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Talk about soda politics! I can hardly believe it but soda taxes have become an issue in the Democratic primary campaign.

This started when Hillary Clinton came out in favor of Philadelphia Mayor Jim Kenney’s proposed soda tax.

I’m very supportive of the mayor’s proposal to tax soda to get universal pre-school for kids. I mean, we need universal pre-school. And if that’s a way to do it, that’s how we should do it.

Given the Clinton Foundation’s long-standing relationship with Coca-Cola, this was unexpected.

In short order, Bernie Sanders distanced himself from her position:

I do not support Mayor Kenney’s plan to pay for this program with a regressive grocery tax that would disproportionately affect low-income and middle-class Americans. I was especially surprised to hear Hillary Clinton say that she is “very supportive” of this proposal. Secretary Clinton has vowed not to raises taxes on anyone making less than $250,000 per year. For reasons that are not clear, she has chosen to abandon her pledge by embracing a tax that targets the poor and the middle class while going easy on the wealthy. That approach is wrong for Philadelphia, and wrong for the country.

This, in turn, induced Paul Krugman, who seems to have little love for Sanders anyway, to weigh in:

It does seem worth pointing out that progressivity of taxes is not the most important thing, even when your concern is inequality. Notably, Nordic countries — very much including Denmark, which Sanders has praised as a model — rely heavily on the VAT, which is a regressive tax; but they use that revenue to pay for a strong social safety net, which is much more important.

If we add in the reality that heavy soda consumption really is destructive, with the consequences falling most heavily on low-income children, I’d say that Sanders is very much on the wrong side here. In fact, I very much doubt that he’d be raising the issue at all if he weren’t still hoping to pull off some kind of political Hail Mary pass.

Soda tax proponents wish that Sanders had better understanding of the health issues.

• Laurie David points out that “there’s nothing populist about soda” and expands on that in HuffPo
• Nancy Huehnergarth says “Senator Sanders is wrong: A soda tax is progressive, not regressive.”
• Margot Sanger-Katz in the New York Times

Proponents say Diabetes is regressive.

Here’s information from the table from Soda Politics on framing the soda-tax debate (see page 385).

I’m in Mexico City doing talks for El Poder del Consumidor, the advocacy group in part responsible for Mexico’s soda tax.  I had some time to be a tourist yesterday afternoon and got to see the Diego Rivera murals at the Palacio Nacional.

These are enormous, and stunning.  They deal with the history of Mexico in conflict and in peace.  Look closely, and you see Rivera’s deep respect for Mexico’s traditional food culture.

Along the corridor flanking the main mural, for example, is a painting above a plaque listing what the world owes Mexico—corn, obviously—but also beans, tobacco (oops), chocolate, hemp, and tomatoes.

Other panels also deal with corn—in this one, production.

Another shows how corn is used.

The corner panel at the end of the corridor is devoted to chocolate.

Along the way, quieter panels display the harvest of fruits and vegetables.

Leave the Palacio, cross the Zócolo, and you come to the Coca-Cola bar and toy store.

A brief look at Mexico’s food culture, then and now.

Last week, StatNews.com revealed that the Walt Disney company tried to withdraw a research study it had funded because its University of Colorado authors, Jim Hill and John Peters, were behind the Global Energy Balance Network, the group funded by Coca-Cola to minimize the role of sugary drinks in obesity.

The headline: “Disney, fearing a scandal, tried to press journal to withdraw research paper.”

StatNews.com based the story on e-mails obtained from the University of Colorado by Gary Ruskin of US Right to Know through open records requests.

An e-mail from John Peters to a Disney representative says “could I ask you to look this [draft press release] over and edit as you see fit.”

But the authors’ conflict-of-interest disclosure statement says:

This work was supported by the Walt Disney Company and by the National Institutes of Health (grant no. DK48520). The Walt Disney Company and the National Institutes of Health had no role in the design, analysis, or writing of this article.

This may be strictly true, but the authors were asking Disney to approve their press release, which is not exactly “no role.”

