Prof Kate Steinbeck [00:00:05] Welcome to the first WH&Y webinar for 2021. We're delighted to present it to you and we of course thank all the people who make this WH&Y webinar possible. Just a few things before we start. First, I'd like to acknowledge the traditional owners of the countries throughout Australia and wherever you are viewing and recognise their continuing connection to land, waters and culture, and we pay our respects to their elders past, present and emerging. There's our website, I encourage you to visit it as we develop our Community of Practice and all of those who listen to our webinars are also part of our community. Thank you. And just a few housekeeping things. We're going to mute you while our presenter is presenting. If you want to respond in any way, there is a chat box and you can see the chat at the top right-hand side of your screen, the little blue chat message, and you can type your comment into the field at the bottom. 

Prof Kate Steinbeck [00:01:34] There's also a box for questions to ask the presenter and we'll expect that you will leave those to the end of the webinar. And you can see the little icon next to the chat, which will open up your access to the question panel. 

Prof Kate Steinbeck [00:01:59] And I think that's all I need to tell you. So, it is now my pleasure indeed to welcome Dr Dr Catharine Fleming. Catharine is a lecturer in Public Health at the School of Health Sciences at Western Sydney University, where a number of WH&Y collaborators are working. And she's also stream co-lead for Youth Participation and Engagement in the Young and Resilient Research Centre. Catharine is passionate about supporting interventions that are co-designed and co-developed by young people for young people. And I think that's what our CRE is all about, no matter what work we do, it's nothing without our young people. So, Catharine, I welcome you today to speak to us on Food and Me: How Adolescents Experience Nutrition Across the Globe. Welcome and thank you. 

Dr Catharine Fleming [00:02:59] Thanks, Kate. Thank you for the introduction and thank you for having me here today for us to share our research with you around adolescent nutrition and participatory methods. 

Dr Catharine Fleming [00:03:10] Before we get started today, I thought I'd just get you thinking a little bit along what we might be discussing today, and if you could pop into the chat mechanism that Kate talked about in her introduction and just put down what you think are the biggest influencers on adolescent food choice. And then as I work through the presentation today, we're going to have a look at what adolescents themselves actually see as the biggest influencers on food choice. 

Dr Catharine Fleming [00:03:43] The study that I'm sharing with you today was a partnership between UNICEF and Western Sydney University and was positioned as a companion report to the State of the World Children's Report on Child Food and Nutrition that was launched in 2019. The study that I will be presenting really aimed to bring and capture the voices of adolescents themselves from the field and across the globe about how they view and see nutrition. The study used a distributed data gathering methodology. I will walk you through this methodology today and also share some of the findings that we had from the report that was released in November 2020. Just a little side note that we did collect all the data prior to the pandemic, so I'm sure things have changed and we don't capture that in this report, but something for the future. 

Dr Catharine Fleming [00:04:42] Distributed-data-gathering method was first developed by the Young and Resilient Research Centre at Western Sydney University in partnership with UNICEF and Harvard University, which is now being used over 70 countries across the world. A key aspect of this method involves training facilitators with partner organisations who are directly working with different countries and people within those countries to then run the creative and participatory workshops that enable participants in this case adolescents to explore their own experiences of food and nutrition in a deep and collaborative way. 

Dr Catharine Fleming [00:05:23] A first step in this methodology is to develop a workshop manual to enable continuity of data collection across multiple countries in a way that creates spaces for adolescents to share their experiences. Once the manual is completed, country workshop facilitators are then given detailed manuals describing workshop content, along with online training from the research team. This allows for not only the upskilling and capacity building of partner organisations, but also for adolescents themselves to gain skills within this methodology. For this report and this study, we developed the workshop manual in partnership with UNICEF Advisory, which included a variety of creative, participatory activities under specific themes. So you can see here in front of us that we identified key themes that we wanted to further explore with adolescents through these workshops. The creative, participatory methods. Used a whole lot of different skills and activities and creative methods by the participants, and I'm going to go into more detail with these in a moment, but I thought I would just start with sharing these photos of the participants themselves in different countries, having fun and acting and sticking things on paper and collaging and drawing to let them have a space to talk about their nutritional experiences. 

