American dietitians, big ‘food’ companies & conflict of interest

I obviously follow like minded people on twitter because one item has dominated my timeline over the past 24 hours. Michele Simon, author of the brilliant book Appetite for Profit, has written a report called “And now a word from our sponsors. Are America’s nutritional professionals in the pocket of Big Food?” I have no doubt whatsoever that they are.

In my 2010 book The Obesity Epidemic: What caused it? How can we stop it? the most shocking discovery in three years of research was captured in Chapter 15 of the book – simply called “Conflicts of interest.” The opening to that chapter forms the major part of this blog and is in blue below.

Appendix 1 to Michele Simon’s report quotes four Registered Dietitians (RDs) who express concern at being part of an organisation in bed with big ‘food’. The American Dietetic Association (ADA) is now called The Academy of Nutrition and Dietetics (AND). You may spot an irony with this as this post unfolds – the former ADA is trying to own the term nutrition while suppressing all nutritionists. The Appendix reveals that Carla is not a member of AND; Aaron was a member until 2013; Heidi has also left the organization and Denise is thinking about leaving. My timeline has been full of support for these pioneers in standing up to their professional body. I think a large issue has been overlooked.

If you read the extract from my book below you will see how a monopoly in dietary advice has been given to dietitians in America. This is how the big ‘food’ companies can get their return on their investment – make sure that only dietitians are allowed to advise 300 million people and make sure we have them representing our interests. Did the ADA fund the legislation necessary to eliminate non-dietitians from the debate on healthy eating? Or did the funding come from the $467 BILLION in the kitty of the ADA friends?

If RDs in America really want to stand up for what is right they will also recognise the benefit that sleeping with the enemy has given them. While Denise is debating whether or not to leave AND, is she prepared to relinquish her monopoly position as a nutritional advisor? Is she prepared to return to a level playing field where advice shall stand or fall on the evidence – whether that evidence comes from a registered dietitian, nutritionist or even a blogger who has done some independent research?

A couple of RDs saying that they don’t think Coca-Cola is a suitable partner does not impress me. When every RD in America leaves the AND and embraces open, evidence based debate on what really does count as healthy eating – then I’ll be impressed.

Fiction or fact?

Imagine you are a multi billion dollar food/drink company. Your stakeholders are essentially customers, employees and shareholders. The company needs to grow – growth means more returns for shareholders and employees may also benefit from higher returns. For real growth (beyond price inflation), you need any, or ideally all, of the following options: existing customers to buy more current products; existing customers to buy new products; new customers to buy current products and new customers to buy new products – and that is generally recognised to be the order of difficulty.

Unless a private company, you have to report quarterly to world markets and your financial position is affected every time you do this and hence you are under continuous pressure to meet, if not exceed, expectations (you have to manage expectations very carefully, however, as exceeding them establishes a new norm). You are also doing none of this in isolation – you have competitors who also want to grow. In fact they want to grow faster than you, so that they can get a better financial position from an influx of investors keen to benefit from their dividends.

The fact that real growth can never be sustained seems to have been overlooked by financial markets and investors. If the Top 10 listed companies in the USA were countries, with their revenue equating to GDP, they would fall into the range occupied by the Top 55 countries in the world.[i] America’s largest company, Wal-Mart, was noted in the 2010 Fortune 500 list as having a revenue figure of $408 billion. According to the International Monetary Fund list of companies by GDP, Wal-Mart would knock Sweden out of 22^nd place on the world ranking. The compound interest calculation tells us that just 3.5% sales growth a year (a ‘reasonable’ shareholder expectation) would double the company revenue every 20 years.

So, expectations are unreasonable, you need growth and the last thing you want is anything that can threaten current revenue, let alone future developments. As a food/drink manufacturer you cannot afford to have any public health advice going against any of your products or planned developments. This would be disastrous. It would be really helpful in fact if public health advice could be promoting your products – this would be idyllic. PepsiCo, the top company on the food consumer products Fortune 500 list, would surely welcome universal low calorie advice to be reiterated. Pepsi Max, Diet Pepsi – you have many options to satisfy this want – even cherry flavour. Kellogg’s, sixth on the Food Consumer Products Fortune 500 list, would no doubt be thrilled to hear the public being told to eat breakfast. Even better that the public are actively told to avoid bacon and eggs and thus (sugary) cereal becomes the normal start to the day.

It would be really helpful for food/drink companies if the public received a consistent message (supporting your products). That USA food pyramid is just great for a cereal company – five to eight ounces of grains per day and three cups of milk – cereal is surely the easiest way to get those. The UK ‘eatwell’ plate even has a box of cornflakes on it – branded (Kellogg’s) in some versions. “Base your meals on starchy foods”. Even the confectionery and soft drink producers have nothing to complain about – the ‘eatwell’ plate has that great 8% segment (let’s round it to 10% – that’s a good 200-250 calories a day for us). The USA government ‘allows’ the same with the discretionary calories covered in Chapter Thirteen. This is terrific stuff.

