From Kim Kardashian to Dr. Oz: the future relevance of popular culture to our health and health policy.

• Author: Caulfield, Timothy
• Position: 7th National Health Law Conference

RIGHTLY OR NOT, CELEBRITIES are playing an increasingly large role in how we think and talk about our health. The goals of this paper are modest: 1) to provide examples of the ways in which celebrity culture is having an impact; and 2) to speculate why this influence is likely to increase in the future. It is not meant to be a comprehensive review and I fully recognize that the relationship between popular representations and public perceptions is complex. Celebrity culture is just one part of a complicated and dynamic process related to how people see, select, interpret, and use health information. That said, in this paper I argue that it is an increasingly important part of the health equation, one that is often overlooked. Perhaps it is easy to disregard celebrity culture because it is often seen as frivolous and/ or only relevant to those foolish enough to follow celebrity advice. Here, I argue that both of these presumptions are wrong. I hope to underscore the fact that celebrity culture does matter and, in the future, it seems likely that it will matter more and more.

A juste titre ou non, les celebrites jouent un role de plus en plus important dans la maniere dont nous considerons notre sante et en discutons. Cet article vise des objectifs assez modestes, soit: 1) de fournir des exemples a propos des differentes manieres dont le cuite des celebrites a une incidence; et 2) de speculer sur les raisons pour lesquelles cette influence va fort probablement aller en s'accroissant a l'avenir. L'article ne pretend pas etre une etude exhaustive de la question et je reconnais que le rapport entre les representations populaires et les perceptions du public est complexe. Le cuite des celebrites n'est cependant qu'une partie d'un processus aussi complique que dynamique relie a la maniere dont les gens voient, selectionnent, interpretent et utilisent l'information en matiere de sante. Cela dit, dans ce texte, je soutiens que cela joue un role de plus en plus important dans l'equation de la sante, mais que cet aspect est souvent occulte. Certes, il est sans doute facile de negliger le cuite des celebrites en raison de son caractere frivole ou du fait qu'il ne vise que ceux et celles qui sont assez nai'fs pour suivre les conseils de vedettes. Je maintiens toutefois que ces deux presomptions sont erronees car le cuite des celebrites tient une grande place dans notre societe et il faut s'attendre a ce qu'il occupe une place de plus en plus importante.

CONTENT I. Introduction II. Celebrity and Health Behaviours and Beliefs III. Inaccurate and Uncritical Portrayals IV. Celebrities and the "Prius Effect" V. Our Celebrity-Filled Future VI. Celebrity Conundrum I. INTRODUCTION

Celebrities love to talk about health. It has become a standard part of the celebrity interview process. "What do you do, Mr. Famous Person, to look so darn fabulous?" And, of course, there are a growing number of celebrities who provide health advice as part of their celebrity brand. In the past year alone, Gwyneth Paltrow, my favourite purveyor of pseudoscience, (1) has suggested that women should steam their vaginas, (2) that infrared saunas are a good way to treat the flu, (3) that we should all get regular colonics, (4) and that wearing a bra increases your risk of getting breast cancer. (5) Not only are all of these recommendations completely science-free, but they are also potentially harmful. Of course, Gwyneth Paltrow is not alone. I could pick on other celebrities, such as Katy Perry and her pushing of vitamin supplements, (6) or, most notorious and infuriating, Jenny McCarthy and her embrace of the vaccines-cause-autism myth. (7) The examples are endless.

This flood of celebrity health advice, endorsements, and musings is having a significant and measurable impact on our behaviour, our beliefs, and even our health systems. It is not simply a benign cultural distraction. And given the expanding reach of celebrity culture, it seems certain that the influence of celebrities, and celebrity culture more broadly, will continue.

The goals of this paper are modest: 1) to provide examples of the ways in which celebrity culture is having an impact on public health behaviours and beliefs; 2) to speculate why this influence is likely to increase in the future; and 3) to outline measures that will protect the public from this celebrity misinformation. It is not meant to be a comprehensive review, as I fully recognize that the relationship between popular representations and public perceptions is complex. Celebrity culture is just one part of a complicated and dynamic process related to how people see, select, interpret, and use health information. (8) That said, below I seek to argue that it is an increasingly important part of the health equation, one that is often overlooked. Perhaps it is easy to disregard celebrity culture because it is often only seen as frivolous and/or relevant to those foolish enough to follow celebrity advice. (9) Here, I argue that both of these presumptions are wrong. I hope to underscore the fact that celebrity culture does matter, and that it seems likely that it will matter more and more in the future.

