Search results: american journal of clinical nutrition

The soft drink industry is using the latest research findings to argue that vending machines in schools are not the problem in childhood obesity, and it’s what kids drink at home that matters. The research in question finds that adolescents get 10% to 15% of their calories from sugary beverages. Average intake among 2 to 5 year olds is 176 calories per day; among 12 to 19 year olds it is 356. Overall average intake rose from 240 calories/day in 1988 to 270 in 2004. Doesn’t what kids drink in school influence what they drink at home, and vice versa? Never mind. Try this one: a new meta-analysis – coincidentally (?) sponsored by the American Beverage Association–finds no relationship between consumption of sweetened beverages and body mass index. High marks to the American Journal of Clinical Nutrition for printing a rather tough sponsorship note: “The research proposal to the sponsor was approved as submitted, but the sponsor requested that an independent expert on meta-analysis—to be chosen by the authors—review the manuscript…One author (MLS) accepted a position with the sponsor after the first decision letter regarding the manuscript was received.” Could this cozy relationship have anything to do with the way the study was designed and conducted? Just asking.

A new analysis of all kinds of studies on the use of calcium to prevent fractures is just out in the American Journal of Clinical Nutrition. The results? “calcium intake is not significantly associated with hip fracture risk in women or men…[results] show no reduction in hip fracture risk with calcium supplementation, and an increased risk is possible.” It sure would be nice if it were that easy to prevent fractures but bone strength requires a good diet containing ALL nutrients, not just calcium (with or without vitamin D), as well as plenty of physical activity, so these results should not come as a surprise. The bottom line: eat healthfully and move!

While I am on the subject of food company sponsorship of nutrition and medical professionals, I might as well say something about sponsored research. Analyses of the phenomenon show that when research is sponsored by food companies, it almost always produces results that favor the sponsor’s products. Two recent examples from the American Journal of Clinical Nutrition: a study comparing the effects of soft drinks sweetened with high fructose corn syrup or sugar (sucrose) finds no difference in perceived sweetness, hunger, or calorie intake. I wouldn’t expect it to, but the study was funded by a grant from the American Beverage Association, which has a vested interest in proving that soft drinks have no effect on obesity. This next one is even better: here is a study showing that if you eat corn or tortilla chips fried in corn oils, which are largely polyunsaturated, your blood cholesterol will be healthier than if you eat chips fried in saturated and trans fats. I thought we knew that already. But doing a study like this gives the sponsor a usable conclusion: “Therefore, if chosen wisely, even snack foods that are often considered to be ‘junk food’ can contribute to a heart-healthy diet.” Would it surprise you to learn that the study was funded in part by Frito-Lay/PepsiCo? I wonder how long it will take to see this research celebrated in Frito-Lay ads.

The MAHA Commission released its report last week: The MAHA Report: Make Our Children Healthy Again.  Assessment.

This is one impressive report, forcefully written and tightly documented (it cites my work, among that of many others).

Overall, it paints a devastating portrait of how our society has failed our children.

It begins by stating that “The health of American children is in crisis” due to:

• Poor diet
• Aggregation of environmental chemicals
• Lack of physical activity and chronic stress
• Overmedicalization

The result: high rates of obesity, type 2 diabetes, neurodevelopmental disorders, cancer, allergies  and mental health problems among kids.

Here are some selected items I particularly appreciated in the report.  The bullet points are direct quotes.

On poor diet

• Most American children’s diets are dominated by ultra – processed foods (UPFs ) high in added sugars , chemical additives , and saturated fats, while lacking sufficient intakes of fruits and vegetables.
• Pesticides , microplastics , and dioxins are commonly found in the blood and urine of American children and pregnant women— some at alarming levels.
• Children are exposed to numerous chemicals , such as heavy metals , PFAS , pesticides , and phthalates, via their diet, textiles, indoor air pollutants, and consumer products.
• To get into schools , many food companies have reformulated their products with minor ingredient adjustments to qualify for the federal Smart Snack program by meeting the school nutrition standards, which children can purchase separate from school meals.

