International Journal of Environmental Research and Public Health, 2020
No studies have documented the prevalence of the food industry’s funding of academic programs, wh... more No studies have documented the prevalence of the food industry’s funding of academic programs, which is problematic because such funding can create conflicts of interest in research and clinical practice. We aimed to quantify the publicly available information on the food industry’s donations to academic programs by documenting the amount of donations given over time, categorizing the types of academic programs that receive food industry donations, cataloguing the source of the donation information, and identifying any stated reasons for donations. Researchers cataloged online data from publicly available sources (e.g., official press releases, news articles, tax documents) on the food industry’s donations to academic programs from 2000 to 2016. Companies included 26 food and beverage corporations from the 2016 Fortune 500 list in the United States. Researchers recorded the: (1) monetary value of the donations; (2) years the donations were distributed; (3) the name and type of recip...
Industry-sponsored nutrition research, like that of research sponsored by the tobacco, chemical, ... more Industry-sponsored nutrition research, like that of research sponsored by the tobacco, chemical, and pharmaceutical industries, almost invariably produces results that confirm the benefits or lack of harm of the sponsor's products, even when independently sponsored research comes to opposite conclusions. 1 Although considerable evidence demonstrates that those industries deliberately influenced the design, results, and interpretation of the studies they paid for, 2 much less is known about the influence of food-company sponsorship on nutrition research. Typically, the disclosure statements of sponsored nutrition studies state that the funder had no role in their design, conduct, interpretation, writing, or publication. Without a "smoking gun" it is difficult to prove otherwise. In this issue of JAMA Internal Medicine, Kearns and colleagues 3 report on having found a smoking gun. From a deep dive into archival documents from the 1950s and 1960s, they have produced compelling evidence that a sugar trade association not only paid for but also initiated and influenced research expressly to exonerate sugar as a major risk factor for coronary heart disease (CHD). Although studies at that time indicated a relationship between high-sugar diets and CHD risk, the sugar association preferred scientists and policymakers to focus on the role of dietary fat and cholesterol. The association paid the equivalent of more than $48 000 in today's dollars to 3 nutrition professors-at Harvard no less-to publish a research review that would refute evidence linking sugars to CHD. The sponsored review appeared in 2 parts in the New England Journal of Medicine in 1967. Its authors acknowledged support from the industry-funded Nutrition Foundation, but they did not mention the sugar association's specific funding of their review. Their first article demonstrates a close correlation between sugar and fat "consumption" (actually amounts in the food supply) and mortality in 14 countries (Figure). 4 To minimize the association with sugar, the authors seem to have cherry-picked existing data. Despite their having previously published studies linking both fats and sugars to CHD risk, their review gave far more credence to studies implicating saturated fat than it did to those implicating sugars. The documents leave little doubt that the intent of the industry-funded review was to reach a foregone conclusion. The investigators knew what the funder expected, and produced it. Whether they did this deliberately, unconsciously, or because they genuinely believed saturated fat to be the greater threat is unknown. But science is not supposed to work
Conditions related to nutrition are commonly seen in clinical practice, yet few physicians have t... more Conditions related to nutrition are commonly seen in clinical practice, yet few physicians have the knowledge, experience, or time todiscusshowpatients’ diets affect their health. Over the last half century, many individuals andgroups have called formore andbetter nutrition instruction duringmedical education. Themost recent plea is in this issue of JAMA Internal Medicine. Nathaniel Morris,1 a student at HarvardMedical School, is acutely awareof the importanceofdiet inpreventingandtreatingchronicdiseasesand isuneasyabout the limited trainingheandhis classmates are getting tohandle the dietary problems of so many of his future patients. “As a medical student,”Morris writes, “I cannot fathomwhymedical schools continue to neglect nutrition education.”1 Our reaction to MrMorris’s justifiable complaint is a profoundsenseofdejavu.Asparticipants inearlyattempts tobring nutrition education into medical training, we share his frustration. Nonetheless, we think we can explain why nutrition has been so long neglected and why now is such a good time to raise this issue again. Medical education is changing rapidly to bettermeet the needs of patients; attention to the role of diet in health—and the skills needed