But, irritatingly, there are rogue traders – nutritionists who tend to (quite outrageously) care about nutrition and the nutritional quality of things that we put in to our bodies. Many of them are telling people to avoid processed foods and sugar. Fitness instructors are telling people to avoid refined carbohydrates and to only eat whole grains, heaven forbid. Even chiropractors, for goodness sake, are advising people to avoid processed food, especially carbohydrates, to lose weight and ease the burden on joints and frames. This must stop.

Imagine then if you could contain dietary advice – particularly all access to public health advice – to one organisation. If only that one dietary organisation could have a monopoly on all dietary advice. Wouldn’t it be great if laws were passed so that no nutritionists, chiropractors, or any other qualified therapists could provide advice or run a practice – that only the members of one dietary association could do this. How much easier things would be if food and drink companies could then sponsor just that one organisation and try to ensure that only the ‘right’ messages got out?

The plot for the next John Grisham novel? Sadly not. This is reality in 46 of the 50 States of America.

The American experience

The Commission on Dietetic Registration (CDR) is the credentialing agency for the American Dietetic Association (ADA).[ii]

Their mission statement is “CDR protects the public through credentialing and assessment processes that assure the competence of registered dietitians and dietetic technicians, registered.”[iii]

The vision statement is “The nation recognizes seeks out and relies on competent CDR credentialed registered dietitians and dietetic technicians, registered, for food and nutrition expertise.”

The CDR was formed in 1969. In 1976 the ADA constitution was amended to allow for registration separate from Association membership (this ensured that all dietitians would be part of the movement going forward, by virtue of being a dietitian rather than needing to be a paid up member of the ADA). In 1984 the first registration eligibility reciprocity agreement was signed with the Canadian Dietetic Association. In 1991 registration eligibility reciprocity was extended to foreign countries whose goals were comparable to CDR’s. In 1992 the first such agreement was signed with the Dutch Association of Dietitians. In 1995 the CDR filed registration eligibility requirements and reciprocity agreements with the USA Trade Representative Office and World Trade Organization. By 2010, 79,411 dietitians were registered with the CDR.

At the time of writing this book, 46 out of the 50 States of America have passed laws to regulate who is able to provide nutritional advice through licensure, statutory certification or registration. The full list of which states have passed each level of restriction is published in Appendix 4.[iv]

The most restrictive level is Licensing – where statutes include an explicitly defined scope of practice and performance of the profession is illegal without first obtaining a license from the state. Nonlicensed practitioners may be subject to prosecution for practicing without a license. 35 states have gone for this highest level of legislation. 25 of these 35 bills were standard ADA bills – the statute has clearly been submitted by the ADA to establish the monopoly position of their dietitian members. Of the 35 states that have passed bills for licensing regulations, 16 have stated that only dietitians can practise in the field of nutrition. Nutritionists may no longer do so. They must retrain as dietitians and become members of the ADA and be recognised by the CDR, or face prosecution. This is clear monopoly practice.

In nine states, nutritionists have been allowed to continue to do their jobs in accordance with their professional qualifications. However, the precise qualifications deemed acceptable have been narrowly defined by the state and many have added an additional requirement to complete 900 hours work under the supervision of a dietitian. This is insulting and restrictive.

A further 10 licensed states have also granted monopoly rights to dietitians, as their statutes use the terms dietitian and nutritionist, interchangeably, but to mean dietitian – defined as a dietitian, again, registered with the ADA and CDR. As an example of legislative clauses, here are some extracts from the Tennessee statute:

-    “American Dietetic Association – When the acronym A.D.A. appears in these rules it is intended to mean American Dietetic Association”.

-    “Dietitian and Nutritionist – A licensed health care professional practicing dietetics/nutrition. ‘Dietitian’ or ‘nutritionist’ may be used interchangeably.”

-    “Registered Dietitian (R.D.) – A person who is currently registered by the Commission on Dietetic Registration of the American Dietetic Association.”

-    “It is unlawful for any person who is not licensed in the manner prescribed in T.C.A. §§ 63-25-101, et seq., to represent himself as a dietitian or a nutritionist or to hold himself out to the public as being licensed by means of using a title on signs, mailboxes, address plates, stationery, announcements, telephone listings, calling cards, or other instruments of professional identification or to use such titles as ‘dietitian/nutritionist’, ‘licensed dietitian’, ‘licensed nutritionist’ or such letters as ‘L.D.N L.D.’ or ‘L.N.’”[v]

This makes the law very clear – these statutes serve to meet the requirements of the ADA i.e. thou shall be a dietitian registered by the CDR of the ADA, or thou shall be prosecuted.

