Currently browsing posts about: Conflicts-of-interest

BMJ (formerly the British Medical Journal) has just released an editorial and four papers on ties between the sugar industry and public health scientists who advise the government on health policy.  Some health policies involve recommendations about intake of sugars.

The BMJ press release explains

Recipients of research funding from sugar and other related industries include members of the Scientific Advisory Committee on Nutrition (SACN), which is currently updating official advice on carbohydrates consumption, and researchers working for the Medical Research Council’s Human Nutrition Research unit (HNR).  HNR scientists have received research funding and funding in kinds from companies including Coca-Cola, Mars, Nestlé, Sainsbury’s, the Institute of Brewing and Distilling, Weight Watchers International and others…Of the 40 scientists affiliated with SACN between 2001 and 2012, only 13 have had no interests to declare.

This, of course, is no different than what we see here.  Food and beverage companies support food and nutrition research as well as professional societies, and conflicts of interest are rampant.

Even so, these well documented studies are alarming and worth serious attention.  And be sure to look at the map.

• Sugar: spinning a web of influence
• Sugar’s web of influence 2: Biasing the science
• Sugar’s web of influence 3: Why the responsibility deal is a “dead duck” for sugar reduction
• Sugar’s web of influence 4: Mars and company: sweet heroes or villains?
• Map showing links between public health scientists and the sugar industry ​

MedPage has a nice summary (I’m quoted).

The furor over these articles

• UK scientists object to the accusations
• Responses to the BMJ
• BBC commentary on the dispute
• Susan Jebb responds
• The Obesity Society’s Position Opposing Ad Hominem Attacks (its term for articles like those in the BMJ)

Joel Leftwich has left his job as senior director for PepsiCo’s public policy and government affairs team (since March 2013) to become staff director for the Senate Agriculture Committee now led by Pat Roberts (R-Kansas).

In some ways, it’s a perfectly logical appointment.  Before joining PepsiCo, Leftwich worked for Roberts as a legislative aide from 2005 to 2010 and as deputy staff director for the Ag Committee from 2011 to 2013.

But his connection to PepsiCo raises concerns.  The Ag committee will be dealing with several issues involving sodas and snack foods opposed by some members of Congress:

• Reauthorization of WIC, the Women, Infants and Children nutrition program (its requirements for healthy foods are always under pressure).
• Preservation of the school nutrition standards authorized by the Healthy, Hunger-Free Kids Act (under attack by the food industry and its friends in Congress).
• SNAP nutrition standards (there is a movement to make sodas ineligible for SNAP-EBT purchases).
• Issuance of the 2015 dietary guidelines, always under pressure not to say anything direct about not drinking sodas.
• Issuance of the new food labels.  The soda industry opposes putting in “added sugars.”   While this is FDA’s purview, not USDA’s, the Ag Appropriations Committee governs FDA’s appropriations.

And on the state level, it’s worth taking a look at what the Texas Commissioner of Agriculture is up to, courtesy of Bettina Siegel’s The Lunch Tray: “cupcake amnesty.”

Clearly, agricultural policies affect public health in highly prominent ways.

That’s why we need to do a much better job of connecting food policy to health policy.

And that’s why having a leading PepsiCo lobbyist in charge of agricultural committee staff raises serious concerns about conflict of interest.

In the past few weeks, I’ve been sent several questions asking my opinion of food professionals’ relationships with food companies.   I thought I would deal with them at one time (all are edited for succinctness and clarity):

Q.  I am a food science student looking into career options in the food industry. I love food science and truly believe that processing food is a good idea that can positively impact the planet and its people.  I want to do something worthwhile,, but I still need to eat.  Can’t the food industry be changed from the inside? Can’t you advise good companies, people, or places where I could start my search? 

A.  I have met social entrepreneurs who strongly believe that businesses can be ethical, do good, and still make heaps of money.  Maybe so.  If you are going to try that route, I think it essential that the company be family or cooperatively owned, and not publicly traded.  You might take a look at food companies incorporated as Benefit Corporations. These are now authorized in about half the states to consider the interests of all stakeholders, not just shareholders, when making decisions.  They are different from B corporations certifying companies that meet certain sustainability criteria.

Many companies work hard to reduce their environmental impact.  But the real question is what they are doing about health impact.  Are they going overboard on health claims?  Are they marketing to children?  These are questions I’d want to ask.  In your shoes, I’d start by looking at companies making products that you like, feel good about, and would be proud to be associated with.   And then take a closer look at how the companies operate.   Working for food companies is always a good learning experience, but if you really want to change the world, you might be better off with a nonprofit agency.