by physicians to help patients improve theirdiets—arenecessarycomponentsof that change. We are optimistic that desirable curriculum changes can at last be achieved. Our interest in this issue startednearly 40years ago,when we were both at the University of California, San Francisco (UCSF), SchoolofMedicine. In 1976, oneofus (R.B.B.)was, like MrMorris, amedical student advocating for nutrition instruction, while the other (M.N.) was a lecturer newly recruited to provide that instruction. For the next decade, we worked together to create “NutritionUCSF,” a comprehensiveprogramof nutrition training that at its peakencompassed 16hoursofpreclinical instruction; regular lectures and ward rounds in several clinical rotations; an intensive, 1-month fourth-year clinical elective; anongoing lecture series for thehealthprofessions community; andpostgraduate continuing education courses.2 In addition to our youthful interest and enthusiasm, we were able to achieve all this for a simple reason:we had funding. Funding came first froma curriculumdevelopment grant fromtheHealthResourcesAdministrationand later fromaprivate foundation. These grants allowed us to pay faculty for a small portion of their time and leverage nutrition hours into thecurriculum.When thegrants endedandwemovedonwith our careers, the nutrition hours were reduced. After a hiatus and a major reform of the entire curriculum,3 nutrition has againbecomean importantpart ofmedical educationatUCSF. Lack of funding and of trained and interested faculty are critical reasonshigh-qualitynutrition instructionhasbeenabsent frommedical education, thenandnow.Other reasons are (1) thebeliefsof somefacultymembersandadministrators that nutrition is insufficiently science-based for rigorous medical education; (2) the lack of a department-based administrative home; and (3) the focus ofmedical training on treating rather than preventing diseases. Together, these formidable barriers lead to the serious “mismatch between the skills of physicians and the needs of patients” that Morris has found.1 Morris cites the latestmedical school survey findings: only 25% of US medical schools offer a dedicated course on nutrition, and the average number of contact hours devoted to nutrition instruction over 4 years ofmedical school is 19.6.4 Dismal as these figures appear to be, however, we think they are the wrong metric. No matter howmany hours of lectures are devoted to specific nutrition topics, the information will not “stick” unless reinforced in daily patient care. The real barrier tonutrition training, thenandnow, is the lackof reinforcement of nutrition principles during the clinical years, residency training, and medical practice. This problem, of course, is not limited to nutrition; it applies to all of current medical training. Efforts are ongoing to transform medical education from course-based didactic instruction to competency-based learning inhealth care teams. These efforts offer the opportunity to teachmedical students about dietary problems in the clinical and outpatient settings in which such issues arise and can best be addressed. In its 2010 study of innovations and challenges inmedical education, the Carnegie Foundation for the Advancement of Teaching5 observed that clinical training still emphasizes facts andinpatientexperience, thatclinical facultyhavetoolittle time to teach, and thathospitals find it increasinglydifficult to support teaching.Preclinical instruction, thestudy found,pays too little attention to experiential learning, patient characteristics,patientsafety,andquality improvement.Furthermore,neitherpreclinicalnorclinical trainingsufficientlyemphasizes the needforphysicians tobecomeadvocates forappropriatehealth care, their patients, and fundamental values…
Should clinicians prescribe fat-controlled diets to prevent coronary heart disease (CHD), and, if... more Should clinicians prescribe fat-controlled diets to prevent coronary heart disease (CHD), and, if so, which patients should be given this advice? In this report, we use a three-step model to explain the hypothesis that dietary fats are a cause of CHD: dietary saturated fat and cholesterol raise serum cholesterol levels (step 1), which are a cause of subclinical coronary atherosclerosis (step 2), and, in turn, clinically manifest CHD (step 3). An evaluation of the scientific evidence for each step leads us to conclude that dietary fats definitely influence the level of serum cholesterol, and that serum cholesterol is probably a cause of atherosclerosis and CHD. To determine the clinical implications, we examined the potential of various foods to keep cholesterol levels lower, as well as the projected magnitude of reduction in CHD risk. The likelihood of benefit varies among patients, ranging from uncertain or trivial (for those with lower serum cholesterol levels, those who are free ...
The author thanks Malden Nesheim, Jennifer Pomeranz, and four anonymous peer reviewers for helpfu... more The author thanks Malden Nesheim, Jennifer Pomeranz, and four anonymous peer reviewers for helpful comments on an earlier draft of this article. 30. Cotter T, Kotov A, Wang S, et al. "Warning: ultra-processed"-a call for warnings on foods that aren't really foods.
