Communicating with the dietetics profession

In Mother Jones this week, Kiera Butler has a striking report about the food industry presence at a conference of the California Dietetic Association. The description of attendees consuming and discussing their free McDonald's salads makes the association seem careless with its valuable public image and credibility.

One might ask, how on earth could dietitians ally themselves with major fast food chains, instead of with advocacy groups -- or hard-hitting magazines -- that seek to better represent the public interest?

Part of the answer, surely, is that the food industry provides funding to the dietetics associations. This is the answer Mother Jones might emphasize.

Another part of the answer is that the food industry publicly endorses the best judgment of dietitians and nutrition scientists on the leading diet and health questions of the day. Actual products may not follow this judgment, but the industry's public communications are deeply respectful of the profession. Industry representatives endlessly tell the profession, "We listen to your advice, while those would-be do-gooders in the public interest community foolishly pursue one nutrition fad after another."

For example, consider the claim in the Mother Jones article that mounting scientific evidence shows that "high-fructose corn syrup prompts more weight gain than other sugars." The article links to this four year old 2010 press release from Princeton University, which imprecisely summarizes its supporting scientific journal article (.pdf), which in turn has been strongly criticized by NYU's Marion Nestle, who is quoted as a trusted authority in the same Mother Jones article (!), and who further links to a more detailed evisceration of this research.

It is fine to criticize high-fructose corn syrup (HFCS) along with sugar, because of strong evidence that both are associated with risk of weight gain. But the current evidence does not support Mother Jones' claim that HFCS prompts more weight gain than other sugars. That claim -- and more specifically the casual and uncritical link to the Princeton University press release -- plays into the industry's strategy for befriending dietitians.

Writers and advocates who care about the public interest really can persuade the dietetics profession to adopt a more independent and skeptical stance in its relationships with the food industry. We could begin by avoiding these failures in summarizing the best scientific evidence.

Recent activities of Dietitians for Professional Integrity

Andy Bellatti last month summarized in a column for Civil Eats the recent activities of Dietitians for Professional Integrity, an initiative to encourage the leading dietetics professional association, the Academy of Nutrition and Dietetics, to distance itself more clearly from its food and beverage industry sponsors.

For years, many of my colleagues and I have voiced our discontent that the professional organization that represents us takes money from and partners with the likes of Coca-Cola, PepsiCo, McDonald’s, and Hershey’s, supposedly to foster dialogue with the industry and help Americans get healthier. In reality, Big Food gets free press for feigning concern, while going about its usual business, and the registered dietitian credential gets dragged through the mud.

“Too often I’ve lost the trust of potential clients because, despite my rigorous education in nutrition, they only see the dietetics field as corrupted by big businesses,” says Matt Ruscigno, MPH, RD, one of Dietitians for Professional Integrity’s co-founders.

Over the past four months, Dietitians for Professional Integrity has shared many statements of concern from registered dietitians on its Facebook page, and helped raise awareness of Big Food’s influence on the Academy (from the world’s largest aspartame producer helping to fund the organization’s evidence analysis team on the artificial sweetener to Coca-Cola’s Academy-approved continuing education webinars which  teach dietitians that soda is unfairly vilified).

A key point is that Dietitians for Professional Integrity is not a "nanny state" initiative.  There are good reasons why it is sometimes difficult for government agencies to take strong public interest positions on key challenges to the healthfulness of the food and beverage industry.  Government institutions in a democracy frequently must represent the mainstream of public opinion.  They explicitly must be concerned both with public health and with encouraging a thriving economy.  When government agencies push too hard or are insufficiently deferential to individual preferences in guiding people toward healthy nutritional choices, the public worries about government overreach.

Because of these constraints on government activism, it is especially important that non-profit public interest organizations such as the Academy of Nutrition and Dietetics speak clearly, boldly, and without bias on the nutrition issues of the day.  I think Bellatti and Dietitians for Professional Integrity have a good point in encouraging this private-sector nutrition organization to be more independent from its corporate sponsors.  Sometimes, the Academy should have more courage to criticize food and beverage industry products and marketing practices that really do contribute to an unhealthy nutrition environment.

Interpreting science at #EB2013 in Boston

While enjoying the excellent sessions sponsored by the American Society of Nutrition (ASN) at the Experimental Biology 2013 meetings here in Boston this week, I was struck once again by the way actual nutrition science research results are filtered or digested into short memes of conventional wisdom before they reach the public.

This filtering process is necessary, unavoidable, and even healthy.  And yet it is a key step, which brings politics and interest into the process of producing nutrition policy and dietary guidance.

Here is a passage from my chapter on Dietary Guidance in Food Policy in the United States: An Introduction (Routledge/Earthscan).

Filtering is the process of reading a large body of research and concisely summarizing its relevant points. Because the scientific literature is so heterogeneous, its policy impact depends heavily on how the research is filtered.

Filtering may be biased toward certain types of conclusions. Food industry organizations hire scientists and public relations specialists to spread the good word about favorable studies, without mentioning unfavorable studies. The public relations specialists are evaluated according to their success in placing favorable stories in the mass media. Reporters do not purposely seek to serve as a vehicle for industry public relations, but they face intense pressure to generate buzz by reporting novel and surprising findings. Hence, even though the balance of evidence in the scientific literature changes only slowly, headlines each week tell the public that everything they previously believed about nutrition and health was a big fat lie.