Q.  I’m a graduate student in nutrition and I would like to know what recommendations you may have for students to navigate conflicts of interest with food companies when beginning a career.  I intend to pursue an academic career but am concerned that my credibility as a scientist could be compromised by my participation in industry-funded publications and research. 

A.  It’s great that you are asking such questions. From the standpoint of ethics, that’s an important first step.  You should most definitely publish your research, no matter how it is funded.  Be sure to disclose potential sources of funding bias and conflicts of interest.  While you are doing your research, you can take special care to control for potential biases—conscious and unconscious—in your study design, conduct, and interpretation to ensure that they are not influenced by the funder.  In searching for jobs, you might consider those in academia, government, and NGOs that are less likely to require you to compromise principles.  Finding such jobs may not be easy, but you will be OK if you are always ethically transparent and as straightforward about biases as it is possible to be.

Q.  Do you believe that relationships between the food industry and nutrition professional organizations like the Academy of Nutrition and Dietetics (AND) and the Association for Nutritional Science (ASN) are problematic? Why?

A.  Sponsorship by food product makers puts nutrition professionals in conflict of interest.   Nutritionists ought to be advising clients and the public about what to eat to stay healthy and prevent chronic disease.  This necessarily means promoting consumption of some foods but discouraging consumption of others.  Nutritionists cannot speak truth to clients and protect corporate sponsorship at the same time.  If nothing else, food industry sponsorship gives the appearance of conflict of interest and makes AND and ASN appear as arms of food company marketers.  But it also affects—or appears to affect–AND ’s and ASN’s positions on key issues in nutrition and health.  Overall, financial relationships between these organizations and their food industry sponsors undermines the credibility of their positions on food issues.

Q.  What sort of changes do you think the Academy needs to make in order to make food industry relationships more beneficial to its members and the public overall?

A.  Nutrition and food professional organizations need to establish a firewall between corporate sponsorship and content or opinion.  This requires setting up rigorous guidelines for what food companies can and cannot expect from their donations.  They should not, for example, be permitted to sponsor content sessions at meetings, not least because opinions expressed at sponsored sessions rarely appear objective.  The organizations should have complete control over how and where corporate donations and company logos are used.

Q.  How can relationships between health professionals and the food industry be beneficial for public health overall?

A.  The role of health professionals is to give the best advice possible about diet and health.  The role of food companies is to provide profits to shareholders.  These goals are not the same and are only rarely compatible.  In my experience, people who want to work for food companies to change corporate culture from within do so from good motives, but soon discover that corporate imperatives take precedence over health goals. If health professional organizations want their advice to be taken seriously, they must establish and adhere to rules and guidelines designed expressly to protect their integrity.

Q.  I read your post on the revolving door,  It seems to me that your underlying premise is the notion that any company that makes food is indicted as part of the big evil food conspiracy. Surely, you can’t really believe that. 

A.  Of course I don’t. But food companies are not social service agencies.   Their job—their legal responsibility—is to continuously expand sales and distribute ever-increasing profits to shareholders.   If they can do this and promote health at the same time, more power to them.  But people would be healthier eating food, not food products.  In our present system, products are far more profitable and the focus on them is rarely works in the interest of public health.

Food and nutrition professionals need to make a living.  Unfortunately, jobs in industry pay better–and sometimes a lot better–than jobs in government or NGOs.  That’s the real dilemma that underlies all of these questions.

My post about the “Revolving Door” elicited a thoughtful response from Jerry Hagstrom, Founder and Executive Editor of the immensely useful Hagstrom Report, to which I subscribe.

He writes: “You seem critical of the “revolving door” but I would ask the following:

• What would you have these people do for employment when they leave government? If they are political appointees,  they can’t stay forever.
• Shouldn’t they use their knowledge? Should they be expected to move into an entirely different field? Wouldn’t it be a shame for the professional world of food and agriculture to lose their expertise?
• What about academics who take government jobs and then go back to academia? Don’t they learn how to get research grants? But their knowledge of how government works is considered valuable to universities and to students.
• Do you see any problem with someone being in government and then going to work for a nongovernmental organization or a foundation or coming from an NGO or a foundation into government? That happens too and those institutions have agendas.

As a reporter I view all these people with a combination of faith and skepticism whether they are in government or out.

Good questions, with no easy answers.

Open Secrets provides many examples of government officials who become lobbyists for the industries they used to regulate.

Conflicts of interest are likely to be even greater for those who revolve the other way—from industry to government–and especially when former industry executives move to high-level positions in regulatory agencies.

If nothing else, I see the revolving door as giving the appearance of conflict of interest.

Readers: What do you think?  How would you respond to Jerry Hagstrom’s questions?