Regulation of health claims made for dietary supplements is shared by two federal agencies, the F... more Regulation of health claims made for dietary supplements is shared by two federal agencies, the Federal Trade Commission (FTC) for advertising and the Food and Drug Administration (FDA) for 1abels.The agencies define their regulatory roles differently.Whereas the FTC has one policy for all types of claims for all products, the FDA distinguishes-and requires much higher levels of scientific support for-health claims as opposed to "statements of nutritional support." In recent years, the supplement industry has been increasingly successful in convincing the public, Congress, and the courts to weaken FDA restrictions on such claims and to make its policies consistent with the weaker FTC approaches. These actions have produced new sales opportunities for dietary supplements and conventional foods, but whether they also will benefit the public remains to be determined. The Federal Trade Commission's (FTC) 1998 Advertising Guide for lndustry explains how the agency applies its truthin-advertising mandate to statements about the health benefits of dietary supplements.' The need for such guidance is apparent. In recent years, the dietary supplement industry has increasingly convinced Congress and the courts to overturn long-standing Food and Drug Administration (FDA) restrictions on therapeutic claims made on the labels of conventional foods and dietary supplements. One result is that health claims have proliferated in advertisements as well as on labels. In an effort to harmonize policies for the advertising and labeling of dietary supplements and conventional foods, the Guide offers 36 examples to illustrate the principles by
RESEARCH AND PRACTICE Objectives. Because larger food portions could be contributing to the i... more RESEARCH AND PRACTICE Objectives. Because larger food portions could be contributing to the increasing prevalence of overweight and obesity, this study was designed to weigh samples of marketplace foods, identify historical changes in the sizes of those foods, and compare current portions with federal standards. Methods. We obtained information about current portions from manufacturers or from direct weighing; we obtained information about past portions from manufacturers or contemporary publications. Results. Marketplace food portions have increased in size and now exceed federal standards. Portion sizes began to grow in the 1970s, rose sharply in the 1980s, and have continued in parallel with increasing body weights. Conclusions. Because energy content increases with portion size, educational and other public health efforts to address obesity should focus on the need for people to consume smaller portions.
Dietary guidelines for health promotion and disease prevention in the USA recommend a consumption... more Dietary guidelines for health promotion and disease prevention in the USA recommend a consumption pattern based largely on grains, fruit and vegetables, with smaller amounts of meat and dairy foods, and even smaller amounts of foods high in fat and sugar. Such diets are demonstrably health promoting, but following them raises ethical issues related to the role of nutritionists in advising the public about healthful dietary choices, as well as to the role of the food industry in food production and marketing. In the USA a shift towards a more plant-based diet would affect the economic interests of producers of food commodities, food products and meals prepared outside the home; it would also affect the environment, food prices, trade with other countries (developing as well as industrialized) and relationships among the food industry, government agencies (domestic and international) and food and nutrition professionals. In a free-market economy any dietary choice has consequences for...
International Journal of Environmental Research and Public Health, 2020
No studies have documented the prevalence of the food industry’s funding of academic programs, wh... more No studies have documented the prevalence of the food industry’s funding of academic programs, which is problematic because such funding can create conflicts of interest in research and clinical practice. We aimed to quantify the publicly available information on the food industry’s donations to academic programs by documenting the amount of donations given over time, categorizing the types of academic programs that receive food industry donations, cataloguing the source of the donation information, and identifying any stated reasons for donations. Researchers cataloged online data from publicly available sources (e.g., official press releases, news articles, tax documents) on the food industry’s donations to academic programs from 2000 to 2016. Companies included 26 food and beverage corporations from the 2016 Fortune 500 list in the United States. Researchers recorded the: (1) monetary value of the donations; (2) years the donations were distributed; (3) the name and type of recip...
Industry-sponsored nutrition research, like that of research sponsored by the tobacco, chemical, ... more Industry-sponsored nutrition research, like that of research sponsored by the tobacco, chemical, and pharmaceutical industries, almost invariably produces results that confirm the benefits or lack of harm of the sponsor's products, even when independently sponsored research comes to opposite conclusions. 1 Although considerable evidence demonstrates that those industries deliberately influenced the design, results, and interpretation of the studies they paid for, 2 much less is known about the influence of food-company sponsorship on nutrition research. Typically, the disclosure statements of sponsored nutrition studies state that the funder had no role in their design, conduct, interpretation, writing, or publication. Without a "smoking gun" it is difficult to prove otherwise. In this issue of JAMA Internal Medicine, Kearns and colleagues 3 report on having found a smoking gun. From a deep dive into archival documents from the 1950s and 1960s, they have produced compelling evidence that a sugar trade association not only paid for but also initiated and influenced research expressly to exonerate sugar as a major risk factor for coronary heart disease (CHD). Although studies at that time indicated a relationship between high-sugar diets and CHD risk, the sugar association preferred scientists and policymakers to focus on the role of dietary fat and cholesterol. The association paid the equivalent of more than $48 000 in today's dollars to 3 nutrition professors-at Harvard no less-to publish a research review that would refute evidence linking sugars to CHD. The sponsored review appeared in 2 parts in the New England Journal of Medicine in 1967. Its authors acknowledged support from the industry-funded Nutrition Foundation, but they did not mention the sugar association's specific funding of their review. Their first article demonstrates a close correlation between sugar and fat "consumption" (actually amounts in the food supply) and mortality in 14 countries (Figure). 4 To minimize the association with sugar, the authors seem to have cherry-picked existing data. Despite their having previously published studies linking both fats and sugars to CHD risk, their review gave far more credence to studies implicating saturated fat than it did to those implicating sugars. The documents leave little doubt that the intent of the industry-funded review was to reach a foregone conclusion. The investigators knew what the funder expected, and produced it. Whether they did this deliberately, unconsciously, or because they genuinely believed saturated fat to be the greater threat is unknown. But science is not supposed to work
