ciplinary approaches to health, and particularly nutrition. She has been trained in Sociology, Social Work, Public Health, and Literature and uniquely combines quantitative, ethnographic, and historical-archival methods. I found fascinating her intellectual curiosity about the large institutional, corporate, and cultural pressures that affect individuals’ health in very intimate ways.
In Public Health, we talk all the time about Social Determinants of Health – how social context, built environment, economic forces, and access to education and healthcare affect individual outcomes. Less often do I hear discussion of Commercial Determinants of Health, and Dr. Schmidt is a consummate interdisciplinary thinker on these. The World Health Organization (WHO) defines these as “the private sector activities that affect people’s health, directly or indirectly, positively or negatively.” Obvious examples include tobacco and climate change on the negative side and vaccines and regulation of industry on the positive side. Dr. Schmidt has focused chiefly on the way the food industry has hooked us on hyperpalatable, highly processed foods that are profoundly undermining our health and happiness.
This interview has been lightly edited for length and clarity.
JMK: Hi, Laura. So nice to meet you! I really appreciate you giving me the time this afternoon.
Dick Jackson recommended I talk to you because your interdisciplinary approach is somewhat similar to the work I'm trying to do now. My PhD training is in literature, and then public health. I had training as an undergraduate in science and have returned to that in my support of Children's Environmental Health (CEH). I really admire that you are so interdisciplinary.
LS: Yes – I have more degrees than anyone needs.
JMK: That's amazing. I was reading some of your work that you did on highly palatable foods. Nutrition in our food system is so complex.
LS: It is very complex. But that’s what sociologists are trained to think about – to think about systems. It’s not that we don’t care about individuals, or that we don’t believe that individual variation occurs. But in order to understand how systems impact individuals, we have to look at systems – which are never just an aggregate of individuals.
There is usually stuff happening at the group level that is independent of what happens at the individual level. And so you can’t capture system effects. You can try to aggregate individual data – but you can’t capture what matters, which is the system impacts on commercial determinants of health. It’s easy for the conversation to turn into something wrong – that it’s a bunch of bad people and corporations doing evil things to kill children. But that’s just not how it works. Systems are set up independent of the individuals – some individuals might not be so nice, and some may be really great – but the systems that they are in are what really matter. There is no reason to think that Corporate America is made up of some bell curve of people skewed towards evil. So figuring out strategies to capture data that speaks to all these different levels and thinking carefully about what are the factors that we care about operating at each of the levels is important. Fortunately, our computer technologies have evolved to such an extent that we can capture all of this stuff in the same models and analyze it.
JMK: This is a problem I have thought about a lot. My former husband has worked for BP.
LS: Oh!
JMK: And so I do understand the idea of people who are not terrible people, who have a conscience and yet get caught up in and complicit with systems that are just monstrous. And then it makes it hard to talk about it without seeming like it’s all about individuals.
LS: Yes. And then there are actual evil mean people who do terrible things – that happens as well.
In order to be able to identify the most efficient ways to make these systems function more equitably or to protect health, not just the bottom line, you have to try to understand what is happening at the systems level. I’m increasingly appreciating how much culture drives this stuff – just the assumptions around what a CEO is supposed to be doing. What really matters is shareholder value. That is culture. There is no institutional imperative to require that. There are plenty of B corporations out there that don’t operate along those lines. So it’s not illegal to start a company that isn’t harming health and creating all these externalities. It’s just that culturally, the bigger the company, the more the CEO feels like the bottom line is to bring home the shareholder value – and that usually means that regardless of that individual’s personal opinions or values, we wind up with perverse outcomes.
JMK: Yes. I just had a student writing about this from a legal perspective. There was a decision early on in the twentieth century that made shareholder value primary in the US compared to other countries.
LS: What decision are you referring to?
JMK: I would have to go back and look [Dodge v. Ford Motor Co., 170 NW 668 (Mich. 1919)], but it's interesting, right? It was a lot older than I had thought.
