Sugar: spinning a web of influenceBMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h231 (Published 11 February 2015) Cite this as: BMJ 2015;350:h231
All rapid responses
Gornall’s superb article1 and the subsequent responses highlight some potentially generic issues around Conflicts of Interest. These include partial advice, altered behaviour, disclosure and, crucially, how best to mitigate future harms.
Can we profit from Gornall’s case studies to generate some generic messages?
There is a long history of industry funded research in nutrition science, and widely acknowledged. But what happens when those same scientists are then elevated from the laboratory to the ministry to advise on national public health policy? Will anyone believe their assertions that substantial and prolonged industry funding does not bias their advice, nor impair their “scientific objectivity and impartiality”? Such claims contradict common sense and deny an extensive literature spanning the tobacco, alcohol, drug and food industries.2,3 Nutrition scientists are also human, and humans rarely bite the hand that feeds them.
Behaviour is clearly altered. Conflicts of Interests can manifest through the mere perception of bias, or through partial advice or altered behaviour. A committee chairman might leak a confidential preliminary conclusion favourable to industry4; or a Government advisor might energetically champion industry-friendly partnerships or “nudge” strategies widely seen as ineffective.5,6 Others might take substantial industry funding for research and multiple Scientific Advisory Board roles while consistently not disclosing these in scientific publications, lectures or broadcasts.1 Some nutrition scientists appear stuck in the denial phase. The public has not been impressed.1,7
Gornall demonstrates that the recent disclosure of food industry interests has clearly been inadequate. Yet, we are probably all conflicted financially, scientifically or personally. So how can potential conflicts of interest in food policy be better managed? The literature offers three alternative strategies: Conservative (do nothing), Descriptive (simply record potential conflicts) or Prescriptive (try and eliminate them). Thus, local and national government have for many years successfully operated clear policies for managing potential conflicts of interest - the Nolan Principles of Public Office.7
Can the UK food policy machine now develop and mature?
Clearly, the same individual scientists who are researching with industry support (however ethical) should not also be leading the formulation of public policy. A solution already exists to capture their expertise while minimising potential influence from industry. The Nolan Principles are already applied very effectively to scientists potentially entangled with the tobacco, alcohol or pharmaceutical industries. Will nutrition science catch up before the British public lose patience?
1. Gornall J. Sugar: spinning a web of influence BMJ 2015; 350 :h231
2. Moodie R et al. Profits and pandemics: prevention of harmful effects of tobacco, alcohol, and ultra-processed food and drink industries. The Lancet doi: 10.1016/S0140-6736(12)62089-3
3. Bes-Rastrollo M, Schulze MB, Ruiz-Canela M, et al. Financial Conflicts of Interest and Reporting Bias Regarding the Association between Sugar-Sweetened Beverages and Weight Gain: A Systematic Review of Systematic Reviews. PLoS Med 10(12): e1001578. doi:10.1371/journal.pmed.1001578
4. Telegraph 9 March 2015: http://www.telegraph.co.uk/news/health/news/10686201/Britain-will-not-ac...
5. G. Rayner, T. Lang. Is nudge an effective public health strategy to tackle obesity? No. BMJ doi: 10.1136/bmj.d2177
6. Panjwani C, Caraher M. (Feb 2014). The Public Health Responsibility Deal: Brokering a deal for public health, but on whose terms?. Health Policy doi:10.1016/j.healthpol.2013.11.002
7. Telegraph 12th Feb 2015: http://www.telegraph.co.uk/news/health/11407141/Government-obesity-advis...
Competing interests: No competing interests
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
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.
Competing interests: B. Popkin in the past 3 years has been funded once to speak on beverage consumption patterns and trends at the British Nutrition Association by Danone Water Research Center. Also he assisted a SSB vs water random controlled trial funded by Danone Water Research Center to the National Institute of Public Health, Cuernavaca, Mexico. At other times in his career for 4-5 years his SPH received gifts from Kellogg Corporation for his group to conduct diet studies with the understanding one paper each year would be on any topic and one would be on a topic related to breakfast.
The Medical Research Council encourages health scientists to form strategic research partnerships with industry, not least to accelerate the translation of research into public benefit. MRC also encourages researchers to give up time to advise the public and policy makers, provided that conflicts of interest are clearly identified. That some researchers do both, in an open and honest manner, is a well-known fact and all that is "revealed" in Jonathan Gornall's article (14/2/15). As I am ultimately responsible for everything MRC does, please add my name to your "tangled web". It would be an honour to stand alongside scientists such as Susan Jebb, Ann Prentice and Ian Macdonald, who are committed to improving public health through research.