Conditions related to nutrition are commonly seen in clinical practice, yet few physicians have t... more Conditions related to nutrition are commonly seen in clinical practice, yet few physicians have the knowledge, experience, or time todiscusshowpatients’ diets affect their health. Over the last half century, many individuals andgroups have called formore andbetter nutrition instruction duringmedical education. Themost recent plea is in this issue of JAMA Internal Medicine. Nathaniel Morris,1 a student at HarvardMedical School, is acutely awareof the importanceofdiet inpreventingandtreatingchronicdiseasesand isuneasyabout the limited trainingheandhis classmates are getting tohandle the dietary problems of so many of his future patients. “As a medical student,”Morris writes, “I cannot fathomwhymedical schools continue to neglect nutrition education.”1 Our reaction to MrMorris’s justifiable complaint is a profoundsenseofdejavu.Asparticipants inearlyattempts tobring nutrition education into medical training, we share his frustration. Nonetheless, we think we can explain why nutrition has been so long neglected and why now is such a good time to raise this issue again. Medical education is changing rapidly to bettermeet the needs of patients; attention to the role of diet in health—and the skills needed by physicians to help patients improve theirdiets—arenecessarycomponentsof that change. We are optimistic that desirable curriculum changes can at last be achieved. Our interest in this issue startednearly 40years ago,when we were both at the University of California, San Francisco (UCSF), SchoolofMedicine. In 1976, oneofus (R.B.B.)was, like MrMorris, amedical student advocating for nutrition instruction, while the other (M.N.) was a lecturer newly recruited to provide that instruction. For the next decade, we worked together to create “NutritionUCSF,” a comprehensiveprogramof nutrition training that at its peakencompassed 16hoursofpreclinical instruction; regular lectures and ward rounds in several clinical rotations; an intensive, 1-month fourth-year clinical elective; anongoing lecture series for thehealthprofessions community; andpostgraduate continuing education courses.2 In addition to our youthful interest and enthusiasm, we were able to achieve all this for a simple reason:we had funding. Funding came first froma curriculumdevelopment grant fromtheHealthResourcesAdministrationand later fromaprivate foundation. These grants allowed us to pay faculty for a small portion of their time and leverage nutrition hours into thecurriculum.When thegrants endedandwemovedonwith our careers, the nutrition hours were reduced. After a hiatus and a major reform of the entire curriculum,3 nutrition has againbecomean importantpart ofmedical educationatUCSF. Lack of funding and of trained and interested faculty are critical reasonshigh-qualitynutrition instructionhasbeenabsent frommedical education, thenandnow.Other reasons are (1) thebeliefsof somefacultymembersandadministrators that nutrition is insufficiently science-based for rigorous medical education; (2) the lack of a department-based administrative home; and (3) the focus ofmedical training on treating rather than preventing diseases. Together, these formidable barriers lead to the serious “mismatch between the skills of physicians and the needs of patients” that Morris has found.1 Morris cites the latestmedical school survey findings: only 25% of US medical schools offer a dedicated course on nutrition, and the average number of contact hours devoted to nutrition instruction over 4 years ofmedical school is 19.6.4 Dismal as these figures appear to be, however, we think they are the wrong metric. No matter howmany hours of lectures are devoted to specific nutrition topics, the information will not “stick” unless reinforced in daily patient care. The real barrier tonutrition training, thenandnow, is the lackof reinforcement of nutrition principles during the clinical years, residency training, and medical practice. This problem, of course, is not limited to nutrition; it applies to all of current medical training. Efforts are ongoing to transform medical education from course-based didactic instruction to competency-based learning inhealth care teams. These efforts offer the opportunity to teachmedical students about dietary problems in the clinical and outpatient settings in which such issues arise and can best be addressed. In its 2010 study of innovations and challenges inmedical education, the Carnegie Foundation for the Advancement of Teaching5 observed that clinical training still emphasizes facts andinpatientexperience, thatclinical facultyhavetoolittle time to teach, and thathospitals find it increasinglydifficult to support teaching.Preclinical instruction, thestudy found,pays too little attention to experiential learning, patient characteristics,patientsafety,andquality improvement.Furthermore,neitherpreclinicalnorclinical trainingsufficientlyemphasizes the needforphysicians tobecomeadvocates forappropriatehealth care, their patients, and fundamental values…
Should clinicians prescribe fat-controlled diets to prevent coronary heart disease (CHD), and, if... more Should clinicians prescribe fat-controlled diets to prevent coronary heart disease (CHD), and, if so, which patients should be given this advice? In this report, we use a three-step model to explain the hypothesis that dietary fats are a cause of CHD: dietary saturated fat and cholesterol raise serum cholesterol levels (step 1), which are a cause of subclinical coronary atherosclerosis (step 2), and, in turn, clinically manifest CHD (step 3). An evaluation of the scientific evidence for each step leads us to conclude that dietary fats definitely influence the level of serum cholesterol, and that serum cholesterol is probably a cause of atherosclerosis and CHD. To determine the clinical implications, we examined the potential of various foods to keep cholesterol levels lower, as well as the projected magnitude of reduction in CHD risk. The likelihood of benefit varies among patients, ranging from uncertain or trivial (for those with lower serum cholesterol levels, those who are free ...
