Conflicts of interest, part 3
Should nutrition professionals interact with industry? And how?
Whether or not nutrition professionals should work with industry is a subject of a lot of controversy.
I tend to take a pragmatic approach in the sense that companies are meant to make money, companies can make products that are useful for us, and people who understand nutrition and health can help companies do that.
For example, moving away from nutrition, if engineers can help develop cars which are less polluting isn’t this a good thing? Yes, if we walked or cycled it would be better; and yes tires produce microparticles which are probably a bit bad. BUT, driving is more convenient for our modern lifestyles than walking or cycling and a less polluting car is better than a more polluting car, right?
However, it's also true that since the goal of companies is to make a shed load of money, whether their product is beneficial/healthy/legit or not is irrelevant to their business model.
Therefore, I do think nutrition professionals need to be very careful in considering how and in what capacity they work with industry. I’ll lay out my views here, and try to share my reasoning!
Development of products and services
This is a common one for nutrition professionals to be involved in. For example dietitians could be involved in the development of medical nutrition products such as hydrating fluids, or stoma bags. I think this is a great place for dietitians to use their skills; as they will have a good understanding of the clinical needs of patients, both physiologically and practically.
Other examples might be designing a nutrition programme, or some kind of dietary and lifestyle intervention.
I also think it’s a good thing for nutritional professionals to be involved in the development of supplements. They will have knowledge of nutritional needs; deficiencies, and how different nutrients work together. However, I think a nutritional professional should be clear about how the product will be tested and promoted. Just because a product is natural it doesn’t mean its safe; and unless it’s been tested, you have no idea if it actually works. I do think nutritionists should insist on these things before getting involved in development.
Things get more complex when it comes to food products. People with nutrition knowledge can help design food products which can do good; or pragmatically – do less harm.
I can see how some people would take a harder line and say nutritional professionals should have nothing to do with companies who make “non-commodity” products. Or that such products are simply “fake food” and nutrition professionals should have nothing to do with them.
I disagree and think that for some foods there is a useful and pragmatic role nutrition professionals can play. For example, for people who cannot tolerate dairy, advice on how to fortify non-dairy milks, yoghurts and cheeses would be useful.
Another example is modifying commonly eaten foods to address the primary nutritional needs of the nation (eg too many calories, not enough fibre). Because the thing is - as much as people hate it - processing and mass production of foods can make foods cheaper, and low-cost food is essential for many people. We live in a very unequal society and if it does ever change, it’s not going to quickly. So for now, this is the reality we live in. Foods like supermarket pizzas or ready meals are going to be part of many people’s diets. If the content of the pizza bread could be designed in such a way to make it more resistant to digestion (therefore lower in calories, and higher in fibre) would that not be a good thing? Compared to what we have now, I think it would be.
I do think a line should be drawn for foods which basically have no nutritional value – eg stuff likes cakes, biscuits etc. Someone could help them be less high in sugar and/or saturated fat. But since these foods are not providing anything we’re lacking in our diets, I think it would be better to leave these types of products alone as “stuff that should be treats and let’s not pretend they provide anything nutritionally”?
Advisors/ advisory committees
This is something I do quite a bit and enjoy.
This role often includes advising the company on trends, or giving specific advice on developing a product or programme. Obviously, the company is interested in using your advice to help them make money. Red flag? I think if your advice is evidence-based (use X ingredient instead of Y to increase fibre/decrease saturated fat) you can help a company make a healthier product, and hopefully the company makes money. And while the company are for sure going to promote the nutritional quality of the product to try to help sell it, the reality is that nutrition is not a significant driver of food purchasing for consumers, especially compared to to price, convenience and taste. So in this sense, the end result is hopefully making a product (and diets) healthier…
What about marketing? “Why the jiggins should a registered dietitian be telling a for-profit company what they should say to sell more of their product?”. I have actually changed my mind on this in the last few years. Because thanks to the attention-economy we live in, members of the public are exposed to an array of misleading messages about nutrition: “supermarket cereals are UPFs so you need to avoid them”; “saturated fat doesn’t play a role in heart disease”; “sugar is better than artificial sweeteners”.