Readers: does any of this sound familiar?  In February, I wrote a blog post about precisely this article for which I wrote an invited Commentary, accepted by the journal but not published.  I said:

The paper turned out to be by a group of authors, among them John Peters and Jim Hill, both members of the ill-fated Global Energy Balance Network, the subject of an investigation by the New York Times last August…I thought Disney’s sponsorship of this research and its withholding of critical baseline and sales data on kids’ meals that the company considered proprietary did indeed deserve comment, and wrote my piece accordingly.  Brian Wansink [the journal editor] soon accepted it for publication but to my surprise, gave it to Peters et al. for rebuttal.  They filed a lengthy response.  I was then given the opportunity to respond, and did so, briefly.

My Commentary—and the back-and-forth—were omitted (although they are online and will be published in a later issue, apparently).

Brian Wansink wrote colleagues who are editing the next issue of the journal that the back-and-forth debate over the article “was heated, and it also dragged on (because of Disney approvals) and – as we feared – it missed the deadline of our issue.”

This suggests that Disney had even more of an involvement, but when I asked Wansink if Disney approvals were responsible for his having dropped my Commentary, he said no, they just ran out of room.

We now know that Disney was more involved than disclosed.  How involved?  We dont know but perhaps other e-mails will surface to answer that question.

In their Rebuttal to my Commentary, Hill and Peters said

We were disappointed by Dr. Nestle’s assertion that Disney’s decision to not allow publication of kid’s park attendance numbers or raw kid’s meal sales numbers (because of their proprietary nature in the competitive business of theme parks) and the fact that Disney funded the study raises “red flags” about the veracity of the data presented…While we believe caution and transparency are always key ingredients when working with industry we also believe that solving the obesity problem will require finding a productive model for working together that can channel everyone’s energy toward finding solutions.  The Disney study is a good example of why partnering with industry can help move the field forward.

I am sorry I disappointed them, but I disagree.

The e-mails demonstrate even more forcefully that the Disney study is a good example of why partnering with industry should raise acres of red flags.

To repeat my response:

The response from Peters and Hill still fails to acknowledge the severity of the problems posed by Disney’s sponsorship of their research—the company’s failure to produce data essential for proper interpretation of study results, and the level to which sponsorship by food companies biases such interpretations.  At one point, Disney boasted of the results of this research, confirming its benefit to marketing goals.  The threat of industry sponsorship to research credibility has received considerable press attention in recent months, as must surely be known to these authors. [References one and two]. 

Because of Disney’s funding, the company must have thought it had the right to determine whether and how its funded study would be published.  And, as these e-mails reveal, therein lies the problem.

Wonder of wonders, the UK’s Chancellor of the Exchequer, George Osborne, has put a soda tax into his new budget initiative (see BBC account, the video and text of Osborne’s speech, and the Treasury department’s fact sheet on the soda tax).

Here’s how the tax is supposed to work:

Osborne says the tax will bring in £520 million ($732 million) in the first year, and he intends to use it to fund more sports in schools.

But it goes into effect in April 2018.  This is to give the industry time to reformulate products with less sugar.  But—the delay also gives the industry ample time to block the tax.

Public Health England supports the tax (see statement).

But the soda industry wasted no time reacting to this bad news.

• Coke, Pepsi, and other soft drink companies strongly objected.
• The immediate result: a fall in their stock prices.
• The immediate reaction: Sue the government.  On what grounds?  Discrimination.  The tax does not affect sugary juices, milkshakes, or processed foods.

The makers of artificial and alternative sweeteners think this will be a win for them.

Will the tax help reduce obesity?  On its own, that would be asking a lot.

Jamie Oliver, the British chef who favors the tax, says of course it won’t work on its own.  It needs to be accompanied by six additional actions (food labels, better school food, curbs on marketing to kids, etc.).

Why are soda companies so worried about this?  It could be catching.

• Mexico already taxes sodas, and the Philippines, India, and South Africa are considering them.
• Berkeley has already passed a soda tax.
• The proposed tax in Philadelphia looks like it has widespread support.

Will the UK tax stick?  Watch Big Soda pull out every stop on this one.

And think about what they are doing to fight soda taxes when you read or hear that soda companies want to be part of the solution to obesity.

Last summer, Brian Wansink, a friend and Cornell colleague and the editor of the new Journal of the Association for Consumer Research, asked me to write a commentary on a paper to be published in its inaugural issue.

The paper turned out to be by a group of authors, among them John Peters and Jim Hill, both members of the ill-fated Global Energy Balance Network, the subject of an investigation by the New York Times last August.