To summarize a complex scientific literature with less bias, scientists prefer to rely on systematic evidence reviews. In a systematic evidence review, an inter-disciplinary team establishes a protocol, a document that describes in advance the procedure for selecting relevant research studies, reducing the temptation to concentrate on studies that are favorable to the team’s prior expectations. For each selected study, the team evaluates the strength of the evidence, again using criteria established in advance.

Systematic evidence reviews do have some limitations. While they can avoid errors that stem from selective reading of just favorable parts of the scientific literature, systematic evidence reviews cannot fix misinterpretations that are widespread in the literature. Also, such reviews may not reflect recent improvements in scientific research. Still, because of their transparency and replicability, systematic reviews can clarify the state of the evidence on contentious scientific issues.

If you are attending the Experimental Biology 2013 meetings this week in Boston, the book itself is on display today at the CRC Press booth (#531 in the exhibition hall).  Please stop by the booth, and please share your thoughts on whether food policy is a worthy topic of study at a meeting of scientists.

An inter-disciplinary approach to U.S. food policy

An excerpt from the first chapter of Food Policy in the United States: An Introduction (Routledge/Earthscan).

The 2010 Dietary Guidelines for Americans, which is the federal  government’s most authoritative official statement on nutrition and health issues (discussed at length in Chapter 8), presents a social and ecological framework for food consumption and physical activity decisions (see Figure). Similar models are found in many other high-profile nutrition policy documents (Institute of Medicine, 2012). To analyze major national problems of obesity and chronic disease, this framework goes far beyond immediate causes such as food and beverage intake and physical activity. Like planetary orbits that are farther from the center, the outer layers list more distant influences on food choices.

The framework calls attention to important topics, including agriculture (Chapter 2), the food and beverage manufacturing industries (Chapter 5), the retailing and restaurant industries (Chapter 6), marketing and the media (Chapter 9) and socioeconomic factors  (Chapter 10). Once nutrition and public health professionals begin to explore these more fundamental influences on food and beverage consumption, they find themselves engaged with challenging topics in economics and political science.

At first, this engagement can be unnerving. When interacting with patients, professionals in medical fields are rightly proud of their ability to diagnose problems and prescribe an appropriate remedy. It is tempting at first to adapt this medical patient approach to food policy applications. For example, if expanding food portion sizes contribute to rising rates of obesity, it is tempting to say government agencies should prescribe smaller portion sizes. If nutrient-dense foods cost too much, it is tempting to say government agencies should prescribe a price ceiling for fruits and vegetables. It is disappointing if policy-makers reject such proposals as politically infeasible. It is downright frustrating if policy-makers say with a straight face that a well-intentioned nutrition policy prescription is unwise. Yet, except in special settings such as school meal programs, determining portion sizes may be a decision that people do not want to delegate to their government. A price ceiling for fruits and vegetables may have unintended consequences, such as reducing the incentives to grow fruits and vegetables.

The outer layers of the social ecological framework bring nutrition policy into contact with many other societal objectives, such as a thriving economy, a healthy environment, poverty alleviation and effective political governance. Powerful policy actors in these outer layers do not—and sometimes should not—behave as if food consumption and physical activity stood alone as the sun at the center of the social ecological solar system. Governments balance food and nutrition concerns against other considerations, just as individuals and families do.

As we explore more deeply the normative question of what food policies best serve the public good, it will appear necessary to discern which decisions should be delegated to governments and which decisions should be made by individuals interacting in economic markets. And, as we explore more deeply the positive question of what policies can win political support, it will appear necessary to anticipate how a variety of producer and consumer interests will respond to such proposals.

These inter-disciplinary explorations are more difficult than simply prescribing the right policy medicine, but ultimately they offer both sharper policy insight and greater potential for political success.

Source: Dietary Guidelines for Americans, 2010.

Dietitians discuss appropriate policies to govern corporate sponsorship at the Academy of Nutrition and Dietetics (AND)

The Hunger and Environmental Nutrition (HEN) practice group within the Academy of Nutrition and Dietetics (AND) has long been encouraging greater transparency about corporate sponsorship issues.  The AND (formerly known as the American Dietetic Association) serves as an influential advocate in U.S. nutrition policy and also as the professional association for registered dietitians.

My students and former students who are registered dietitians have worried about AND corporate sponsorships.  They send me a steady stream of awkward examples of ill-chosen sponsorships, for example with sugar sweetened beverage companies and meat checkoff programs.  One Friedman School graduate student, Ashley Colpaart (who for some years co-blogged here at U.S. Food Policy), has been proposing reforms for AND's corporate sponsorship practices for many years.