If a celebrity doctor is making £££££ from a book warning people about the dangers of supermarket bread, should a nutritionist who is far more familiar with the scientific literature advise companies on how to counter incorrect messages? To be clear I think this is the right thing to do based on the evidence we have - breads can be high in fibre, nutrient-rich, can help make cheap nutritious meals and for god’s sake stop being silly about glucose spikes.
So let’s say an influencer or industry-funded campaign is trashing wholegrains or something. Think “omg lectins” or “carbs cause hyperinsulinaemia”. Would it be *wrong* for a nutrition scientist to advise a wheat company on messaging to counter the nonsense? If you’re thinking that the nutrition scientist should do that anyway - and should not be paid for it - the problem as I see it is that people like me don’t have a voice/influence or access to effective advertising and marketing the way companies (and influencers with 1M+ followers) do. Even the British Dietetic Association have a tiny, tiny impact.
So I view this area with a lot more nuance than I did a few years ago.
And to clarify I obviously think dietitians absolutely should not advise companies on how to sell more unequivocally unhealthy products like cakes and chocolates etc.
Promoting products
This is the most challenging one I think.
In 2020 there was a media campaign launched by a few meat industry organisations for Blue Monday - the day in January when people feel the most “down”. The campaign used dietitians and other influencers to promote the micronutrient content of meat and show how these micronutrients are important for energy and mood.
This campaign was one of those which was the basis for the Washington Post article on influencer dietitians, and it understandably caused a lot of controversy.
Since nutrition is so grey, there wasn’t anything I saw that was outrageously incorrect that people were saying in their posts. (And in [some] defence of the dietitians in question, most of the posts also explained where people could find those same B vitamins in other foods, too). BUT…. I think because the posts didn’t put meat into context, it was a misleading. I think intellectual honesty here is really important. For example, most of the posts said things like “B vitamins [like those found in meat] can help with energy” but it would have been more intellectually honest to put the likelihood of deficiency into context - ie most men have more than enough iron. There’s no benefit of getting more of these micronutrients if people are not deficient - and actually in excess some micronutrients can cause harm.
I also think it would have been more accurate (and again, honest) to emphasise that as of right now a Mediterranean-style diet has the current best evidence behind it for depression. There’s a good chance this is due to the plants and fibre within this diet….and also this diet tends to have a small amount of red meat in. So, unless people have a deficiency (and most people don’t), there’s probably no specific benefit of meat on mental wellbeing. Not really what those posts said is it?
Promotion can mean lots of things. I obviously think “Buy this product” type of promotion is always inappropriate and too egregious in nutrition because the benefits of a product are often context dependent. I used to think that nutrition professionals should not even talk about/educate on commercial products, but I have softened my stance on this lately too. And yes, a large part of this is as a result of misinformation by book sellers, podcasters and other influencers.
I actually think that showing how products can be used in a healthy way can be useful. For example, the denigration of all breakfast cereals as being “OMG UPF you’re gonna die” is wildly unhelpful. Instead I think simple, visually appealing educational reels of how people can make a really healthy, low-cost breakfast would be really useful. (Take your branflakes or similar, add the lowest costs seeds or some dried/frozen fruit etc). The same with supermarket bread. I eat supermarket bread and supermarket baps (and UPF margarines HAHAHA) but I load them up with veges and other plant-based foods. Again, I think we’re getting to the point where this type of obvious(?) practical dietary guidance is needed.
There’s also a lot of warnings around against packet foods and ready meals. But for families who don’t have time to cook, they very often have to rely on at least some convenience foods; likewise for shift workers or people doing shift work, ready meals can be a staple. So I think a dietitian showing how to make healthy meals using ready meals or other packaged products is useful. For example, as a dietitian I would often show people the lower cost ready meals which also had reasonable nutritional profile. At the same time, even the healthiest type of ready meals tend to have no vegetables or only tiny portion of them. So I would offer tips on low cost ways to have veges on the side - microwaving frozen peas or carrots; or popping into the supermarket on the way home from work and getting a microwaveable packet of veges on sale. (Also a 3 minute whizz in the microwave uses much less energy than cooking something in the oven for 25-30 mins - important for many families). It will blow people’s minds, but - depending on the content of ready-meal - this can actually be a healthy way to eat.