Titled “Using Healthy Defaults in Walt Disney World Restaurants to Improve Nutritional Choices,” the paper described the benefits of improving the composition of kids’ meals at Disney World.

The healthy defaults reduced calories (21.4%), fat (43.9%) and sodium (43.4%) for kid’s meal sides and beverages sold in the park. These results suggest that healthy defaults can effectively shift food and beverage selection patterns toward healthier options.

The authors explain:

This work was supported by the Walt Disney Company and by the National Institutes of Health…The Walt Disney Company and the National Institutes of Health had no role in the design, analysis, or writing of this article. Full disclosure: JH is a consultant for the Walt Disney Company and for McDonalds; KA is a consultant for the Walt Disney Company.”

I thought Disney’s sponsorship of this research and its withholding of critical baseline and sales data on kids’ meals that the company considered proprietary did indeed deserve comment, and wrote my piece accordingly.  Brian Wansink soon accepted it for publication but to my surprise, gave it to Peters et al. for rebuttal.  They filed a lengthy response.  I was then given the opportunity to respond, and did so, briefly.

The paper by Peters, et al. did was published in the journal’s first issue.   This issue also includes several commentaries on other papers (none of which are accompanied by rebuttals).

My commentary—and the back-and-forth—however, were omitted.

After some discussion, the journal published my commentary online.  You have to scroll down to find it.  The site provides no links to it in the table of contents or in the article by Peters et al.

Is it possible that Disney or the authors’ contractual relationships with Disney could have had anything to do with the omission of my accepted-for-publication commentary?  Brian Wansink says no, they just ran out of room (despite room for others).

Whatever.

Here’s what I wrote:

Dietary nudges for obesity prevention: They work, but additional policies are also needed

In 2006, the Walt Disney Company announced a new initiative to improve the nutritional quality of meals served to children at its theme parks. The company would be changing the default kids’ meals—the components that come without having to be ordered separately–to include low-fat milk, juice, or water rather than soft drinks, and sides such as apple sauce or carrots rather than French fries. Parents who wanted sodas or fries for their children would have to ask for them, something many might not bother to do. Health groups had long advocated for this policy change (Wootan 2012).

As I commented to a reporter at the time, “going to Disney World is an excuse for eating junk food…Disney or its advisers must be feeling they have some responsibility” (Horovitz and Petrecca 2006). Indeed, the healthier defaults were part of a larger effort by Disney to deal with its contribution to obesity in America. After ticket prices, food is the second greatest source of revenue at Disney World. Although reducing the amount of food consumed at the parks might help create a less “obesogenic” food environment, revenues might fall. But the default change might be revenue neutral. By 2008, Disney could report that two-thirds of U.S. customers ordering kids’ meals had accepted the default, with no loss in sales. In Hong Kong Disney parks, nearly all customers accepted the default. The report, however, did not include data on the numbers or proportions of customers ordering kids’ meals (Walt Disney Company 2008).

Disney’s more recent summary of its child health initiatives states that it is funding investigators at the University of Colorado to conduct a more formal evaluation of use of the default options (Walt Disney Company 2015). The paper by Peters et al. (2016) in this issue of the Journal presents the results of that research. Their work confirms the ongoing effectiveness of the strategy. Nearly half the customers ordering kids’ meals accepted the healthy default side dishes and two-thirds accepted the healthier beverages. These choices resulted in significant reductions in the calories, fat, and sodium in purchased kids’ meals, but not sugar (Peters et al 2016).

The authors argue that gentle nudges changes like these are preferable to more coercive policies that smack of nanny statism. Such reductions help, but are they enough to make a real difference? To answer this question, it would help to know what else the children were eating along with the drink and side dishes. Although the authors were given raw sales data, Disney did not permit them to use this information as part of the overall analysis. The company also refused to provide information about the number of children who visited the park or the number of kids’ meals sold.

