The effects of industry funding seem to occur at an unconscious level, so much below the radar of conscious thought that the influence is not recognized.
—Marion Nestle, Unsavory Truth1
One of the standard ways that industry, be it makers of food, cigarettes, or pesticides, seeks to influence public opinion and public policies is to hire academic specialists to conduct research, provide advice, lobby government officials, give talks, and speak out in the media. The scientists who receive industry funding invariably take the side of industry: they downplay risks found in independently funded research or say that more evidence is needed before concluding that a product is harmful. Numerous academic studies have found that when companies sponsor research on artificially sweetened beverages, juice, milk, soft drinks, and the fake fat olestra, the outcomes are much likelier to favor the companies than when studies are independently funded.2
And so it is with salt. Companies such as Frito-Lay, the biggest maker of salty snacks, and the Salt Institute, the lobbying group funded by the salt industry (and the subject of chapter 5), have used scientists as paid or unpaid consultants. Indeed, Frito-Lay’s former chief scientist, Dr. Bob I-San Lin, told me it was not difficult to “pay and persuade” scientists to help the company and to take a position that was consistent with the company’s.3 Funding might support research or pay scientists to be consultants. Sometimes the funding is disclosed in scientific papers or at conferences, but oftentimes not. Of course, receiving corporate funding does not guarantee that a person will take an industry-friendly position. And conversely, some academics have views supportive of particular products without receiving any funding from their makers. But make no mistake about the influence of funding. David Michaels, a professor at the George Washington University Milken Institute School of Public Health, is one of the most astute observers of the politics of regulation based on his experience as a top health official in the Clinton and Obama administrations. He states in his book, The Triumph of Doubt, “the funding source for any research—who’s footing the bill—is a powerful motivator of anyone’s reasoning.”4
Most medical journals ask authors to disclose conflicts of interest to alert readers of possible biases. Disclosure is seen as a partial remedy for that perennial problem because it may lead readers to evaluate the articles with a more skeptical eye and enable them to reach their own judgments about the significance of the funding. But journals (and journalists) accept whatever information about conflicts of interest that scientists provide, and some may not provide full and honest disclosures. Consider the inconsistent statements about and by Michael H. Alderman, the hypertension researcher at Albert Einstein College of Medicine.
In 2014, Feng J. He and Graham A. MacGregor, the British campaigners for less-salty foods, charged that Alderman, as co-author of an article in the American Journal of Hypertension, “has once again failed to declare that he has worked over many years as a consultant to the Salt Institute. As [he was] editor-in-chief of the American Journal of Hypertension, this could be viewed as a very serious conflict of interest.”12 While the medical community does not have a uniform guideline for determining when authors no longer need to disclose past conflicts, Alderman’s inconsistent statements hardly reflect full disclosure.
Alderman denies that his varied connections to the Salt Institute influenced his judgment. He told me, “It was the unexpected finding in my own research—never refuted, but frequently reproduced—that changed my mind from a believer [in cutting sodium] to a skeptic.” I asked him if he regrets ever taking funding from the salt industry, and he told me, “Yeah, I think it’s a mistake.”13
Another long-time defender of salt is David A. McCarron, a former professor of medicine at Oregon Health and Science University and former unpaid associate researcher at the University of California, Davis (and recently a presumably unpaid but cheerful deliveryman for his wife’s pet food company14). His assistance as a paid consultant to the salt industry is lauded in a tribute on his website by Dick Hanneman, the president of the Salt Institute:
The Salt Institute has valued Dr. McCarron’s consulting expertise for a quarter century and has appreciated the professionalism and responsiveness of his expert team. . . . Dr. McCarron has earned our respect and admiration for the quality of his counsel.15
Over the decades, McCarron wrote numerous articles putting “sodium into its correct context” and downplaying the role of salt in promoting cardiovascular disease.16 He has contended that the salt–blood pressure “hypothesis has never been fully supported by either the researchers or the data in this area of investigation.”17 And he’s claimed: “We have signals from many different sources telling us that maybe it is calcium and not sodium that is the problem.”18 At one time, McCarron was receiving $3,000 a year from the Salt Institute (possibly enough to reinforce his views on sodium, though only a pittance compared to the six-figure fees that some researchers get from drug companies19), and he served as a consultant at least through 2010.20 (McCarron did not respond to my request for an interview.)