2. CELEBRITY AND HEALTH BEHAVIOURS AND BELIEFS

   It is still unclear exactly why and how celebrity culture has an impact on our health behaviours and beliefs. (10) There has been speculation that we are evolutionarily predisposed to follow the influence of individuals with prestige and profile. (11) That our interest in celebrities relates to our universal love of gossip is a predisposition that has been linked to primate grooming behaviour. (12) And that we cannot help but compare ourselves to others--a phenomenon that happens unconsciously--even when the other is a celebrity image on our smartphone. (13) Regardless of the underlying biological, social, and psychological mechanisms at play, there is a growing body of empirical work that demonstrates the degree to which celebrity culture is linked to a range of health behaviours. (14) To cite just a few examples, there are numerous studies that have associated celebrity cancer screening behaviour with an increase (for better or worse) in public interest in and use of the associated technologies. (15) Media reports of celebrity suicides are associated with an increase in suicide rates. (16) Celebrity endorsements can have a significant impact on the consumption of unhealthy foods. (17) And celebrity culture is connected to a range of unhealthy behaviours, including smoking, drinking, and sunbathing. (18)

   Cosmetic surgery presents another powerful example of the impact celebrities have on our health. Research tells us that many of the aesthetic norms that drive the industry are established and reinforced by celebrity culture. Kate Middleton's nose. (19) Michelle Obama's arms. (20) Hugh Jackman's jawline. (21) And Kim Kardashian's gluteus maximus. (22) These are the features that are often requested by individuals seeking to modify their bodies through surgery. The last example is of particular interest. Butt enlargement was, until recently, a relatively rare procedure. Now it is one of the fastest growing forms of cosmetic surgery. (23) And its popularity can be traced to the pop culture interest in just a handful of celebrities. (24) Thus, celebrity culture influences a range of beliefs and behaviours that have a direct and significant impact on health and health policy, including altering the utilization patterns of various health services. But the reach of popular culture goes much further than that. Indeed, we should not underplay its influence on the broader lifestyle issues that are core to our health, such as diet and exercise.

   While there is no research directly on this point, (25) there is little doubt that endorsements by high-profile celebrities have contributed to the growth in the popularity of many evidence-free health trends, such as gluten-free eating, (26) juicing, (27) and colonics. (28) Without celebrity endorsement, it seems unlikely that these practices would have gained such a large amount of cultural traction. Billions of dollars are being spent. And, as I will argue below, these kinds of trends create a large amount of fact-free noise about nutrition and health that distracts us from the simple, evidence-based truth. For example, the juicing industry--which includes juice bars, speciality products, and a host of new production methods--continues to increase in size, despite the fact that there is no evidence to suggest that it provides any real health benefits. (29) Pictures of celebrities holding their favourite green juice or smoothie can be found everywhere. They are in magazines, newspapers, and on Instagram and Twitter. (30) It is, as a Forbes headline noted in 2012, "A Celebrity Trend Gone Wild." (31)

   One of my favourite illustrations of the impact of celebrity culture on health behaviours is the emergence of the huge detox and cleansing industry. The idea behind the phenomenon is that special foods, supplements, or a particular way of eating will help rid your body of unwanted and harmful toxins. There is absolutely no evidence to support this practice. (32) Nor is it ever explained how, exactly, the proposed regimens work on the toxins that are supposedly residing in our bodies. But despite the absurdity of detoxing, its market and cultural profile continues to grow. And, as with juicing, celebrity culture seems to have played a dominant role. (33)

   These may seem like frivolous examples that only have a marginal impact on public health. But they highlight the broad impact of celebrity culture and, more importantly, how it can impact public perceptions of what it takes to live a healthy lifestyle, and how it can have an adverse impact on food literacy. (34) In total, there is little doubt that celebrity culture can increase or facilitate unhealthy trends, such as lower vaccination rates and increased smoking and tanning; lead to...