Other Friedman School graduate students conducted analyzed a survey of dietitians last year, noting that many dietitians share at least some of these concerns [small edit Feb. 3].  The article was an important source for Michele Simon's hard-hitting and highly critical report this week on AND corporate sponsorship.  The students, Lauren Adler, Alyssa Koomas, and Catherine Wright, wrote:

ADA’s corporate sponsorship program has become a topic of public discussion in recent years. A total of 370 HEN members were surveyed to shed light on member opinions of the corporate sponsorship program and whether our DPG approves or disapproves of the program. The majority of survey respondents appear to disapprove of the corporate sponsorship program, indicating that it negatively impacts their public image as food and nutrition professionals. Additionally, 61% of respondents were willing to pay higher ADA membership fees in order to decrease reliance on corporate sponsors.

In a letter to AND leadership last year (.pdf), some Hunger and Environmental Nutrition practice group members recounted the common experience of having their own independence called into question by others who were aware of the Academy's corporate sponsorship relationships:

[R]egardless if they are real or perceived, the influence of Academy corporate  sponsors has not only sparked scrutiny among journalists, but has led to several conversations in which members have had to defend these relationships and the profession at national conferences and forums. These confrontations have led to rising humiliation and a growing discomfort while fulfilling the role as Delegates. In some instances, this has led to long-­‐time members leaving the organization. We urge the Academy to uphold more transparent and stricter guidelines on access of corporate  sponsors to Academy leadership and to remove their presence at meetings, such as HOD [the AND House of Delegates], in which decisions about the profession and/or the organization are made. This will avoid conflict of interest, advance transparency, maintain professional and organizational integrity, and establish a more credible national presence.

It is difficult for any professional association to find a business model that works, providing needed support for association activities without conflicts of interests.  For example, the HEN practice group itself last year sought to develop its own policies for sponsorships (.pdf), describing the ideal potential sponsors as companies with a combination of nutrition and environmental virtues. I wish them well finding such terrific sponsors, but, realistically, we should admit that giving up compromised sponsorships may imply accepting a smaller scale of operation and revenue for a professional association.

Even recognizing those difficulties, it would have been wise for AND to listen to the input from its own internal rank and file.  As an outsider to AND, nutrition policy advocate Michele Simon offers much harsher criticism of the Academy in her report this week. With hindsight AND leaders might wish they had listened more sympathetically to internal concerns before matters came to this point.

When Marion Nestle blogged about this issue yesterday, generally agreeing with Simon's report, some of the open comments from dietitians were defensive, while others agreed with the concerns about corporate sponsorship.  Nestle has a very good follow-up post today, responding to the discussion so far.  The New York Times also covered this issue, which is unlikely to just fade away any time soon.

A proposal for a global ban on trans fats

While labeling strategies provide a sound public policy response to some food ingredient dilemmas, in other cases it is simpler and more effective to make do without the ingredient altogether.  Some argue that trans fats fall into the category of ingredients that should just be eliminated (with the exception of the small amount of trans fat that occurs naturally in animal food products).  These fats replaced healthier traditional oils and fats just a few decades ago, and some countries have recently been rapidly shifting back away from their use without any major food system damage.

In a commentary this week for the World Public Health Nutrition Association, Vivica Kraak, Uriyoán Colón-Ramos, and Rafael Monge-Rojas recommend a near-complete global ban on trans fats.

This commentary presents a case for public health professionals, practitioners, academics, industry and government representatives, funders, public-interest non-governmental organisations and consumer advocates, to collaborate to support a global trans-fat ban. Coordinated actions to remove this harmful substance from our food and eating environments will be able to contribute to reducing chronic non-communicable disease mortality by 2025.

From nutrition scientists "on behalf of Corn Refiners Association"

Here is a newsletter I received today from an email account labeled oddly: "ASN on behalf of Corn Refiners Association."

Follow the link for the full web version of the email.

The ASN is of course the American Society for Nutrition.  "Experimental Biology 2012" is the most important annual meeting for nutrition scientists.

The tiny footer to the email's web page says:

This email is a paid advertisement sent by ASN on behalf of Corn Refiners Association. ASN occasionally promotes to its members the efforts of other organizations promoting products, services or events that advance ASN's mission: excellence in nutrition research and practice. ASN never releases members' email addresses to any third party. 

While this footer to the email discloses the advertisement, the newsletter's .pdf file from the link does not mention that it is an advertisement.  Clearly, the whole package is designed to look like a newsletter from a scientific association.  In the gentlest way, the newsletter defends fructose and corn sweeteners from criticism.

Does this type of advertisement cost the scientific association much in terms of independent authority and reputation?

Why Calories Count

Why Calories Count, the new book by Marion Nestle and Malden Nesheim, nicely bridges the world of food policy commentary and nutrition science. It offers a great counterpoint to the loud and untrustworthy bazaar of diet books, each blaming some simple villain for the obesity epidemic (too much carbs, too much fat, too little calcium, whatever).  Why Calories Count teaches a wealth of detail about how calories are measured and how their effects are studied.  It also tells great stories, from the history of nutrition science to the poignant service of wartime conscientious objectors who participated in a clinical study of human starvation.  If I were a graduate student in nutrition or public health, I would find this book inspiring as an eloquent and engaging secondary reading alongside a nutrition science textbook.  Strongly recommended.

Links: Jane Brody, Mark Bittman.