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The Nutrition Challenge: Can evidence and conflict of interests go hand in hand?

Jul 17, 2013

'Manipulation by association’ seems to be a clever strategy used by the private sector in marketing, writes Arun Gupta.

Arun Gupta

In an unprecedented gesture of advocacy on nutrition, the Lancet , a scientific and academic journal, launched its Series on Nutrition in London and Delhi in June 2013. Ten  “evidence” based nutrition specific interventions are recommended, eight of which are products. It has a chapter on nutrition sensitive interventions and another on “The politics of reducing malnutrition: building commitment and accelerating progress”.

An Indian expert group shot a letter to the Government of India and Minister Jairam Ramesh who was to inaugurate. They challenged the academic excellence and power of evidence and pointed out that authors of Lancet Series had conflict of interest.

This statement was widely quoted in the media before and after the launch.

Priority in Lancet

The Lancet authors have done an exercise to estimate total additional annual cost of achieving 90% coverage with ten nutrition interventions, in 34 countries with more than 90% of the burden of malnutrition. It comes to about 9.6 billion dollars and large part of this is expected to be spent on nutrition products. It is recommended that priority should be given to management of ‘severe and moderate acute malnutrition’ (SAM and MAM) as these can prevent highest number of under five deaths. As per the indications in Lancet, most children suffering from SAM would be expected to consume Ready to Use Therapeutic Foods (RUTFs), almost at a unit cost of US $ 220. In fact out of 9.6 billion dollars projected, 27% i.e. about 2.6 billion dollars has been estimated to be spent on SAM management. This was challenged and so was the use of multiple micronutrient powders.

What went wrong? The science behind it, and conflict of interest

An Indian professor of pediatrics Prof. Vinod Paul at AIIMS, who was among the panel of experts at the launch, said in no uncertain words, “4 out of 10 recommendations will not work in India”. He shared that an independent and transparent exercise involving over 60 Indian scientists and policy makers, had rejected four Key Interventions (mega-dose Vitamin A supplementation, preventive zinc supplementation, multiple micronutrient supplementation in pregnancy and management of MAM).

At the same time two new systematic reviews by the Cochrane Collaboration appeared on the scene and provided solid arguments to challenge the evidence presented in Lancet. Cochrane is recognized as the international benchmark for evaluating the effectiveness of health interventions. In the first analysis of Ready to Use Therapeutic Foods (RUTFs) for the home treatment of children with Severe Acute Malnutrition (SAM), the Cochrane authors conclude "Current evidence is limited and, therefore, we cannot conclude that there is a difference between RUTF and flour porridge as home treatment for severely malnourished children, or between RUTF given in different daily amounts or with different ingredients. Either RUTF or standard diet such as flour porridge can be used to treat severely malnourished children at home. Decisions should be based on availability, cost and practicality. In order to determine the effects of RUTF, more high-quality studies are needed".

In this context I do want to let the readers know that India was under tremendous pressure from the UNICEF and others in 2009 to use commercial RUTF for SAM. After this Government of India did constitutes a committee to undertake local research and results should be made available in 1-2 years.

The second Cochrane analysis reveals that giving Lipid-based nutrient supplements (LNS) does not reduce progression from Moderate Acute Malnutrition (MAM) to SAM and has no impact on child mortality. Whatever benefit emerged from the studies on MAM was in the form of weight gain (which was not as lean body mass- the muscle mass), and higher rates of recovery; however, a significant proportion of recovered infants and children relapse into MAM within six months. It also takes note that no research was done to compare commercial with home-made foods and continued breastfeeding – the most sustainable approach to reducing the burden of child malnutrition.

What do you do when you have such an influential journal on one side and other experts have an opposing view? If we believe the Cochrane and Indian experts views to be right, you have to ignore Lancet. Treating SAM and MAM finds a high value in saving under five child deaths in the Lancet without convincing evidence. Going by the calls to spend as much as 27% on SAM management then is questionable. The authors later denied that they are for commercial RUTF products; they recommend local foods with good quality. However, costing is done with RUTF use.

