Backlash Over Meat Dietary Recommendations Raises Questions About Corporate Ties to Nutrition Scientists - American Medical Association

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News & Analysis Medical News & Perspectives Backlash Over Meat Dietary Recommendations Raises Questions About Corporate Ties to Nutrition Scientists Rita Rubin, MA I t’s almost unheard of for medical jour- nals to get blowback for studies before the data are published. But that’s what happened to the Annals of Internal Medi- cine last fall as editors were about to post several studies showing that the evidence linking red meat consumption with cardio- vascular disease and cancer is too weak to recommend that adults eat less of it. Annals Editor-in-Chief Christine Laine, MD, MPH, saw her inbox flooded with roughly 2000 emails—most bore the same message, apparently generated by a bot—in a half hour. Laine’s inbox had to be shut down, she said. Not only was the volume un- precedented in her decade at the helm of the respected journal, the tone of the emails was particularly caustic. “We’ve published a lot on firearm in- jury prevention,” Laine said. “The response from the NRA (National Rifle Association) was less vitriolic than the response from the True Health Initiative.” The True Health Initiative (THI) is a nonprofit founded and headed by David representing previously undisclosed con- In an accompanying editorial, coau- Katz, MD. The group’s website describes its flicts of interest. thors Aaron Carroll, MD, and Tiffany Doherty, work as “fighting fake facts and combating But what has for the most part been PhD, wrote that the guideline “is sure to false doubts to create a world free of pre- overlooked is that Katz and THI and many of be controversial, but it is based on the ventable diseases, using the time-honored, its council members have numerous indus- most comprehensive review of the evi- evidence-based, fundamentals of lifestyle try ties themselves. The difference is that dence to date.” and medicine.” Walter Willett, MD, DrPH, their ties are primarily with companies and Carroll, a regular JAMA contributor who and Frank Hu, MD, PhD, Harvard nutrition organizations that stand to profit if people directs the Indiana University School of researchers who are among the top names eat less red meat and a more plant-based Medicine’s Center for Pediatric and Adoles- in their field, serve on the THI council of diet. Unlike the beef industry, these enti- cent Comparative Effectiveness Research, directors. ties are surrounded by an aura of health and also wrote in the New York Times about the Katz, Willett, and Hu took the rare wellness, although that isn’t necessarily difficulties involved in conducting high- step of contacting Laine about retracting evidence-based. quality nutrition research. the studies prior to their publication, she “Even observational trials are hard to do recalled in an interview with JAMA. Per- State of the Science well,” Carroll wrote. In the short-term, it’s dif- haps that’s not surprising. “Some of the The Annals published 5 systematic re- ficult to find big differences in death and dis- researchers have built their careers on views—4 that included results from random- ease rates, even in large groups of people, he nutrition epidemiology,” Laine said. “I can ized clinical trials (RCTs) and observational noted. “But quantifying what people are eat- understand it’s upsetting when the limita- studies examining the relationship be- ing over long periods is challenging, too, be- tions of your work are uncovered and dis- tween red meat and health, and a fifth that cause people don’t remember.” cussed in the open.” looked at health-related values and prefer- The guideline’s lead author, Bradley Subsequent news coverage criticized ences about eating meat. Based on the re- Johnston, PhD, is a cofounder and director the methodology used in the meat papers views, the authors produced a guideline that of NutriRECS, an independent group that and raised the specter that some of the au- concluded adults needn’t change their meat- says it uses its members’ expertise in clini- thors had financial ties to the beef industry, eating habits. cal issues, nutrition, public health, and jama.com (Reprinted) JAMA Published online January 15, 2020 E1 © 2020 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Texas A&M University User on 01/15/2020 News & Analysis evidence-based medicine to produce so much nutrition research is observa- be published online. Laine said Katz was on nutritional guidelines that aren’t ham- tional and so little involves RCTs. “We can’t the Annals’ press release list because he pered by conflicts of interest. Besides sys- randomly assign people to diets for writes a weekly column for the New Haven tematic reviews about the relationship decades,” Katz told JAMA. “Even if we Register, a Connecticut newspaper. between dietary patterns, food, and nutri- could…we couldn’t blind them to what Katz said he circulated only the press re- ents and health