LS: There are some anti-trust opinions from the 1940s that sort of laid the groundwork for things like corporate personhood. Shareholder value is really the driving force, part of the neo-liberal movement of the late 1980s. I don’t think that you see quite the toxic behavior of CEOs until then. We haven’t implemented anti-trust laws very well in this country for a while. Companies get way too big, and they start moving towards monopolizing and dominating. I think there is a dynamic that the bigger the scale, the more the CEO focuses on the bottom line. Maybe that is cause and effect. Maybe the companies get big because that’s the driving force behind leadership. The idea has been around for a while – but my reading of business is based on my mentor, the director of my dissertation – one of the founders of Economic Sociology. He argues that shareholder value is a new phenomenon – one of those things that take on the aura of the present. But actually, historically, usually you can find the underpinnings of these ideas in the law and policy, but they may not be driving action in the same way that they are today. If you look at the early twentieth century, I don’t think shareholder value was what was driving Corporate Standard Oil to become big. It was something else about achieving economies of scale and scope, and that is different. Anyway, there is a lot out there in the literature on this.
JMK: In my previous book I looked at the cultural influences on how we could be doing this to ourselves – it’s astonishing.
I do have a list of questions, but I really want to get your stories, and so feel free to take whatever tangents you prefer. But how did you get to this place where you are focused so much on nutrition and health and the big picture in this way? Was there some point in your childhood or early training that got you here?
LS: I started my PhD training through Public Health, and I got all the way through orals – and I was just deeply unsatisfied with the intellectual underpinnings of Public Health. It’s just that there are none. Really.
The closest you can come is sort of the late nineteenth-century, early-twentieth century progressive-era social engineering as a concept. It’s just fundamentally unsatisfying. It’s a great way to fix problems, but it’s not the best way to understand what’s underneath those problems and what drives those problems. And so analytically, I never felt satisfied.
I wound up reaching out to mentors outside of the School of Public Health. I got through orals and sucked it up and felt like I’d mastered Public Health. I started over with my PhD in Sociology. It works for me because Sociology lacks any applied dimension – the closest you can get to applying anything is probably social work or social organizing, the social movement side of things.
If you sit down and talk to a sociologist, they will tell you inequity is institutionalized – it’s the way the system works. They can explain in gruesome detail all the dynamics – the way material interests and culture come into play and create and institutionalize inequality in modern societies.
And yet they can’t tell you what to do about it. The closest they can get to it would be sociologists who do policy-related advising on economic policies or social policies – or sociologists who believe that social movements are really the only way to get out of these corners. And so when societies are not serving the needs and interests of the whole population, sociologists can tell you a really deep analysis of why that is, but at the end of the day, most of the time, they will tell you there isn’t a lot we can do about it.
Public Health is the flip side of that – it’s this uber-optimistic sort of progressive-era orientation that there are levers that can be pulled to make things better for everyone, that we can control bad things that happen to populations and so forth. So the combination really works. I try to deeply understand the systems that are driving us into these bad places and then leverage public health strategies to exit those systems.
Or if interests and values have become so hegemonic that there is nothing you can do about it – then you revert to social movements and activism. Then it’s time to really unpack the society and start over again, essentially. That the lens I bring to it.
There are areas where health problems have become so bad and the system so impossible – where vested interest are so powerful – that there is little impact that can be made. As with climate change, you basically need people in the streets because otherwise you’re not going to get a lot of change.
I’m increasingly thinking that reproductive rights and the Supreme Court generally in America – we basically need people in the streets at this point because it’s not getting any better and is actually moving in the wrong direction. Then you revert to what your average sociologist would say – mobilize and overturn the system. Try to reframe everything around a different agenda. Those moments are few and far between when you can successfully make structural change happen. And so what do you do in the in-between times? How can you soften the hard edges of systems? That’s the orientation I bring to all this.
I started out my career in addiction research in the late 2000s. I was doing a lot of work in communities – participatory research in very low-income communities. I started to see on the ground what the food there was. If you spend a lot of time thinking about controlling alcohol or tobacco use, you are steeped in an understanding of what levers to pull to make those problems less harmful. It felt like we weren’t doing anything around food.
I was in the field a decade or two after the obesity crisis had started to rear its awful head and before we had a complete saturation of the food supply with ultra-processed foods, as we do today, where the majority of what people eat is ultra-processed. We had the basic public health infrastructure – for alcohol and tobacco and commercial substances, not cannabis – that’s happened since. We were watching childhood diabetes rates tick upward among low-income children of color – it’s such a profound inequity.