Around 2016, McCarron received funding from the Academy of Nutrition and Dietetics (AND, the professional organization of dietitians), which had obtained it from the Salt Institute.21 The funding was for developing a protocol for a randomized controlled trial (RCT) on sodium and cardiovascular disease (I discuss these RCTs in chapters 3 and 5). McCarron co-authored an article proposing such a study—on prisoners—but failed to disclose the funding he previously received from the Salt Institute, Grocery Manufacturers Association (GMA, which since morphed into the Consumer Brands Association), and ConAgra Foods (maker of Chef Boyardee, Marie Callender’s, and other salty processed foods).22 (I spurred the journal to publish two corrections noting McCarron’s relationships with GMA, ConAgra, and AND, but did not get it to disclose the Salt Institute.)23 He also failed to disclose that funding when he spoke at a 2018 meeting that the National Academy of Medicine held on sodium.24 One industry insider told me, “David McCarron has his whole career pegged on salt. And David McCarron is somebody that you [can] almost never convince there’s anything wrong because . . . this is his life.”
In a media interview, McCarron gave a laughable excuse for not acknowledging his industry connections in the article that proposed the prisoner study: “McCarron said that he left those positions off because, in his view, they were already widely known. ‘It’s common knowledge I have these relationships.’”25
Salim Yusuf of McMaster University Medical School in Hamilton, Ontario, has led the PURE research program that associated low sodium intakes with higher rates of deaths from cardiovascular disease than the higher intakes typical in industrialized countries. PURE studies have received a small amount of funding from Unilever (one of the more nutrition-conscious manufacturers) and the South African Sugar Association, but the great majority is from traditional medical research funders and the drug industry. Yusuf is also the executive director of the Population Health Research Institute (PHRI), which is affiliated with McMaster. Campbell Soup, ConAgra, PepsiCo, and other food-industry giants funded a PHRI nutrition conference in 2014, some of which focused on sodium.26 But PHRI’s main work relates to contracts with Bayer, Novartis, and other drug companies to conduct tens of millions of dollars’ worth of research unrelated to salt.27 (Yusuf declined my requests to discuss his group’s research and funding.)
Some people assume that companies give professors money or perks (such as covering the costs of speaking at a conference in a nice place like Hawaii) to persuade them to change their views and defend industry. But that is a simplistic analysis. Often, in this chicken-or-egg situation, companies learn of professor whose views or research might be supportive of their products or practices. They then might cultivate those professors, perhaps inviting them to a conference or research facility or asking for advice on a letter they are sending to a government agency. If a professor expresses interest, company officials might deepen the relationship by asking the professor to be a consultant or offering to support a research project. Next thing you know, the professor is on television defending the industry or its products or arguing that a product has not been proven harmful—often without mentioning the corporate funding.
Some of the consulting fees, honoraria, and travel expenses that professors receive from industry are modest, but that does not mean they have no effect. Even small gifts—free lunches, stationery, drug samples—have been shown to influence doctors’ attitudes and prescribing habits.28 Is there any reason to assume that nutrition researchers would be any less influenced by consulting fees, free travel to conferences, or other gifts? Moreover, it is only human that when friendships develop, without money changing hands, it is hard to publicly criticize people.
Much as I am suspicious of the conflicts of interest that industry funding causes, it certainly is possible for professors to accept funding and still retain their integrity and objectivity. As food-industry critic and New York University professor emerita Marion Nestle has written, “Financial ties with food companies are not necessarily corrupting; it is quite possible to do industry-funded research and retain independence and integrity. But food-company funding often does exert undue influence, and it invariably appears to do so.”29 And to push this argument further, one might actually want companies to get advice from the most renowned experts. But many researchers do not want to risk being tainted by industry funding or even non-monetary relationships.
As an illustration of how complex the conflict of interest can be, it is fair to acknowledge, as defenders of industry funding sometimes contend, that non-industry funding could also lead to biases. Funding, or the desire for funding, from the National Institutes of Health, American Heart Association, or other non-industry agencies could distort a professor’s views. Knowing that such organizations have concluded that high-sodium diets are harmful, some professors might think they could enhance their chances of getting a grant by exaggerating the evidence that salty diets are harmful, understating gaps in the evidence, or avoiding doing research that might show that salty diets are not a problem.
While funding presents an obvious bias, intellectual bias might represent a more subtle influence. A researcher who conducted a study showing that something is, or is not, a problem may conduct further research with the hope of reinforcing that finding. That kind of bias can be a problem for any researcher, including ones who believe salty diets are risky or those who believe them to be safe.
In the previous two chapters I offered an inside look at how lobbyists operate and examined how biases in industry funding can affect researchers. Let’s now look at the efforts by dozens of countries around the world to reduce sodium intake.