outcomes, NutriRECS said they’re eating…everything about nutri- lease—“that’s in the public domain”—but not it considers patient and community val- tional epidemiology cries out for the use of the embargoed articles, among THI col- ues, attitudes, and preferences in its other methods [besides GRADE].” leagues, telling them that the guideline guideline recommendations. Katz and coauthors including Willett “looks like it’s going to be a serious problem In the Annals papers, NutriRECS mem- recently published an article about a tool for us.” bers and their coauthors wrote that they they constructed that deemphasizes the Actually, embargoes apply to press re- sought to bring scientific rigor to current importance of RCTs in evaluating evidence leases as well as the articles themselves, said meat intake guidelines based mostly on ob- about what they call lifestyle medicine, Angela Collom, the Annals media relations servational studies that don’t establish including diet. “We’re not anti-meat,” said manager. The Annals and many other jour- cause-and-effect relationships. Katz, founding director of the US Centers nals post releases to a website run by the Johnston, an associate professor with for Disease Control and Prevention– American Association for the Advance- Texas A&M University’s nutrition and food funded Prevention Research Center at ment of Science that restricts access to science department, and his coauthors Griffin Hospital, a 160-bed acute-care members of the media who agree to em- used the GRADE (Grading of Recommen- community hospital in Derby, Connecticut, bargo policies. dations, Assessment, Development, and that’s affiliated with the Frank H. Netter “ Th o s e c h a n n e l s a r e n o t p u b l i c Evaluations) approach to assess the quality MD School of Medicine at Quinnipiac Uni- domain,” Collom said. Because Katz shared of evidence upon which they based their versity and the Yale School of Medicine. the press release, she added, the Annals guideline. The GRADE framework consid- “We’re just pro-science.” dropped him from the list of journalists eli- ers evidence from randomized controlled The problem, said Harvard Medical gible to receive embargoed releases trials (RCTs) to be of the highest quality School obesity specialist David Ludwig, MD, or articles. and observational data to be of lower qual- PhD, is that the science is not that good. “The Four days before the articles were pub- ity because of residual confounding. average research study in nutrition is just lished, Katz and 11 THI members sent Laine A panel of 14 individuals from 7 countries lower quality.” a letter asking her to “pre-emptively retract voted on the final guideline recommenda- In a recent JAMA Viewpoint, Ludwig publication of these papers pending fur- tions, and 3 dissented. and his coauthors wrote that compared ther review by your office.” The signatories The authors, who noted that their rec- with pharmaceutical research, dietary stud- included THI council members Hu and ommendations were “weak” and based on ies are far more challenging in terms of con- Willett; Neil Barnard, MD, president of the low-certainty evidence, found no statisti- sistency, quality control, confounding, and Physicians Committee for Responsible Medi- cally significant link between meat consump- interpretation, which makes translating cine (PCRM); former US Surgeon General tion and risk of heart disease, diabetes, or those findings into public policy “exceed- Richard Carmona, MD, MPH; David Jenkins, cancer in a dozen RCTs that had enrolled ingly difficult.” MD, PhD, a nutrition professor at the Uni- about 54 000 participants. They did find a Instead of coming up with tools to give versity of Toronto Faculty of Medicine; and very small disease risk reduction among more weight to observational studies in Dariush Mozaffarian, MD, DrPH, dean of the people who consumed 3 fewer servings of guideline development, nutrition scientists Friedman School of Nutrition Science and red meat weekly in epidemiological studies need to rethink how they design studies, Policy at Tufts University. that followed millions, but the association John Ioannidis, MD, DSc, of the Stanford Uni- “It’s really frightening that this group, was uncertain. versity School of Medicine, wrote in a 2018 which includes people like Walter Willett The authors acknowledged that other JAMA Viewpoint. and Frank Hu at the Harvard School of reasons besides health—namely concerns “The field needs radical reform,” Public Health, which happens to be my about the environment and animal welfare— Ioannidis noted. alma mater, were aware of this and assist- might motivate people to reduce their meat ing it,” Laine said. intake, although those factors did not bear Word Gets Around What’s more, THI member John on the recommendations. Demands to retract the Annals papers Sievenpiper, MD, PhD, also signed the let- “That would require a systematic re- before they were published suggest that ter to Laine even though he coauthored view of the relevant