May 5th, 2014

What Role Should Coca-Cola Play in Obesity Research?

Max Coke

Original illustration by Max Husten

What role should Coca-Cola and other food and beverage companies play in funding and communicating research about nutrition and obesity?

The question is prompted by a recent article in the Journal of the American College of Cardiology. The “state-of-the-art” paper reviews the relationship of obesity and cardiovascular disease and presents the case that a decline in physical activity is the primary cause of the obesity epidemic.  The article downplays the role of calories and diet and does not include the words “sugar,” “soda,” or “beverage.” Three of the five authors of the paper report financial relationships with Coca-Cola.

It is important to acknowledge that there is an active scientific controversy about the relative importance of diet and exercise. But it also seems clear that the perspective on this controversy as presented in this paper is remarkably congruent with the interests of Coca-Cola.

Defending Coca-Cola

I asked the lead author of the paper, Carl Lavie, a Louisiana cardiologist and obesity expert, to respond to concerns that the authors’ relationships to Coke may have affected the content of the paper. Here is Lavie’s (lightly edited)  response:

My personal relationship was providing consulting and giving a couple of lectures on the importance of fitness. My colleagues have also consulted and received non-restricted educational grants  for research studies. Coca-Cola had nothing to do with the details of the study, analyzing results, or publishing the paper. Therefore, I do not think that this relationship adversely impacts any of the results of their studies or my invited state-of-the-art review article, which happens to be on a topic where I have published more than anyone else in the world during the past 10-15 years.

My article really was not on sugar, and you are correct that this (or diet in general) was only briefly mentioned. Although there is a lot of attention on fast foods and sugary beverages causing obesity, the research from my colleagues and I show that very marked declines in physical activity, which is also a major component in leading to fitness, is by far the major cause of obesity, not sugar and fast foods. Nevertheless, I agree if the physical activity is very low, one must cut all calories to compensate, including those from sugar and fast foods. Regarding Coca-Cola, although their “flagship” product is a sugary beverage, keep in mind that they have many more low or no calorie products in their comprehensive arsenal!!

In the medical field, many companies fund studies and educational programs, but the investigators and speakers are not changing what they say due to who sponsors the work!”

Lavie subsequently sent a succinct summary of his position:

1) Hopefully the science speaks for itself, regardless of the sponsor.

2) Science itself is improved by data and facts.

3) Not to be too harsh, but my opinion (based on my interpretation of the science) is not for sale and cannot be bought. I am sure my colleagues feel the same way.

4) All researchers have bias, as do I, but if you try to eliminate every researcher/scientist/clinician with bias, there will be hardly any left.

5) Therefore, the best way to proceed is to focus on well-designed and well-executed studies.”

I then sent Lavie some followup questions:

Do you believe there should be any limitation on industry funding of research and education? What about research sponsored by a tobacco company?

Lavie: I do not think so, as long as it is fully disclosed. I believe that in some of the tobacco settlements they are having to pay money for research. There are very little potential health benefits of tobacco, although I guess if one smoked one cigarette a week there may not be much harm. I personally have no problem with [some]one accepting funds, particularly as a non-restricted educational grant, but suspect few would do so considering the negative feelings that so many have about the tobacco industry. I suspect that very few feel as strongly about Coca-Cola, Pepsi cola, McDonalds, Burger King, Taco Bell, etc.

What about unconscious bias or subtle bias? For instance, isn’t it possible that the paper would have contained a brief discussion of sugar and sugar-sweetened beverages (SSBs) without the financial associations of the authors with Coke?

Lavie: This is possible I guess if one were working for a company, but in my case for example, receiving a few minor honorarium would hardly taint my views. My first lecture for Coca-Cola was just a couple of years ago, and I have been publishing on this topic for nearly 15 years, so this is probably not applicable. I have never published on sugar or even related to this in any of my nearly 800 publications, so personally this really does not apply much…

What do you think is Coca-Cola’s motivation in providing funds for research and education? Does this represent altruism on the company’s part? Would it be likely to fund researchers who hold opinions that are less congenial to their business?

