Conflicts of Interest, Corporate Partnerships, and the Dietitian

I sometimes wonder what it’s like to have a job that requires no human interaction, where neither services rendered nor collaborations are a requirement. Are geologists lonely in an office where specimens under a magnifying glass are their only company, or, do they experience serene stability in knowing that their rocks will always reliably be, well, rocks? By comparison, working with people must seem like an endless battlefield. Our interactions with one another are pockmarked by conflicts of interest, virtues in the face of vice, and fallibility that everyone seems certain is conquered in themselves. Such themes were under intense scrutiny in Anahad O’Connor’s recent piece in the Washington Post, the lead author who addressed a small group of dietitians partnered with food organizations to promote affiliated products. The controversial topic of corporate influence on food systems, and the subsequent role dietitians should play, is nothing new to the realm of dietetics. It’s a hot debate that merits discussion, and while some of O’Connor’s arguments are valid, others are asinine and romanticize a world of ideal human behaviors that do not exist.

The article opens up with a nod to the World Health Organization’s (WHO) recent joint news release that aspartame be categorized as a Group 2B carcinogen (more on this in a moment), then goes on to cite several dietitians of the ‘influencer’ variety who publicly countered the WHO’s claim.

Then, the damming condemnation that sets the tone for the rest of the piece:

“What these dietitians didn’t make clear was that they were paid to post the videos by American Beverage, a trade and lobbying group representing Coca-Cola, PepsiCo and other companies.”

O’Connor is justified in crying foul at any failure to declare paid promotions, as personal disclosures and transparency in practice are embedded with the dietitians’ code of ethics, which the article fairly cites. But as the piece continues, it becomes clear that O’Connor’s central concern is not a lack of transparency between dietitians and food companies, but that such relationships exist in the first place. That is a perplexing position, and doesn’t take much explanation to reveal why.

To begin, if I was to malign someone for their support of a food additive, that additive would absolutely not be aspartame. The WHO’s categorization of aspartame as possibly carcinogenic seems unwarranted, given minimal evidence that is limited almost entirely to mechanistic studies in animals. And no, nobody is paying me to say that. Contextually, a group 2B carcinogen is the third lowest of four designations, falling into the same categorical risk as being a barber, or constantly carrying nickels around in your pockets. The WHO’s own press release confirms as much, stating that an adult would need to consume more more than 9 cans of a diet soft drink before hitting the recommended limit of aspartame (>40mg/kg of body weight). If your central argument is that corporate relationships unduly influence a dietitian’s perspective, what does that say when you choose a topic where the corporation is right? Regardless of compensation, why target people who are promoting accurate and contextually appropriate information?

The International Agency for Research on Cancer’s hazard classification chart

The article continues on about dietitians who partner with candy companies, or promote messages that normalize sugar intake. Again, here we find an angle where criticism is much more valid, given how most Americans simply consume too much sugar. Speaking metabolically, sugar is nothing but energy, and an excess of this energy can lead to obesity and displacement of nutrients the body needs. And while added sugar intake has been decreasing over the last two decades in the United States, there is still too much, and it is everywhere. Dietitians who promote a normalized intake of sugar, or attempt to de-stigmatize desserts, are correct in their assertions that excessively restricted patterns of eating (AKA, “diets”) can ultimately backfire for both children and adults. However, messaging such normalizations can easily be abused and taken too far. Evidence from food pattern modeling shows that a person’s daily nutrient needs can be met and leave room for a limit of extra calories. But “limit” is the operational term here, as the current Dietary Guidelines for Americans assert that no more than 10% of our calories should come from added sugar, and no amount of “anti-diet” slogans will change that.

Turning to the article’s central criticism about partnerships in the food industry, I have more casual observations and questions than I do answers. For starters, the authors share results from their analysis of posts promoted by 68 ‘influencer’ dietitians, and found that half of them promoted food, beverages, or supplements to their audience.

Food and nutrition experts promoting and discussing food products to their audience?! STOP. THE. PRESSES!

