Primary Care Corner with Geoffrey Modest MD: Sugar Industry’s Role in Creating Policy

By Dr. Geoffrey Modest

The NY Times ran a recent story on the historic role of the sugar industry, in close relationship with academia, in promoting the role of fats/undercutting the role of sugar in the development of coronary artery disease (CAD)

The Details:

  • In 1954, the Sugar Research Foundation (SRF) president stated that there was a chemical connection between fats and atherosclerosis, and that the carbohydrate industries could dramatically increase their market share by getting people to eat less fat. The industry spent $5.3 million (in 2016 dollars) to promote this, along with “that sugar is what keeps every human being alive and with energy to face our daily problems”
  • Since 1957, the British physiologist John Yudkin reported several studies finding that sugar was at least as important as fats in promoting CAD
  • The SRF in 1964 decided to pursue CAD research to see “the weak points there are in the experimentation [of the anti-sugar reports], and replicate the studies with appropriate corrections. Then we can publish the data and refute our detractors”
  • The SRF recruited Frederick Stare, chair of Harvard School of Public Health (HSPH), to join the SRF Advisory Board as an ad-hoc member.
  • There were a few articles in the Annals of Internal Medicine by D Mark Hegsted from HSPH linking sucrose to CAD, corroborating Yudkin, finding that “sucrose must be atherogenic”
  • In 1965, the SRF paid that same Hegsted and another person $48,900 (in 2016 dollars) to write a review article on sugar’s role, under the supervision of Stare, with a goal of undercutting the increasing scientific and public concerns about the role of sugar (the New York Herald Tribune had just run a full-page article about the Annals’ articles by Hegsted and others, highlighting the adverse role of sugar). This review article was delayed by ongoing evidence in the medical literature of sugar’s negative role in development CAD, but ultimately led to a 2-part NEJM review article, including both Hegsted and Stare as authors, which concluded that there was “no doubt” but that the only intervention to decrease CAD was to substitute polyunsaturated fat for saturated fat. The review article did comment on the sugar link but then discounted its role in CAD, through very inconsistent arguments. Although this review did disclose industry funding, it did not mention the SRF funding (it was not till 1984 that NEJM required authors to report financial disclosures/conflicts-of-interest).
  • One point that the review article highlighted and promoted was that it was okay to look just at serum cholesterol levels as a surrogate marker for CAD (at that time, we could only measure the total cholesterol levels), and ignore the often documented role of sugars in raising triglyceride levels.
  • The Sugar Association (the current name for SRF) then went on to undercut the role of sugar in dental caries, ultimately involved in shifting the 1971 emphasis of the National Institute of Dental Research’s National Caries Program to interventions other than restricting sucrose consumption.

Commentary:

  • As we know, as a result of reducing fat consumption as the target of the American Heart Association, various Nutrition societies etc; sugar/carbohydrate consumption has increased dramatically over the past many decades (e.g., witness the proliferation of low-fat foods, which basically substitute carbs for fats), as has the prevalence of obesity and its many unfortunate sequelae (diabetes, etc.). And there are pretty clear connections between sugar intake and CAD, as above, which date back to the 1950s. I did take a course on nutrition and health in the 1970s at the Harvard School of Public Health, when I read a book written by a decorated British military physician using cross-cultural epidemiologic studies to demonstrate a strong association between refined sugars and most chronic diseases at that time, though i cannot remember the author’s name. At that time Frederick Stare was still the head of HSPF, but retired in 1976 at least in part because of his role in the sugar industry: the nutrition dept at that time was openly up-in-arms against him). Hegsted later became the head of nutrition at the US Dept of Agriculture and played a key role in writing the government’s nutrition guidelines. It is pretty striking how the sugar industry was able to take the author of several anti-sugar articles in the Annals and (?? through $$, ??other political influences) was able to get him to write the 2-part NEJM review undercutting the role of sugar in CAD. And I do remember those reviews as being very well-read and oft-cited at the time.
  • The current article also brings up the concerns about using surrogate markers for clinical disease (as many of you know, I have very real concerns about using A1C levels instead of actual clinical outcomes as the measure of the benefit of new diabetes drugs: witness rosiglitazone, and the increasing reports of problems with most of the new meds. see many blogs in  http://blogs.bmj.com/bmjebmspotlight/category/diabetes/). In the CAD case above, we did not measure LDL or HDL levels at the time, and we now know that increasing triglyceride levels physiologically track with decreasing HDL levels, and conversely, a low glycemic index diet is pretty consistently associated with increasing HDL and decreasing triglyceride levels. Another faulty surrogate marker…
  • And this article does reinforce the disproportionate role of the most prestigious journals (e.g. NEJM) in informing general clinical practice (and, i wouldn’t be surprised if these types of articles also influence future research done as well)
  • Of course, the above article is limited by what was available in the archives they searched, so the above findings should be interpreted not as “rock solid”, but pretty suggestive
  • But it really does reinforce the concern about the increasing role of industry in designing and performing clinical trials — there has been a dramatic shift from the 1970s, effected by President Reagan, where funding for research began to shift from the public to the private sectors, researchers shifting their affiliations from the largelyscientifically-independent medical schools to private companies (with the often attendant shift in their incomes), to the point that most clinical studies now reported in the literature are industry-funded. Although the disclosure requirements are much better defined, if company-sponsored studies are the only source of data available to clinicians, it is hard to ignore them (and this is reinforced by drug company detailing and direct-to-consumer advertising, etc.). See http://blogs.bmj.com/bmjebmspotlight/category/pharmacy/ as well as http://blogs.bmj.com/bmjebmspotlight/2015/08/31/primary-care-corner-with-geoffrey-modest-md-regulation-of-medical-devices/ for several blogs on drug company “shenanigans”, including covering up adverse information about the drugs they are making, the role of direct-to-consumer advertising, drug company unseemly profits, ghost-written scientific articles by drug companies, and drug companies/medical device makers marked inconsistency in reporting negative studies as required by law.

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As an addendum, Karen Henley sent me an email about STAT, and its article on conflicts-of-interest: https://www.statnews.com/2016/09/09/ijme-journal/
My comments:

STAT has some great, daily, free emails dealing with Zika (a daily update on the medical, political and funding issues) as well as highlights of pharmaceutical shenanigans (of which there have been way too many over the past few years, most recently with Mylan and the epi-pens).

The STAT article commented on an article in the Indian Journal of Medical Ethics, which is actually an old journal which has been getting more attention over the past few years. They highlighted the rather profound conflicts-of-interest in the elite medical journals, highlighting the twists and turns of New England Journal of Medicine and their publishing an industry-sponsored article on Vioxx (rofecoxib), then refusing to publish the warning about the increasing numbers of patients (tens of thousands) who died from the drug (see the link in the STAT article). This was also exposed by Marcia Angell and others a few years ago in her very pointed concerns about the direction of NEJM, but I think the Indian journal also added a broad view of the issue of conflicts-of-interest –> which I think are a huge problem, pretty omnipresent, and make me very wary about being an early adopter of new medications.

Also, see prior blog http://blogs.bmj.com/bmjebmspotlight/2015/10/26/primary-care-corner-with-geoffrey-modest-md-academic-conflicts-of-interest/ , which highlights the huge conflicts of interest with the leaders of academic medical centers, including some near and dear highly-acclaimed academic medical centers (i.e., the Brigham), and with comments by Marcia Angell

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