Lavie: I think that they want to provide a public service that is good for their image. Also, I believe that at least many in such a company want to learn the scientific truth. I would suspect that they know that some of the studies they fund may come out neutral or even negative for their products. It would be reasonable to think that they would not want to fund someone who is viciously attacking them, but I would believe they would still fund a good, honest scientist who did a study that found some negative effect of one of their products. Pharma does this all the time. They fund studies that are stopped due to toxicity or have negative findings. Also, good drugs have adverse effects in some, and sometimes many have adverse effects and still the negatives may not outweigh the pros.

What are your thoughts about Coke (and other companies) having financial relationships with health organizations like the ACC and the AHA? How would the objectivity of these organizations be affected by these relationships in regard to public policy advocacy, such as sodas in school or a tax on SSBs? And to push this question: Should organizations like these accept support from tobacco companies?

Lavie: As long as it is all out in the open, I do not believe that the ACC or AHA would sell their scientific statements. Also, the money they would accept would have no strings attached and be for educational purposes. The AHA is not going to endorse or not endorse products based on their funding source, and I am sure the AHA/ACC would be happy to get funds from Pepsi and many of the fast food chains, who also have some “healthier choices” compared to others. McDonalds and Taco Bell are not the cause of the obesity epidemic, lack of physical activity is. I suspect that these organizations may feel uncomfortable taking funds from the tobacco industry, but I am personally okay as long as it is disclosed. If the tobacco companies, which clearly cause adverse health outcomes, provide funds from their profits that in some ways lead to promotion of better health, why would this be a bad thing?

3 Responses to “What Role Should Coca-Cola Play in Obesity Research?”

  1. Gervasio Antonio Lamas, MD says:

    This is a really interesting problem that may not have a solution. I reject the concept that if you have a financial conflict of interest, all you have to do to “cure” that conflict is to declare it. Supposedly, this keeps you honest, and forces your incredibly intelligent audience to look for and discount any biased statements.

    Who are we fooling? Just ourselves. I have been on both sides, conflicted, and non-conflicted, and I can tell you that declaring the conflict does not remove the financial pressure to please. I even sat on a DSMB once for a pharma study – and I was lecturing for them. When I decided my DSMB role was not appropriate, I was told by colleagues that all I needed to do was declare the conflict. I resigned the DSMB.

    On the other hand, it is a rich man who turns away funding. And I am rich in that sense. I have been funded by NIH for many years, and no company is interested in TACT – so it is easy.

    So we may be stuck with the present non-solution: declare conflicts and trust to alert journalists to be gadflies and keep the researchers honest. There has to be a better way.

  2. I want to take advantage of the CardioExchange comments section to address a few individual points.

    1. Lavie writes that his views are “not for sale.” I do not want to suggest anything so stark, but I also think it is fair– and studies have demonstrated– that gifts, even very small gifts, can exert strong unconscious effects. When combined with the flattery and attention of being designated a “key opinion leader” an unconscious alignment with a company can easily occur.

    Moreover, as I wrote last year, in a recent paper in PLOS Medicine researchers conducted a systematic review of systematic reviews examining the association between sugar-sweetened beverages and weight gain and obesity. For the papers in which the authors reported no conflict of interest, 10 out of the 12 findings supported the association between sugar-sweetened beverages and weight gain or obesity. In stark contrast, 5 out of the 6 papers with industry support failed to find evidence for any such association. In other words, systematic reviews with industry support were 5 times more likely to find no significant association.”Our results,” wrote the authors, “confirm the hypothesis that authors of systematic reviews may draw their conclusions in ways consistent with their sponsors’ interests.”