 

 

 

Here are the burning questions about sodium (which is 40% of salt) intake:

(a) Does too much dietary sodium cause high blood pressure?   Answer: an unambiguous yes (although not necessarily in everyone).

(b) Are public health recommendations to reduce salt intake warranted?  I think so, but others disagree.

(c) If so, to what level?  Although virtually all committees reviewing the evidence on salt and hypertension view public health recommendations as warranted, and advise an upper limit of about 2 grams of sodium (5 grams of salt, a bit more than a teaspoon (see table from the Wall Street Journal), these too are under debate.

These recommendations are strongly opposed by The Salt Institute, the trade association for the salt industry, its industry supporters, and some groups of investigators.

Now the New England Journal of Medicine weighs in with three new studies, an editorial, and a cartoon video.  The papers:

• Association of Urinary Sodium and Potassium Excretion with Blood Pressure: A. Mente and Others | N Engl J Med 2014;371:601-611
• Urinary Sodium and Potassium Excretion, Mortality, and Cardiovascular Events: M. O’Donnell and Others | N Engl J Med 2014;371:612-623
• Global Sodium Consumption and Death from Cardiovascular Causes: D. Mozaffarian and Others | N Engl J Med 2014;371:624-634

Start with the video,  narrated by the editor, Dr. Jeffrey Drazen (click on video link on the right side).  It gives an excellent summary of the three papers.  Despite their methodological differences, all confirm (a).  They disagree on (c) and, therefore, (b).

Are public health recommendations warranted?

But note Dr. Drazen’s suggestion: “throw away the salt shaker.”

He is in favor of reducing salt intake.  But the salt shaker is not where most dietary salt comes from.  At least 75% of salt in American diets comes from restaurant and processed foods.   As Dr. Yoni Freedhoff explains:

If you’d like to reduce the sodium in your diet, rather than keep a running tally of how much you’re actually consuming, why not try instead to determine what percentage of your diet comes from restaurants and boxes? Sure, there’s data to suggest you might simply find other ways to add salt to your diet. But visit restaurants and consume processed foods less frequently, and I’d be willing to wager that you’ll be far more likely to see health benefits than were you to simply fill your grocery cart with low-sodium versions of highly processed foods.

Individuals cannot cut down on salt on their own.  That’s one reason why public health policies are needed—to get restaurants and processed food manufacturers to reduce salt content.

Two of the papers say that the only people who need to cut down on salt are those with hypertension and older people (one of the studies says that means people over age 55).

• How many Americans have hypertension?  67 million (1 out of every 3 adults) according to the CDC.
• How many Americans are over age 55?  More than 80 million, and rising.

You can’t expect 70 or 80 million people to reduce salt intake on their own.  Hence: public health recommendations.

Conflict of interest alert

Some of the investigators report receiving grants or fees from companies that make anti-hypertensive drugs but the editorial accompanying the papers is of special concern.   Written by Dr. Suzanne Oparil, it says about one of the studies:

These provocative findings beg for a randomized, controlled outcome trial to compare reduced sodium intake with usual diet. In the absence of such a trial, the results argue against reduction of dietary sodium as an isolated public health recommendation.

These conclusions sent me right to her conflict-of-interest disclosure statement.  Although Dr. Oparil reports receiving grants or fees from companies making anti-hypertensive drugs—-and, even more remarkable, from The Salt Institute—she states that she has no conflicts of interest.

I think she does.

Implications

Her editorial is especially unfortunate because it influences the way reporters write about the studies.

The Associated Press account, for example, begins:

A large international study questions the conventional wisdom that most people should cut back on salt, suggesting that the amount most folks consume is OK for heart health — and too little may be as bad as too much. The findings came under immediate attack by other scientists.

As well they should.  Blood pressure rises with age and huge swaths of the population would be healthier eating less salt.   The AP reporter quoted me saying so:

“People don’t eat salt, they eat food,” she said. “Lots of people have high blood pressure and lots of people are getting older,” making salt a growing concern, she said. “That’s the context in which this is taking place.”

The three studies are complicated to interpret because of differences in methods and discrepancies in outcomes.  They agree that if you already have hypertension or are “elderly,” or eat a lot of salt, you should cut down.

This seems like a good idea for just about anyone.   People don’t eat salt; they eat foods containing salt, and foods high in salt tend to be high in other things best consumed in small amounts.

The studies also talk about the protective effects of potassium, best obtained from vegetables.

Eat a lot of vegetables and not too much junk food, and you don’t have to worry about any of this.

Former USDA Secretary Dan Glickman has just been named chairman of the board of the Foundation for Food and Agriculture Research (FFAR).

Research on agriculture has long been the underfunded stepchild of the federal research enterprise.  The 2014 budget gave USDA under $3 billion in total to fund all of its in-house research units and their granting operations: Agricultural Research Service, National Institute of Food and Agriculture, Economic Research Service, and Agricultural Statistics Service.