Conflict of interest

Conflict of interest weakened the power of evidence. The Lancet seems to have ignored the fact that many of the authors or advisors have a perceived or declared conflict of interest. The lead author and one more have declared that they sit on the ‘Nestlé’s Shared Value Advisory Committee’. I believe, if any one is a member of this committee of world’s largest baby food manufacturer he or she subscribes to the viewpoint of the company. It is not about financial transactions or paid positions. It is about “association”. ‘Manipulation by association’ seems to be a clever strategy used by the private sector in marketing. How do people interpret such associations?

While I appreciate Lancets role in advocacy on nutrition, I wonder what consideration was given to the public perception that a lead author is a member of a board created by the world’s largest food company that violates internationally agreed recommendations and laws on a routine systematic basis. This is not history – these violations continue.

The industry front organisation Global Alliance for Improved Nutrition (GAIN) is an advisor. GAIN's stated objective is to benefit the 600 odd industries in order to reduce malnutrition with a focus on fortification. Did Lancet look at the conflict of in this case? GAIN is a significant player in the infant and young child nutrition world that lobbies governments and the UN to open up markets for its many corporate partners. Issues around GAIN have been raised since 2008 in India. In India GAIN briefed a group of MPs, and within few weeks a private members Bill on fortification was introduced.

In January 2013 GAIN was refused accreditation by WHO as an NGO pending answers about “the nature and extent of the Alliance’s links with the global food industry, and the position of the Alliance with regard to its support and advocacy of WHO’s nutrition policies, including infant feeding and marketing of complementary foods”

Lets have a look at the organisers in India launch in the context of conflicting interests. Event in India was co-sponsored by Coalition of Nutrition Security that has never set its rules to avoid conflict of interests (personal experience) and it has GAIN as its members. It is hosted by ‘Save the Children India’ who receive funding from many including Pepsi. Another organiser was IFPRI, who had organised an international event in 2011 on nutrition and agriculture funded by Gates foundation and Pepsi. This is what Pepsi representative said to Times Of India at that time, “We would need market based solutions that will leverage the capabilities of food companies like PepsiCo that have competencies across the value chain ranging from agriculture, processing and mass distribution.''

Is it about private sector or science?

I think this Lancet series is quite an example of promotion of private sector. The Paper 4 “The politics of reducing malnutrition: building commitment and accelerating progress,” suggests that the private sector is called upon for the “Generation of evidence about the positive and negative effects of private sector and market-led approaches to nutrition.” This provides no clarity on how the private sector should be involved but suggests that new forms of Public Private Partnerships should be found. The Scaling up Nutrition movement (SUN) is presented as a viable alternative to a fragmented nutrition system. Yet SUN has food industries and GAIN on its lead body and promotes the creation of multi-stakeholder platforms at national level with a  ‘business network’ as an integral part. The authors agreed when asked a question about SUN’s promotion but deny that they promote any product or industry.

There are more pointers to promote or take a soft view of private sector and its role in tackling nutrition. The impression is given that a big opportunity would be lost if we failed to engage with private sector. Another Lancet article in February 2013 in fact points the opposite concluding, “Despite the common reliance on industry self-regulation and public—private partnerships, there is no evidence of their effectiveness or safety. Public regulation and market intervention are the only evidence-based mechanisms to prevent harm caused by the unhealthy commodity industries”

Private sector is known to call for friendly legislations. It is worth mentioning here that India faced a tough call in 2005, when a call to repeal one of its progressive legislations Infant Milk Substitutes Feeding Bottles, and Infant Foods (Regulation of Production, Supply and Distribution) Act 1992, and Amendment Act 2003 was proposed to be repealed and it took many months to un do that decision.

The World Health Assembly has been repeatedly calling for the application of clear conflict of interest rules since 1996, so that private commercial entities are not allowed undue influence over policymaking. But private sector continues relentlessly to defeat this agreed intent. Furthermore, the Supreme Court of India recently observed that while scientific panels can consult with industries, the members of the panels must be independent and conflict of interest free.

In the interest of translating evidence into policy – rather than policy driven evidence - and maintaining the credibility of science, I think the Lancet could have seen this conflict of interest more effectively. Declaration is not enough. If that is enough, readers have their interpretations presented here. It is a call for revisiting existing policies in academic journals.

Laudable work of the Lancet, with its important implications for public health, should not be allowed to tainted with the suspicion of its authors and their conflict of interest.

Arun Gupta is Member, Indian Prime Ministers’ Council on India’s Nutrition Challenges and Convener, Alliance Against Conflict of Interests(AACI).

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