Health Articles

Sugar: spinning a web of influence

BMJ 2015;350:h231 doi: 10.1136/bmj.h231 (Published 11 February 2015) Sugar: spinning a web of influence
Public health scientists are involved with the food companies being blamed for the obesity crisis,
reports Jonathan Gornall
Jonathan Gornall freelance journalist, Suffolk, UK An investigation by The BMJ has uncovered evidence of the was appointed chair of the food network for the government's extraordinary extent to which key public health experts are Public Health Responsibility Deal.
involved with the sugar industry and related companies Jebb, professor of diet and population health at the University responsible for many of the products blamed for the obesity of Oxford, is listed as the sole or coprincipal investigator in 10 crisis through research grants, consultancy fees, and other forms industry funded research projects between 2004 and 2015 with a total value of £1.37m, plus funding in kind. All projects linked Among the main targets in the United Kingdom for an industry to the food industry were completed before her government facing increasing pressure from government to reduce the health appointment, although a randomised controlled trial to test the harms caused by its products are researchers working on effectiveness of primary care referral to a commercial weight nutrition issues for two key government funded loss provider, funded at a cost of £186 280 by Weight Watchers, organisations—the Scientific Advisory Committee on Nutrition is not due to end until this year.
and the Medical Research Council's Human Nutrition Research The MRC stressed that the income does not benefit researchers unit at Cambridge.
personally but instead goes into the unit's central budget to fund The BMJ has found that for more than a decade funding from "project activities and may include staff/staff time, consumables industry has flowed to scientists involved with the research unit.
and equipment, other project costs and contributions to Scientists working on Medical Research Council (MRC) projects infrastructure and support costs." have received research funding from organisations including Researchers within the MRC's units and institutes were Coca-Cola, PepsiCo, Nestlé, the Institute of Brewing and "encouraged to work closely with the private sector, including Distilling, Weight Watchers International, NutriLicious (a public the pharmaceutical and food industries," said a spokesperson.
relations firm specialising in conveying "nutrition and health This enabled "the more rapid transfer of the best ideas into new messages" for the food industry), Sainsbury's, W K Kellogg interventions, the development of solutions that will benefit the Institute, and GlaxoSmithKline.
public, and improvement on the return of the MRC's investment Others received consultancy fees from Boots, Coca-Cola, Cereal in medical research." Partners UK, Mars, and Unilever Foods. They have also sat on Funding or funding in kind for research projects in which Jebb advisory boards for Coca-Cola, the Food and Drink Federation, is listed as principal or coprincipal investigator has come from and the Institute of Grocery Distributors.
Cereal Partners UK (which makes breakfast cereals under the Figures obtained through freedom of information requests Nestlé brand), the National Association of British and Irish suggest industry funding of the work of scientists in the Human Millers, Rank Hovis McDougal, Sainsbury's, pharmaceutical Nutrition Research unit alone may have averaged close to £250 company Sanofi, Tanita UK (a manufacturer of weighing scales), 000 (€330 000; $380 000) a year for the past decade. Industry Coca-Cola's Beverage Institute for Health and Wellbeing, and funding for the three years from 2010 to 2012 totalled £697 469, peaking at £380 874 in 2010—5% of the unit's total income Of these, Nestlé, Sainsbury's, Coca-Cola, and Unilever are for that year.
partners in the responsibility deal chaired by Jebb.
Between 2008 and 2010 Coca-Cola's beverage institute paid The BMJ has obtained a summary of the unit's research projects £194 652 for a clinical trial led by Jebb in the UK and US to between 2004 and 2013. Scientists whose work was funded, or test the effect on weight loss of a product being developed by part funded, by industry include Susan Jebb, who in March 2011 the company. Other significant sums included £194 000 from Sanofi, for a 2004-05 trial investigating "the effect of Rimonabant (an anti-obesity drug now withdrawn from the For personal use only: See rights and repr BMJ 2015;350:h231 doi: 10.1136/bmj.h231 (Published 11 February 2015) market) on energy intake in obese patients with or without If he did not, there would be "real concerns" that the group's intensive diet restrictions." The sum included "funding relating recommendations would be "prejudiced by commercial factors to advisory board membership which cannot be differentiated." rather than scientific public health priorities."6 7 Between 2007 and 2010 Weight Watchers International gave Macdonald, professor of metabolic physiology at the University £610 140 to a project led by Jebb to analyse data from the of Nottingham and director of research in the faculty of medicine Weight Watchers NHS referral scheme.