Dr Catharine Fleming [00:07:02] So some of these tasks included drawing or mapping, and often the drawing and mapping also used cutting-out examples of foods, local foods that they had, and I'll again go through this in more detail shortly. Also, we had scenario-based group exercises and discussions where they had to act out a nutrition experience or they had to talk about an ad or some form of nutrition interaction. We had short surveys and short questions as well. So it was a real mixed bag of different activities that the participants took part in. 

Dr Catharine Fleming [00:07:43] So, I'm going to show you a short video of adolescent girls in a rural area of a farm in Ethiopia to really demonstrate how some of these activities took place. 

Video plays [08.00] UNICEF: State of the World’s Children 2019: Afar Region Ethiopian Workshops. Shows adolescent girls in a rural setting in Ethiopia demonstrating how some of the workshop activities took place.

Dr Catharine Fleming [00:09:20] So, after seeing some of these activities in action, I'm just now going to step you through in a little bit more detail what they involved and what specifically we were looking at collecting information on. So for dietary intake we adapted  the 24-hour recall methodology. As a gold standard dietary assessment method, we were not trying to apply or replicate this validated tool, but rather take the underlying ideas of reporting what a person has eaten in the previous 24 hours and apply the creative, participatory methodology by having a participant self-record what they had eaten in the previous 24 hours along a timeline. They were able to draw what they had eaten on the timeline or stick pictures or write what they had consumed and then also map the time of day that they had eaten that food. This allowed us to not only see what the dietary intake was, but also we overlaid nutritional knowledge component by having participants, as you can see here, circle the foods they thought were unhealthy in red or healthy in green or unsure in the yellow color, or give them a green tick you can see or an orange tick if they were unsure. We also asked them to star their favourite food, which you can see here on the right from participants from Egypt to indicate what was their most favourite food consumed throughout the day. This provided a rich context of not only what was eaten, but also how and where they ate foods throughout the day to provide a more social context. 

Dr Catharine Fleming [00:11:00] Another diet-based activity related to what the participant had had for dinner last night. As you can see here, we've got two dinner plates with two very different indications of what was consumed. This not only provided us an opportunity to see the variety of what had been eaten in the previous evening's meal, but also the amount of volume of food. So, the plate that's on the right that says lentils and fish was from an adolescent in a refugee camp in Sudan where food insecurity and access was a real issue, and a lot of the time they had very minimal to eat throughout the day and their evening meals, as you can see, were very reduced. The plate on the left was a participant from Guatemala where they were able to access fresh veggies and beans and have more variety for the evening meal along with the drink. From both these activities, we could gauge levels of food intake and an indicator of those that may be experiencing food shortage or food inadequacy due to insecurity. 

Dr Catharine Fleming [00:12:11] After dietary intake, we also wanted to have a look at body image or how young people and adolescents within the study viewed and perceived their body shape. We were interested in how they perceive their bodies to further investigate these, we adopted a standardised silhouette testing method. For cross-cultural application, we asked adolescents about their current body perception. To help address evidence gaps in low- and middle-income countries, especially around how they viewed their body image. Instead of using the standardised methodology on the left of the silhouetted body shapes, we used fruit. This provided an opportunity for cross-cultural application within some countries, such as in the Middle East, where using body images was often not going to be acceptable. As you can see from the picture, adolescents were then asked to circle how they currently viewed their body shape in a red, and then they were asked how they would like their body shape to be, or their dream body shape to be, in a black, which you can see is just here on the right. And then they were also asked to star what they viewed to be a healthy body shape for young people. 

Dr Catharine Fleming [00:13:43] The next aspect that we wanted to look at was the influence of the media on food choice. We know how connected adolescents and young people are, especially to social media and digital advertising, and we really wanted to see how they viewed this and what experiences they had. We had an activity called the power of the brand and we asked them to write down or draw what their favourite food advertisement was. And as you can see here very quickly, we can see a soft drink surfacing, food chains such as Pizza Hut, this one's KFC, and these are all from very different countries. So, we've got one here on the left, which is from China, these ones are from Guatemala and this one was from Egypt. So, you could see very quickly that across the globe there are some commonalities in themes emerging from their favourite branded foods. 