The second level down is Statutory certification – which limits use of particular titles (e.g. dietitian or nutritionist) to persons meeting predetermined requirements, while persons not certified can still practice the occupation or profession. Ten states have opted for statutory certification.

One state, California, has opted for Registration, which is the least restrictive form of state regulation. As with certification, unregistered persons are permitted to practise the profession.

Four states, Arizona, Colorado, New Jersey and Wyoming have, thus far, refused to pass the ADA sponsored legislation.

Dietitians in America, therefore, enjoy a unique monopoly position and they have unfettered access to hospitals, schools, large institutions, prisons – all public health diet advice. When Michelle Obama launched her childhood obesity initiative, at the United States conference of mayors on 20 January 2010, she said that mayors were key to making the plan work. In subsequent speeches, no mention of mayors was made. Perhaps someone had explained to the First Lady that mayors were not allowed to help with dietary programmes. As a result of the legislation passed by previous government, that was the domain of dietitians. Thanks to the elimination of, or at least strict control over, nutritional practice, in over ninety percent of the States in America, dietitians also have sole access to private health advice. So, it is critical for us to know who is behind this monopolistic advice.

The partners of the American Dietetic Association (ADA) are as follows.[vi] The 2008 or 2009 revenue figures, for each sponsor, are alongside:[vii]

-    Aramark (a ‘dining away from home’ company) – $12.3 billion;

-    Coca-Cola – $31.4 billion;

-    GlaxoSmithKline – $45.2 billion (not listed on the web site, but listed in the 2008 ADA annual report);

-    National Dairy Council – The National Dairy Council is the nutrition research, education and communications arm of Dairy Management Incorporated. (All but one of the current spokespeople for the organisation is a registered dietitian);

-    PepsiCo – $44.3 billion;

-    Unilever (including spreads) – $55.8 billion (using a Euro dollar exchange of 1.4 for this Anglo Dutch company).

The premium sponsors of the American Dietetic Association (ADA) are as follows:

-    Abbott Nutrition (infant formulas, nutrition bars etc) – parent company revenue was $30.8 billion;

-    Corowise (including products designed to lower cholesterol) – parent company, Cargill, revenue was $116.6 billion;

-    General Mills (“the world’s sixth largest food company”) – $14.9 billion;

-    Kellogg’s – $12.7 billion;

-    Mars – $30 billion;

-    McNeil Nutritionals (makers of Splenda sweeteners) – the revenue of the parent company, Johnson & Johnson, was $63.8 billion;

-    SoyJoy (sugared cereal bars) – the revenue of the parent company, Otsuka Pharmaceuticals, was $9.2 billion (on the web site, but not in the 2008 annual report);

-    Truvia (sweetener) – the parent company is Cargill, as above (on the ADA web site, but not in the 2008 annual report).

That adds up to $467 billion worth of revenue amongst a dozen organisations that sponsor the ADA.

There are also event sponsors listed in the 2008 annual report:

-    American Beverage Association, formerly the National Soft Drink Association – this is the ‘voice’ of the soft drink industry – Coca-Cola and PepsiCo are members, as examples;

-    ConAgra Foods – producers of an assortment of processed foods for stores, restaurant and food service establishments;

-    Post Cereals – a cereal manufacturer;

-    Safeway – grocery retailer.

There is also mention in the 2008 annual report of funding from the Grocery Manufacturers Association. Finally, the annual report thanks donors who made gifts of $10,000 or more to support research, education and public awareness initiatives: Abbott Nutrition; Almond Board of California; American Council for Fitness and Nutrition; Aramark; The Beef Checkoff, through the National Cattlemen’s Beef Association; The Coca-Cola Company; Colgate Palmolive; Consultant Dietitians in Health Care Facilities DPG; Corowise brand; Dietitians in Nutrition Support DPG; Ecolab Inc.; Ensure; General Mills; GlaxoSmithKline Consumer Healthcare; Kellogg Company; Kraft Foods; Mars, Incorporated; McNeil Nutritionals, LLC; Mead Johnson Nutritionals; National Dairy Council; PepsiCo; Unilever and Washington State Dietetic Association.

For the year ending 31 May 2008, total revenue for the ADA was just short of $32 million. $2.7 million was noted as coming from sponsorship. I have no idea how much it costs to sponsor legislation in 46 states across America. More than a couple of millions I suspect. Lobbying may have been funded directly from partner/sponsor organisations, but this is not about a forensic exercise in multi billion dollar balance sheets. This is about two thoughts to put to you:

1)  What do the American Dietetic Association and their partner/sponsor organisations from the food, drink and drug industries stand to gain from this legislation?

2)  What does America and its 309 million citizens stand to lose?