These missing pieces raise red flags because this is a Disney-funded study that produced results that Disney can use to advertise itself as a company that cares about kids’ health, and to deflect attention from Disney World’s’ reputation as a junk-food paradise. Corporate funding of research introduces conflicts of interest and reduces the credibility of the results, not least because the biases inherent in such research are largely unconscious, unintentional, and unrecognized (Moore et al 2005) The results of this study merit especially careful scrutiny. Taking them at face value, the default strategy worked well for the drink, but the sides are still a problem, and so are the sugars. They do not reveal much about what kids eat in a day at Walt Disney World

Nudges like this default are an important part of strategies to counter childhood obesity. But are they enough to deal with the public health problem? To make a real difference, they need to be accompanied and supported by a range of policy approaches. Current thinking about such approaches recommends combining insights from behavioral research, economics, and public health to establish a food environment far more conducive to making the healthy choice not only easy choice, but also the preferred choice. Doing so is likely to require multiple actions—for example, regulation of nutrient content and marketing; incentives such as subsidies of healthier foods; disincentives such as taxes, warning labels, and nutritional rating systems for unhealthier foods; and education of adults and children (Hawkes et al 2015). Disney’s voluntary default is a small step in the direction of such policies, but many more are needed if we are to make real progress in reducing the prevalence of childhood obesity.

• Margo G. Wootan. Children’s meals in restaurants: families need more help to make healthy choices.   Childhood Obesity 2012;8(1):31-33.
• Bruce Horovitz and Laura Petrecca.  Disney to make food healthier for kids.  USA Today, October 17, 2006.
• Walt Disney Company. Walt Disney Company—2008 Corporate Responsibility Report. 2008.
• Walt Disney Company.  Magic of Healthy Living brochure.  2015. https://thewaltdisneycompany.com/sites/default/files/MOHL_Brochure.pdf.
• John C. Peters, Jimikaye Beck, Jan Lande, Zhaoxing Pan, Michelle Cardel, Keith Ayoob, and James Hill. Using healthy defaults in Walt Disney World restaurants to improve nutritional choices.  J Assoc Consumer Res., 2016;1:1.
• Don A. Moore, Daylian M. Cain, George Loewenstein, and Max H. Bazerman, editors.  Conflicts of Interest: Challenges and Solutions in Business, Law, Medicine, and Public Policy.  Cambridge University Press, 2005.
• Corinna Hawkes, Trenton G Smith, Jo Jewell, Jane Wardle, Ross A Hammond, Sharon Friel, Anne Marie Thow, Juliana Kain.  Smart food policies for obesity prevention. The Lancet 2015;385:2410–2421.

And here’s my response to the rebuttal by Peters et al.

The response from Peters and Hill still fails to acknowledge the severity of the problems posed by Disney’s sponsorship of their research—the company’s failure to produce data essential for proper interpretation of study results, and the level to which sponsorship by food companies biases such interpretations.  At one point, Disney boasted of the results of this research, confirming its benefit to marketing goals.  The threat of industry sponsorship to research credibility has received considerable press attention in recent months, as must surely be known to these authors.^1,2 

1  Anahad O’Connor.  Coca-Cola funds scientists who shift blame for obesity away from bad diets.  New York Times, August 9, 2015. http://well.blogs.nytimes.com/2015/08/09/coca-cola-funds-scientists-who-shift-blame-for-obesity-away-from-bad-diets/

2  Candice Choi.  AP Newsbreak: Emails reveal Coke’s role in anti-obesity group.  US News, November 24, 2015.  http://www.usnews.com/news/business/articles/2015/11/24/apnewsbreak-emails-reveal-cokes-role-in-anti-obesity-group

On my way to Australia, I stopped in Auckland.

The Auckland train station is clean and beautiful—and a perfect site for advertising Coca-Cola.

A short ferry ride lands you in vineyards.

Food thoughts to ponder early on a Monday morning in Sydney (Sunday afternoon in New York).

Several members of the Academy of Nutrition and Dietetics (AND–formerly the American Dietetic Association) sent me a letter from the Academy’s president, Evelyn Crayton, announcing its new policy on sponsorship.

AND’s previous policy, which encouraged sponsorship by food companies selling fast food, salty snacks, and sugary drinks, has been the subject of a critical investigative report and induced members of the Academy to create Dietitians for Professional Integrity to get the policy changed.

This advocacy worked.  It induced AND’s leadership to appoint a Sponsorship Advisory Task Force (SATF) to recommend a less conflicted policy to AND’s Board of Directors.