So I wound up meeting up with some really interesting people at UCSF – Rob Lustig being one – who were thinking about this from radically different perspectives. What I really love about being in a medical school as a social scientist is that I can work with people who understand the mechanics of how these products work in the human body, which is very valuable. Working in really deeply interdisciplinary teams attracted me into this space.
There were people who were asking questions that were so obvious and had such obvious answers – if you knew anything about the history of tobacco and alcohol control and how to regulate harmful substances. The closer for me was when a local supervisor at the San Francisco Board of Supervisors was very sincerely worried about children and diabetes. He had just rotated off the school board and now was a city elected official, and said, will you come to my office and tell me what you think we should do about this problem? I had been working in the Tenderloin on alcohol and drug issues, and it was so obvious that it’s just the same problem – the environmental saturation of a community with outlets. If you live there, you are stuck eating what is available. In the same way, if you grow up in a place like the Tenderloin – where there are 45 liquor outlets in a few city blocks – you get to know alcohol and drugs really fast.
So this was a good place to apply what I knew about alcohol and drugs and poverty. I started working with him, and it was just amazing. We ended up with the first soda tax in the country, the first warning label that actually got made into law. And then the American Beverage Association sued the City, but it was quite remarkable how just taking very low-hanging fruit and applying these same principles to ultra-processed food products, you could make a dent in the problem. The really nice thing about the tax is that a Citizens Board allocates the proceeds back into the community. So you have this circular economy happening there that is really productive.
So that got me started. I experienced quite a bit of harassment for doing my job – that got my attention. That made me even more committed to this kind of work. When those powerful interests are picking on you because you disagree with them, it doesn’t sit well.
JMK: That is so true. The mosquito spraying company in my town come after little old me, threatening to sue me for libel and slander because I shared out information about their pesticides to local municipalities. Now I have earned credentials and can work from the inside. And I agree that that kind of injustice and silencing just makes you dig your heels in.
LS: It either does that, or it makes you leave.
It made me realize how powerful these companies are – the more you learn, the uglier it gets. The exporting these products to low- and middle-income countries in Africa and Latin America is unconscionable. Having an addiction background is very helpful – because with all these products, industry is exploring how to make consumers want to buy more. By the time I got into food, I had studied addiction for 20-30 years and understood how environments drive addiction. Why is it that low-income people have more drug and alcohol problems? They are not systematically bad people. It's not a genetic susceptibility. There has to be something going on if a whole class of people are uniquely prone to a bad health outcome – there is something going on in the environment – and as a sociologist, that’s what I am interested in.
It’s turned out to be a very helpful lens. The more I learned about the way these bad food actors function – and now we work with the Industry Documents Library – the more I could unpack their marketing and product development practices. There is a big push to get people to buy more, and that manifests in a lot of different ways.
It’s very handy to understand addictive substances and habituation – craving, lingering…. I’ve never liked cell phones, and it was because I instinctively knew from the get-go where that was heading. And now we are starting to see that product designers at Meta were intentionally designing game apps to work like slot machines. It’s scientifically interesting. I’ve written some on this topic – what are the boundaries around addiction in this late capitalist mega-corporate consumer-driven global economy that is now presenting itself? I do think that knowledge about addiction, habituation, craving, reward, and drive is intrinsic to how unhealthy commodities are developed and marketed. That’s a good thing to have our eyes on.
JMK: Yes. I love the connection you're making to cell phones. I just recently banned any screens whatsoever in my classroom, and I am never going back….
LS: Oh, that's hard.
JMK: It is hard, because you want them to be able to have their computer there. But I said, I don't care. Take notes by hand if you want or not – but be present. And more students than not are saying that it's helping them, because otherwise, their experience is always mediated.
LS: And it’s robbing them of their education.
JMK: Yes. They rarely have time when they are not behind the screen.
So the next question: you’ve done so much in so many different fields. Is there one thing or a few things of which you are proudest?