Dr Catharine Fleming [00:14:47] We also wanted to explore their food environments. So, for this, we wanted to look at two things. We wanted to look at the diverse interactions they have at home within their own food environments, at home, at school, and also as individuals when they are given the autonomy to go out. The activity on the left we called the 'money challenge'. They were told that they had one US-dollar (or whatever was the equivalent currency within that country) and they could spend it on whatever food they wanted when they were out with their friends. They also wanted them to tell us what they would buy, where they would eat it, and also who they would share it with to give us a context around those environments when they are out as young people out of the family food environment. The one on the right, on the other hand, we had them have their little house in the centre here, and we then asked them to map what where they go outside the home with family to eat and what the interactions were, who they eat with and what they eat within those food environments outside the home. And this was a way of us looking at that interaction between family and individuals around the food environments. 

Dr Catharine Fleming [00:16:08] There's many other activities and I won't take you through all of them today, but one we also wanted to really look at was the barriers and workarounds that young people use within their food environments. And for this, we developed an obstacle course and they had to talk about the barriers or hurdles they needed to jump over to access healthy foods. So, we had them write along the obstacle course and the barriers that they experience, what they were. And also, we asked them to note how they get around it. What are some of the things that they do to try and overcome the barriers themselves? 

Dr Catharine Fleming [00:16:49] So, just as a little summary of those activities, I'm going to share another video with you, this is a workshop from Nigeria, and this video starts with young adolescent mothers talking about the nutrition knowledge they gained from the workshops and finishes with young people having a lot of fun with interpretive dance and also, again, talking about not only the workshop activities they did, but the knowledge they also gained through the workshops. 

Video plays [00:18:38] Shows young people learning about nutrition in innovative ways, and talking about what nutrition means to them and what they eat in an average day.  

Dr Catharine Fleming [00:19:33] So after all the workshops have been completed and as you can see all the activities data is collected, it Is all scanned and translated by the in-country facilitators that I described earlier on to you and then brought back essentially to us here at Western Sydney University for cleaning, coding and analysis. 

Dr Catharine Fleming [00:19:58] So I will just talk through the analysis process for you in a short way. It's quite a lengthy process but I'll just give you a summary of how we completed some of this analysis. So, the data is digitised and uploaded through our secure online repository. Data analysis then utilises qualitative thematic coding and quantitative descriptive statistics that was generated from the dietary coding of the foods under the NOVA classification system. We classified these as minimally processed foods, processed culinary foods and ultra-processed foods as the food groups. We fully acknowledge that this is not population-based measurement of dietary intake. So, the data is only snapshots of what participants ate in the previous 24 hours and is not generalised for data. But as you can see here, through some of the outputs that were generated, it does give us a nice snapshot from that 24 hours in which the majority of foods sit for the participants and I'll go through those findings with you shortly. 

Dr Catharine Fleming [00:21:06] So, without any further delay, let's actually have a look at what the young people and adolescents in our workshops had to say about their nutrition and dietary intake. The data was collected, as I said, in 2019 prior to the Covid pandemic, and we had 18 countries, conducted 37 workshops with 656 adolescents in both rural and urban locations across the globe. These countries were predominantly lower-income countries, but also included the US and Australia. A diverse range of adolescents participated, including some highly vulnerable groups such as displaced refugees in Sudan. 

Dr Catharine Fleming [00:22:00] So, overwhelmingly, adolescents do see health as a priority and healthy eating as an essential priority in their lives for a prosperous future. Being healthy was in part about being free of disease, although not only, for others, health was more about maintaining a balanced lifestyle that incorporated exercise and eating well. 

Dr Catharine Fleming [00:22:25] There were deep interconnections between physical and mental health, and often adolescents did discuss the need for wellness and health to include mental wellness as well. Across all 18 countries, 99 percent of participants identified nutrition, good nutrition, as being important for their bodies and for a healthy, prosperous future. 

Dr Catharine Fleming [00:22:56] Adolescents, said they valued good nutrition and saw it as an important part of a healthy future. Despite the value they place on eating well, our findings show that adolescents reported eating minimal fruit and vegetables in the previous 24 hours. In fact, one third of what they ate in the previous 24 hours prior to the workshops consisted of ultra-processed foods, which was largely wrapped candies. Adolescents in high-income countries and middle-income countries consumed more ultra-processed foods, whilst those in lower-income countries, interestingly, did have a higher intake of fruit and vegetable intake. 

