Hey, Sugar, pay no attention to the man behind the curtain.
Today, the Journal of the American Medical Association dropped an alleged bombshell when it disclosed that the sugar industry lobby influenced research on coronary heart disease by effectively bribing Harvard researchers to promote the theory that dietary fat, and not sugar, causes heart disease.
The story is trending on Facebook at this very moment, and the JAMA Facebook post states that "Policymaking committees should consider giving less weight to food industry-funded studies, and include mechanistic and animal studies as well as studies appraising the effect of added sugars on multiple CHD biomarkers and disease development."
All of this is well and good (actually, no, not really), but I've got to ask you--are you really surprised?
And now I've got to ask, no, are you really surprised, or just playing along with our news cycle and water-cooler conversations?
Shouldn't the public know better by now? Especially those of us who are more than a couple of decades old?
In the 1980s, it was common knowledge--science!--that fat causes fatness. Duh. Eat fat, get fat. Same with dietary cholesterol: eat high-cholesterol food like eggs and your cholesterol will spike. And so everyone went fat free, and processed foods replaced fats with sugars.
In the 1990s, the sheer massiveness of those who stuffed their faces with fatfreeness and became fat in so doing caused the Western hemisphere to outweigh the East, throwing the planet off balance and contributing to global warming. No, not really. That did not happen. But if I had ended that sentence with "according to a new study," it seems a lot of people would believe it.
Today we know--according to new studies--that, actually, eggs aren't so bad for your cholesterol at all. Neither is high-cholesterol seafood. This is newer science and so, we collectively agree, it is better science. Whatever is newer is factier. Yes, factier--it is a newer, better word.
We go through these dietary fads based on what we assume to be credible science. First it was fat free, and then it was carb free, and then it was macrobiotic, and then it was paleo. Today, everyone I know under the age of 30 seems to subsist exclusively on diets of kale, quinoa, and Muscle Milk. According to a new study (a conversational poll of a generation of people who eat kale, quinoa, and Muscle Milk, but you don't really want the boring methodology details, do you?), this is the diet that will lead you to rule the world.
I hate to say this because it's true, and because saying it will make most people who read this think that I have no credibility: We invest far, far too much faith in scientific and governmental authorities, and we do so based on a strange phenomenon of "the now" always being more credible than "the then." This doesn't mean we shouldn't invest faith in science--real, objective scientific investigation is truth seeking. Unfortunately, Science with a capital S in some instances operates like the Church with a capital C, issuing dogmatic decrees and exerting peer pressure to favor the majority agreed-upon beliefs of scientific organizations over new scientific investigations. This is where things get tricky, especially when we as a public--and when non-investigative health writers--regurgitate information without asking questions about where it comes from and if there is a financial incentive behind it.
Ask anyone who is living on a paleo diet today and they will tell you that people who replaced fats with sugars in the 80s were naive or ignorant, and that they foolishly compromised their health. They'll tell you that the Atkins diet was a probably not very healthful fad. And then they will tell you you should eat mostly kale and quinoa if you want to be healthy. Maybe goji and acai berries. Are they still a thing?
Here's my insane and incredible view: anytime we find ourselves excluding any natural component of a diet (barring severe food allergies and other considerations), we're under the influence of marketers, not anyone who is looking out for our well being or the well being of our children.
Being native to the Washington, D.C. area, living and working in the city, it's no secret that everything comes down to money, and money funds lobbying in an effort to fund sales; lobbying funds elected officials' campaigns and influences not only votes, but political appointments at every level, and those appointments often are loyal to the funds that contributed indirectly to their jobs. Likewise, lobbyists help to determine to a certain degree how funds are allocated for public health research; and beyond the lobbyists, companies pay for their own research, which is quite frequently covered by news media who can't resist an "according to a new study" headline--especially if that headline tells people what they've been waiting, sometimes literally, all their lives to hear: FINALLY, an easy way to be thin!
Oh, and healthy, too.
To most news media outlets, it doesn't matter whether a study is funded by the National Institutes of Health or the National Biscuit Company. (That's the old-fashioned name of Nabisco, btw.) It just doesn't matter as along as the study is "sexy"--weight loss is a surefire hit, and so is "wine will save your life," and so is "chocolate will save your life." Also perennial arguments: For many, the debate of butter vs. margarine or sugar vs. artificial sweeteners is as heartfelt and heated as pro life vs. pro choice debates. People really love to be right.