LS: I’m really proud of the policy. The older I get, the more I think about where I came from. I’m a product of public education. Most of my research is federally funded. How do we reward and take advantage of what we know and apply it as quickly and effectively as possible in the real world? That’s a big piece of what I think about. Once a new strategy for corralling and handling some of these problems is developed and tested, I’m not the person who goes back and evaluates these things because I’m a boundary spanner among different fields, bridging silos. There is a lot of potential for creative thinking about interventions and solutions – you see models in one field that could be applied in another. The system dynamics that drive a lot of these problems around commercial determinants are similar enough that you can apply them across fields. It’s a niche I have occupied in this space – the cultural construction of frames that are appealing and effective.
A lot of times, when we are talking about commercial determinants of health, we get stuck, locked into industry-sponsored frames around individual choice. It’s not just about coming up with something that is technically effective – there’s also a need to think about new ways to understand and think and position and talk about these problems that get us out of mental boxes that our culture drives us into – because most of these industries have big megaphones. They work together, and they mutually reinforce narratives around individual responsibility for health and around denial of urgent problems and around the creation of doubt in science – all these anti-democratic narratives.
They all generally reinforce these narratives in their marketing in very efficient and effective ways. I’m a Weberian, which, following Max Weber, took Marx, which is focused on material interests, and said, true – but here is how culture matters too. These kinds of ideas can really be important in driving these debates. It’s not just about coming up with technical solutions, but narratives and frames that allow us to think differently about these issues. Sometimes it’s about leveraging science and knowledge to tweak these frames and narratives.
Very early in my career, one of the first big impacts I was able to have was to influence the welfare reform debate. The Republicans, the predecessors of the Tea Party, were arguing for work requirements and cutting women with addiction issues off of aid. The reality is that minority and poor women are the most abstemious in the population. Rich people drink because they can afford to. And so it’s quite a game-changer if you actually look at the evidence.
I had an early experience of publishing a paper in the American Journal of Public Health (AJPH) pointing this out using epi data and saying we have a problem. If we are trying to cut women off aid because they are uniquely prone to alcohol and drug addiction, the reality is that they are less prone, less at risk because they are minority, low-income women. That inconvenient fact actually makes a dent if you get the information into the right hands.
Similarly, I collaborated with a woman who is a research psychologist and has come up with an operational science-based definition based on brain research of hyperpalatable foods. Why do people eat more ultra-processed foods? How do we actually measure that in the food? That narrative is a game-changer because it completely scrambles the script if you are talking about food that is engineered to make people want more and eat more.
Everything the industry has to throw at that challenges them. It’s partly about framing, and then there are simple methods, generic tools like taxation that work in Public Health. How do you make them work in adjacent fields?
Right now, I have a sixteen-site cluster-randomized trial. We’ve taken sixteen hospital campuses and randomized them, taking soda out of the workplace in parts of them. Then on top of that, we layer a brief psychological counseling intervention for people who struggle with reducing their consumption – and the combination is really powerful. Those two tools come straight out of mainstay alcohol and tobacco interventions – like smoke-free workplaces along with a brief intervention.
No one had thought to apply them to something different – in the food space. We picked one that is really bad – soda. Our outcomes are blood samples, which are good indicators of insulin sensitivity. We’re in hospitals, so we can get a fasting blood draw very conveniently. Part of the reason we use these hard biomarkers is because I got so sick of the industry attacking people who do taxes, claiming that they don’t work or make any difference. The industry says it’s not enough to say that people consume less – so screw it – we will just measure the outcome. Are you going to argue with Hg A1C? It’s really important to craft the right new interventions – this one was quite effective. In the pilot study, people lost a half inch in their waist circumference in ten months just by having a good psychologist helping them do that.
As soon as we make that intervention happen, we’ve helped some other institutions take advantage of it. I won’t spend a lot of time evaluating it – I just try to scale it up and then move on to the next thing.
If you understand the way institutions work and how institutional and social change happens, then you look for those things. Sociologists look for leverage points – like it’s really going to embarrass the CEO of this hospital system. Basically, we shamed the UCSF Chancellor into getting rid of soda, and there is still no soda ten years later.
JMK: I think there is a role for shame.
LS: Yes. He wouldn’t put it that way. The Chancellor said, “That’s right. We are kind of hypocritical.” And then you show that you can actually improve your employee health, which means saving money in healthcare spending.