The driving factors for poor diets

• Consolidation of the food system
• Distorted nutrition research and marketing
• Compromised dietary guidelines

On the dietary guidelines  

They maintain problematic reductionist recommendations, such as:

• Advising people to “reduce saturated fat” or “limit sodium” instead of focusing on minimizing ultra-processed foods.
• Treating all calories similarly, rather than distinguishing between nutrient-dense foods and ultra-processed products.
• Remain largely agnostic to how foods are produced or processed: There is little distinction between industrially processed foods and home-cooked or whole foods if their nutrient profiles look similar.
• Added sugars, saturated fats and sodium are treated as proxies for ultra-processed foods. For instance, a cup of whole-grain ready to eat fortified breakfast cereal and a cup of oatmeal with fruit might both count as “whole grain servings,” and the guidelines do not weigh in on differences in processing.

They also,

• Do not explicitly address UPFs.
• Have a history of being unduly influenced by corporate interests .

On food systems

• The greatest step the United States can take to reverse childhood chronic disease is to put whole foods produced by American farmers and ranchers at the center of healthcare.
• Traditional Field Crops vs. Specialty Crops : Historically, federal crop insurance programs have primarily covered traditional field crops like wheat , corn , and soybeans, while providing much less support for specialty crops such as fruits, vegetables, tree nuts, and nursery plants.

On Corporate Capture 

• Although the U.S. health system has produced remarkable breakthroughs, we must face the troubling reality that the threats to American childhood have been exacerbated by perverse incentives that have captured the regulatory bodies and federal agencies tasked with overseeing them .
• Limited comparisons between industry-funded research versus non- industry studies have raised concerns over potential biases in industry-funded research…Additionally, some industry leaders have engaged in promoting ghostwriting and sponsored reviews to influence the scientific literature.
• Notably, this ghostwriting strategy mirrors tactics used by the tobacco industry to distort scientific consensus is largely propelled by “corporate capture,” in which industry interests dominate and distort scientific literature, legislative actions, academic institutions, regulatory agencies, medical journals, physician organizations, clinical guidelines, and the news media.
• The pharmaceutical industry, with its vast resources and influence, is a primary driver of this capture, though similar dynamics pervade the food and chemical industries.

Research recommendations

• GRAS Oversight Reform: Fund independent studies evaluating the health impact of self-affirmed GRAS food ingredients, prioritizing risks to children and informing transparent FDA rulemaking.
• Nutrition Trials: NIH should fund long-term trials comparing whole-food, reduced-carb, and low-UPF diets in children to assess effects on obesity and insulin resistance.
• Large-scale Lifestyle Interventions: Launch a coordinated national lifestyle-medicine initiative that embeds real-world randomized trials-covering integrated interventions in movement, diet, light exposure, and sleep timing-within existing cohorts and EHR networks.

Comment

The report has been criticized for not getting some of the science right.  The agriculture industry is particularly concerned about the attack on the chemicals it uses.  It is said to be outraged by the report.  The report did throw Big Ag this bone: “Today, American farmers feed the world, American companies lead the world, and American energy powers the world.”

But the report raises one Big Question:  What policies will this administration come up with to deal with these problems?  These, presumably, will be in the next report, due in about 80 days.

This is an extraordinary report, a breath of fresh air in many ways, and I would love to know who wrote it.

But to fix the problems it raises will require taking on not only Big Ag, but also Big Food, Big Pharma, Big Chemical, and other industries affected by these and its other recommendations (the report also says a lot about drugs and mental health).  Big Ag has already weighed in.  Others are sure to follow.

Oh.  And it’s hard to know how policies can be implemented, given the destructive cuts to FDA, CDC, and NIH personnel and budget.

I will be watching this one.  Stay tuned.

Resources

• The press release: MAHA Commission Unveils Landmark Report Exposing Root Causes of Childhood Chronic Disease Crisis
• The Executive Order establishing the MAHA Commission
• The Commission report: Make Our Children Healthy Again Assessment

Additional resource

• Errol Schweizer sent me his analysis on Medium, well worth reading.