and health sciences, has not stepped down but told a SACN Jebb told The BMJ she was committed to "using funding from meeting last February that he would "not attend advisory board industry to support important pieces of research and to make meetings at Coca-Cola and Mars Europe at least until the . .
the information from these studies available for the public good." review is completed." She pointed out that the trials for Weight Watchers and Public Health England moved swiftly to counter suggestions Coca-Cola had investigator led protocols and were analysed that SACN's carbohydrates review had been compromised, and reported independently by the MRC.1-3 One of the criteria pointing out safeguards to ensure that "the report . . would for research collaborations between the MRC and companies, reflect considerations of the whole of SACN and would not be written into the contract, was "the independent right of the influenced by an individual member of the committee." These investigators to publish the data—whatever they may show." safeguards included "oversight by independent experts and Jebb pointed out that in the Coca-Cola research the product was government officials, the SACN main committee and the SACN found to be ineffective and did not lead to additional weight loss. "Personally, I am pleased that this was tested by However, the chair, Prentice, is the head of an institution that independent scientists and not the company themselves and that itself receives research funding from industry.
the results of this research are now in the public domain." Prentice confirmed that the declarations against her name in the She added: "Everything I do, whether in my research or as chair SACN register of interests relate to institutional funding into of the responsibility deal, is to try to improve public health. I MRC Human Nutrition Research and that she had "no personal do think that requires discussions with the food industry, and I involvement with, or research funding from, any of the funders think it is appropriate that we should be encouraging them to invest in research conducted by independent scientists." But The BMJ has discovered that the extent of industry Other researchers carrying out work for the Human Nutrition engagement with SACN experts is far greater than revealed Research unit with industry funding include senior investigator earlier, and not limited to the members of the committee's Ravin Jugdaohsingh (£58 248 from Coca-Cola Enterprises).
carbohydrates working group. An analysis of the annual Alison Lennox, professor of public health nutrition at the declarations of interest by SACN members shows that in the University of Surrey, collaborated with Jebb on a project funded 12 years from 2001 to 2012 there were 539 individual by Cereal Partners and the National Association of British and declarations of involvement with commercial organisations, Irish Millers and was also the principal investigator on Human including food firms, industry groups, and drug companies.
Nutrition Research studies funded by Mars (£3000) and the World Sugar Research Organisation (£10 000).
Of these, 179 were listed by Prentice and linked to the MRC.
Since her membership of SACN began in 2001, she has declared "non-personal interests" in 34 separate food or drink companies or organisations.
The news about researchers' interests follows the revelation last Membership of SACN has altered and increased over the years.
year that experts on the Scientific Advisory Committee on But of the 40 scientists listed as being members between 2001 Nutrition (SACN), which has just completed the first revision and 2012, only 13 have never declared interests in the of government advice on carbohydrates in the diet since 1991,4 committee's annual report.
had received funding from industry organisations with vested From the perspective of global food and drink companies the interests in the outcome of their work.
SACN members—and, indeed, the MRC—are just one small The committee was formed in 2001 to offer independent group of public health specialists in one relatively small market.
scientific advice to the Department and Health and the Food But multiply this purchased engagement with public health Standards Agency. From the start, it has published annual across all global territories and the scale of this tactic can begin declarations of members' conflicts of interest.
to be appreciated.
Ann Prentice, a founding member of the committee, and its This, perhaps, is the contemporary manifestation of the magnetic chair since 2010, is also director of MRC's Human Nutrition "field of influence" of the sugar industry to which John Yudkin, Research unit. Her declarations of non-personal "institutional a professor in the department of nutrition at Queen Elizabeth interests" include details of funding received by unnamed MRC College, London, referred in his 1972 bestselling book, Pure, researchers for whom she is responsible as director of the unit.