JMK: I really love that. I also admire the use of direct measures. It has been very similar with environmental chemicals and childhood health. When the Eskenazi group at UC Berkeley started using direct measures and showing that the kids who have the highest levels of chlorpyrifos in their blood are 7 IQ points lower than the lowest levels, that was very convincing because it is a direct, obvious measure.
LS: Once you learn how the industry tries to box us into these narratives, you learn evasive maneuvers to get out of the box.
JMK: I love that.
LS: That’s where the harassment is actually helpful! [We both laugh.] It gives you a read on how you are doing. When they come after you, what are they saying? Where are they trying to undermine science? Once you learn the scripts, you learn how to blow them up.
JMK: What is an example of some of the worst harassment you've gotten?
LS: I have had my email FOIA’ed. I’ve had online death threats, emails, and so forth. But the worst was a series of text messages that were photographs of what looked like my son in a hospital bed. These images ended up on my phone, and then I made the mistake of going to the police rather than the FBI. And that was really, really chilling. That was by far the worst.
I understand politicians these days who are being harassed into silence. When they target your family members, it really changes your whole experience. I don’t know a lot of people working in commercial determinants who haven’t had something happen to them. I know a chemist who was working on chemicals of concern who had a bomb under his car.
JMK: Oh my goodness! I was talking with Mark Miller at the PEHSU at UCSF. I don't know if you know him. But he was saying that at least in this country, usually, environmentalists aren't killed. But in other countries, they're routinely murdered.
My next question is very apropos, which is, has this been difficult for you? As you said, the more you learn, the more discouraging and disheartening it tends to get. And then also, how do you frame something that can be very anxiety producing?
LS: Yes. The harassment did drive me off social media, which was not an essential component of what I do. I experienced this well before the pandemic, and then I got swept up on the periphery of some of the Pegasus spyware that occurred among scientists and advocates in Mexico City. They were the people behind the Mexican soda tax, which was the first national soda tax in the world.
I’ve worked with people in Columbia and other unsafe contexts, so that side of things did really change my behavior in terms of the care I take around digital security. I think the situation is getting worse. I’m encouraged to see the Biden Administration is trying to beef up anti-trust enforcement and that there are people in Washington who do get it. I’m thrilled to see Attorneys General sue the opioid industry, and Meta, and these other health-harming industries. So I think part of it is being in community with others collaborating and supporting and helping like-minded scientists who are working in this space.
To be honest, it’s intellectual curiosity that motivates me most – I am genuinely excited and curious and interested about how these companies have figured out this strategy in just the last 20-30 years: a strategy for industrially producing food (if you can even call it that) that has the kind of impact on the human body that this stuff does. It changes brain function, hormonal function, body composition, the placement of fat, and intramuscular fat. The effects on the microbiome are fascinating.
The idea that there is a big industry out there filled with labs and scientists who are engineering sustenance and having all these massive impacts – potentially the biggest impacts on human health overall come from food and nutrition.
In some ways, these monstrous products are the pinnacle of many industries. You’ve got cannabis in these products – junk food – toddlers consuming their parents’ cannabis snack foods. They have the chemicals of concern or the colors, flavors, and cosmetic additives. It’s called ultra-processed food because it’s so complex and includes petrochemicals and PFAS – all in one product line!
The clever and sophisticated marketing strategies use aspirational marketing. If you are a scientist interested in behavior and sociology, it’s fascinating. Sometimes, I feel like I am reverse engineering this stuff to understand. Why would they put that chemical in – why that class of chemicals? They are putting people in fMRIs to figure out what is going on in the brainstem. It has a sort of scientific appeal. They have made a massive mess.
I don’t know if you are familiar with Kevin Hall’s big clinical trial that came out a couple of years ago. He’s a scientist at the NIH, and he runs these highly controlled metabolic studies. He fed healthy volunteers diets of ultra-processed vs. minimally processed foods – equivalent diets – and found that people on the ultra-processed diets ate 500 calories a day more. If we get a 200-calorie a day reduction, we feel like it’s a huge win.