    2. Lavie defends Coke’s funding of research by saying that “pharma does this all the time.” This analogy represents a stretch of logic. Although pharma-funded research is often criticized, and there are many active battles over the precise role for pharma in research, it is widely agreed that pharmaceutical companies must play a vital and important role in medical research. No one would seriously argue that Coca-Cola has medicinal value. The only active question is exactly how bad an effect Coke has on public health. A much better analogy, though still imperfect, is the tobacco industry.

    3. I think it is naive to believe with Lavie that Coke’s main interest in providing financial support to researchers in this field is “to provide a public service.” For-profit companies like Coke and Pepsi don’t spend enormous sums of money just to provide a public service. They expect a significant return on their investment, though this may be difficult to quantify. In any case, it is more than obvious why Coke would be interested in supporting scientists who maintain that sugar does not play an important role in the obesity epidemic.

    As I mentioned earlier, there is a very active controversy about the relative contributions of diet and activity to the obesity epidemic, but in my experience the vast majority of experts agree that diet, and sugar in particular, plays some sort of significant role in the problem. Regarding this point, another of the JACC authors, Timothy Church, a Louisiana preventive medicine specialist and exercise expert, sent a comment to elaborate on LaVie’s defense of the paper’s focus on exercise and its neglect of sugar and diet:

    We could also have mentioned the effects of air conditioning, bacteria, viruses, cars, lack of sidewalks, antibiotic use, c-sections etc, etc on obesity. There are outstanding research papers looking at all of these things and more.

    We were focused on exercise and fitness. There are thousands of diet and obesity papers that do NOT mention exercise, yet every time we do an exercise paper we are expected to go into great depth about diet. It is an interesting double standard.

    But this view does not withstand critical scrutiny. Sugar is by no means equivalent to air conditioning, viruses, or c-sections. Sugar is at or near the center of nearly all discussions about obesity. It’s just silly to pretend otherwise.

    Here’s a useful analogy: by itself an article about the genetic factors that lead to lung cancer would be unremarkable. But if the researchers had received support from a tobacco company, and if the article specifically downplayed or ignored the role of tobacco in favor of genetics, then it would be completely appropriate to point out the missing role of tobacco in causing lung cancer, and to speculate about the motives of a tobacco company for its involvement in this research.

  3. michael finn, MD says:

    Every day that I’m in the office,obese patients with diabetes,hi blood pressure, and heart disease come in for care. Especially with new patients, I take a detailed dietary history and a majority of the patients initially deny they overeat “too much”.Delving into their diet history further reveals a majority of them drink several sodas a day or lots of sweetened ice tea, have double portions at meals ,eat out at chain restaurants several times a week,and eat fast food. At the end of the dietary history, most of the obese or overweight patients demonstrate they are taking in 2-3 times the recommended daily caloric intake for their age.
    I am not a nutritionist or obesity expert but after 33 years as a cardiologist taking dietary histories , I have the following observations:
    Many patients ,both depressed or non depressed ,seek comfort in food .The food industry which is one of the largest industries in the world eagerly obliges the public, esp. the American public by making high calorie carbohydrate, fat and salt laden food easily accessible .
    Many patients resort to unhealthy cheap food for stress relief.Cheap accessible food provides an outlet for stress relief to many people who are unable to afford luxuries as health clubs,theater, movies,vacations, etc.
    Exercise is obviously important in maintaining general health and in conjunction with a good diet , will help in combating obesity. Many overweight or obese patients do not have the time, resources or discipline to maintain a regular exercise program.Many patients feel that they will lose weight just by exercise alone and imply that if only they would exercise they wouldn’t have to cut their caloric intake.I emphasize that I would rather see them cut out the 2 slices of bread a day ,stop the liter of coke,sweetened ice tea, and deserts to lose real weight. I find that first educating patients about the deleterious effects of their poor diet and modifying their diet has a much greater impact on their health than emphasizing an unrealistic exercise program which a majority of them won’t follow on a regular basis.
    Yes, Dr. Lavie, exercise is important but getting Coke, soft drinks, fast food, restaurant visits,snack food, etc out of our patient’s diet is much more important. Just ask the patients- they will confirm this.