White and Deadly.8 The most recent annual report, for 2013, published in August this year, shows continuing MRC research funding from Coca-Cola, the Institute of Brewing and Distilling, and Weight Watchers International.5 For Alan Jackson, chair of SACN from 2001 to 2009, it is government funding policy that is to blame for driving scientists In January 2014 it emerged that five members of SACN's into the arms of industry. Members of SACN and its sub-groups, carbohydrates working group had worked in various advisory he told The BMJ, had "followed to the letter . . with due or consultancy roles for the food and beverage industry, probity" the guidance on transparency and declarations of including Coca-Cola and Mars.
interest that had been set out at the birth of the committee. The The medically led pressure group Action on Sugar told the Daily real problem, he said, lay with "a failure within government" Mail newspaper that the group's chair, Ian Macdonald, who had that placed individual scientists "in the invidious position of received funding from Coca-Cola and Mars, should step down.
particular vulnerability to being conflicted." For personal use only: See rights and repr BMJ 2015;350:h231 doi: 10.1136/bmj.h231 (Published 11 February 2015) A report last June by Universities UK, which represents almost and beverage industry. Any partnership must create profit for all of the UK's universities, identified a "real terms decline in the industry, which has a legal mandate to maximise wealth for the overall level of core public funding for university research," with universities estimated to have lost more than £460m Macdonald does not agree. "The issue of potential bias and between 2009-10 and 2012-13 and expected to lose a further conflicts of interest needs to be recognised," he told The BMJ.
£150m by 2015-16.9 As a consequence, collaboration between "But I think it's important to provide industry with balanced, higher education and business was becoming "more strategically accurate information and to do the same with government. I important for universities," with income rising steadily over the don't actually see why we should prevent industry having access past decade and surpassing £2bn in 2012-13.
to what is regarded as the best information." What industry did "Over the past 10-15 years government has increasingly with that information was "up to them, and it's the same for the encouraged and required individual academics, in common with secretary of state." other parts of society, to develop a mixed portfolio of support While he accepted that some companies collaborated with the for their individual research," Jackson said. "This has explicitly public health community in the hope of looking like good included support from industry. So most, if not all, researchers corporate neighbours, "the interactions I've had in an advisory will have some form of industry support and funding and hence sense with Mars and Coca-Cola and in a research collaboration have potential conflicts of interest. By the very nature of its sense with Mars and Unilever [tell me] that they really do take complex roots and wide interdisciplinary engagement nutrition the problems of obesity, metabolic syndrome, and diabetes has particular vulnerabilities in this regard, but it is by no means seriously and they are seeking advice to try to make a positive unique to nutrition." contribution towards it.
Illusion of self regulation
"The anti-camp would say, well, they should just stop making those things, but it's a bit more complicated than that," said But behind all the apparent concern for our wellbeing, just how Macdonald, who is the sole public health member of the serious are these firms about their commitment to public health, responsibility deal food network's high level steering group.
through mechanisms such as the UK responsibility deal? Other members come from PepsiCo, Tesco, the British Not very, says David Stuckler, professor of political economy Hospitality Association, the British Retail Consortium, the Food and sociology at Oxford University, who has written about the and Drink Federation, catering company Sodexo, and consumer impact of the food and beverage industries on public health.
organisation Which? Furthermore, he believes that public health experts who think "It isn't just fatty foods, sugary drinks, confectionery that are they can effect change from the inside are fooling themselves.
contributing," he added. "It's a combination of lots and lots of "All this falls into the category of efforts to crowd out public things, and just taking one thing out of the market is not going regulation, to try to weaken public health by working with it," to solve the problem. Making changes to the products they make, Stuckler told The BMJ.
changing the way they communicate with people, and getting them to demonstrate role model examples to other components "They much prefer voluntary self regulation to get government of the food industry is likely to be much more effective." intervention off their backs and will tend to do the minimum required to prevent regulation from upping the ante, just enough Competing interests: I have read and understood BMJ policy on to deflect public discontent or government intervention. That's declaration of interests and declare I am in receipt of funds from the why at least the real threat of government regulation is a European Union co-financed project ALICE RAP necessary ingredient for self regulation to work.
Provenance and peer review: Commissioned; not externally peer "For us, the bottom line is the data, and we've yet to see clear convincing data that ceding ground to market forces to effectively do nothing will enable industry to self regulate itself Jebb SA, Ahern AL, Olson AD, Aston LM, Holzapfel C, Stoll J, et al. Primary care referral in pursuit of public health goals." to a commercial provider for weight loss treatment versus standard care: a randomised controlled trial. Lancet 2011;378:1485-92.