Now we have the smoking-gun evidence. And now the question is how? Why? What is it about the food? Is it transit time through the gut? Is it the effects on the microbiome? Is it the hyperpalatability? Is it the added chemicals? Is it obesogens – endocrine disrupting chemicals (EDCs)? What exactly are they doing in these factories? So you can fulfill your scientific curiosity while also saving lives – that’s not a bad way to go. It’s absolutely fascinating.
JMK: Yes. I do tell my students, we're facing potentially the worst problems of any generation. Yet it is really interesting how this is going to work out – or not.
LS: I think we're hitting a bit of a turning point.
I’m very interested in cosmetic chemical additives. This is important from an FDA standpoint. The cosmetic additives aren’t there to preserve the shelf life of the ultra-processed food – they are in there to make it palatable. So one big concern is to look at all the endocrine disruptors we are putting into food. And even at very small doses, they can really mess up children. And companies will say, oh no, that’s coming from the water. [Laughing….] That’s not us.
JMK: That reminds me of Devra Davis’s Secret History of the War on Cancer. She talks about how the chemical industry and the tobacco industry just blamed each other. Maybe they knew that that would work. It’s infuriating.
We only have time for maybe one more question. What do you think will be the status of children’s health in the year 2050?
LS: Oh my goodness. I’m really worried – especially about low-income kids. It’s just – we’re bombarding their bodies. From where I sit, we’re seeing the upward march of obesity and diseases that travel with it, and I don’t see big changes there. The reason is our food supply has crossed a threshold. I have been talking with Bernie Sanders’s office, trying to put a warning label on junk food. What should the label look like? Should it look like a big stop sign, which they put on food in Chile and all over Latin America, and which has been very effective? You put the label on to tell parents, don’t feed this to your kids. When you put the red stop sign on it, purchases go down by 25% in Central America. We were laughing that in America, everything in our food supply is going to have a red stop sign – except for the stuff around the perimeter – fruit, veggies, and maybe the milk. And so how do you create a warning label? Don’t eat?
From what we know about the way companies have organized their business model, they don’t have an answer for this. They knew going in, as early as 1990 – we have public statements – that this was a big issue and problem. Yet food companies don’t have a way to shift. They could substitute aspartame for sugar, but that’s about the best they can do. They can’t reformulate their way out of this, especially if it turns out that the problem is that they take grains or proteins and basically extrude it – and put that into a machine – and make it into something like a Dorito chip – and then coat it with colors and flavors so that it tastes palatable. Then they can ship it all over the world. You can’t put lettuce in a box. And they are the majority of the food system.
The work I’m doing right now is on low-income communities – food deserts – trying to create an intervention that remedies the situation with small businesses. There are systemic market failures driven by the few companies that have a monopoly and produce ultra-processed foods. The only alternatives in low-income communities are small businesses, and there are many reasons they cannot compete with McDonald’s and so forth. We have a National Science Foundation (NSF) project where we are developing strategies that are designed to remedy this. I’m an economics sociologist, so I think this way – how can we alter local markets to remedy some of the problems?
The food companies have proprietary knowledge about consumer taste and how to make it cheaply and what consumers want to buy. And the small businesses don’t, so if you can get that information into their hands, the local ethnic family restaurant can maybe compete – can find a way to put it into convenient packaging, like grab-and-go or whatever the local market wants. We need to think about strategies to bolster what remains of the food system – the 40 % of food that is not ultra processed – and work through market strategies to help. The current solution that USDA and CDC are trying will work, which is to make friends with big food by getting dollar stores and grocery chains to sell lettuce to these communities, or even to open a store. But people don’t have the ability to get there or to cook it – it’s just not working. This is a project that just got funded out of the NSF Convergence Accelerator, which is a part of NSF that gets interdisciplinary teams together to try to come up with novel solutions to vexing social problems. They just gave us a big grant, along with USDA, to develop a new approach. That’s where I think we need to be going – and also there are climate reasons why it is a good idea to make more resilient local food systems for low-income people who struggle to meet their needs. You don’t want all the food to be trucked in from the outside in these communities that are prone to floods and so forth. And there are a lot of reasons not to rely only on these big companies – and a lot of people get that.
JMK: I love everything you're saying. Thank you so much!
LS: I really appreciate it and feel free to reach out to me again.