Competing interests: Employed by MRC and University of Edinburgh. Research funding from MRC.
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?
Competing interests: No competing interests
As a group of scientists working within academia, we were concerned by the implications of a commissioned feature suggesting industry should stop funding external research . Universities are one of the best types of institution to carry out nutrition research. Academic researchers are interested in finding out the truth. If all universities refused to work with the food industry and the food industry carried out their own research without any collaboration with Universities, would this be a better situation? We think not. It would lead to more inferior research, greater potential for bias, and the decision to publish resting with the sponsor, potentially increasing publication bias.
Most journals have clear guidelines for declaring potential competing interests . The guidelines specify that the funding body should have no role in the study design, analysis of the data or content of publication. Even freelance journalists commissioned by the BMJ declare their many competing interests. Yet it is this transparency that forms the basis of the criticism contained in the feature.
In addition to singling out individuals for criticism, simply because they follow best practice in declaring competing interests, the BMJ feature targeted the Carbohydrates working group of the government’s Scientific Advisory Committee on Nutrition (SACN). The feature failed to mention that the SACN committee commissioned their own independent research on carbohydrate and cardio-metabolic health, conducted by the University of Leeds, to inform their recommendations. As independent researchers we published our own separate findings and subjected them to further peer review in leading medical journals [3-6]. The SACN committee is comprised of some of the most active and competent researchers in nutrition research, and we query whether there is anyone at this senior level who would not be declaring some form of competing interest.
It is vital that nutritionists are a well regulated and recognised profession. Journalists should not get confused by those who call themselves ‘nutritionists’ following a short, non-accredited training programme, compared to degree level training from accredited courses. The Association for Nutrition  protects and benefits the public by defining and advancing standards of evidence-based practice across the field of nutrition. Furthermore, nutritionists can potentially lose their registration if found to have not upheld these professional qualities, offering further protection against bias.
In summary, we strongly believe that it is simply unrealistic to expect government to fund all research used to inform nutrition policy. Therefore, providing there are robust systems in place to ensure that nutritionists declare all potential conflicts of interests and that research and publishing processes are transparent, there should be no barrier to researchers seeking funding from any source.
1. Gornall J. Sugar – spinning a web of influence. BMJ 2015;350:h231
2. Good Publication Practice (GPP2, 2009) (http://www.ismpp.org/gpp2)
3. Threapleton DE, Greenwood DC, Evans CE, Cleghorn CL, Nykjaer C, Woodhead C, et al. Dietary fibre intake and risk of cardiovascular disease: systematic review and meta-analysis. BMJ 2013;347:f6879.
4. Greenwood DC, Threapleton DE, Evans CEL, Cleghorn CL, Nykjaer C, Woodhead C, et al. Glycemic Index, Glycemic Load, Carbohydrates, and Type 2 Diabetes: Systematic review and doseresponse meta-analysis of prospective studies. Diabetes Care 2013;36:4166-71.
5. Threapleton DE, Greenwood DC, Evans CE, Cleghorn CL, Nykjaer C, Woodhead C, et al. Dietary fiber intake and risk of first stroke: a systematic review and meta-analysis. Stroke 2013;44:1360-8.
6. Greenwood DC, Threapleton DE, Evans CE, Cleghorn CL, Nykjaer C, Woodhead C, et al. Association between sugar-sweetened and artificially sweetened soft drinks and type 2 diabetes: systematic review and dose-response meta-analysis of prospective studies. British Journal of Nutrition 2014;112:725-34.
7. Cade J, Eccles E, Hartwell H, Radford S, Douglas A, Milliner L. The making of a nutrition professional: the Association for Nutrition register. Public Health Nutrition 2012;1-8.
Competing interests: Competing interests to declare Dr Charlotte E L Evans has worked on government funded projects as well as projects funded by the Medical Research Council, Kelloggs, Warburtons and Kids Company charity. Dr Darren C Greenwood has worked on projects funded by government, Medical Research Council, WCRF, Kelloggs, Meat and Livestock Commission and Danone. Dr Victoria J Burley has worked on projects funded by government, WCRF, Medical Research Council, Kelloggs and Meat and Livestock Commission and the Sugar Bureau. Professor Janet E Cade is Registrar for the Association for Nutrition; and has worked on government funded projects as well as projects funded by the Medical Research Council, WCRF, National Prevention Research Initiative, Kelloggs, Meat and Livestock Commission and the Kids Company charity
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?