Dr Catharine Fleming [00:23:38] Limited daily over intake of any food was seen in participants from Sudan, Zimbabwe, Nigeria, Ethiopia, Philippines and Sudan. Over 50 percent of participants in Zimbabwe, the USA, Mexico and Guatemala had consumed more confectionary, or wrapped candies, than vegetables in the past 24 hours. 

Dr Catharine Fleming [00:24:03] Adolescents from a range of countries also reported they don't have the knowledge or skills for healthy eating, especially shining a light on the lack of cooking and food preparation skills. Specifically, for those adolescents in Australia that participated in the workshops, they had reported that in the previous 24 hours they consumed, 80 percent of them had reported consuming ultra-processed foods and of this, the majority had consumed white bread, followed by lollies and soft drinks. Adolescents in most countries discussed basic nutritional knowledge and healthy eating. Although a mixed picture did emerge about their ability to identify which of the foods and drinks consumed in the previous 24 hours were actually seen as healthy. And if you think about back to that activity that I showed you at the start with the food line, this was where we obtained a lot of this information and they had the option of saying, yes, green or no red for unhealthy, and then there was the amber in the middle where they didn't know, and a lot of the food sat around the amber, they weren't sure if it was a healthy food or if it was a processed or unhealthy food. 

Dr Catharine Fleming [00:25:27] In some low-income countries such as Afghanistan, nutritional literacy was particularly an issue, and it was seen to be an issue with this in school curricula, and I'll talk about that more in a minute. Adolescents from a range of countries really identified that the nutritional literacy skills, such as cooking and shopping skills, were low and this did limit their ability to eat healthfully. They often talked about the fact that they didn't have access or the time to learn a lot of these, both within the home and outside the home. So, they often weren't cooking at home, parents weren't cooking with them, and they lacked that nutritional knowledge about how to cook healthy foods and also go shopping for foods. 

Dr Catharine Fleming [00:26:13] We also asked about disease prevention and getting them to talk about their knowledge around good nutrition and the interaction with that and prevention of diseases such as obesity, and there was definitely limited knowledge across all countries for this, particularly around obesity and anemia. They seemed to not understand the concept of prevention of these diseases through healthy foods and dietary intake. 

Dr Catharine Fleming [00:26:48] It was also interesting to hear that throughout the workshops, participants often spontaneously mentioned body image, indicating that it features constantly in their daily decision-making around nutritional intake. From the activity, we found that 70 percent of adolescents indicated they wanted to change their current body shape to either be thinner or larger. Of particular concern is the young age at which adolescents desired an extremely thin body ideal. We found that 47  percent of 13-year-old participants and 34 percent of 14 year-olds indicated a desire to have a BMI that was less than 18, which is considered underweight. When asked if they do anything to actively change their body shape, 86 percent of adolescents reported engaging in physical activity to directly change their body shape and 78 percent actively changed their eating behaviours to alter their body shape. These included specific dieting practices such as intermittent fasting, tracking of calories and increasing protein intake. 

Dr Catharine Fleming [00:28:05] So, thinking back to the activity that I showed you before where we looked at food environments and trying to get adolescents to talk about how they see their personal food environments, we found that adolescents in the workshop explained different elements of their personal food environment, such as their individual purchasing power, the time that they had, the convenience and also the access to foods were all drivers of their food choices within their own personal food environments. They often reported a lack of time to cook and or their families lack of time to cook, which resulted in purchasing convenience foods regularly for eating, particularly in countries such as Indonesia where often parents were working extended hours, children were in school for extended hours, and there was limited time to cook within their home environment. So this resulted in easy access to street vendors and purchasing foods outside the home. I talked about the money challenge before, when we looked at giving adolescents that financial autonomy themselves to choose what and where and how they consume foods in their environment with the money they had to spend, we found that they often preferred unhealthy food choices, and they said that this was because it was the cheapest option for them, and they often did this and they would always choose to do this with their friends. 

Dr Catharine Fleming [00:29:41] Looking at the external food environments, at least one third of adolescent meals are often outside their home. As such, adolescent food choices and dietary intake are deeply influenced by the physical food environments, including access to food in markets, school environments and other locations. The report found that hanging out with friends outside the home most often centred around purchasing takeaway or convenience foods at markets, malls, restaurants and cafes. 

