Currently browsing posts about: Conflicts-of-interest

My e-mail inbox is filled with items about the Academy of Nutrition and Dietetics (AND, formerly the American Dietetic Association).  Its “seal of approval” on Kraft cheese singles (as discussed in an earlier post) was embarrassing—so embarrassing that it was discussed by Jon Stewart: “The Academy is an Academy in the same way this [Kraft Singles] is cheese” (the clip starts at 4:37).

The Onion also had some fun with this.

But now there is even more about how food companies buy the opinions of dietitians.

Candice Choi writes about how Coca-Cola pays dietitians to promote its drinks as healthy snacks (for an example of one of the paid posts, click here).  She explains that the dietitians

wrote online posts for American Heart Month, with each including a mini-can of Coke or soda as a snack idea. The pieces — which appeared on nutrition blogs and other sites including those of major newspapers — offer a window into the many ways food companies work behind the scenes to cast their products in a positive light, often with the help of third parties who are seen as trusted authorities.

Ms. Choi quotes a Coca-Cola spokesman:

“We have a network of dietitians we work with,” said Sheidler, who declined to say how much the company pays experts. “Every big brand works with bloggers or has paid talent.”

Other companies including Kellogg and General Mills have used strategies like providing continuing education classes for dietitians, funding studies that burnish the nutritional images of their products and offering newsletters for health experts. PepsiCo Inc. has also worked with dietitians who suggest its Frito-Lay and Tostito chips in local TV segments on healthy eating.

These are individual actions.  But at last the dietetic membership is objecting to the Academy’s partnership with Kraft.

1. They have started a Change.org petition to #RepealTheSeal.
2. The President of the New York State AND chapter (NYSAND), Molly Morgan, sent out a note in support of the petition.

Thank you to the many of you that have expressed your concern and disappointment about the Academy of Nutrition and Dietetics partnership with Kraft. This issue has been reviewed carefully by the NYSAND Board of Directors and the entire board is in support of actively taking steps to share our members concerns. Below are the action steps that NYSAND is taking:

–       Last week (March 11, 2015) the NYSAND Sponsorship Task Force recommendations were received and yesterday (March 16, 2015) at the March NYSAND Board of Directors meeting the Sponsorship Task Force recommendations were reviewed. Please stay tuned for more updates and note that a motion will be forth coming this week for the board to take the next step in addressing sponsorship for NYSAND.

–       Today (March 17, 2015) a letter was sent to the Academy president and emailed to several Academy leaders expressing the views that our members have shared and that as an Affiliate we are not comfortable responding with the talking points provided by the Academy on this issue.

–       Dietitians have started a petition, “Repeal the Seal”; NYSAND will be sharing this on our Affiliate Facebook and Twitter pages and encourages all members who share the concern to sign the petition as well. CLICK HERE to sign the petition.

3.  The AND national CEO, Patricia M. Babjak, sent out this letter to members, also on March 17:

Let me begin by apologizing for the concerns caused by the education initiative with Kraft. The Academy and the Foundation are listening. As a member-driven organization, the Academy’s staff and leadership hear your concerns and welcome your input.

Unfortunately, recent news articles misstated a collaboration as a Kids Eat Right “endorsement” of Kraft Singles, and that it represents a “seal of approval” from Kids Eat Right, the Foundation, or the Academy. It is not an endorsement. It is not a seal of approval. We understand this distinction is of little consequence to many Academy members who are concerned with the perception. We are working on a solution.

In addition, we are working to establish a joint, member-driven Member Advisory Panel. This Panel will work closely with both Boards to:

• Establish dialogue with members
• Gather input and give feedback on member issues
• Make specific recommendations

Recognizing sponsorship as a significant issue of concern among members, the House of Delegates leadership team, who also serve on the Board of Directors, scheduled a dialogue on sponsorship for the upcoming virtual House of Delegates meeting, May 3. We encourage all members to reach out to your delegates and share your thoughts on the benefits of, concerns about and suggestions for the sponsorship program. The Academy and Foundation Boards are looking forward to your input.

Applause to members who are speaking out.

As I said in an interview with TakePart:

The food companies have learned from tobacco and drugs and other industries like that how to play this game…Let’s confuse the science, let’s cast doubt on the science, let’s shoot the messenger, let’s sow confusion.

But since everyone has to eat, the food industry has been given a pass on its pay-to-play practices….

The capital N news…is that dietitians are fighting back at last.

I hope they join Dietitians for Professional Integrity and insist that the leadership respond to their concerns.

Addition: A dietitian sends this communication from the Executive Board of the California Dietetic Association to members about the Kraft situation:

We would like to direct your attention to what the California Dietetic Association (CDA) has done to address our own issues surrounding sponsorship. We heard your concerns regarding CDA Annual Conference sponsorship and we have listened. We voted and McDonalds was not invited as a sponsor in 2015. This decision has impacted our finances; however, we believe it was important to respond to our member feedback. In addition, an ad hoc committee approved by the CDA executive board, reevaluated the sponsorship guidelines. The new sponsorship policy will be posted soon on www.dietitian.org.