 

A reader, Effie Schultz, sent this one, with a comment that it comes with the longest conflict of interest statement she had ever seen (I’ve noted one that was two pages long in the first item in a post in 2015).

Association of Low- and No-Calorie Sweetened Beverages as a Replacement for Sugar-Sweetened Beverages With Body Weight and Cardiometabolic Risk: A Systematic Review and Meta-analysis.  McGlynn ND, and 20 other authors.  JAMA Network Open, March 14, 2022. 2022;5(3):e222092.  doi:10.1001/jamanetworkopen.2022.2092

The research question: Are low- and no-calorie sweetened beverages (LNCSBs) as the intended substitute for sugar-sweetened beverages (SSBs) associated with improved body weight and cardiometabolic risk factors similar to water replacement?

The conclusion: This systematic review and meta-analysis found that using LNCSBs as an intended substitute for SSBs was associated with small improvements in body weight and cardiometabolic risk factors without evidence of harm and had a similar direction of benefit as water substitution. The evidence supports the use of LNCSBs as an alternative replacement strategy for SSBs over the moderate term in adults with overweight or obesity who are at risk for or have diabetes.

Comment: Research on artificial sweeteners remains controversial.  I think we will be arguing forever about their safety and efficacy in helping people lose weight.  Studies with conflict of interest disclosures like the excessively extensive one here do not help resolve the research questions.

I strongly support revealing conflicted interests that might influence any aspect of research design, conduct, and interpretation.  For this study, I would be interested in financial ties or arrangements with companies that might either gain or lose sales or marketing advantages from results showing artificial sweeteners or diet drinks to be harmless or beneficial, as these do.  At issue here is whether financial ties to companies with corporate interests in the outcome of such research bias results or interpretation, consciously or unconsciously.

You have to search through this mess of unnecessary and distracting disclosures to find the ones that matter.  They are there.  You have to search for them.

Much of what is disclosed is irrelevant and, therefore, not helpful.

You may well disagree with that assessment.  Judge for yourself.