Dr Catharine Fleming [00:30:15] Across all countries, of all places, adolescents consumed food outside. In most countries, less than half of adolescents reported that eating healthy food options were not available at school. So, they directly talked about the fact that they couldn't access healthy foods within their school environments and often unhealthy foods near the school entrance from nearby street vendors were an issue or a barrier to then consuming healthy foods throughout the day. So, the photos here in the middle are two examples that we had sent in from some of the participants' workshops in China. And these are food stores directly outside the gates to the school, which is selling deep-fried foods and snacks that the children eat as they're entering the school. So not only were foods not available within the school environment, it was also not talked about within the curriculum or made a priority within the schooling system. 

Dr Catharine Fleming [00:31:26] So now, just going back to what I got you to think about at the start of the webinar today and thinking about what you might have thought was the greatest influencers on food choice for adolescents, this is what we found adolescents told us. The strong theme of families was prominent throughout the workshops, and families were reported as the biggest influence on adolescent food choices. Adolescents reported that parents tended to make decisions about what families ate and how they ate. They also discussed a range of parental rules and restrictions that shaped food choices and meals within the home environment. These discussions also demonstrated that adolescents had limited food autonomy over what and when they ate within the home environment. So, I'm not sure what you might have also had in your options, I can't see the chatline at the moment, but after families, adolescents reported social media as the most influence on their food choices. This was then followed by peers, and they also talked about the fact that social media and their peers encouraged them to make unhealthy food choices. Individual factors such as taste also may have played a major role in determining adolescent food choice. Adolescents commonly reported, preferring the taste of unhealthy foods more than healthy foods. While they understand the need for a healthy diet, they expressed reluctance about eating more fruit and vegetables due to the taste. 

Dr Catharine Fleming [00:33:15] For 60 percent of adolescents across the sample, financial constraints were the greatest barrier to healthy eating. This was not only a low-income problem and the majority of adolescents in both the USA and Australia identified cost as the primary barrier to healthy eating on par with countries such as China, Egypt and Serbia. Also, over one third of adolescents found accessing healthy foods a key barrier given the ready availability of unhealthy foods in their communities, which comes back to those food environments and food systems that we had them map. The vendors outside the school gates, the ready access of corner stores that they hung out with friends and malls and markets, made that availability of unhealthy foods really drive their dietary intake. For those in rural locations, they found it harder to access animal protein and fresh fruit and vegetables compared to the urban counterparts. Within the school environment, less than half of adolescents reported healthy food options available. Interestingly, culture and gender also pose a barrier for young women to choose healthy food options. In some countries, gendered norms often meant that family eating patterns were dictated by senior male, and this is exacerbated by the fact that men are more likely to maintain financial control over the food purchases. 

Dr Catharine Fleming [00:34:46] So as I come to the end of our findings from the report, the core aim of our work in this project was really to surface the adolescent voice and give them space to not only provide us with experiences that they have had within their food systems, food environments and their dietary daily intake, but also what some solutions might be for them moving forward. 

Dr Catharine Fleming [00:35:12] So, I'm going to move now to a short video of a young girl in Nigeria. When she actively voices what she sees as some solutions within her own country and what might enable them in the future to have healthier food choices. . 

Video plays [00:35:35] Interviewer: What you think about good nutrition? Young Girl: Good nutrition is the food in which we take into our system to make us grow well, like rice, beans, vegetables. Interviewer: In your community, what are the difficulties in accessing good food? Young Girl: The challenges we do face in our community is caused by our parents, because we maybe eat before we go to school and when we come home they tell us to eat the same food cause they don't have money to prepare another meal . Interviewer: What would you like to tell the UN they should do. Young Girl: I was told in my school, they told us that nutrition helps us to grow well, and in our community here we lack development, no jobs, no job opportunities. I am pleading with the UN to provide infrastructure for our youth.  

