Monday, September 7, 2015
Coca-Cola, calories, and conflicts of interest
If space in the title bar allowed, I would have extended the above, with this addendum following the colon: The Case for Differentiating the Dots. We will come to dots, and differentiation, presently. For now, our tale begins with coverage in the New York Times about the perspicacious suspicions of my friend and colleague, Yoni Freedhoff, and the apparent disrobing of a public health wolf in sheep's clothing.
Some months ago, as I was recruiting among highly accomplished colleagues for additions to the True Health Coalition (which is exactly what it claims, and has no closets, let alone skeletons) I in turn received an invitation to join the Global Energy Balance Network, or GEBN. I never did get around to joining, for which I am now quite grateful, but I was favorably disposed for two reasons at the time. First, the invitation came from colleagues I have long regarded highly and well. Second, the purported mission of the network was to restore a basic understanding of the fundamental relevance of energy balance.
I do think that restoration is in order. Iconoclasts, whom I presume to be well meaning but misguided, have turned the simple concept of calories and energy balance into an unfathomable fog. The question they pose, do calories count? is, in a word, silly. Of course calories count, exactly the way inches, miles, liters, leagues, degrees, and pounds count.
Most of us have gone quite a few miles along the road of life, and I suspect we all agree: Not all miles are created equal. A mile is a mile, but there are pleasant and unpleasant miles; easy and hard miles. But that is not cause to question the basic measurement. A literal mile is still exactly that: 5,280 feet, every time.
Just so with calories. They are a precise and clearly defined measure of energy, or heat if you prefer. But when the topic is human nutrition, then clearly not all calories are created equal. They can come from nutritionally vapid, rapidly metabolizable junk; or from nutrient replete, wholesome foods. They can come from lollipops, or lentils. Obviously, those qualitative differences matter.
The false question, then, that has unhelpfully complicated the matter of energy balance is this: which matters, the quality of calories, or the quantity? The correct answer is the obvious one that all of the pseudo-probing of the topic ignores: both! The quality of calories is tantamount to the nutritional quality of food, which is obviously of vital importance; otherwise, we could all get by nicely on 2,000 kcal of Doritos every day. But the quantity is also important, since studies show clearly our capacity to gain weight on too much good stuff, and lose weight on calorie-controlled dosing of utter junk.
This, then, was the alleged mission of GEBN: to reassert the basic relevance of calories, and restore the uncontested understanding we once had that a balance between calories in and calories out, however nuanced it might prove to be in its particulars, determines our weight.
According to the New York Times, however, the actual mission was something else altogether. Coca-Cola is a principal funder of GEBN, and a significant sponsor of the scientists leading the effort. That effort, it now appears, was actually directed at obscuring the importance of calories in, and preferentially emphasizing the importance of calories out. In other words, the GEBN message would have translated to: Drink all the Coca-Cola you want, but be sure to get your exercise. And since exercising might make you thirsty, drink more Coca-Cola.
This, obviously, is a scandalous betrayal of public health. For one thing, it is a false proposition. In my opinion, while exercise is unassailably important to health and vitality, it matters far less to weight control per se than do calories in, for a very basic reason. In a world awash in hyperpalatable, energy-dense food and drink, it is vastly easier to out-eat exercise than to out-run all those calories. The calories expended in hours of intense exertion can be replaced in mere moments of effortless, mindless indulgence. Coca-Cola, with its 10 teaspoons of sugar per 12 ounces, would certainly do that job handily.
But leaving aside the specious contention that we can exercise our way to energy balance while blithely disregarding calories in, there is the blatant conflict of interest here. In fact, this is a conflict of interest so vivid that it serves to define “conflict” of interest.
The Coca-Cola Company is interested in selling Coca-Cola, and has an established track record of obfuscating the science linking soda to obesity and diabetes, and of marketing the fantasy that we can happily exercise away the calories their signature product delivers. The interest of GEBN was, supposedly, a truthful representation of energy balance and its determinants. A public health program devoted to truth, backed by a company opposed to the very truth in question, defines a conflict. These dots are not hard to connect.
But this leads to the differentiation of dots with which I began. Just as we tend todumb-down dietary truths until they distort into the nonsense that has made us fatter and sicker for decades (e.g., just cut fat; just cut carbs; just cut gluten), so, too, have we dumbed-down the representation of conflict so that it fails to differentiate baby and bathwater. An expansive disparagement of “industry funded” research, for instance, is not justified.
Almost everything we know about pharmacotherapy is courtesy of industry-funded research. The drug companies that sponsor the studies that bring new FDA-approved drugs to market clearly have a vested interest. But they do not have a conflict of interest per se. They fund studies hoping to show their drugs work well. The public shares an interest in drugs that work well. The motivation is transparent, and unconflicted.
That does not mean it is always virtuous. We are all aware of times drug companies spun results excessively to the positive or withheld data, inviting reprisals. But in general, the interests of the public and the companies alike are served by bringing to market those drugs that work, and weeding out those that do more harm than good. If the drug companies were funding studies designed to refute the notion that drugs can be harmful in any way, while the public was interested in exposing those harms, there would be a conflict.
The same applies to any other funder. The idea that research can be entirely unbiased in its objectives is naïve. No researcher wastes time conducting studies without an “interest” in the outcome. That interest constitutes a bias, and it is generally shared by the funder, even when the funder is the NIH. But biased hopes are not the same as biased methods, and bias is not the same as conflict. Robust research methods are specifically those that protect researcher, and funder alike, from their own biased motivations.
There is no methodological defense against conflict. In my lab, for example, we have studied the health effects of walnuts with funding from the California Walnut Commission. We have used the customary methods -- randomization, blinding, control group -- to defend against our biased hopes. But just as important, the California Walnut Commission has a track record of integrity. They fund research proposed by researchers, and it gets published however it turns out. They then talk about the weight of evidence, rather than working to refute it. As it happens, the weight of evidence is decisively in favor of health benefit from walnut consumption. Were it otherwise, perhaps the CWC would stop funding research. But if ever they engaged in a marketing campaign to refute or discredit the weight of evidence, they would no longer constitute a respectable research funder, for they would be conflicted.
Bias does not discredit research funding, but conflict does. When we are connecting dots to see the big picture, this distinction is important.
As for GEBN, it is mired in conflict and cannot be what it purported to be. The scientists running it cannot serve public health, and their funder- for the two are at odds.
Coca-Cola is not merely biased on the topic of energy balance; they are conflicted. If the truth about energy balance inveighs against their product, as it does, they will work against the interests of public health and attempt to conceal that reality- as they have. They have no business funding a campaign about calories and truth, because the truth about calories is not in their interest.
David L. Katz, MD, FACP, MPH, FACPM, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care. He is a board certified specialist in both Internal Medicine, and Preventive Medicine/Public Health, and Associate Professor (adjunct) in Public Health Practice at the Yale University School of Medicine. He is the Director and founder (1998) of Yale University's Prevention Research Center; Director and founder of the Integrative Medicine Center at Griffin Hospital (2000) in Derby, Conn.; founder and president of the non-profit Turn the Tide Foundation; and formerly the Director of Medical Studies in Public Health at the Yale School of Medicine for eight years. This post originally appeared on his blog at The Huffington Post.
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