Conflict of Interest Disclosures: Ms McGlynn reported receiving a Canadian Institutes of Health Research (CIHR)-Masters Award during the conduct of the study and being a former employee of Loblaws Companies Limited outside the submitted work. Dr Khan reported receiving grants from CIHR, International Life Science Institute, and National Honey Board outside the submitted work. Dr Chiavaroli reported being a Mitacs Elevate postdoctoral fellow and receiving joint funding from the Government of Canada and the Canadian Sugar Institute. Mr Au-Yeung reported receiving personal fees from Inquis Clinical Research outside the submitted work. Ms Lee reported receiving graduate scholarship from CIHR and the Banting & Best Diabetes Centre at the University of Toronto outside the submitted work. Dr Comelli reported being the Lawson Family Chair in Microbiome Nutrition Research at the Joannah and Brian Lawson Centre for Child Nutrition, University of Toronto, during the conduct of the study and receiving nonfinancial support from Lallemand Health Solutions, donation to research program from Lallemand Health Solutions, personal fees from Danone, sponsored research and collaboration agreement from Ocean Spray, and nonfinancial support from Ocean Spray outside the submitted work. Ms Ahmed reported receiving scholarship from the Toronto Diet, Digestive tract, and Disease Centre (3D) outside the submitted work. Dr Malik reported receiving personal fees from the City and County of San Francisco, Kaplan Fox & Kilsheimer LLP, and World Health Organization outside the submitted work and support from the Canada Research Chairs Program. Dr Hill reported receiving personal fees from General Mills and McCormick Science Institute. Dr Rahelić reported receiving personal fees from the International Sweeteners Association, Abbott, AstraZeneca, Boehringer Ingelheim, Eli Lilly, Novo Nordisk, Merck, MSD, Salvus, and Sanofi outside the submitted work. Dr Salas-Salvadó reported receiving personal fees from Instituto Danone Spain, nonfinancial support from Danone Institute International, personal fees as director of the World Forum for Nutrition Research and Dissemination from the International Nut and Dried Fruit Council Foundation, financial support to the institution from Fundación Eroski, and financial support to the institution from Danone outside the submitted work. Dr Kendall reported receiving grants and/or in-kind support from Advanced Food Materials Network, Agriculture and Agri-Food Canada, CIHR, Almond Board of California, Barilla, Canola Council of Canada, International Nut and Dried Fruit Council, Peanut Institute, Pulse Canada, Tate and Lyle Nutritional Research Fund at the University of Toronto, and Unilever; receiving nonfinancial support from General Mills, Kellogg, Loblaw Brands Limited, Oldways Preservation Trust, Quaker Oats (Pepsi-Co), Sun-Maid, White Wave Foods/Danone, International Pasta Organization, California Walnut Commission, Primo, Unico, International Carbohydrate Quality Consortium (ICQC), and Toronto Diet, Digestive tract, and Disease Centre (3D) outside the submitted work; receiving personal fees from McCormick Science Institute and Lantmannen; and being a member of the Diabetes and Nutrition Study Group (DNSG) Executive Board and Dietary Guidelines, a member of the expert committee of the DNSG Clinical Practice Guidelines for Nutrition Therapy, a member of the scientific advisory board of the McCormick Science Institute, a scientific advisor for the International Pasta Organization and Oldways Preservation Trust, a member of the ICQC, an executive board member of the DNSG, and being the director of the Toronto Diet, Digestive tract, and Disease Centre (3D) Knowledge Synthesis and Clinical Trials Foundation. Dr Sievenpiper reported receiving nonfinancial support from DNSG of the European Association for the Study of Diabetes (EASD), grants from CIHR through the Canada-wide Human Nutrition Trialists’ Network (NTN), PSI Graham Farquharson Knowledge Translation Fellowship, Diabetes Canada Clinician Scientist Award, CIHR Institute of Nutrition, Metabolism and Diabetes and the Canadian Nutrition Society (INMD/CNS) New Investigator Partnership Prize, and Banting & Best Diabetes Centre Sun Life Financial New Investigator Award during the conduct of the study; receiving grants from American Society for Nutrition, International Nut and Dried Fruit Council Foundation, National Honey Board (the US Department of Agriculture [USDA] honey checkoff program), Institute for the Advancement of Food and Nutrition Sciences (IAFNS; formerly ILSI North America), Pulse Canada, Quaker Oats Center of Excellence, United Soybean Board (the USDA soy checkoff program), Tate and Lyle Nutritional Research Fund at the University of Toronto, Glycemic Control and Cardiovascular Disease in Type 2 Diabetes Fund at the University of Toronto (a fund established by the Alberta Pulse Growers), and Nutrition Trialists Fund at the University of Toronto (a fund established by an inaugural donation from the Calorie Control Council); receiving personal fees from Dairy Farmers of Canada, FoodMinds LLC, International Sweeteners Association, Nestlé, Abbott, General Mills, American Society for Nutrition, INC Nutrition Research and Education Foundation, European Food Safety Authority, Nutrition Communications, International Food Information Council, Calorie Control Council, Comité Européen des Fabricants de Sucre, International Glutamate Technical Committee, Perkins Coie LLP, Tate and Lyle Nutritional Research Fund at the University of Toronto, Danone, Inquis Clinical Research, Soy Nutrition Institute, and European Fruit Juice Association outside the submitted work; serving on the clinical practice guidelines expert committees of Diabetes Canada, EASD, Canadian Cardiovascular Society, and Obesity Canada/Canadian Association of Bariatric Physicians and Surgeons; being an unpaid scientific advisor for the Food, Nutrition, and Safety Program and the Technical Committee on Carbohydrates of IAFNS; being a member of the ICQC, executive board member of the DNSG of the EASD, and director of the Toronto Diet, Digestive tract, and Disease Centre (3D) Knowledge Synthesis and Clinical Trials Foundation; his spouse is an employee of AB InBev. No other disclosures were reported.