Dr Catharine Fleming [00:37:19] Across other countries there were also very different solutions voiced by adolescents themselves and their experiences within their own countries and their own food systems. And I think that was something that surfaced nicely through this methodology is that not only the specific needs of adolescents within countries, but there are also synergies across the countries. There are a few presented here on this slide about different aspects and solutions presented by participants in the workshops. I particularly want to point out the one from Australia and a group of adolescents that we were working with in the workshops, really talked about the fact that they couldn't understand food labeling and they knew that often labeling wasn't truly representative of what was in the products, but they weren't able to know how to read them and they wanted greater regulation around that. They directly called out the government asking for regulation around enabling healthy, better labeling and ensuring that unhealthy foods were actually labeled correctly and held accountable within the system. 

Dr Catharine Fleming [00:38:36] So in summary, across the globe, adolescents reported that food systems are failing them and thwarting their ambitions for healthy futures. Adolescents are not getting the nutrition they need, many regularly skip meals and some eat the majority of their meals alone. They reported that both at home and outside the home, healthy food options were hard to find. Affordability and accessibility across all income levels and all countries were key barriers to consuming a nutritious diet. The reality is that healthy foods are not readily available in most communities around the world, and when they are, they're cost prohibitive. Young people are calling for a whole of community action to address the dietary challenge that confronts them. As you can see from this slide, adolescents identified across all countries four priority areas where policy action would make a meaningful difference in their ability to make healthy eating choices. To achieve this, all levels of community must come together to ensure adolescents can thrive. 

Dr Catharine Fleming [00:39:46] Learning about what really matters and how young people interact every day with their food environments, both physical and digital, is key to enable the start of a conversation with policy programme makers. The challenge then comes to be able to embed ongoing youth-centred engagement in this process. That includes decision making for and by young people at the heart of nutrition policy and programmes across the globe to create a change where change is most needed. 

Dr Catharine Fleming [00:40:22] So, this project was huge and I would like to thank my co-authors, it very much was a team effort by everyone listed on this slide. Many hands make light work, so I can't leave today without thanking my co-authors here. And of course, the project was very much made by those that participated across all 18 countries, and also our Project Advisory, which included a team from UNICEF, Yale University and also JSR Research and Training in the US. I'd like to also thank Rafaelle and Peggy for putting a huge amount of time and the UNICEF team into developing the project that I've presented today. 

Dr Catharine Fleming [00:41:16] Thank you all for listening today, and I hope you've taken something away from today. And if you'd like more information, there is a lot of detail in data. You're welcome to obtain the links to these reports that are listed here. Also, we'll have a question and answer session now. So, I am happy to answer some questions that you may have as well. But thank you for your time. 

Prof Kate Steinbeck [00:42:02] Thank you for a fantastic presentation, you really fitted so much into that and such interesting techniques to obtain data that was interesting, but for me also very sobering, so much to do with cost and also the very sad fact that most young people eat alone, which I found very sad. We have a lot of questions for you. So I'm going to start now and thank you for leaving plenty of time at the end of your presentation. So I'm just going to get those questions up. 

Prof Kate Steinbeck [00:42:36] And the first question I think you've answered already was, did Australia have a cohort in this study? I think the answer is yes, but perhaps you could tell us where they came from. 

Dr Catharine Fleming [00:42:49] Yes, we did. We had adolescents from the inner west in Sydney participate in the project. So, yes, the two high-income countries were the US and Australia and the adolescent youth in Australia were from inner west in Sydney. 

Prof Kate Steinbeck [00:43:11] Where in America did they come from?

Dr Catharine Fleming [00:43:16]  They were from the Bronx. They were more disadvantaged youth from the Bronx area in New York. 

Prof Kate Steinbeck [00:43:28] Thank you. Now the next question is again, and they thank you for a great talk. They wondered what were the logistics of conducting such a complicated study? I suspect that could take you an hour to answer, but perhaps you could give us some highlights of those logistics. 

Dr Catharine Fleming [00:43:53] It is. That's why I had to especially put up those names at the end there, because it is a monumental team effort and it really centres around the methodology that I was describing. We used the UNICEF platform in the fact that we developed the manuals with an organisation in this case UNICEF, and they then use their organisational structures on the ground within the countries and we trained those facilitators within countries, so the country facilitators were contacted by the UNICEF in New York, and then we conducted the training direct webinar training with the in-country facilitators in each country. They then go and run the workshops themselves, they recruit the participants, particularly we wanted the facilitators working with the disadvantaged youths. We have street kids in India, the refugee camp in Sudan. We needed them to be local facilitators for an understanding of the local context. So, they then take the methods, adapt it, translate it, then they translate the workshops into the local language. They translate it back into English and then it's uploaded. It comes back essentially to our research team here at Western Sydney, where we have some wonderful project team members here that upload the analysis. And we then go from there, in writing up the reports and the findings from that. So, yes, it's very much a team effort and not only from the research side, but also that important role of upskilling the youth and in-country facilitators that we then hope to gain knowledge and go forth with what they've learned on it during that workshop as well. 