evidence, which was be- the journal’s embargo policy had been vio- the NutriRECS systematic review about yond the scope of our work—and indeed, of lated. (Embargoes prohibit reporters and the relationship between meat consump- our expertise,” Johnston and his coauthors press officers at the authors’ institutions tion and all-cause mortality and the risk of commented on the Annals website in re- from circulating articles before they’re cardiovascular disease, heart attack, and sponse to criticism for not considering en- published. Breaking an embargo is a seri- type 2 diabetes. vironmental impact. ous breach.) Laine said she contacted Sievenpiper, Katz and other THI members have An article on the THI website states that a nutrition scientist at the University of criticized the authors’ use of GRADE be- the organization had obtained the meat ar- Toronto, after receiving the letter and cause, unlike pharmaceutical research, ticles 5 days before they were scheduled to pointed out that he had signed a standard E2 JAMA Published online January 15, 2020 (Reprinted) jama.com © 2020 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Texas A&M University User on 01/15/2020 News & Analysis form affirming his agreement with his pa- author of the NutriRECS meat consump- Annals study that was funded by the non- per’s conclusions. That had not changed, he tion guideline; and “evidence-based aca- profit International Life Sciences Institute told her, but he did not agree with the guide- demics,” namely NutriRECS and Gordon (ILSI), which is primarily supported by the line paper, of which he was not an author. Guyatt, MD, MSc, chair of the panel that food and agriculture industry. Hours before the meat articles were wrote the meat consumption guidelines. He and his coauthors of the 2016 posted and the embargo lifted, Barnard’s “It was part of my talk addressing the article used GRADE to conduct “a separate PCRM went so far as to petition the Federal confusion that the public gets from the me- and independent review of the method- Trade Commission (FTC) “to correct false dia about diet and health,” Willett said in an ological quality of dietary guidelines that statements regarding consumption of red email to JAMA. “Some of this relates to the address (added) sugar recommendations,” and processed meat released by the Annals triangle of disinformation that is…feeding Johnston told JAMA. They found that the of Internal Medicine.” But the FTC describes into this. The same strategy is being used to evidence to support recommendations to its role as protecting consumers and pro- discredit science on sugar and soda con- cut back on added sugars was low to very moting competition in the marketplace, so sumption, climate change, air pollution, and low, highlighting “methodological defi- it’s unclear what authority or interest it would other environmental hazards.” c i e n c i e s i n n u t r i t i o n a l g u i d e l i n e s ,” have in this case. Guyatt, a distinguished professor at Johnston said. “This paper did not say Despite PCRM’s name, less than 10% of McMaster University in Hamilton, Ontario, sugar is okay to consume.” its 175 000 members are physicians, accord- led the development 30 years ago of the He said he received the ILSI funding in ing to its website, which describes the orga- concept of evidence-based medicine. In 2015, which was before the 3-year period for nization’s mission as “saving and improving an interview with the Canadian Broadcast- which he was required to report competing human and animal lives through plant- ing Company a few days after the meat interests for the meat articles. However, ac- based diets and ethical and effective scien- articles were posted, Guyatt called the cording to a December 31 correction in the tific research.” response to them “completely predict- Annals, Johnston didn’t include on his per- able” and “hysterical.” sonal disclosure form a grant from Texas “Information Terrorism” Tufts University professor Sheldon A&M AgriLife Research that he received The rebukes continued for weeks after Krimsky, PhD, described it differently. “It within the 36-month reporting period. The publication of the meat articles, but Katz sounds like a political campaign,” said grant funded investigator-driven research didn’t comment via the typical routes of Krimsky, who spoke on a panel about cor- about saturated and polyunsatured fats, ac- posting comments on the journal’s web- porate influence on public health at the an- cording to the correction. site or writing a letter to the editor. He said nual meeting of the American Public Health Johnston isn’t the only one who’s had he did neither because he’s “able to react Association. “I’ve seen Monsanto do the ILSI ties. True Health Initiative member much more immediately and generate same thing on the other side.” Sievenpiper served as a scientific advisor a much wider awareness with my own Krimsky, who studies linkages between for ILSI’s Carbohydrates Committee and blog platforms.” scienceandtechnology,ethicsandvalues,and