Reference: For a summary of research on the “funding effect”—the observations that research sponsored by food companies almost invariably produces results favorable to the sponsor’s interests and that recipients of industry funding typically did not intend to be influenced and do not recognize the influence—see my book, Unsavory Truth: How Food Companies Skew the Science of What We Eat.

I am indebted to David Ludwig for passing along this bit of nutritional history.

The study: PROLONGED MEAT DIETS WITH A STUDY OF KIDNEY FUNCTION AND KETOSIS.*
BY WALTERS. McCLELLAN AND EUGENE F. Du BOIS.  Journal of Biological Chemistry Volume 87, Issue 3, 1 July 1930, Pages 651-668
Method:  Several men agreed to eat nothing but meat for a year.  The meats included beef, lamb, veal, pork, and chicken, in various parts.  This was a high-fat, low-carb diet.  The men lived at home mostly.

Conclusion: In these trained subjects, the clinical observations and laboratory studies gave no evidence that any ill effects had occurred from the prolonged use of the exclusive meat diet.

Funder: These studies were supported in part by a research grant from the Institute of American Meat Packers.

Comment: I did not realize that industry sponsorship of favorable studies went back that far.  I’ll bet there are lots more.  Researchers: start digging!

If you are a marketer of fruit juice, you have a problem.  Fruit juice has a lot of sugar and retains little of the fiber of whole fruit.  Dietary recommendations increasingly suggest limits on the amounts consumed, especially for children.

But according to the trade group, the Juice Products Association, “The 2015 Dietary Guidelines for Americans and the American Academy of Pediatrics (AAP) concur that 4 to 6 ounces of 100% fruit juice per day is appropriate for young children. For children age 7 and older, the AAP recommends a daily serving of 8 to 12 ounces per day.”

No it does not!  The American Academy of Pediatrics suggests a limit to that amount.  Big difference.

Juice should not be introduced into the diet of infants before 12 months of age unless clinically indicated. The intake of juice should be limited to, at most, 4 ounces/day in toddlers 1 through 3 years of age, and 4 to 6  ounces/day for children 4 through 6 years of age. For children 7 to 18 years of age, juice intake should be limited to 8 ounces or 1 cup of the recommended 2 to 2.5 cups of fruit servings per day.

What about adults?  Adults do not need more sugars or the calories they provide.   They too would be better off eating fruit.

Juice trade associations to the rescue.

The study:  100% Fruit juice intake and cardiovascular risk: a systematic review and meta-analysis of prospective and randomised controlled studies. Lanfranco D’Elia, et al.  European Journal of Nutrition (2020)

Methods: This is a meta-analysis of prospective studies and randomized controlled trials (RCTs) examining the relationship between consumption of 100% fruit juice (FJ) and the risk of cardiovascular disease (CV).

Conclusions: “The results of these analyses indicate that 100%FJ consumption is not associated with higher CV risk. A non-linear inverse dose–response relationship occurs between 100%FJ consumption and CV disease, in particular for risk of stroke, probably mediated by the decrease in blood pressure.”

Funding: “Open access funding provided by Università degli Studi di Napoli Federico II within the CRUI-CARE Agreement. This project was funded by the European Fruit Juice Association (AIJN) via an unrestricted grant. AIJN was not involved in the design, conduction, analysis and interpretation of the results.”

Comment: Why would anyone think that fruit juice, of all things, would be associated with heart disease risk?  You would have to be drinking a lot of it —at the exclusion of healthier foods—for it to make  a significant difference.  The only point of this study is to try to convince adults to drink more juice.  When I was a kid, fruit juice was expensive and we drank it in 4-ounce glasses.  If you drink fruit juice at all, that’s still a good idea.

The press release from the Annals of Internal Medicine arrived last week under embargo, sent to me by several reporters: “New guidelines: No need to reduce red or processed meat consumption for good health.”