The SATF delivered its report to the Board on January 13.  As Evelyn Crayton explains,

The Board voted to implement a pilot program encompassing many of the SATF’s recommendations. The one-year pilot program includes appointing a Sponsorship Committee to review national-level sponsor opportunities and to develop assessment tools that will support the sponsorship process.

The Board of Directors approved the following newly revised sponsorship guidelines, which take effect immediately for all Academy organizational units. Dietetic Practice Groups and Member Interest Groups will be required to adhere to these guidelines and Affiliates are encouraged to adopt them.

Sponsorship approval requires that:

• The sponsor’s vision and mission align with the Academy’s Vision, Mission and Strategic Goals.
• The sponsor’s product portfolio is broadly aligned with the Academy’s Vision: Optimizing health through food and nutrition.
• The sponsor relationship and sponsor product portfolio are broadly aligned with official Academy positions.
• All aspects of the sponsorship (such as research, consumer messaging or professional education for members) align with the Academy’s Scientific Integrity Principles.
• The Academy does not endorse any company, brand or company products, nor does the Academy’s name or logo appear on any product. Such endorsement is neither actual nor implied.
• The Academy maintains final editorial control and approval of all content in materials bearing the Academy name or logo.
• There is clear separation of Academy messages and content from brand information or promotion.
• Relevant facts and important information are included.
• The Board is confident that these revised guidelines and the new Sponsorship Committee pilot program will enable the Academy to better serve the organization and our members.

This looks impressive and deserves congratulations.  The policy calls for transparency, separation, and alignment—all laudable goals.

I have only two concerns:

• What did the SATF report actually say?  How about making it available?  [If anyone has a copy and can send, please do.]
• What is the definition of “alignment with the Academy’s goals and principles?”

As always, the devil is in the details.  As Andy Bellatti explains,

Some of these guidelines (i.e.: “the sponsor’s mission and vision align with AND’s”) already exist in the current policy — the same policy that considered PepsiCo (and former sponsors Coca-Cola, Kellogg’s, and General Mills) an appropriate sponsor.

The Academy’s Board can start the process by making the SATF report public (at least to members) and then explaining its process for setting the policy.*

It also needs to explain how “alignment” will be defined.  What are the actual criteria for deciding whether AND will accept food-industry sponsorship.

But this is a great first step and deserves much praise.

*Update: the Academy released the report.

If you have been following this saga, you will know that since mid-March 2015 I’ve been collecting examples of published research supported wholly or in part by food companies.  As of today, the collection includes 95 studies with results favorable to the sponsor’s marketing interests as opposed to just 9 with unfavorable results.

Here are the most recent five.  These bring up general and specific questions that I’m pondering these days and I’ve indicated them in red.

The Effects of Water and Non-Nutritive Sweetened Beverages on Weight Loss and Weight Maintenance: A Randomized Clinical Trial.  John C. Peters, Jimikaye Beck, Michelle Cardel, Holly R. Wyatt, Gary D. Foster, Zhaoxing Pan, Alexis C. Wojtanowski, Stephanie S. Vander Veur, Sharon J. Herring, Carrie Brill, and James O. Hill. Obesity (2015) 00, 00–00. doi:10.1002/oby.21327.

• Conclusions: Water and NNS [non-nutritive sweetened] beverages were not equivalent for weight loss and maintenance during a 1-year behavioral treatment program. NNS beverages were superior for weight loss and weight maintenance in a population consisting of regular users of NNS beverages who either maintained or discontinued consumption of these beverages and consumed water during a structured weight loss program. These results suggest that NNS beverages can be an effective tool for weight loss and maintenance within the context of a weight management program.
• Funding agencies: The study was fully funded by The American Beverage Association. The American Beverage Association was not involved in the design, conduct, interpretation, or manuscript preparation of this study. Furthermore, a third-party organization (Biofortis-Provident) was hired at the PIs’ request. Biofortis-Provident audited data at both clinical sites to check for the accuracy and integrity of the data…Disclosure: J.C.P. and J.O.H. received consulting fees from The Coca-Cola Company outside of the submitted work.
• Questions: Does recruiting a third party to audit data increase confidence in the credibility of this study?  Isn’t it more relevant to ask about how the research question is framed? 

