bibliography

Abramovitz, B. A. & Birch, L. L. (2000). Five-year-old girls’ ideas about dieting are predicted by their mothers’ dieting. Journal of the American Dietetic Association, 100 (10),   1157-1163.

Canadian Food Inspection Agency, “Nutrition Labelling Compliance Test” (9 September 2014), Canadian Food Inspection Agency (website), online: <http://www.inspection.gc.ca/food/labelling/food-labelling-for-industry/nutrition-labelling/additional-information/compliance-test/eng/1409949165321/1409949250097?chap=2>.

Danielle Isbell, “Fitness Trends of the Last Six Decades” (4 June 2015), Spry Living (blog), online: <http://spryliving.com/slideshows/fitness-trends-of-the-last-6-decades/>.

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^[1] Office of Dietary Supplements, “Dietary Supplements for Exercise and Athletic Performance” (4 October 2017), National Institutes of Health (websites), online: <https://ods.od.nih.gov/factsheets/ExerciseAndAthleticPerformance-Consumer/>.

^[2] Supra note 1.

^[3] Canadian Food Inspection Agency, “Nutrition Labelling Compliance Test” (9 September 2014), Canadian Food Inspection Agency (website), online: <http://www.inspection.gc.ca/food/labelling/food-labelling-for-industry/nutrition-labelling/additional-information/compliance-test/eng/1409949165321/1409949250097?chap=2>.

^[4] Supra note 3.

^[5] Supra note 3.

^[6] Supra note 3.

^[7] Food and Drugs, 21 CFR tit 21s s 170.3 (2012).

^[8] Supra note 7.

^[9] Supra note 7.

^[10] Supra note 7.

^[11] Supra note 7.

^[12] Supra note 7.

^[13] Supra note 7.

^[14] Supra note 7.

^[15] Dietary Supplement Health and Education Act of 1994, 21 USC s 7 (1994).

[16] Supra note 15.

[17] Supra note 15.

[18] Supra note 15

^[19] Danielle Isbell, “Fitness Trends of the Last Six Decades” (4 June 2015), Spry Living (blog), online: <http://spryliving.com/slideshows/fitness-trends-of-the-last-6-decades/>.

^[20] Supra note 19.

^[21] Supra note 17.

^[22] Supra note 17.

^[23] Supra note 17.

^[24] Supra note 17.

^[25] Supra note 17.

^[26] Ian Kenney, “Protein Powder Toxicity” (3 October 2017), Livestrong (blog), online: <https://www.livestrong.com/article/299115-protein-powder-toxicity/>.

^[27] Supra note 24.

^[28] Supra note 24.

^[29] David Lariviere, “Nutritional Supplements Flexing Muscles As Growth Industry” (18 April 2013), Forbes (blog),  online: <https://www.statista.com/statistics/308579/global-prediction-nutritional-supplement-revenue/>.

^[30] Maeve Hanan, “Protien Supplements: Weighing up the Pros and Cons”, (18 October 2015), Dietically Speaking (Blog), online: <https://dieteticallyspeaking.com/protein-supplements-weighing-up-the-pros-and-cons/>.

^[31] Supra note 28.

^[32] Supra note 28.

^[33] Supra note 28.

^[34] Luigi et al. “Decreased consumption of branch chain amino acids improves metabolic health.” (2016) 16:2 HHS Public Access 520, online: <https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4947548/>.

^[35] Supra note 32.

^[36] Lily Dara, Jennifer Hewett & Joseph Lim, “Hydroxycut Hepatoxicity: A Case series and review of liver toxicity from herbal weight loss supplements” (2008) 14:45 World J of Gastroenterology 6999.

^[37]Lauren Pelley, “Timothy Caulfield debunks celebrity health trends, from gluten-free diets to colon cleanses”, (8 January 2015), The Star (Newspaper), online: <https://www.thestar.com/life/health_wellness/2015/01/08/timothy_caulfield_debunks_celebrity_health_trends_from_glutenfree_diets_to_colon_cleanses.html>.

^[38] Supra note 35.

^[39] Supra note 35.

^[40] “How Instagram can encourage eating behaviour disorders”, (3 March 2017), Eating disorder hope(Blog), online: <https://www.eatingdisorderhope.com/blog/instagram-encourage-eating-disorder>.

^[41] Supra note 38.

^[42] Supra note 38.

^[43] Supra note 38.

^[44] Vanessa Chalmers, “Is Instagram making you sick? Study explains why photos of breakfast bowls and #fitness inspiration can drive you to an eating disorder.”, (19 May 2017), Daily Mail(Newspaper), online: <http://www.dailymail.co.uk/health/article-4522730/Why-Instagram-posts-eating-disorder.html>.

^[45] Supra note 42.

^[46] Supra note 42.

^[47] Supra note 42.

[48] Skwiat, Tim Wells, Shawn. “The Truth About Supplements” (2018) Biotrust Radio (ITunes Podcast).

[49] Eisenberg, M. E. & Neumark-Sztainer, D. (2003). Associations of Weight-Based Teasing and Emotional Well-Being Amond Adolescents. Archives of Pediatrics & Adolescent Medicine, 157(6), 733-738.

[50] Neumark-Sztainer, D. R., Wall, M. M., Haines, J. I., Story, M. T., Sherwood, N. E., van den Berg, P. A. (2007). Shared Risk and Protective Factors for Overweight and Disordered Eating in Adolesecents. American Jounral of Preventative Medicine, 33(5), 359-369.

[51] Abramovitz, B. A. & Birch, L. L. (2000). Five-year-old girls’ ideas about dieting are predicted by their mothers’ dieting. Journal of the American Dietetic Association, 100 (10), 1157-1163.