Prof Kate Steinbeck [00:45:45] So did you use a lot of translators for those workshops?

Dr Catharine Fleming [00:45:49] So the translators were all in-country so we didn't actively pay to have the translation completed. UNICEF engaged the local people and the local nutrition facilitators had English capability, so they were able to do the translating. And we ran the local Sydney one, which was so much fun. 

Prof Kate Steinbeck [00:46:19] Another one which I think a number of people have thought about is that we know that boys and girls, males and females, tend to think a little bit differently about body image, and those who want to be thinner, are often girls and those who want to be heavier are often males. I'm wondering, do you have any data around body image and some of the aspects of food and food culture split into gender? 

Dr Catharine Fleming [00:46:49] Absolutely, and a great question. And yes, we were surprised at how strong that came out. And yeah, in the essence of time, I could have probably spent a whole hour dissecting the information on that. But yes, so we had two shapes there. We had the pear and the apple and we didn't ask, we just gave the sheet to the participants, male and female got exactly the same. But we found that statistically significant indication that the males selected the apple, which was seen as more of a masculine shape with a bigger upper body, and more female participants selected the pear shape. And yes, we had a lot of qualitative data with boys saying they want to bulk up, we need to be stronger, we need to be muscly. That really sort of masculinity was coming through strongly there. And then the girls were predominantly looking to be thinner. What took us by surprise was that we thought that might have been a westernised ideal and we didn't know if it would come through as strongly in some of the lower-income countries, but it did, it came through really strongly in India and parts of sub-Saharan Africa. And they talked directly about the influence of social media on those ideals and really starting to learn or gain their knowledge about an ideal from social media platforms. 

Prof Kate Steinbeck [00:48:27] Thank you. The questions keep coming, so we'll keep going. The next question is, did you adjust the healthy BMI range for children? Because BMIs of 17 or 18 in younger age groups could probably be or will be within the healthy range. And I'm wondering how you estimated BMI using the images because it doesn't look as though you did height and weight. 

Dr Catharine Fleming [00:49:00] No, and that's a very good question. And it was a very big, long debate about the methodology and you're absolutely right. The BMI z scores for adolescents are what you need to calculate them with height and weight. We took the option of the standardised silhouette testing as a validated tool and they use the adult BMI. It has been validated in adolescent populations so that was a conscious choice that we did do. So we weren't calculating their BMI, using the BMI z scores but we were applying that standardised tool, which is based on adult BMI cutoff ranges. But it is a tool that has been validated in the adolescent population. In saying that we weren't you know, it's not bullet-proof what we're saying, we're not trying to make generalised statements from this, it was more us to start that conversation that we were just having Kate, around well how are they viewing their body shapes and whatnot, and they really were selecting, girls particularly very thin ideals. So, yes, no, we didn't collect height and weight to calculate their own BMIs, but we applied that standardised tool which had already applied an adult BMI. 

Prof Kate Steinbeck [00:50:22] Thank you. I think that was almost answering our next question as well. And that was where there was a relationship between gender and desired body image. But there's a little bit of an extension here about did these relationships differ across low, middle income and high-income countries? Was it possible from your data to see the bigness in males? 

Dr Catharine Fleming [00:50:59] Yeah, that was a big surprise for us. It didn't differ too much. We thought they would be a big shift in terms of high- income countries with the girls wanting that really thin ideal and talking about dietary practices like dieting practices, but not across a lot of the sub-Saharan African countries and India and Egypt as well. One difference we did see was in Afghanistan, where the more weight they girls carried the better and more prosperous future they had because they were seen to be wealthier. So that connotation and stigmatisation of a skinny girl was not someone from a wealthy family. And the Advisory Team at UNICEF thought that that might surface a lot more in other low- income countries. But it seems to be that it was predominant only in Afghanistan and a lot of the other low-income countries had that more westernised sort of body ideal, gendered body ideal coming through. 