There are, he says, "numerous examples of failure but few Ahern AL, Olson AD, Aston LM, Jebb SA. Weight Watchers on prescription: an independently monitored examples that have worked outside observational study of weight change among adults referred to Weight Watchers by the NHS. BMC Public Health 2011;11:434.
at least the pressure of public regulation. I just came from the Haddock CK, Poston WS, Lagrotte C, Klotz AA, Oliver TL, Vander Veur SS, et al. Findings World Public Health Nutrition Association where a series of from an online behavioural weight management programme provided with or without a voluntary self regulation initiatives in Mexico, Peru, and fortified diet beverage. Br J Nutr 2014;111:372-98.
Scientific Advisory Committee on Nutrition. Draft carbohydrates and health report. 2014 Thailand had been evaluated and had not succeeded.
"As we do with any drug or clinical intervention, we need to Scientific Advisory Committee on Nutrition. Annual reports, 2001 to 2012. have rigorous confirmation whether it's safe, and effective." Claims by industry to be addressing the health harms of its Action on Sugar. Are top government nutrition advisers addicted to sugar? Press release, products should be regarded with scepticism, he says. In a paper published in PLoS Medicine in 2012, Stuckler dismissed Renton A. Obesity tsars, sugar firms paying them a fortune and a very unhealthy voluntary self regulation or partnerships with public health as relationship. Daily Mail 2014 Jan 21. worse than useless. "Public health advocates . . may take jobs Yudkin J. Pure, white and deadly. Penguin, 2012.
with industry in order to make positive changes from within, Universities UK. Research and postgraduate research training—the funding environment for universities 2014. or actively seek partnerships and alliances with food companies.
Food, they say, is not tobacco."10 10 Stuckler D, Nestle M. Big food, food systems and global health. PLoS Med But there were "inherent conflicts of interest between 11 PepsiCo, Inc. Form 10-K for the fiscal year ended December 28, 2013. corporations that profit from unhealthy food and public health 12 Malik V, Popkin BM, Bray GA, Després JP, Willett WC, Hu FB. Sugar-sweetened collaborations . . We find no evidence for an alignment of beverages and risk of metabolic syndrome and type 2 diabetes. Diabetes Care public health interest in curbing obesity with that of the food 13 Capewell S. Sugar sweetened drinks should carry obesity warnings. BMJ 2014;348:g3428.
For personal use only: See rights and repr BMJ 2015;350:h231 doi: 10.1136/bmj.h231 (Published 11 February 2015) Box 1: Global threats to the industry
A clue to why so many global companies with nutritionally contentious products feel the need to fund research and invite public health experts
onto their advisory boards and into their boardrooms as consultants—and why they have been prepared to engage in the UK with the government's responsibility deal—can be found in two of the most recent annual submissions to the Securities and Exchange Commission in the US.
By law, for the benefit of investors, companies must submit a 10 K form to the commission listing all the risk factors a company faces. It is clear from the most recent submissions by Coca-Cola and PepsiCo that these sugary drink manufacturers live in fear of two things: ongoing research into the health effects of their products and the threat of health driven regulation and taxes.
"Maintaining a good reputation globally is critical to selling our branded products," reads PepsiCo's submission for the year ending December 2013. That reputation, it warns investors, could be adversely affected by "health concerns (whether or not valid) about our products or particular ingredients in our products, including whether certain of our products contribute to obesity."11The company's submission also shows its alarm at the increase in research into the health effects of sugary drinks and the possible consequences for its business.
"Studies are underway by third parties," it says, "to assess the health implications of consumption of certain ingredients or substances present in certain of our products, including … sugar."One example is the 2010 meta-analysis of 11 cohort studies published in Diabetes Care.12 The authors concluded that, in addition to weight gain, higher consumption of sugar sweetened beverages was associated with the development of metabolic syndrome and type 2 diabetes.