Competing interests: No competing interests
A few weeks ago the BMJ published an article purporting to show that over 200 MPs and peers were in some way connected to the private health industry and that this affected the way they voted with regard the government's NHS reforms. The excellent Radio 4 programme, the scourge of the innumerate, successfully demolished this showing that those with a direct involvement were barely 10% of that number, and not even all of those voted for the reforms. The programme attempted to contact the author and eventually discovered that he was a "researcher" for the Unite trade union. The presenter drily suggested that we should be told how many MPs had links with Unite.
Now we have the same technique of attacking the integrity of scientists and others by innuendo, without any evidence whatsoever that the quality of their research had been in any way affected..
Of course the BMJ does not want impartial research, it wants people who conform to its prejudices and get the "right" answers and have correct opinions. Some years ago I commented on a similar attack on those who formulated diabetes guidelines and actually had been involved in drug trials - so had some actual knowledge of the drugs. Unfortunately the strain of holier than thou sanctimoniousness, mixed with juvenile agitprop, shows no signs of diminishing. Perhaps the BMJ could ease its tormented conscience by refusing adverts from the evil pharmaceutical industry?
Competing interests: I eat chocolate
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.
Competing interests: No competing interests
Whatever the rights and wrongs of the arguments the debate on the Today programme this morning between Colin Blakemore and Fiona Godlee was totally unfair to her and to listeners attempting to form any opinion. Firstly the amount of time to put relevant information into the debate was far too short, secondly and importantly the views of Colin Blakemore were given more weight simply by the fact that the BMJ editor's views could not be clearly heard and had to be shortened or cut into, giving more time to Colin Blakemore . That would possibly if she could hear the problems on the line, make presenting an argument more difficucult.. The presenter dismissively brushed the problem off as this is what happens when skype is being used in a broadcast. It was not so much just just a waste of time but being so badly presented by the Today programme made the BMJ's campaign whether justified or not look petty and unreasonably biased against industry's involvement in food policy.
Competing interests: No competing interests
Gornall alleges that the scientists he names in his series are influenced by the food industry to work against the cause of public health but produces no evidence of this. Instead, he collects quotes from people to suggest that the current policies are not working, which he attributes to the malign operations of the food industry, working at least partly through these scientists.
The opposite appears to be the case. For example, the SACN report proposed that no more than 5% of a person’s energy intake should be in the form of sugar. In the UK, the average child consumes about 15% and the average adult about 12% of their energy as sugars. The SACN target is much lower than current UK intake. It is hard to see how policy actions would be different if the target had been set lower, say to 3%., if Gornall is correct and that SACN target was pulled upwards by industry-influenced scientists. The problem of nutrition is not what we should eat but how we persuade ourselves to eat it.
There is broad consensus in public health that we need wholesale shifts in the food environment that put the sugary treats we like to eat out of consciousness. There is no chance of imposing this change on politicians or the public who currently neither share nor want this vision. We need instead to build consensus that such change is necessary. The gains in tobacco control that regulated the market were achieved by patient consensus building. Attacking scientists leading this work damages this cause because it undermines the trust of public and professionals in the science that underpins these recommendations. Arguing for a more radical vision than the Responsibility Deal could ever deliver does not require commentators to be blind to or criticise the gains achieved by it.
There is a strong tide of sanctimony in British public health and riding this tide is a luxury more easily enjoyed by commentators than those who are actively involved in improving health. The reality is that the scientists named in Gornall’s reports deserve to sleep the sleep of the just. I am privileged and proud to work with Susan Jebb, one of the scientists named. The sadness of this kind of attack is that I have seen the very real personal toll. It is just one more way that this BMJ series has harmed health.
Competing interests: I am working on two current trials of weight management in primary care in which commercial weight loss companies (Slimming World, Rosemary Conley, and Weight Watchers) donate free 12-week treatment courses to the NHS that that NHS would otherwise have paid for. This is not a benefit to me personally or my department. I have given and received hospitality on a few occasions to members of these companies. I have also worked with the pharmaceutical industry on smoking cessation. Once in the past three years I gave a day's consultancy to Pfizer on general topics related to smoking cessation that led to payments to me and the University of Oxford.