The U.K. Daily Mail notes at the top of its coverage of the Harvardsugargate scandal that "It was in the 1960s - before conflict of interest had to be reported."
Here, the Daily Mail gives readers an important bit of information--one that subtly suggests that research practices have been improved in such a way that the information consumers are given today is reliable. The problem with this is that it comes down to two things that are not always available in abundance: ethical practice and journalistic investigation.
I have written at length about Lyme disease, and so I will use this body of knowledge as an example. Here, we have "major article" from Clinical Infectious Diseases, a peer-reviewed medical journal published by Oxford Journals. This is all very impressive!
The article is very academic-y sounding, and frankly not very sexy (in a news headline sense), titled "A Systematic Review of Borrelia burgdorferi Morphologic Variants Does Not Support a Role in Chronic Lyme Disease." The paper states that " Some have proposed that round morphologic variants of Borrelia burgdorferi, known variably as "cyst forms" and "L-forms," are responsible for the pathogenesis of chronic Lyme disease," and the conclusion of the paper reads "There is no clinical literature to justify specific treatment of B. burgdorferi morphologic variants."
If this study were to make a splash in the news, the headline would read something akin to "Myths about Lyme disease debunked."
Or, indirectly, "If You Think You Have Chronic Lyme Disease, Most Doctors Say You're Wrong." In that news story, one of the articles of the academic article, Paul Auwaerter, essentially anchors the story. He is presented as a sort of voice of reason in the story, his quotes and paraphrased words wrapped around several cases of patients who were misdiagnosed with Lyme disease, or who he believes doesn't have it. He feels bad for them the story says; they are being taken for a ride.
The problem in this reporting is that to the average reader, this respected and well-published infectious diseases expert is assumed to be an unbiased authority--exactly like the Harvard researchers who were paid by the Sugar industry to blame fat for heart disease when they evidently knew otherwise.
But that was before conflict-of-interest disclosures were required, right?
Well, did you happen to notice (or care about) the note that appears in fine print at the end of the article linked above? It reads: "Potential conflicts of interest. P. G. A. has served as an expert witness in malpractice cases involving Lyme disease." P.G.A. is Paul Auwaerter, and "expert witness in malpractice cases" often equates to "paid expert witnesses," although there is no requirement of compensation disclosure as such.
From the legal-advice website Nolo:
Expert witnesses can be very expensive. They often bill on an hourly basis at a high rate, not only for their testimony, but also for the time they spend preparing. Experts are sometimes crucial, and the stakes often make it worth it for the defendant to dig deep to find the requisite funds.
So now things get a bit sticky. A conflict-of-interest disclosure has been made in a scientific journal--in tiny print where only those trained to look would typically look--and the expert who has been published in said prestigious journal obviously is a no-nonsense, absolutely trustworthy expert around whom to base a solidly journalistic article. Right?
It gets a little bit stickier. The VICE article that liberally quotes Auwaerter doesn't mention anything like the conflict-of-interest disclosure that must be included in scientific journals that publish Auwaerter's work. So readers never would know about that conflict of interest. Neither would they know that Auwaerter has been criticized by those who are fighting for Lyme disease parity because of apparent bias.
The fight comes down to a few things: requests for Lyme disease research to be funded by the federal government; a demand for recognition of chronic Lyme disease as a serious and often disabling health condition; and the right for Lyme disease specialist physicians to treat patients without fear of being sued by medical insurance companies for malpractice--which happens more than most people would ever know. Now is when we should ask: If this expert is theoretically paid to serve as an expert witness in malpractice cases against doctors who treat Lyme disease patients, then we have a conflict of interest.
It gets hairier. Auwaerter publicly endorses the Lyme disease treatment guidelines of the Infectious Diseases Society of America, which discourage prolonged antibiotic treatment for Lyme disease, even when it restores patients' health. Auwaerter is such a friend to the IDSA that the medical association features videos of him "debunking" persisting Lyme disease on its website--a resource for other medical professionals. The IDSA's position on Lyme disease is at the crux of Lyme patients' please to receive improved medical treatment and medical investigation into the disease: the CDC follows IDSA treatment guidelines, and several states, including Virginia and Massachusetts this year, have had to pass laws to protect Lyme disease specialists from prosecution when treating patients, and to mandate that health insurance pay for their care. The IDSA's official position on prolonged antibiotic treatment is that it should not be used.
Now, let's go back to the impressive Clinical Infectious Diseases (a publication of impressive-sounding Oxford Journals!) article. You may not have noticed the conflict of interest disclosure at the end, but I'm certain you noticed the even smaller copyright information: © The Author 2013. Published by Oxford University Press on behalf of the Infectious Diseases Society of America.