This discovery is as ground-breaking as O’Connor’s declaration that the food industry’s use of dietitians is a “little-known tactic”. I suppose next you’re going to tell me that food companies make foods that their audiences are more likely to buy?! Sarcasm. We all know this, and to repeat myself, when there is a financial incentive involved in these partnerships, dietitians must disclose it. But expecting dietitians to not have direct involvement in food systems is akin to expecting lawyers to not be involved in legal affairs. Dietitians promote foods and food patterns, optimal to the populations they work with, and according to the best evidence and goals of that population.

It would be intensely naive to presume that money never pollutes integrity, but its a disingenuous insinuation that principles are always compromised whenever money is involved. Disingenuous, given how quick people are to report on the biased and compromised motivations of everyone around them, while maintaining the sanctity and wholesomeness of their own (even though money is still somehow involved). As an aside, did O’Connor think to disclose the books on nutrition and diet he sells, or that he was probably paid to write this article, or that he has an unusual fixation on dietitians, taking counsel from people who have a lengthy list of conflicting interests, themselves?

But a question I’m far more interested in is whether or not any dietitians have surrendered their principles for a paycheck? To that, no evidence is presented. Most of the dietitians mentioned in this article are presented as opportunistic influencers who were approached with money, and took up a position as promoted. From what I’ve observed, that scenario usually plays out in reverse. Many of these dietitians have a position or philosophy to practice that they’ve long promoted, which came to the attention of a food company who offered sponsorship to keep doing what they were already doing. You can claim this may be unwise, or promote a poorly received message, but you can’t necessarily claim integrity has been compromised. Disclosures should be treated as personal prompts to check behavior, and provide information that your audience can consider. The vast majority of dietitians understand this and make painstaking efforts to analyze any personal conflicts of interest.

And reviewing the posts included in the article, I see many instances of positive message promotion. Kraft Mac and Cheese on its own, is Kraft Mac and Cheese. But Kraft Mac and Cheese that has had sautéed vegetables and proteins added in to it, as prepared by Steph Grasso, is a more nutritious meal. For individuals who have suffered to maintain a healthy relationship with food, hearing someone give them permission to enjoy some of the foods they eat, as Cara Harbstreet does, may be a balm upon their soul that elevates them to a better quality of life. Restrictions, medical conditions, or picky eating habits may make it difficult for some children to obtain adequate nutrient needs, and promoting supplements which ameliorate those needs, as Cinthia Scott does, may be of benefit.

Listen. I won’t put a defense to every engagement of partnership behavior, as I personally know some of the promoted messages are contrary to scientific findings. I take issue with some of the Academy of Nutrition and Dietetic’s brand messaging, or their tacit acceptance of certain practice groups’ whose claims outweigh their empirical evidence. But if I only need worry about a handful of cases, out the 110,000 dietitians who work diligently in every field of food and nutrition, I feel pretty good about that performance rate, and fairly proud of my colleagues.

You don’t understand, the public should not have to deal with these dilemmas in the first place. The fact these foods exist and are promoted as a choice is the problem. They should be removed entirely.

Well, dear reader, if this in any way represents your perspective, here is our dilemma. Starting in the mid-20th century, the world’s food supply started to expand. New technologies and techniques increased yields and expanded access. In time, many nations began to arrive at a completely new destination of food that the world had never before known. That destination was, abundance. In such abundance, people could now modify and experiment with their foods, producing new items that never before existed, coming into existence almost purely as a form of recreational eating. Gone are the days of scarcity, as food insecurity for today is an issue of economics and access.

This is the only world we have in which to operate. A world where the human brain likes things that taste good, and nutritive dietary choices require a certain level of consciousness and educational awareness. A world where assuming you can obtain compliance by simple mandates merely reveals your limited understanding of human dietary behaviors. Where everyone must evaluate the evidence, and aim for the best possible outcome. Where change is more feasible from within, than from without. And no amount of pearl clutching, nor pining for a romanticized past that never really reflected this world, is going to change that.