I’ve been collecting examples of conflicted research for the past week or so.  These are studies paid for in part by food businesses or trade associations with a vested financial interest in the outcome of the research.

These almost invariably promote the financial interests of the sponsor.  To wit:

Cocoa flavanol consumption improves cognitive function, blood pressure control, and metabolic profile in elderly subjects: the Cocoa, Cognition, and Aging (CoCoA) Study—a randomized controlled trial, by Daniela Mastroiacovo, Catherine Kwik-Uribe, Davide Grassi, Stefano Necozione, Angelo Raffaele, Luana Pistacchio, Roberta Righetti, Raffaella Bocale, Maria Carmela Lechiara, Carmine Marini, Claudio Ferri, and Giovambattista Desideri.  Am J Clin Nutr 2015; 101:538-548 doi:10.3945/ajcn.114.092189.

• Conclusion: These data suggest that the habitual intake of flavanols can support healthy cognitive function with age.
• Sponsor: Mars, Inc.

Sugar-Sweetened Product Consumption Alters Glucose Homeostasis Compared with Dairy Product Consumption in Men and Women at Risk of Type 2 Diabetes Mellitus, by Kevin C Maki, Kristin M Nieman, Arianne L Schild, Valerie N Kaden, Andrea L Lawless, Kathleen M Kelley, and Tia M Rains.  J Nutr. 2015; 145:459-466 doi:10.3945/jn.114.204503.

• Conclusion: These results suggest that SSP consumption is associated with less favorable values for HOMA2–%S, LMTT disposition index, HDL cholesterol, and serum 25(OH)D in men and women at risk of T2DM vs. baseline values and values during dairy product consumption.
• Sponsor: Dairy Research Institute/National Dairy Council

Squeezing Fact from Fiction about 100% Fruit Juice, by Roger Clemens, Adam Drewnowski, Mario G Ferruzzi, Cheryl D Toner, and Diane Welland. Adv Nutr 2015;6: 236S-243S. doi: 10.3945/​an.114.007328.

• Conclusion:  The preponderance of evidence supports the position that 100% fruit juice delivers essential nutrients and phytonutrients, provides year-round access to a variety of fruits, and is a cost-effective way to help people meet fruit recommendations.
• Sponsor: Juice Products Association

Can probiotic yogurt prevent diarrhoea in children on antibiotics? A double-blind, randomised, placebo-controlled study, by Michael J Fox, Kiran D K Ahuja, Iain K Robertson, Madeleine J Ball, Rajaraman D Eri.  BMJ Open 2015;5:e006474.  doi:10.1136/bmjopen-2014-006474.

• Conclusion: A yogurt combination of LGG, La-5 and Bb-12 is an effective method for reducing the incidence of antibiotic-associated diarrhoea in children.
• Sponsor: Parmelat Australia

Chronic consumption of flavanone-rich orange juice is associated with cognitive benefits: an 8-wk, randomized, double-blind, placebo-controlled trial in healthy older adults, by Rebecca J Kean, Daniel J Lamport, Georgina F Dodd, Jayne E Freeman, Claire M Williams, Judi A Ellis, Laurie T Butler, and Jeremy PE Spencer.  Am J Clin Nutr 2015; 101:506-514 doi:10.3945/ajcn.114.088518.

• Conclusion: Chronic daily consumption of flavanone-rich 100% orange juice over 8 wk is beneficial for cognitive function in healthy older adults.
• Sponsor: Partially funded by the State of Florida Government, Florida Department of Citrus.  The authors report: “Florida Citrus helped designed [sic] the research. None of the authors reported a conflict of interest related to the study.”

Dairy consumption and risk of cardiovascular disease: an updated meta-analysis of prospective cohort studies, by Li-Qiang Qin PhD, Jia-Ying Xu PhD, Shu-Fen Han PhD, Zeng-Li Zhang PhD, You-You Zhao PhD, Ignatius MY Szeto PhD.   Asia Pac J Clin Nutr. 2015 Mar;24(1):90-100. doi: 10.6133/apjcn.2015.24.1.09.

• Conclusion:  This meta-analysis provided further evidence supporting the beneficial effect of dairy consumption on CVD. Low-fat dairy products and cheese may protect against stroke or CHD incidence.
• Sponsor: Nestec Ltd. (Nestlé R&D (China) Ltd.  Two of the authors work for the company (to which I am not related).

In each of these cases, the sponsors got what they paid for.  Recent sponsored studies have not come to conclusions contrary to the interests of the sponsor.

Coincidence?

You decide.

Michele Simon’s latest investigative report deals with sponsorship by food corporations of the Australian Dietetics Association.

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.