Sugar: spinning a web of influence

Dear BMJ:

As a scholar who has been actively fighting to reduce added sugar in our diet for several decades and as one who has not only published extensively on the topic but actively worked with governments to tax sugar-sweetened beverages,1-4 I thought the BMJ article missed the key elements for when industry influences scholars.5-7 Furthermore, I felt that Dr. Jebb, with whom I wrote one paper on beverage consumption plans and was working with her on planning to tax SSB’s in the UK, was quite incorrectly impugned.8 I should note that I also have interacted with, evaluated their practices, and worked with the food industry. This has involved private discussions with other noted scholars and the food industry on nutrition topics, public negotiations on many key issues related to program implementation in a number of low or middle income countries and I have received gifts from industry that were unfettered to undertake diet studies. Also I worked with very respected scholars on several random-controlled trials, where industry funding was involved. But few would call me a friend of the food industry. However, I do feel we must reform them, cannot just ignore them, and must use regulatory changes to push this process. I use this background of mine as a basis for pointing where we need to look for scholars whose work is truly affected by their industry-funded efforts.

Consultation and active helping is absolutely a no-no. First, there are a number of scholars who consult and aid the sugar industry globally. We have a number in my country and one of our major network news programs actually had 5 minutes to discuss one scholar suspected of such bias who received funding and consultancies from this sector.9 And there are the scholars who were funded by the big sugar and beverage industries that paid for their salaries and offered handsome consulting arrangements who continue to work to obfuscate the research on sugar and health. I will not name any of them but some are quite known and others are just on boards of industry groups, hired to give speeches in other countries (e.g., when an eminent Colombian endocrinologist was paid to go to Mexico City a day before a government SSB tax to give a talk that stated that soft drinks and sugar were fine to consume and did not affect diabetes). This is the most blatant use of industry funding to pervert science, but more subtle cases are usually found. Those are the scholars the BMJ should have sought out and they are the ones who have created the biased literature noted in a few reviews.10 11

Second, there are few scholars who have not attended conferences with industry sponsorship or worked at one time or another on projects that received industry funding who work in the food and nutrition area. But few of them are actively promoting and working with industry in the manner ascribed in this BMJ article and certainly from my many conversations with Dr. Jebb, she is not one of them. This is certainly the case with respect to sugar.

Big tobacco provides the best example of the harmful effect of industry funding. But certainly the sugar and food industry have also worked in a similar manner.12 To me the major issue is that first and foremost, the food industry has paid prominent scientists to conduct studies which blatantly are designed to give answers questioning other science that goes against the industry and also these individuals usually act as advisers and consultants with the intent of countering potentially damaging scientific evidence. But this is based on funding studies directly relevant to that industry and then having the scholars speak up for the industry. There are clear cases where the industry has bought scientists and science as noted above and the big sugar and big beverage area is absolutely filled with such scholars. But I think the article did not undertake the due diligence to find where personal gain and where scientists as well as just as often professional organizations are bought. Then industry does use its funding to mislead and obfuscate public knowledge. And big beverage has been using spokespersons and scientists like this for decades. But I do feel that the wrong individuals were singled out. I certainly know that a person that pushed for an SSB tax like Dr. Jebb does not fit this bill.

In summary, I felt this set of BMJ articles5-7on the influence of sugar was not only naïve but misguided and missed the people in the UK funded by the industry to help them directly and actively to obfuscate science around key policy issues. And there were and remain many who actively continue to keep the public health agencies from undertaking further actions in the tobacco area. Now we are seeing an increasing number of those in many other medical areas and certainly now in the food arena work actively to stop regulatory actions which are essential if we are to improve our diets and reduce our risks of a vast array of diet-related noncommunicable diseases. At the same time it is almost impossible not to have some interactions with the food industry if one wishes to make changes at a time when for half of the low and middle income countries and most of the higher income countries significant proportions of our food intake comes from package food purchases, most processed minimally or ultraprocessed.13.

Barry M. Popkin

References

1. Ng SW, Slining MM, Popkin BM. Use of caloric and noncaloric sweeteners in US consumer packaged foods, 2005-2009. J Acad Nutr Diet 2012;112(11):1828-34.e6.
2. Popkin BM. Sugary beverages represent a threat to global health. Trends Endocrinol Metab 2012;23(12):591-93.
3. Brownell KD, Farley T, Willett WC, et al. The public health and economic benefits of taxing sugar-sweetened beverages. New Eng J Med 2009;361(16):1599-605.
4. Popkin BM, Nielsen S. The sweetening of the world's diet. Obes Res 2003;11(11):1325-32.
5. Gornall J. Sugar’s web of influence 3: Why the responsibility deal is a “dead duck” for sugar reduction. BMJ 2015;350.
6. Gornall J. Sugar’s web of influence 2: Biasing the science. BMJ 2015;350.
7. Gornall J. Sugar: spinning a web of influence. BMJ 2015;350.
8. Ng SW, Ni MC, Jebb S, et al. Patterns and trends of beverage consumption among children and adults in Great Britain, 1986–2009. Br J Nutr 2012;108:536-51.
9. Harris D, Patrick M. Is 'Big Food's' Big Money Influencing the Science of Nutrition? Secondary Is 'Big Food's' Big Money Influencing the Science of Nutrition? 2011. http://abcnews.go.com/US/big-food-money-accused-influencing-science/stor....
10. Lesser LI, Ebbeling CB, Goozner M, et al. Relationship between funding source and conclusion among nutrition-related scientific articles. PLoS Med 2007;4(1):e5.
11. Vartanian LR, Schwartz MB, Brownell KD. Effects of soft drink consumption on nutrition and health: A systematic review and meta-analysis. Am J Public Health 2007;97(4):667-75.
12. Brownell KD, Warner KE. The perils of ignoring history: Big Tobacco played dirty and millions died. How similar is Big Food? Milbank Q 2009;87(1):259-94.
13. Popkin BM. Nutrition, agriculture and the global food system in low and middle income countries. Food Policy 2014;47:91-96.

