 You may have heard the expression, knowledge is power. Well, today we're going to give you more power to control your diet and lifestyle by giving you the facts. Welcome to the Nutrition Facts Podcast. I'm your host, Dr. Michael Greger. Today, we have the first of an eight-part series in how industries impact dietary and health guidelines, and we start with Big Sugar. In 2019, a series of reviews were published in the Annals of Internal Medicine that concluded the same thing that past reviews have concluded. Adherence to dietary patterns lower in red or processed meat intake may result in decreased risk for premature death, cardiometabolic disease and mortality, meaning the risk of getting and dying of diseases like heart disease and type 2 diabetes, as well as the risk of getting cancer and dying from cancer. Therefore, they concluded in their Dietary Guideline recommendations, continue your current red meat consumption, continue your processed meat consumption. Wait, what? Yeah, premature death, cancer, heart disease, diabetes, but keep eating your burgers and bacon. To understand what just happened, we have to go back to 2015. The Dietary Guidelines had just had the audacity to recommend people have reduced their sugar intake. Imagine you work for the sugar industry. The evidence is overwhelmingly against you. What do you do? Well, what did the tobacco industry do? One method involved the tobacco industry's funding of and involvement in seemingly unbiased scientific groups to manipulate the scientific debate concerning tobacco and health. Groups like the ILSI, the International Life Sciences Institute, which has joined a long and serious collaboration with the tobacco industry, that same industry group shapes food policy around the world. The International Life Sciences Institute, technically a non-profit with an innocuous-sounding name, has been quietly infiltrating government health and nutrition bodies around the world. It was created by a top Coca-Cola executive and almost entirely funded by goliaths of the agribusiness, food, and pharmaceutical industries. After decades largely operating under the radar, the Institute is coming under increasing scrutiny by health advocates in the United States and abroad who say it's little more than a front group advancing the interests of the 400 corporate members among them Coke and Pepsi. So in the 2015 Dietary Guidelines advised eating less sugar, the Soda-funded International Life Sciences Institute sponsored a review concluding that the guidelines on sugar were simply not trustworthy. Who did they pick for this hatchet job? Bradley Johnston. Published in the Annals of Internal Medicine, the scientific basis of guideline recommendations on sugar intake and concluded there basically wasn't one. Guidelines on dietary sugar do not meet criteria for trustworthy recommendations as they are based on low-quality evidence. This comes right out of the tobacco industry's playbook, Cast Doubt on the Science, said Professor Marion Nessel. This is a classic shameful example of how industry funding biases opinion. Yes, the paper was paid for by the likes of Coca-Cola, Hershey Red Bull, and the makers of Oreos, but the authors swore they wrote the protocol and conducted the study independently. Turns out that was a lie, forcing the journal to publish a corrected version after the Associated Press obtained emails showing the industry front group requested revisions. It also came out that a co-author conveniently forgot to mention a 25 grand grant she got directly from Coca-Cola. You know it's bad when candy bar companies criticize an industry-funded paper on sugar. The makers of Snickers, Skittles, and M&M's broke ranks with other food companies and denounced the industry-funded paper. They themselves were a member of the ISLI, but come on, telling people to ignore guidelines to cut down on sugar? That's just making us all look bad. If you look at the relationship between funding source and the conclusions in nutrition-related scientific articles, there's like seven or eight times the odds that the conclusion will skew favorably compared to studies with no industry funding. For interventional studies, the proportion of studies paid for by industry that reached unfavorable conclusions about their own products was a big fat zero percent, which should not surprise anyone. So what can journals do to counteract the tactics that industry often uses to advocate for the safety of unsafe products or question the integrity of science that calls their products into question? To combat the tobacco industry's influence over scientific discourse, leading journal editors have refused to be passive conduits for articles funded by the tobacco industry. They just won't accept tobacco industry-funded studies, period. Accordingly, high-quality journals could refrain from publishing studies on the health effects of added sugars funded by soda and cookie companies, but they're not. This was published in the Annals of Internal Medicine. And so, four years later, with the next batch of dietary guidelines on the way, and the last scientific report of the Guidelines Committee encouraging people to eat diets, not just lower in sugar, but lower in meat as well, Big Beef decided to follow in the footsteps of Big Butterfinger. Same journal, same guy, same scientist for hire Bradley Johnston as lead author, and the rest is history. We'll dig into exactly how he pulled it off. Next. In 2016, Washington-based lobby group