Three states move to keep weight-loss supplements away from youth

For children and teens who struggle with weight and body image, the disruptions and isolation of the pandemic have been brutal. Some pediatricians say they are seeing rapid weight gain among their patients. Doctors at Stanford Children’s Health Comprehensive Eating Disorders Clinic reported last spring that the number of patients hospitalized for complications of eating disorders had skyrocketed to its highest in decades.

These struggles leave young people especially vulnerable to targeted ads on social media for weight-loss pills and other potentially dangerous supplements. Children of color are disproportionately bombarded by such ads. Now three states — California, Massachusetts and New York — have introduced legislation to severely restrict or ban sales and marketing of these products to minors.

Will controlling sales of products that have largely eluded regulation for decades protect children from misleading and dangerous products? Or will such laws — if they pass — simply drive sales to the dark corners of the internet, as an industry representative claims?

Weight-loss supplements are a gamble for adult and adolescent health. Some products contain toxic ingredients that are unrelated to weight loss or muscle building. In some instances, these ingredients have led to severe health conditions and even death. 

Under the Dietary Supplement Health and Education Act of 1994, supplements are not vetted by any government body before being released into the market, as drugs are. When complaints and health problems surface, the Food and Drug Administration can pull a product off store shelves. 

The lack of regulation allows supplement manufacturers to behave recklessly, said Dr. S. Bryn Austin, a professor in the department of social and behavioral sciences at Harvard T.H. Chan School of Public Health. 

“These supplements are being laced with illegal products,” Austin said. “It could be banned pharmaceuticals. It could be steroids or excessive stimulants. There’s no oversight by the government before they end up on store shelves. It’s only after they go to the market and we see a cluster of stroke or a cluster of liver injury that the FDA will step in and do an investigation. But that’s too late for consumers.”

Two health crises collide

Girls face pressure to be thin, boys face pressure to look buff, and young people spend a lot of time on the internet and scrolling through social media, where supplement ads abound.

“You can see in these ads that they are using younger and younger models,” said Jeana Cost, executive director of ACUTE Center for Eating Disorders in Denver. “Part of the reason for that is they want younger kids to relate more with these ads.”

Without age restrictions on these products, children and teens can purchase them in stores and pharmacies. 

In 2019, the Journal of Adolescent Health published a disturbing study: from January 2004 to April 2015, nearly 1,000 people ages 25 and younger had conditions such as abdominal pain, back pain and chills that were linked to dietary supplements. Around 40% of those conditions were severe. The study documented 166 hospitalizations and 22 deaths.

Cost says that isolation during pandemic lockdowns made it difficult for many children to stay healthy and feel good about their bodies. 

“For kids, a lot of eating behaviors go back to wanting to control something in their lives,” Cost said. “When COVID hit and they had to do remote learning and not see their friends, they lost what little control they had. So they were sitting at home on the internet and that was not a healthy environment to get trapped in. It triggered more comparisons (of body types) and more unrealistic expectations.” 

Two recent investigations showed how Facebook ads for weight-loss products targeted young teens. The Tech Transparency Project (TTP) examined how Facebook collects personal data on teens starting at age 13 and allowed advertisers to use that information to promote diet foods and pills — not to mention alcohol, dating sites and gambling. Reset Australia analyzed how businesses track young teens online and use their patterns and preferences to craft ads to capture the attention of younger audiences. 

‘Worse than snake oil’

Oftentimes when the narrative about dietary supplements is explained, a white teen or adult is at the center. But misuse of dietary supplements and muscle enhancements is not exclusively a white problem. Black and Hispanic people are not immune to the societal pressures around body image and the shame associated with weight gain. 

“We know that marketers with their savvy and deceptive advertising are preying on communities with low income and less education and ones where English is not their first language,” Austin said. “We see higher rates of use among African American and Latina communities than in white communities. We see higher rates of use of these products in households where the annual income is less than $40,000. We see that people are unaware of the recalls on these products. This is worse than snake oil.” 

The data on the effects of supplements in Black and Hispanic communities is limited. But statistics published by Strategic Training Initiative for the Prevention of Eating Disorders show that Latinx teens are 40% more likely to use over-the-counter diet pills than white teens. 

Many teen boys also struggle with body image, but the issue often isn’t weight. Boys who dream of looking like their favorite sports celebrity may take so-called performance-enhancement supplements in hopes of making their muscles bigger and giving them boundless energy for strenuous workouts. 

Dr. Michele LaBotz, a member of the American Academy of Pediatrics Council on Sports Medicine and Fitness, says boys are misled into thinking that over-the-counter performance enhancers are anabolic steroids designed to bulk them up. “Anabolic steroids are a controlled substance. They are controlled the same way we do narcotics for their distribution and use. They are drugs, not a supplement. But a lot of supplements are trying to mimic or market themselves as anabolic steroids.”

As with weight-loss supplements, performance enhancers can pose a serious risk to teenage health, sometimes causing heart palpitations, muscle cramps, dehydration, insomnia, and weight gain. “There’s no way these supplements are going to stimulate puberty or speed up their biological time clock. When you talk about things that are sold for weight loss and performance enhancement the biggest issue is the lack of efficacy. They are not effective,” LaBotz said.

Post-pandemic prescription for children’s health

There is a lot of focus on preventing children from accessing weight loss products. But is restricting access the solution? Steve Mister, president and CEO of the Council for Responsible Nutrition, a trade association representing manufacturers of dietary supplements and ingredients and their suppliers, objects to age restrictions on these products. 

“We acknowledge that there are eating disorders and there is a problem, particularly among many young people, around body dysmorphia and having unrealistic expectations of what their bodies should look like. But these bills are being introduced under the premise that if we restrict access to these products that we're somehow going to solve the eating disorder problem,” Mister said. “The reality is there is not a shred of evidence that suggests that these products contribute to or cause eating disorders.”

The estimated value of the global dietary supplement market in 2013 was about $110 billion dollars. By 2019 the value had ballooned to nearly $168 billion. That market includes an array of products, including vitamins and minerals in addition to weight-loss and muscle-building supplements. It is unclear how much of the industry’s growth can be attributed to internet sales, but having the web at consumers’ fingertips makes getting these products much easier. Mister defends his organization's opposition to proposed legislation by arguing that one lost sale in the stores is a sale gained online. 

“So you're taking sales away from local stores and what you're really doing is encouraging young people to go to the internet to try to find them because none of these bills have any kind of effective enforcement for internet sales.”

Mister says the council supports more regulation of weight-loss products on a federal level and the removal of products containing illegal ingredients.

But efforts to impose federal regulation on supplements have been thwarted for years. So advocates are taking the fight to state legislatures. In 2019, state Rep. Kay Khan proposed a bill in Massachusetts that would ban sales of dietary supplements to minors and keep products in an inaccessible location of stores. 

A bill making its way through the New York State Legislature would restrict the sale of over-the-counter diet pills and dietary supplements for weight loss or muscle building, and increase civil penalties for the sale or promotional distribution of dietary supplements containing ephedra. 

And in California, Assembly bill 1341 would prohibit a retail establishment from selling dietary supplements for weight loss and over-the-counter diet pills to anyone under 18 without a prescription. 

Even if these measures pass, a larger challenge remains: What must be done now that the COVID-19 pandemic has met the childhood obesity epidemic? 

A recent study in the Journal of Pediatric Nursing calls for resources that support children to become more active and incorporate better nutritional choices into their lifestyles. Shame and stigma only exacerbate the problem and increase children’s risk for developing depression. Increasing time outside will reduce exposure to online ads promoting supplements — and get children moving again.