The author thanks Malden Nesheim, Jennifer Pomeranz, and four anonymous peer reviewers for helpfu... more The author thanks Malden Nesheim, Jennifer Pomeranz, and four anonymous peer reviewers for helpful comments on an earlier draft of this article. 30. Cotter T, Kotov A, Wang S, et al. "Warning: ultra-processed"-a call for warnings on foods that aren't really foods.
Regulation of health claims made for dietary supplements is shared by two federal agencies, the F... more Regulation of health claims made for dietary supplements is shared by two federal agencies, the Federal Trade Commission (FTC) for advertising and the Food and Drug Administration (FDA) for 1abels.The agencies define their regulatory roles differently.Whereas the FTC has one policy for all types of claims for all products, the FDA distinguishes-and requires much higher levels of scientific support for-health claims as opposed to "statements of nutritional support." In recent years, the supplement industry has been increasingly successful in convincing the public, Congress, and the courts to weaken FDA restrictions on such claims and to make its policies consistent with the weaker FTC approaches. These actions have produced new sales opportunities for dietary supplements and conventional foods, but whether they also will benefit the public remains to be determined. The Federal Trade Commission's (FTC) 1998 Advertising Guide for lndustry explains how the agency applies its truthin-advertising mandate to statements about the health benefits of dietary supplements.' The need for such guidance is apparent. In recent years, the dietary supplement industry has increasingly convinced Congress and the courts to overturn long-standing Food and Drug Administration (FDA) restrictions on therapeutic claims made on the labels of conventional foods and dietary supplements. One result is that health claims have proliferated in advertisements as well as on labels. In an effort to harmonize policies for the advertising and labeling of dietary supplements and conventional foods, the Guide offers 36 examples to illustrate the principles by
RESEARCH AND PRACTICE Objectives. Because larger food portions could be contributing to the i... more RESEARCH AND PRACTICE Objectives. Because larger food portions could be contributing to the increasing prevalence of overweight and obesity, this study was designed to weigh samples of marketplace foods, identify historical changes in the sizes of those foods, and compare current portions with federal standards. Methods. We obtained information about current portions from manufacturers or from direct weighing; we obtained information about past portions from manufacturers or contemporary publications. Results. Marketplace food portions have increased in size and now exceed federal standards. Portion sizes began to grow in the 1970s, rose sharply in the 1980s, and have continued in parallel with increasing body weights. Conclusions. Because energy content increases with portion size, educational and other public health efforts to address obesity should focus on the need for people to consume smaller portions.
Dietary guidelines for health promotion and disease prevention in the USA recommend a consumption... more Dietary guidelines for health promotion and disease prevention in the USA recommend a consumption pattern based largely on grains, fruit and vegetables, with smaller amounts of meat and dairy foods, and even smaller amounts of foods high in fat and sugar. Such diets are demonstrably health promoting, but following them raises ethical issues related to the role of nutritionists in advising the public about healthful dietary choices, as well as to the role of the food industry in food production and marketing. In the USA a shift towards a more plant-based diet would affect the economic interests of producers of food commodities, food products and meals prepared outside the home; it would also affect the environment, food prices, trade with other countries (developing as well as industrialized) and relationships among the food industry, government agencies (domestic and international) and food and nutrition professionals. In a free-market economy any dietary choice has consequences for...
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