Intake "should be limited to reduce obesity related risk of chronic metabolic diseases."12Inspired by such research, regulators in some countries have been edging towards tougher regulation of sweetened drinks. Last May the California State Senate passed and referred to the state assembly a bill that seeks to see all drinks with more than 75 calories carry the warning, "Drinking beverages with added sugar(s) contributes to obesity, diabetes, and tooth decay."13Coca-Cola's submission noted that bad publicity resulting from such research or new warnings on labels or at point of sale could raise "consumer concerns, whether or not valid," about the health implications of consuming ingredients such as sugar. As a consequence, "demand for our products could decline and we could be subject to lawsuits or new regulations that could affect sales of our products."14Coca-Cola is equally aware of the threat to its bottom line, listing on its form "Obesity, poor diets and inactive lifestyles" among six key challenges and risks to its business.
"There is growing concern among consumers, public health professionals and government agencies about the health problems associated with obesity, which results from poor diets that are too high in calories combined with inactive lifestyles. This concern represents a significant challenge to our industry."Coca-Cola, it says, "understand and recognise that obesity is a complex public health challenge and are committed to being a part of the solution," yet it insists that "all of our products can be part of an active, healthy lifestyle that includes a sensible and balanced diet, proper hydration and regular physical activity."14 Box 2: Scientists funded by industry
Among the "institutional interests" declared in 2009 by SACN chair Ann Prentice were consultancies with both Coca-Cola and PepsiCo. The
following year her former husband, Andrew Prentice, head of the MRC International Nutrition Group and professor of international nutrition at the London School of Hygiene and Tropical Medicine, declared a consultancy with PepsiCo, in addition to a one-off consultancy with Danone and work as a lecturer for the Nestlé Nutrition Institute. He joined SACN in 2004 as an external expert on a working group reviewing dietary reference values.
Coca-Cola's support was mentioned in each of SACN's annual declarations of interests from 2001 to 2010, associated with three of the committee's scientists, including Ian Macdonald, chair of the carbohydrates working group, and anything from one to 14 unnamed MRC researchers.
The following MRC related declarations of interest in the Coca-Cola company are made under Ann Prentice's name in the SACN annual 2001: Nutritional consultancy2002 and 2003: Coca-Cola's membership of the MRC Human Nutrition Research forum2004 and 2005: Provision of lecture expenses2006: Consultancy with the Beverage Institute for Health and Wellness and Coca-Cola2007: Posts on the advisory boards of the beverage institute and Coca-Cola2008: Research funding from the beverage institute and post on Coca-Cola advisory board2009: Consultancy with Coca-Cola and research funding from the beverage institute2010: Research funding, consultancy, and membership of the company's main advisory board Of the SACN scientists, Macdonald, who joined the committee in 2005, made six separate declarations of involvement with Coca-Cola: as a member of the company's European advisory committee from 2007 to 2010 and for attending a meeting of the company's European Scientific Council in 2012. In 2009 Macdonald also declared an honorarium ("paid into university research funds") as a member of Coca-Cola's international public policy advisory board.
Two other SACN members have been associated with Coca-Cola. Sue Fairweather-Tait, head of the nutrition and consumer science division at the Institute of Food Research, received research funding from Coca-Cola for six years, from 2005 to 2010, and in 2010 Chris Riddoch, head of the London Sport Institute at Middlesex University, also received research funding from the company.
Mars has also funded at least one MRC and two SACN scientists in the UK. Macdonald served on the company's advisory board and received funding for a research project for six years, from 2005 to 2010, and research and PhD funding in 2011 and 2012. In 2012 Macdonald also attended a meeting of the Mars Scientific Advisory Council. In 2002 Fairweather-Tait received research funding from the company, while according to Prentice's declarations anonymous MRC researchers were awarded Mars consultancies in 2007 and 2008 and research funding in 2009.
14 Coca-Cola Company Form 10-K for the fiscal year ended December 31, 2013. Cite this as: BMJ 2015;350:h231 BMJ Publishing Group Ltd 2015 For personal use only: See rights and repr

BMJ 2015;350:h231 doi: 10.1136/bmj.h231 (Published 11 February 2015) [Enter caption here][Image: [Enter picture credit here]] Tangled web: connections between the sugar industry and UK government advisory bodies. Links represent research funding, consultancy, and advisory board membership. [Image: WILL STAHL-TIMMS] For personal use only: See rights and repr

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