Now could/should dietitians do this for free or as part of their professional organisations/events? Yes (and they do!) but without commercial backing and marketing, such piecemeal education has a tiny amount of reach.
Finally, what about promotion of/education on supplements. Promotion here is nearly always a no, no for me. Even if they have been tested properly, this is a bit of a red flag because supplements are nearly always second-best (and therefore should be a last resort) compared to actually getting the right nutrition from the diet. Most have not been tested properly at all, so “this supplement lowers X or improves Y” is straight out wrong and misleading. If you’re a nutritional professional and your standards are as low as the Glucose Goddess, have a word with yourself.
Honesty and Good Faith
Ultimately, I think the lodestar for any nutrition professional working with industry should be honesty and good faith. Honestly because (sorry if this is obvious) you are a credentialed professional and people trust you. Good faith because noone is perfect. You might get things wrong, or you might misinterpret the evidence. But you must act in good faith (again, you are a credentialed professional and people trust you).
Good faith also means sticking within your scope of practice and abilities. For example, I am not a gastro expert, so under no circumstances would I accept an offer from a company to develop a new probiotic for inflammatory bowel disease. Likewise, if you have no experience running clinical trials, should you really be advising a company on how they should run a trial to test a product? And helping them explain what the results of the trial mean to the public? No, because you’ll probably get it wrong, be [unintentionally but inevitably] misleading and “sorry I didn’t understand what I was doing” isn’t good enough.
The opposite of good faith is deception. It’s not the same thing as lying. Lying is making a false statement. Deception is doing or saying something that is misleading. And if you’re a scientist (or indeed anyone with a vocabulary and credentials who can very easily deceive a layperson), you…shouldn’t mislead people. It’s wild this needs to be said but it does.
For example, throwing around words like “randomised controlled trial” and “gold standard”, without explicitly mentioning the control was a leaflet or croutons is an example of this.
If you are using scientific jargon or withholding critical details about a study to sell a product because you know the average person on the street won’t notice that what you’re saying isn’t strictly true? Again, you really do need to take a long, hard look at yourself.
Advice I would give to young up-and-coming nutritionists
One of the really tough things - especially now - about graduating either as a nutritionist, dietitian or a PhD is that the financial pressures on young people are much greater than when I graduated. Salaries for nutritionists and dietitians are not high at all. Young people nowadays are graduating with tens of thousands of pounds in debt and the possibility of buying a house is non-existent or decades in the future. For those with a strong social media presence, the opportunity to earn a lot of money very quickly is probably close to impossible to resist.
My approach - and it was part intention, part serendipity - is to always have a “full time/regular” job that essentially pays my bills, and I do consultancy work on the side on projects that I believe in. I would really recommend this approach to any young nutritional professional because it means you aren't as tempted by “help-us-promote-this-new-probiotic” money when the rent is due. I also like the variation my roles offer me by doing academic work, a small amount of clinical work and then some consultancy work on the side.
I also do think you need to be strong person to do this role well, and you definitely cannot be a people pleaser. For example, I have worked with companies and told them things they definitely didn’t want to hear (because they were doing things that weren’t in line with the evidence). For this I think you need a lot of experience and confidence in yourself. That can be hard, and there is always a risk that a company might not want to extend your contract or work with you again.
But apart from the moral obligation (lol) not to mislead, there are other reasons why you should value and protect your integrity, for yourself and for your profession:
When the public perceives that nutrition professionals provide honest, evidence-based advice, it fosters trust and (we hope?) encourages adherence to our recommendations. But this trust also extends to companies and organizations that rely on nutritional experts to guide product development, marketing, and health initiatives. If the public loses faith in the integrity of you as a nutrition professional, companies will also begin to question your value.
Having a nutrition degree from KCL or being a Stanford professor might mean something now; but a few more years of £39 packets of “developed-by-science” seeds and “use HUBERMAN24 discount code for your $99 $70 Athletic Greens” and it won’t for much longer.