No?
Well, then if you read the VICE article linked above in which IDSA-favorite Auwaerter is quoted--without any conflict of interest disclosure whatsoever--you had to have noticed the big, bold disclaimer at the top of the VICE article that reads "This story is part of a partnership between MedPage Today and VICE News."
What's MedPage Today, you ask? (OK, let's be honest, you didn't ask. Who would?)
Good question!
MedPage Today is an online publication for medical practitioners. Doctors can receive continuing medical education credits (necessary to maintain medical board certification) by taking in the information published by MedPage Today. In other words, MedPage Today is an authority that patients can trust to inform and educate doctors--and of course to partner with independent journalistic organizations such as VICE.
MedPage Today promotes conferences convened by the IDSA and other medical organizations. It also has a page dedicated to infectious diseases. Lyme disease is the most common vector-borne infectious disease in the United States, and the fastest-spreading vector-borne infectious disease in the country. With over 300,000 new cases of Lyme diagnosed annually in the U.S., one might think that an educational publication for physicians would mention Lyme disease among the subspecialties listed here, which include Ebola, HIV/AIDS, swine flu, and (oddly?) vaccines and surveillance. But no, no mention of Lyme.
Interestingly, in addition to being the name of a comprehensive medical resource website, MedPage Today--the name of the partner in the VICE article that denies the existence of persisting Lyme disease--is also the name of an IDSA publication.
What is the point of all this?
I'll break it down:
First, if you read all this, you've actually read more than a headline. Many people would not. Treat yourself to something sugary--but not too much: Your heart is at stake. I hope that you'll think about and share this line of thinking, because the example I detailed is only one example of how the information we receive can mislead us--potentially in very serious and significant ways, just as the sugar story did.
Next, conflicts of interests must be disclosed today--in peer-reviewed academic articles. But let's not be naive. No, let's not be ignorant. Let's not pretend that average Joes and Janes read peer-reviewed articles (or especially the fine print). Joe and Jane are busy and, if they are well, they don't read medical information because they have no reason to do so: they read news headlines, and occasionally the first few paragraphs of a news story. Or they listen to what they are told on television. What they are told, or what they read, never in the real world discloses that, for example, "the person to whom we are presenting to you as an unbiased expert has a financial and professional stake in the outcomes of the studies we are discussing, disclosed conflicts of interest in the paper that generated this headline, and undisclosed potential conflicts in that s/he publicly represents the limited political perspective of a single organization, which happens to be the publisher of the study that generated this headline."
None of this disclosure is given to the public under normal circumstances, and the public trusts news media to vet information that is reports. Hell, even when the public doesn't trust the news media, we still consume and discuss the information and passively accept it as fact.
For example, we know for a fact that salt causes high blood pressure.
According to a new study, according to the news, it does one week, doesn't the next, and does the next. Sometimes while discussing this at the office Keurig machine, we ask "well, does it or doesn't it? Why do all these studies contradict one another?"
What we never ask is, "where does this information come from?"
Or, more importantly than anything, the fundamental tenet of old-fashioned investigative journalism: Follow the money. The question to ask at the beginning of the story is, who the hell paid for this and why?
It would be really, really, really remarkable if health writers transformed into investigative journalists. As the industry stands today, health writers most often call up an expert and ask for their opinions, assuming that their opinions represent scientific consensus. And then health writers quote these experts or professional organizations, or cite an article (without ever looking at stated conflicts of interest or looking for unstated conflicts of interest) and relay whatever information is given to them out to the public as fact. That's not journalism. It's regurgitation.
Let's jump from sugar to salt: Where do you stand on the debate about whether salt causes high blood pressure? Do you still avoid it because you believe it does--because that's what we've been told forever? Or have you discarded that old myth because new, presumably better research has overturned it?
What you probably haven't done, even after the Harvard sugar study revelation, is though, "Hmm. I wonder who funds the salt studies?" That is what you should think every time you read "according to a new study." You should think "according to whose new study?" And when the "who" is Harvard Medical School, you should think, "but who the hell paid Harvard? Harvard ain't cheap." (And by the way, a Harvard-branded anything isn't necessarily a high-quality thing.)
Rather than following headlines and trends, we should all do what Grandma recommended--everything in moderation. Especially consumption of new studies. But not sugar. Sugar, we now know according to the new JAMA paper, is bad news.