This may seem like a lot, but NIH gets $30 billion a year.

The 2014 farm bill contained a provision aimed at raising money for agricultural research.  It provided $200 million (peanuts in federal dollars) to establish FFAR, which will operate as a non-profit corporation to obtain matching funds from private industry.

The members of the board were announced a couple of weeks ago.

It should be no surprise that many of the board members represent industry.  Industry nominated 7 of the members.  The other 8 were selected from a list provided by the National Academy of Sciences.

Now the board has to raise at least $200 million from industry, presumably with no strings attached.

Here’s the foundation’s dilemma: if industry funding has no strings—earmarks for certain research projects, for example—why would industry want to contribute?  But if the contributions do come with strings, they create conflicts of interest.

This will be fun to watch.  Stay tuned.

The big surprise in Michael Moss’s tough look at health claims on coconut water in today’s New York Times—worth looking at online for the terrific video—is this:

One Last Comparison

These days, coconut water’s big rival may be plain old water. How do they compare? Scientists are still wrestling with the question, and while their findings vary, water is starting to look just fine for most people. A 2012 study (funded by Vita Coco) in the Journal of the International Society of Sports Nutrition found that neither coconut water nor sports drinks were better than water in hydrating young men after hourlong workouts.

Really?  An industry-funded study that comes to a conclusion against the interest of the funder?

This requires a look at the original paper.

So a round of applause please for the authors who did this funded study, “Comparison of coconut water and a carbohydrate-electrolyte sport drink on measures of hydration and physical performance in exercise-trained men,” and nevertheless came to this conclusion:

Our data indicate that both coconut water (natural, concentrated and not from concentrate) and bottled water provide similar rehydrating effects as compared to a carbohydrate-electrolyte sports drink.  Moreover, none of the beverages impacted treadmill exercise performance differently during the rehydration period.

Lest there be any ambiguity about what this means, their data clearly show that VitaCoco, a sports drink (not named but I’d bet on Gatorade), and coconut water from concentrate all rehydrated men who spent 60 minutes on a treadmill to the same extent.

In other words: for rehydration, water works just as well as coconut water or sports drinks.   No surprise, really.

VitaCoco must be disappointed, but it still has one thing going for it: coconut water tastes really good.

August 1 is the deadline for filing comments on FDA’s food label proposals.

Two were released yesterday, one for and one against.

The Union of Concerned Scientists (UCS) organized a statement in support of listing added sugars signed by 280 scientists, physicians, and public health officials (including me).

The press release says:

In a letter submitted as a public comment for the agency’s first label update since 1994, the signatories point out that sugar overconsumption contributes to diabetes, cardiovascular disease and other ailments….Many food and beverage manufacturers add excessive amounts of sugar to their products, including those that they market as healthy options. In our current food environment, many people are unknowingly and unavoidably consuming excess sugar. Given our soaring rates of chronic diseases and the link between sugar and these diseases, citizens have a right to know how much sugar has been added to their foods.

People who signed the letter include many from Healthy Food Action, a national network of health professionals founded by Dr. David Wallinga.  I am a co-author of the statement with UCS staff and Dr. Robert Lustig.

In contrast, the American Society for Nutrition (ASN), an organization of nutrition scientists to which I belong, produced a strong statement against labeling added sugars.

ASN also has concerns that the inclusion of added sugars on the label may divert attention away from total calories and other important contributors to weight gain. The inclusion of added sugars on the label may confuse consumers and create the perception that naturally occurring sugars are somehow more beneficial because they are “natural” and do not have health effects similar to added sugars…There is no supporting evidence that indicates that the inclusion of added sugars on the food label will translate into the American public reducing caloric intake from added or total sugars or total energy intake…it is important to consider potential unintended consequences of  reformulation as well. When sugar is removed from a solid food product…The replacement is often fat and/or starch which could lead to a product with higher calories per serving. ASN encourages FDA to carefully consider potential adverse consequences of this proposed determination, including gaining input from food scientists…An investment in consumer education… is likely to be most productive for consumer understanding relative to added sugars, and would assure that consumers do not experience increased confusion, which they may encounter if added sugars are declared on the Nutrition Facts label.

These comments, which read as though written by sugar trade association groups, were signed by the president of ASN.  Although the statement letter gives no indication of the process by which these comments were developed, I’m told it was prepared by ASN’s public policy committee.

If so, it would help to know whether members of the committee have financial ties to the sugar industry or to food companies that use sugar in their products.

I wonder how much of the ASN membership agrees with this position on Added Sugars.   I certainly don’t.