published a scientific review, which concluded that evidence in favor of guidelines recommending limits on added dietary sugar was low quality and did not meet criteria for trustworthy recommendations. This was a group funded by multinational food and agrochemical companies from Coke to Monsanto to the captains of corn syrup, accused of hijacking the scientific process in a disingenuous way to sow doubt and jeopardize public health. But exactly how did they get away with it? Here's their paper questioning the scientific basis of guideline recommendations on sugar intake. Using the grade approach, they concluded that the overall quality of evidence to support such recommendations was low to very low. Grade stands for the Grading of Recommendations Assessment Development and Evaluation Initiative, which was developed to make clinical guidelines more evidence-based and thank heavens for that. Clinical guidelines like which drug to give to whom used to be developed by like the gobsat method, just some good ol' boys sitting round a table. Under grade, high quality evidence appears to be derived exclusively from randomized trials. This is not surprising, given that the grade process was designed for drugs. And of course, you want your drugs put to the test. Like remember the premarin story, where for a decade organizations recommended that clinicians encourage post-menopausal women to use hormone replacement therapy because women who are taking it appear to have fewer heart attacks. But when put to the test, randomized controlled trials instead show the opposite. So we definitely want drugs put through randomized double-blind placebo-controlled trials, where people are randomized to take the drug or unknowingly take a placebo instead, and no one knows who's in which group until the code is broken at the end, and you see how well the two groups did compared to each other. Everyone agrees that randomized controlled trials are enormously viable in many areas of medical research, such as the testing of drugs. But wait a second, how do you do that with diet? There's no such thing as a placebo diet. How can you randomize people to different diets, but somehow hide from them which diets they're following? People tend to notice what they put into their own mouths. In RCTs, randomized controlled trials are so expensive. They typically last for only weeks or months, but it takes most cancers decades to develop. So it's nearly impossible to see if different diets prevent or cause cancer that way. To see if smoking causes cancer, you can follow large cohorts of smokers and non-smokers out for decades to see who gets cancer and who doesn't. But it's not like you can randomize people to smoke or not smoke for decades. When studying lifestyle interventions, you often just can't do randomized controlled trials, and even if you could, it might not be ethical. Take crib death, for example. Sudden infant death syndrome. A pivotal study, studying the habits of infants who died, discovered that sleeping on their stomachs was a risk factor. So we started educating parents face up to wake up, and the SIDS rates dropped. What more do we need? Would it even be ethical to randomize thousands of babies to sleep on their backs or fronts and count up the deaths at this point? You can get sufficient evidence to make lifestyle recommendations that save lives without randomized controlled trials. Critical questions, like what dietary pattern produces the best health outcomes over a lifetime, simply can't be answered with randomized controlled trials. You can't randomize people to different lifetime diets and expect them to stick to them, so we need to compile an amalgamation of evidence from other study designs. But the lack of evidence from randomized controlled trials has become a common argumentation strategy for criticizing nutrition recommendations. Similar claims were made by the tobacco industry in its attempt to discredit evidence on the harms of tobacco. Case in point, the so-called sound science campaign carried out by Philip Morris. This is all straight out of the tobacco industry playbook. Philip Morris used public relations firms and lawyers to develop a sound science program that involves recruiting other industries in issues to obscure the tobacco industry's role. They tried to enshrine, quote-unquote, good epidemiological practices that would make it impossible to conclude that second hand smoke and thus other environmental toxins caused diseases. Public health professionals need to be aware that the sound science movement is not an indigenous effort from within the profession to improve the quality of scientific discourse, but rather reflects sophisticated public relations campaigns controlled by industry executives and lawyers whose aim is to manipulate the standards of scientific proof to serve the corporate interests of their clients, and not just tobacco clients, but hopes to expand to the food, plastics, and chemical industries. Philip Morris went beyond just creating doubt controversy about the scientific evidence to attempting to change the scientific standards of proof. But randomized controlled trials aren't the only source of good evidence. As Sir Bradford Hill himself said, who pioneered the randomized controlled trial, any belief that the controlled trial is the only way to go would mean not just that the pendulum had swung too far, but that it had come right off the hook. 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