You may have heard the expression
“knowledge is power.”
Well, today we’re going to give you more power
to control your diet and lifestyle
by giving you the facts.
Welcome to the Nutrition Facts Podcast.
I’m your host, Dr. Michael Greger.
Today we have the first in an eight-part series
on how industries impact dietary and health guidelines.
And we start with Big Sugar.
In 2019, a series of reviews was published in the
Annals of Internal Medicine that concluded the same thing
that past reviews have concluded: adherence to dietary patterns
lower in red or processed meat intake may result in decreased risk
for premature death, cardiometabolic disease and mortality,
meaning the risk of getting and dying of diseases
like heart disease and type 2 diabetes, as well as the risk
of getting cancer and dying from cancer,
therefore, they concluded in their Dietary Guideline Recommendations,
“continue [your] current red meat consumption,”
“continue [your] processed meat consumption.”
Wait, what?! Yeah, premature death, cancer, heart disease,
diabetes, but keep eating your burgers and bacon.
To understand what just happened, we have to go back to 2015.
The Dietary Guidelines had just had the audacity
to recommend people reduce their sugar intake.
Imagine you work for the sugar industry.
The evidence is overwhelmingly against you; what do you do?
Well, what did the tobacco industry do?
One method involved the tobacco industry’s funding of
and involvement in seemingly unbiased scientific groups
to manipulate the scientific debate concerning tobacco and health.
Groups like the ILSI, the International Life Sciences Institute,
which has enjoyed a long and serious collaboration
with the tobacco industry,
that same industry group, shapes food policy around the world.
The International Life Sciences Institute (ILSI),
technically a nonprofit with an innocuous sounding name
“has been quietly infiltrating government health
and nutrition bodies around the world.”
It was created by a top Coca‑Cola executive, and
“almost entirely funded by Goliaths of the agribusiness,
food, and pharmaceutical industries.”
“After decades largely operating under the radar,
the Institute is coming under increasing scrutiny
by health advocates in the United States and abroad who say
it's little more than a front group advancing the interests
of the 400 corporate members,” among them Coke and Pepsi.
So, when the 2015 dietary guidelines advised eating less sugar,
the soda-funded International Life Sciences Institute
sponsored a review concluding that the guidelines
on sugar were simply not trustworthy.
Who did they pick for this hatchet job? Bradley Johnston.
And here it is, published in the Annals of Internal Medicine.
The Scientiﬁc Basis of Guideline Recommendations on Sugar Intake,
and concluded there basically wasn’t one.
“Guidelines on dietary sugar do not meet criteria for trustworthy
recommendations as they are based on low-quality evidence.”
“This comes right out of the tobacco industry’s playbook:
cast doubt on the science,” said Professor Marion Nestle,
“This is a classic (shameful) example of how industry funding biases opinion."
Yes, the paper was paid for by the likes of
Coca-Cola, Hershey, Red Bull, and the makers of Oreos.
But the authors swore they wrote the protocol
and conducted the study independently.
It turns out that was a lie, forcing the journal to publish
a corrected version after the Associated Press obtained emails
showing the industry front group “requested revisions.”
It also came out that a co-author conveniently forgot to mention
a $25 grand grant she got directly from Coca-Cola.
You know it’s bad when candy bar companies criticize
an industry-funded paper on sugar.
The maker of Snickers, Skittles, and M&M’s broke ranks with
other food companies and denounced the industry-funded paper.
They themselves were a member of the ILSI, but come on,
telling people to ignore guidelines to cut down on sugar?
That’s just making us all look bad.
If you look at the relationship between funding source
and the conclusions in nutrition- related scientific articles,
there’s like seven or eight times the odds that the conclusion
will skew favorably compared to studies with no industry funding.
For interventional studies, the proportion of studies paid for
by industry that reached unfavorable conclusions about their own
products was a big fat 0 percent, which should not surprise anyone.
So, what can journals do to counteract the tactics
that industry often uses to advocate for the safety
of unsafe products, or question the integrity of science
that calls their products into question?
To combat the tobacco industry's inﬂuence over scientiﬁc discourse,
leading journal editors have refused to be passive conduits
for articles funded by the tobacco industry.
They just won’t accept tobacco industry-funded studies period.
Accordingly, high-quality journals could refrain
from publishing studies on health effects of added sugars
funded by soda and cookie companies. But they’re not.
This was published in the Annals of Internal Medicine.
And so, four years later, with the next batch of dietary guidelines
on the way, and the last scientific report
of the guidelines committee encouraging people to eat diets
not just lower in sugar but lower in meat as well.
Big Beef decided to follow in the footsteps of Big Butterfinger.
Same journal, same guy, same scientist-for-hire,
Bradley Johnston, as lead author, and the rest is history.