Nutrition and Health Disparities: The Role of Dairy in Improving Minority Health Outcomes.  Constance Brown-Riggs.  Int. J. Environ. Res. Public Health 2016, 13(1), 28; doi:10.3390/ijerph13010028.

• Conclusion: Because of the presence of lactase-producing cultures, yogurt is often a more easily digestible alternative to milk, and thus more palatable to people who experience symptoms of lactose intolerance. This was a key factor cited in the final rule to include yogurt in the Special Supplemental Nutrition Program for Women, Infants, and Children.
• Funding: This work was supported by The Dannon Company Inc. (White Plains, NY). The Dannon Company Inc. provided information for this article but did not have final approval for its content.
• Conflicts of Interest: Nutrition advisor for Dannon’s One Yogurt Everyday Initiative, providing consultation services on the health issues affecting African Americans.

Protein Supplementation at Breakfast and Lunch for 24 Weeks beyond Habitual Intakes Increases Whole-Body Lean Tissue Mass in Healthy Older Adults.  Catherine Norton, Clodagh Toomey, William G McCormack, Peter Francis, Jean Saunders, Emmet Kerin, and Philip Jakeman.  Nutr. 2016; 146:65-69 doi:10.3945/jn.115.219022.

• Conclusions: Protein supplementation at breakfast and lunch for 24 wk in healthy older adults resulted in a positive (+0.6 kg) difference in LTM compared with an isoenergetic, nonnitrogenous maltodextrin control. These observations suggest that an optimized and balanced distribution of meal protein intakes could be beneficial in the preservation of lean tissue mass in the elderly.
• Funding: Supported by Food for Health Ireland and Enterprise Ireland grant CC20080001.  Author disclosures: C Norton, C Toomey, P Francis, J Saunders, E Kerin, and P Jakeman, no conflicts of interest. WG McCormack was an employee of Carbery Ingredients on secondment to Food for Health Ireland during the in vivo data collection and analysis.
• Comment: The Carbery Group advertises itself as “a global leader in food ingredients, flavours and cheese.”
• Question: Why would Carbery put one of its employees to work on this study?

Dietary vitamin D dose-response in healthy children 2 to 8 y of age: a 12-wk randomized controlled trial using fortified foods.  Neil R Brett, Paula Lavery, Sherry Agellon, Catherine A Vanstone, Jonathon L Maguire, Frank Rauch, and Hope A Weiler.  Am J Clin Nutr 2016; 103:144-152 doi:10.3945/ajcn.115.115956.

• Conclusion: Increasing the vitamin D intakes of young children through fortification of alternative dairy products results in significantly higher serum concentrations of 25(OH)D and a significantly greater proportion of children with serum 25(OH)D $50 nmol/L during periods of minimal ultraviolet B radiation exposure.
• Supported by funding from Dairy Farmers of Canada, the Canadian Foundation for Innovation and Canada Research Chairs, and in-kind support from Agropur and Ultima Foods for the study products.
• Question: Does providing study products introduce conflicts of interest?

Comparison of the DASH (Dietary Approaches to Stop Hypertension) diet and a higher-fat DASH diet on blood pressure and lipids and lipoproteins: a randomized controlled trial.  Sally Chiu, Nathalie Bergeron, Paul T Williams, George A Bray, Barbara Sutherland, and Ronald M Krauss.

• Conclusions: The HF-DASH diet lowered blood pressure to the same extent as the DASH diet but also reduced plasma triglyceride and VLDL concentrations without significantly increasing LDL cholesterol
• Supported by Dairy Management Inc. and by the National Center for Research Resources and the National Center for Advancing Translational Sciences, NIH, through University of California, San Francisco Clinical & Translational Science Institute grant UL1 RR024131.  RMK has previously received and is currently receiving research funding from Dairy Management Inc. for this and other projects. None of the other authors reported a conflict of interest. This was an investigator-initiated study, and its financial supporters had no role in the study design, implementation, data analysis, or data interpretation.
• Question: Does this mean that the investigators decided what they wanted to study and then asked Dairy Management Inc for funding, knowing that Dairy Management would have congruent interests?  Does something like this increase confidence in the results?

I don’t have clear, unambiguous answers to such questions and am collecting opinions in preparation for my next book project.  If you have thoughts about these matters, do share.