as vice chair of the ILSI North America Sci- In his October 6 column for the public policy, said THI is part of a plant-based entific Session 2018. And in late 2015, New Haven Register, Katz compared the ar- diet “movement.” “If Katz wrote a paper, and Canada’s National Post newspaper reported ticles, which he called “a great debacle of it was published in one of the journals, I would that the Corn Refiners Association retained public health” to “information terrorism” that assume he would have to disclose his relation- Sievenpiper as an expert witness to sup- “can blow to smithereens…the life’s work of ship with his organization.” port its case that high-fructose corn syrup innumerable careful scientists.” Steven Novella, MD, founder and execu- is no less healthy than sugar. About 3 weeks later, PCRM asked the tive editor of the Science-Based Medicine Shortly after the meat papers were pub- district attorney for the City of Philadelphia, website and a long-time critic of Katz, was lished, THI Director Jennifer Lutz posted an where the Annals editorial office is located, more pointed in his assessment of the THI article entitled “Steak Holder Interests: In- “to investigate potential reckless endanger- campaign against the meat articles. “It’s a dustry Funding and Nutrition Reporting,” ment” resulting from the publication of the total hit job,” Novella, a Yale neurologist, told The article called out Stover, who meat papers and recommendations. JAMA. “They have a certain number of go-to coauthored the NutriRECS meat guideline, Another salvo came during a recent strategies…in order to dismiss any scien- for having an undisclosed conflict of inter- 1-day preventive cardiology conference, tific findings they don’t like.” One such strat- est because his school receives funding where half the presentations were on plant- egy, he said, is to lodge accusations of “tenu- from the beef industry. Stover is vice chan- based diets. During his keynote address, ous” conflicts of interest. cellor and dean for the Texas A&M College Willett showed a slide entitled “Disinforma- of Agriculture and Life Sciences, which is tion” that faulted several organizations and “Confluence” or Conflict of Interest? part of Texas A&M AgriLife. Lutz’s article individuals: the “sensationalist media,” spe- The New York Times was the first organiza- noted that 44 Farms, the largest Texas cifically the Annals and longtime New York tion to raise the issue of potential conflicts producer of Black Angus cattle, has Times science reporter Gina Kolata, who of interest among the meat papers’ established an endowment at Stover’s wrote the newspaper’s first story about the authors. An October 4 article noted that school to support the International Beef meat papers; “Big Beef,” specifically Texas Johnston, who reported having no con- Cattle Academy. A&M and nutrition scientist Patrick Stover, flicts of interest in the 3 years prior to pub- However, the beef industry provides PhD, vice chancellor at the school and a co- lication, coauthored a December 2016 only about 1.5% of AgriLife’s funding, which jama.com (Reprinted) JAMA Published online January 15, 2020 E3 © 2020 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Texas A&M University User on 01/15/2020 News & Analysis it posts online, spokeswoman Olga a confluence of interest. The work you do Katz also is senior nutrition advisor for Kuchment said. Federal sources, such as the is what you care about…No one’s ever paid Kind Healthy Snacks—a THI partner—and has US Department of Agriculture, account for me to say anything I don’t believe.” received $153 000 in research grants from about half of AgriLife’s funding, Kuchment Katz is a past president of an organiza- the company. In 2015, the year Katz be- added. Besides animal science, AgriLife tion called the American College of Life- came an advisor to Kind, it received a research areas include nutrition and food sci- style Medicine (ACLM), whose website warning letter from the US Food and Drug ence, horticultural science, and soil and crop states that THI was “birthed from under Administration (FDA) for false nutrient sciences. Although he has received AgriLife ACLM’s wing” in 2015, during his 2-year term. claims, including the use of the word funding, Johnston said, “I personally have The ACLM established the American Board “healthy,” on its labels. never had ties with the beef industry.” of Lifestyle Medicine, which isn’t recognized Meanwhile, industry ties and other po- by the American Board of Medical Special- Consumer Confusion tential conflicts of interest seem to be com- ties. Among ACLM’s corporate “partners” is Do consumers lose when nutrition research- mon among THI council members and the Plant Strong by Engine 2, which holds re- ers can’t play nice? organization itself. treats “designed to foster and celebrate your Timothy Caulfield, LLM, research direc- Among the not-for-profit “partners” plant-based potential,” and MamaSezz, tor of the University of Alberta’s