The details of the involvement of nutritionists leading the negotiations with the sugar industry provided by ‘The Editors Comments and Analysis' cannot be disputed. What is questionable is that lasting changes in the practices of the sugar based industry can only follow crusades, confrontation and legislation. A historical parallel might be drawn with Prohibition of alcohol in the United States.

Many years ago I received research finance from the National Association of British and Irish Millers for a large study on measurements of diet, blood chemistry and faecal weight. Twice a year over several years I met amicably with the Association Director and the Chairmen of the two large Milling and Baking Companies along with two medical Professors. Over many meetings the clinicians were able to persuade the Bakers of the nutritional and economic merit of wholemeal and other brown loaves over their previously favoured white loaf. A lasting nutritional advantage was achieved.

The nutritionists indicted in the articles are surely aware of the complex issues. Their non-confrontational approach will almost certainly yield the required dietary results.

It must surely be preferable to discuss, debate and achieve change by education & negotiation rather than by attempting to enforce change by legislation?

The BMJ is quite wrong to suggest that research funded through industry collaborations and professional bodies can’t be trusted. Research institutions already have in place processes to achieve transparency and robust independent review in addition to the individual code of ethics followed by the professional scientists who are either commissioning or undertaking the research.

The UK needs to be doing much more research. Society faces some very challenging issues of which obesity is one. Many of us are working to increase the amount of research being undertaken so as to improve the evidence base on which individuals, governments, regulators, industry and society can base their decisions.

The tax payer cannot afford to fund all the research that is needed to improve and expand our evidence base. It is absolutely right that industries should be partners in finding the solutions we need so we should be encouraging them to contribute more to the overall research activity in their fields of interest – not less. It’s worth noting also that the research outcomes will be public and may be more widely applicable beyond reducing sugar giving us a deeper understanding of other sources of minerals for improving nutrition and food quality.

It’s troubling that the BMJ takes this stand on food related research but not on other issues of public concern. For the most part the BMJ calls for the pharmaceutical and bio-tech sectors to be making a greater investment in UK science rather than taking their R&D overseas.

It is society as a whole that sets out its concerns and the agenda of improvements and change that they want to see – such as tackling obesity. The industries then come under pressure from their own shareholders, consumers and the wider public to respond to those concerns and it’s clearly right that they should seek a sound research and evidence base on which to move forward. How can they change their products otherwise?

Society as a whole calls for energy companies to be doing more in terms of funding research to enable all of us to reduce our carbon foot print. Society encourages and welcomes the aeronautical industries' funding of research that improves air travel safety, noise reduction and pollution. Transport sectors are expected to invest in research that reduces dependence on fossil fuels and increases safety. The BMJ welcomes with open arms (and makes some of its own profit from) medical and health research that was in part funded directly or indirectly from pharmaceutical companies and other vested interests. Those same people also advise government on health issues , drive forward changes in health policy and campaign to support more research in their own areas of interest. Why is the BMJ calling for different standards for food research?

We felt compelled to write in response to the BMJ feature highlighting “a sinister web of influence” that industry supposedly has over UK nutrition research and public policy.

The article and surrounding press coverage suggests poor quality and biased research may have been undertaken because nutrition studies are often funded by industry. However, this piece actually fails to show any evidence of this, and merely highlights the well-known fact that a proportion of UK nutrition research has been funded by industry. This information is already clearly in the public domain and cited as a funding source or conflict of interest in each of the peer review publications the work has been published in.

Industry funding is an inevitable consequence of limited government research funds. In addition it is useful for academia to link with industry as this allows research findings to be more rapidly translated into products and interventions. Quicker implementation of findings and roll out to the public has the potential to influence public health rather than remaining as static academic information. I believe this article goes to show that the author (and by extension the BMJ) does not fully understand how research funding works. Personally, I think it is encouraging that companies are seeking out the help of independent world class researchers such as Professor Jebb to carry out research on wider nutritional issues beyond their immediate product lines.

Public health nutrition is an extremely important and challenging research field with the potential to improve the nation’s health, and that of future generations. This has never been more present than with current trends of obesity, unhealthy lifestyles and associated diseases including diabetes, cardiovascular disease, cancer and dementia.

Good scientific debates around nutrition and policy are to be encouraged and will improve recommendations, and are what we expect to see published in peer review journals like the BMJ. However the press coverage and debate around this piece has been headline-grabbing and unhelpful. This comes in a week when the BMJ open Heart journal published a review of data collected 35 years ago to highlight a lack of evidence for cardiovascular disease prevention guidance in 1983 (Harcombe et al BMJ Open Heart 2015;2: doi:10.1136/openhrt-2014-000196). “Dietary recommendations were introduced for 220 million US and 56 million UK citizens by 1983, in the absence of supporting evidence from RCTs”. Both pieces seem to be attacks on public health researchers and policy to create headlines.

The leading researchers listed in the feature have undertaken many years of vital high-quality research to determine the most effective dietary guidelines, explore the best way to implement guidelines and to encourage public adherence to the recommendations. They are widely-respected researchers of great intellect and integrity who aim to advance nutritional science and improve public health. The same could not be said of this and the BMJ Open Heart feature.

Confusing and contradictory headlines create uncertainty, mistrust of researchers and public policy, and disengage the public from health messages. This will ultimately only serve the nation harm, and increase the ever-growing number of individuals with weight and diet-related illness; more diabetes, heart disease, stroke, cancer and dementia.