We’ll dig into exactly how he pulled it off next.
In 2016, a Washington-based lobby group published a scientific review
which concluded that evidence in favor of guidelines
recommending limits on added dietary sugar was “low quality”
and did not “meet criteria for trustworthy recommendations.”
This was a group funded by multinational food and agrochemical companies
from Coca-Cola to Monsanto to the captains of corn syrup,
accused of “hijacking the scientific process in a disingenuous way
to sow doubt and jeopardize public health.”
But exactly how did they get away with it?
Here’s their paper, questioning the scientiﬁc basis
of guideline recommendations on sugar intake.
Using the “GRADE” approach, they concluded that the overall quality
of evidence to support such recommendations was low to very low.
GRADE stands for the Grading of Recommendations Assessment,
Development and Evaluation initiative, which was developed to make
clinical guidelines more evidence- based and thank heavens for that.
Clinical guidelines, like which drug to give to whom,
used to be developed by something like the GOBSAT method,
(just some Good Old Boys Sitting Around a Table).
Under GRADE, high-quality evidence appears
to be derived exclusively from randomized trials.
This is not surprising given that the GRADE process was designed
for drugs, and, of course, you want your drugs put to the test.
Like remember the Premarin story, where for a decade,
organizations recommended that clinicians encourage
postmenopausal women to use hormone replacement therapy,
because women who were taking it appeared to have fewer heart attacks.
But when put to the test,
randomized controlled trials instead showed the opposite.
So, we definitely want drugs put through randomized double-blind,
placebo-controlled trials, where people are randomized
to take the drug or unknowingly take a placebo instead,
and no one knows who’s in which group
until the code is broken at the end, and you see how well
the two groups did compared to each other.
Everyone agrees that randomized controlled trials
are enormously valuable in many areas of medical research,
such as the testing of drugs, but wait a second,
how do you do that with diet?
There’s no such thing as a placebo diet.
How can you randomize people to different diets
but somehow hide from them which diet they’re following?
People tend to notice what they put in their own mouths.
And RCTs (randomized controlled trials) are so expensive
they typically last for only weeks or months,
but it takes most cancers decades to develop;
so, it’s nearly impossible to see if different diets
prevent or cause cancer that way.
To see if smoking causes cancer, you can follow large cohorts
of smokers and nonsmokers out for decades to see who gets cancer
and who doesn’t, but it’s not like you can randomize people
to smoke or not smoke for decades.
When studying lifestyle interventions, you often just can’t do
randomized controlled trials, and even if you could,
it might not be ethical.
Take crib death, for example, sudden infant death syndrome.
A pivotal study studying the habits of infants who died
discovered that sleeping on their stomachs was a risk factor;
so, we started educating parents “face up to wake up,”
and the SIDS rates dropped. What more do we need?
Would it even be ethical to randomize thousands of babies to sleep
on their backs or fronts and count up the deaths at this point?
You can get sufficient evidence to make lifestyle recommendations
that save lives without randomized controlled trials.
Critical questions, like “What dietary pattern produces
the best health outcomes over a lifetime?”
simply can’t be answered with randomized controlled trials.
You can’t randomize people to different lifetime diets
and expect them to stick to them;
so, we need to compile an amalgamation of evidence from other study designs.
The lack of evidence from randomized controlled trials
has become a common argumentation strategy
for criticizing nutrition recommendations.
Similar claims were made by the tobacco industry in its attempt
to discredit evidence on the harms of tobacco.
Case in point: the so-called “sound science” campaign
carried out by Philip Morris.
This is all straight out of the tobacco industry playbook.
Philip Morris used public relations firms and lawyers to develop
a “sound science” program that involved recruiting other industries
and issues to obscure the tobacco industry’s role.
They tried to enshrine “good epidemiological practices”
that would make it impossible to conclude that secondhand smoke—
and thus other environmental toxins—caused diseases.
“Public health professionals need to be aware that
the ’sound science’ movement is not an indigenous effort
from within the profession to improve the quality
of scientific discourse, but rather reflects sophisticated
public relations campaigns controlled by industry executives
and lawyers whose aim is to manipulate the standards of
scientific proof to serve the corporate interests of their clients,”
and not just tobacco clients but they hope to expand
to the food, plastics, and chemical industries.
Philip Morris went beyond just “creating doubt” and “controversy”
about the scientific evidence, to attempting to change
the scientific standards of proof.
But randomized controlled trials aren’t
the only source of good evidence.
As Sir Bradford Hill himself said, who pioneered the randomized
controlled trial: “Any belief that the controlled trial
is the only way to go would mean
not just that the pendulum had swung too far
but that it had come right off (the) hook.”
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please go to the Nutrition Facts Podcast landing page.
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plus, links to all of the sources we cite for each of these topics.
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