The Sugar Scandal: Corrupted Science in the Debate of Fat vs. Sugar and Coronary Heart Disease

For anyone who may have missed it, JAMA (The Journal of the American Medical Association) Internal Medicine released a damning report uncovering the blatant manipulation of industry-funded scientific research to benefit a trade group’s agenda. Specifically in this case, the Sugar Research Foundation (SRF), now known as the Sugar Association, bribed three Harvard scientists to shape the conclusion of a landmark 1967 literature review published in the New England Journal of Medicine (NEJM) that identified dietary fats (vs. carbohydrates/sugar) as the main culprit in coronary heart disease (CHD).  

This is no conspiracy theory. The authors unearthed documents, reports, and written correspondence that explicitly outlined the goals of the agreement (minimizing sugar's role in CHD and squarely placing blame on fats - total fat, saturated fat, and dietary cholesterol) and the monetary rewards the researchers received (the total sum equivalent of a mere $50,000 in today’s dollars) for their unethical work.    

Background: 

During the 1950s and '60s, the spike in heart disease (and most publicly President Eisenhower's heart attack) spurred research to identify the cause, and two competing camps began to emerge: namely added sugars spearheaded by Dr. John Yudkin and dietary fats/cholesterol led by Ancel Keys, with his “Seven Countries” study that popularized the “Mediterranean diet” (dissecting Keys’ flawed methodology, intentional destruction of Yudkin’s reputation, and influence in developing national nutrition recommendations warrants its own article, however it's worth noting I am a proponent of the principals associated with this eating pattern).    

Executives at the SRF were paying attention, and one such individual, John Hickson, took initiative. He hired the researchers to design a literature review (the SRF even had a hand in selecting which studies to include) with a favorable outcome for the sugar industry by deflecting Yudkin's work and specifically positioning fat as the malicious macronutrient. The conclusions of the study were widely accepted (it may have helped that financial disclosures were not required with the NEJM until the 1980s) and the rest, as they say, is history.  

Perhaps lending to the study’s credence was simply that it was published in the highly respected New England Journal of Medicine. It’s rather time consuming to read through studies and perform your own analysis of the design, methodology, conclusion of outcomes, and implications (and that’s assuming all the data and results are included). As such, many (I admit, myself included) use the integrity of the publishing journal as a barometer for the integrity of the study, a shortcut that can clearly fail.    

What’s more alarming is that the findings of this study, and the researchers involved, went on to shape the country’s Dietary Guidelines for Americans. And make no mistake about the connection, as one of the three scientists involved in the original scandal (D. Mark Hegsted) rose to become the head of nutrition at the USDA. During his tenure he helped draft the 1977 precursor to the (first) 1980 Dietary Guidelines for Americans.   

At first glance, you may not see what all the fuss is about; after all “Avoid Too Much Sugar” is listed there as #5. But scroll down and you’ll see that sugar’s sole accountability is its contributions to tooth decay and dental caries.    

As such, the questionable practices and information disseminated extended far beyond a single study published in a reputable journal; it became the official party line of the United States government’s public health recommendations. Think about all this for a moment. $50,000, split three ways, and that’s all the sugar industry had to pay to alter the course of nutrition research and recommendations for more than five decades (well, that’s assuming the SRF only partook in this singular event of bribery).

Furthermore, this perpetuated idea that increased total fat, saturated fat, and dietary cholesterol intake leads to increased harmful blood lipids (not the full story by any stretch, see below for one such example) which leads to an increased incidence of cardiovascular disease, scared everyone out of eating even healthy fats which provide an abundance of vital nutrients (think omega-3 fatty acids, for one). This fueled the low-fat craze of the 1980s and 1990s (SnackWells, anyone?), and thus the inevitable shift towards increased consumption of refined carbohydrates (because when you reduce intake of one nutrient/food group, you replace it with another). And we all know where that got us.  

Implications of Shady Research:

It'd be unfair to assume the SRF/Sugar Association is the only trade group that participates in this kind of controversial activity. Industry-funded research is nothing new (and I'm not saying it's all bad, we need major funding to advance science, but we need to be judicious in parsing out the results and conclusions). Neither are the conflicted interests generated by the revolving door of executives heading mega corporations (think Big Ag and Pharma) and regulatory governmental agencies (e.g., FDA, USDA, EPA). But what’s so remarkable about this report is the black and white evidence of corruption. 

This gross misconduct is akin to “Dr.” Andrew Wakefield’s 1998 Lancet study which fraudulently (per the word choice of the BMJ's editorial exposing the scandal) concluded a link between the measles, mumps, rubella (MMR) vaccine and the increasing prevalence of autism and bowel disease. In this case he reportedly falsified data to achieve his intended outcome. Thankfully Wakefield's medical license has since been revoked and his article retracted, but the longterm damages of his work continue to be felt. 

Wakefield's study undoubtedly was a major catalyst in the heated debate and resistance against vaccinations, ultimately resulting in fewer vaccinations of children and a resurgence of these once-considered eradicated infectious diseases. Again, the abuse of power to serve a person's or group's agenda (Wakefield was reportedly set to financially gain from the vaccination scare) caused millions of people pay the biggest price: their own health and the health of loved ones.  

Current Research:

Over the past few years there have been more rumblings questioning the science behind limiting saturated fats and dietary cholesterol to improve heart health, most notably a 2014 systematic review and meta-analysis in the Annals of Internal Medicine that concluded reduced saturated fat intake and increased polyunsaturated fat intake did not necessarily lead to reduced coronary disease incidence. This report was not without its own flaws and criticism, primarily for not acknowledging the presumed benefit of replacing saturated fat intake with polyunsaturated fats.    

And just as not all dietary fats are created equal, not all LDL cholesterol (aka “bad” cholesterol) is created equally. Research has long shown the increased risk of heart attacks, decreased HDL levels (aka “good” cholesterol), and increased triglyceride levels associated with the smaller, denser LDL phenotype as opposed to the larger LDL particle size.  It turns out that a diet high in carbohydrate intake, specifically refined carbs, leads to more of the atherogenic smaller LDL particles, whereas increased saturated fat intake leads to more of the benign, larger LDL particles.      

No doubt about it, nutrition science is often confusing, contradictory, and sometimes compromised. Just check out this recent New York Times article highlighting many of the grievances I share with my industry’s research. In fact, I often refer to nutrition as a “soft science” due to its inherent challenges in design (ethics/IRB approvals are a notable roadblock to RCTs), reliance on faulty measures of intake (e.g., Food Frequency Questionnaires), and ability to meaningfully apply the laboratory results in the real-world setting to achieve the purported benefits (how many cups of green tea can you really drink in one day?). 

So where does that leave us? 

As a registered dietitian, I’m asked daily by friends, family, colleagues, and/or patients, what should I be eating? Clearly this is a loaded question, and not just because of the issues noted above. You also have to consider where a person’s at (e.g., financially, motivation-wise) and make recommendations to improve their current situation, even in small ways, versus preach perfection. Then there’s a person’s medical history which may influence my response (for example, potassium-rich fruits and vegetables are generally deemed “healthy” for the average person, but can wreck havoc in people with chronic kidney disease).  

But that’s going into the nitty gritty. I think the changing tide towards focusing on healthy eating patterns versus individual food/nutrient intake is imperative. It’s simple, it’s sound, and it’s attainable. So when it comes down to it, my default answer is to defer to Michael Pollan. I think he has it just right and manages to summarize my thoughts in the fewest words possible:   

“Eat food. Not too much. Mostly plants.”