The press announcement was accompanied by 5 review papers, a sixth with this recommendation, and an editorial.  These are posted on the website of their publisher, the American College of Physicians, implying this organization’s endorsement of this guideline.

Collectively, these papers challenge dietary advice to eat less processed meat and red meat on the grounds of inadequate science.

These papers argue:

• Eliminating processed and red meat from the diet may reduce disease risks but the effects are small and evidence for them is of low quality and low certainty.
• Omnivores are unwilling to eat less meat.
• If you continue to think eating meat is bad for you in the face of this evidence, you are a victim of the “the less you know, the more you hold to your beliefs” syndrome.
• You can ignore dietary guidelines (regardless of source) and continuing eating meat as you always have.

This is a good example of what I call nutritional nihilism, an approach that insists that because observational studies are based on self-reported information and necessarily flawed, their conclusions are unscientific and should be discounted.  Therefore, because we can’t do more rigorous studies, we should not advise the public about diets best for health or the environment.

I have several concerns about all this:

• Yes, the effects are small but that is true of nutrition studies in general.  The small effects show benefits from eating less meat.  The authors could easily have interpreted their work as suggesting that eating less meat might be useful.  This is an example of interpretation bias.
• The authors took a strictly science-based approach to a problem strongly affected by social, economic, and political factors and values.
• The studies look at previous studies that compared people who eat meat to those who eat less. The authors excluded studies of vegetarians compared to meat-eaters.
• They look at meat outside its context of calories.
• The authors did not look at the totality of the evidence; they excluded laboratory and animal studies that can be more closely controlled.
• They excluded studies of environmental impact, which has a significant bearing on human dietary practices (meat production adds more greenhouse gases than vegetable production).
• The conclusions fall into the category of “everything you thought you knew about nutrition is wrong.”  This rarely happens.  Science usually works incrementally, not in one enormous reversal like this.

Do the authors really believe that all those other committees and commissions urging less meat were wrong and continue to be wrong?   Their strictly science-based approach seems unrealistic.

The papers come across to me as a concerted attack on dietary guidelines (national and international), on nutrition science in general, and on nutritional epidemiology in particular.

The meat industry and its supporters will love them.

Attacks on the quality of nutrition research have been coming from many sources lately: the food industry, of course, but also statisticians (John Ioannidis at Stanford is making a career of this), and some scientists (usually with ties to food companies).  The criticisms themselves are not new.

What is new is the vehemence and level of effort to discredit observational studies, particularly those based on self-reports of dietary intake.  Yes, nutritional epidemiology has flaws, but the methods have been useful in many instances, as argued convincingly by two of its leading practitioners.

In looking at nutrition research, I think it is essential to evaluate the totality of information available: laboratory, animal, human epidemiology and clinical studies—and to do this in the context of what people actually eat and the number of calories they consume, as well as adding in a hefty dose of common sense.

Common sense is what’s missing in these studies.  Do the authors really believe that:

• Meat eaters are healthier than vegetarians?
• Eating more meat is better for health?
• Meat eaters are less obese and have less heart disease and cancer than those who eat less?

If not, the conclusions make no sense.

Most of the authors report no financial ties to the food industry.  I would love to know the back story about why they chose to do these studies and to interpret them in this way.

Reactions (I will be adding to this list as they come in)

• The Harvard School of Public Health Nutrition Department issued a statement
• The True Health Initiative (THI) issued a press release outlining its concerns (the link is here)
• THI council members sent a letter to the journal editor stating objections (the link)
• THI collected quotes from members of its council and others (including mine)
• THI also produced graphics.  Here is one example.

• David Katz weighs in
• New York Times: 5 things you should know
• New York Times coverage: “Eat less meat, scientists said.  Now some believe that was bad advice.”
• From Dean Ornish
• Consumer Reports (I’m quoted)
• From the World Cancer Research Fund
• Vox’s crystal clear explanation
• NPR’s The Salt’s excellent analysis
• Aaron Carroll’s follow-up to his editorial