Health Law listed on the THI website are #NoBeef, the which delivers “ready-to-eat whole food Institute and a THI council member, gave Olive Wellness Institute, which describes it- plant-based meals with no BS (you know, 3 public lectures in 1 week not long after self as a “science repository on the nutri- Bad Stuff).” Annals published the meat articles. “This is- tion, health, and wellness benefits of olives Carmona, the THI council member and sue came up at all 3,” Caulfield said. and olive products”; and the Plantrician Proj- former surgeon general, serves on the board “I understand both the concern about ect, whose mission is “to educate, equip, and of Herbalife Nutrition, the dietary supple- conflict of interest, especially in nutrition re- empower our physicians, healthcare practi- ments company, and as “chief of health search, and the value of advocating [for] a tioners and other health influencers with innovation” at Canyon Ranch, “the world’s more plant-based approach to nutrition,” he knowledge about the indisputable benefits recognized leader in…luxury spa vacations.” said. “But there is so much public confusion of plant-based nutrition.” In a 2018 commentary entitled “Resist- surrounding diet. I worry about any messag- Among THI’s for-profit partners are ing influence from agri-food industries on ing that might be interpreted as dogmatic.” Wholesome Goodness, which sells “better- Canada’s new food guide,” THI council mem- Caulfield, described in a 2018 profile in for-you foods” such as chips, breakfast ce- ber Jenkins listed under his “competing in- Toronto’s Globe and Mail as “one of North reals, and granola bars “developed with guid- terests” dozens of research grants from com- America’s most high-profile skeptics, tak- ance from renowned nutrition expert panies and industry groups, including the ing on the rising tide of pseudoscience and Dr David Katz”; and Quorn, which sells meat- Pulse Research Network, the Almond Board misinformation,” noted that “the [THI] coun- less products made of mycoprotein, or fer- of California, the International Nut and Dried cil has many alternative medicine practition- mented fungus made into dough. Fruit Council; Soy Foods Association of North ers and embraces ‘integrative health.’ This Katz, who on his personal website de- America; the Peanut Institute; Kellogg’s can be difficult to square with a science- scribes himself as an entrepreneur, bristles Canada; and Quaker Oats Canada. based approach.” at the suggestion that he, his organization, Katz’s 66-page CV provides much food When asked if he planned to step down or any of his council members might have for thought about industry funding of nutri- from the THI council, Caulfield said, “I’ll need conflicts of interest. tion research. He lists 2 grants from Hershey to put more thought into this. I haven’t asked “We weren’t telling people: Buy our Foods totaling $731 000 to study the ef- them to remove my name…but I haven’t kumquats,” he said. fects of cocoa on vascular function in people been actively involved.” Perhaps not kumquats, but Katz, ac- with hypertension and in those with obe- The cacophony that has erupted over cording to his curriculum vitae (CV), and Hu sity. He received 4 grants totaling $662 000 the meat papers is drowning out the valid have received funding from the California from the Egg Nutrition Center, the research points they made, Laine said. Walnut Commission. And the T.H. Chan and education division of the American Egg “The sad thing is that the important School of Public Health, Hu’s and Willett’s Board. One of the egg grants was awarded messages have been lost,” she said. “Trust- academic home, has received hundreds of in August 2010, around the same time he worthy guidelines used to depend on who thousands of dollars from the walnut group. published an article entitled “Recent anthro- were the organizations or the people they “I don’t think there is any basis in the pologic and clinical research raises ques- came from.” Today, though, “the public world to accuse Walter Willett of conflict of tions about egg/cholesterol relationship– should know we don’t have great informa- interest. He and Frank Hu have genuine in- Eggsoneration” in the Egg Nutrition Center’s tion on diet,” Laine said. “We shouldn’t terest in the health effects of nuts,” Katz said. Nutrition Closeup newsletter. He also re- make people scared they’re going to have “There’s nothing fundamentally wrong ceived $249 701 from ISOThrive to study the a heart attack or colon cancer if they eat [with] industry funding.” effects of its eponymous “gastroenterolo- red meat.” And, Katz told JAMA, “I think there’s a big gist recommended microFood” in over- Note: Source references are available through difference between conflict of interest…vs weight adults. hyperlinks embedded in the article text online. E4 JAMA Published online January 15, 2020 (Reprinted) jama.com © 2020 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ by a Texas A&M University User on 01/15/2020