Prof Kate Steinbeck [00:52:11] That's a fascinating piece of information that only really one country that you visited had had the thing that we often consider that lower income countries may well still favour a heavier body image. And so, you have to be in a very poverty stricken and malnourished land in order for that still to happen. That's really a tremendous transformation, a cultural transformation. There is one more question here about, again, looking at eating. Did you have any stats for prevalence of eating disorders in each of these countries? So I'm assuming perhaps the question is asking whether those  prevalences came from other data. 

Dr Catharine Fleming [00:53:03] So we didn't look at eating, disordered eating, is it that the question? 

Prof Kate Steinbeck [00:53:08] No, I think the question is more, did you have any prior knowledge of what the stats for eating disorders might have been in those countries? A difficult question to answer I suspect.

Dr Catharine Fleming [00:53:26] So we did quite a comprehensive literature review prior to and development of the tools and then in the write up of the findings as well. And we found minimal information in lower income countries. So, yeah, we didn't look at disordered eating, we just looked at body perception. And then asked if they changed their body shape using any certain practices so we didn't use a validated tool to measure so that yes, we did do a baseline literature review and found very, very minimal information in lower income countries around what prevalence rates are in these countries, it's not known, especially from a more clinical perspective. And I mean, it varies in the Western countries, but we were mostly looking for the lower income countries. 

Prof Kate Steinbeck [00:54:22] Do you have any information on some of the practices that those young people were using in order to get to their desired body weight? 

Dr Catharine Fleming [00:54:38] Yeah, and a great question. And they were quite openly discussing in workshops between themselves around calories. And this was noted in the Sydney workshop, girls between themselves I will track what I eat, I'll track the calories that I had, so calorie counting and calorie tracking and not going over a certain amount of calories per day. Intermittent fasting was discussed as well. And the boys also actively would say, we try and eat as much protein as we can. We want to get big muscles and strong and talking about skipping meals. That was the other one, we separated out meal skipping from lack of availability of food, and these were actively commented around, I choose not to have breakfast or I choose not to have dinner because I'm concerned about my  weight and my shape, so meal skipping was another one. 

Prof Kate Steinbeck [00:55:36] Very, similar to higher income countries as well. I've just got one question that I'd like to answer to ask actually, and it really struck me the fact that young people eat alone. Do you think this is and I guess the answer, the potential answer I heard was parents too busy, both working. Do you have any idea why that's happening? 

Dr Catharine Fleming [00:56:11] I'm glad you've touched on that Kate. When I was doing all the data analysis that really stood out to me as well as a concern. The main reason was yeah busy schedules that meant that with long schooling days, so often in a lot of the countries, including Australia, they were off at 7am to do something before school than they were at school all day. And even within school, often adolescents reported eating alone, not with peer groups at times because they were doing forms of study or whatnot, then they get home late at night, parents are still working and in Australia, especially the reporting of families eating together was at most once a week in a lot of these families. So families are not eating together and often adolescents are eating alone, and that's when they are also not having foods cooked within the home, they will grab something on the way home or parents will grab something on the way home. 

Prof Kate Steinbeck [00:57:16] Thank you. That did stand out. And Catharine, we're pretty much at the end of this, but is there any one final thing you would like to say to us? Anything else that's popped into your head because of the questions, anything that you'd like to add? It was such a great talk. 

Dr Catharine Fleming [00:57:36] Thank you Kate. And look, I just think it's the start of a conversation. And I think and I'm keen to say and I can see a few comments in the chat about surfacing Western Sydney, these themes come through as well. And I think that we need to start bringing this to the agenda of policymakers. And in Australia, the adolescents gave such a good call to action for the government, how they want to see a sustainable change in the food system that will help them make healthy food choices. We need to start listening and just providing a platform for those young people to really make change in this space. 

Prof Kate Steinbeck [00:58:15] I think that's a great comment to end on. And so, Catharine, on behalf of everyone who's attended, thank you so much. And we hope to have you back at a later time to see how your work progresses. So thank you again. 

Dr Catharine Fleming [00:58:35] Thanks, Kate. It's been a pleasure. Bye, everyone.