Tuesday, November 13, 2012

Guest Post: Pharmacist Blasts Canadian Diabetes Association Over Juice Endorsement

His name is Tony Nickonchuk and he's a pharmacist, a blogger, and an all around evidence-based good guy.

He's also a certified diabetes educator and as such he receives a regular publication produced by the Canadian Diabetes Association called the Diabetes Communicator.

He was horrified to find in the most recent edition, an advertorial for the consumption of fruit juice that was paid for by PepsiCo. So horrified in fact that he penned a letter to the Editor-in-Chief of the publication along with the President and CEO of the Canadian Diabetes Association.

He kindly included me on the letter's cc list and at my request, allowed me to include it here as a guest post.

A fascinating read
Dear Ms. Rand:

I opened the latest issue of The Diabetes Communicator ready to learn. The stated purpose of The Diabetes Communicator is “to inform members of the activities of DES (Diabetes Educator Section), and to publish relevant, practice-based diabetes education information...[and] strives to be accountable and accessible to the DES membership”(1). As a DES member, I now ask you to demonstrate this accountability by removing corporate- sponsored advertorials from all future Diabetes Communicator releases.

I speak of the PepsiCo promotional document entitled The Juicy News(2). Although disguised as an evidence-based clinical practice tool for Certified Diabetes Educators, it is nothing but sciencewashing, an advertorial designed to increase consumption of PepsiCo fruit juice and fruit drink products.

The premise itself, that Canadians don't get their required servings of fruits and vegetables, is scientifically sound. The solution the document offers (I cannot say "authors" because they are not listed, only the reviewers), that 100% fruit juices are an appropriate replacement for whole fruits and vegetables, is not. Nor are the claims that consumption of 100% fruit juice may reduce the risk of cardiovascular disease and contribute to maintenance of a healthy body weight.

The Canada Food Guide(3) does state that 125mL of 100% fruit juice is an acceptable choice as a fruit and vegetable serving. However, this does not make it true. Britain's National Health Service recommends much the same, but adds the caveat that only ONE serving per day should include juice(4). As does Ireland(5). Not surprisingly, and counter to the obvious purpose of this document, Ireland and Britain have much lower per capita fruit juice consumption than Canada, which leads the way among developed nations(6).

The document then shows a comparison between fruit juice and whole fruit that states that by 100g fresh weight of edible portion, the two are practically identical. The comparison is disingenuous. To honestly compare the two we need to compare one serving of fruit as per the Canada Food Guide to one serving of fruit juice. Using grapes as an example, 20 grapes are listed as a serving in the Food Guide, containing 68 calories, 18 g of sugar, and 1 g of fiber(7). Tropicana 100% Grape Juice contains 85 calories, 20 g of sugar, and no fiber per 125mL (1 Food Guide serving)(8). In reality, 125mL of Pepsi-Cola comes closer in nutrient content to whole fruit, containing 53 calories and 14.5 g of sugar(9). But stating, based on this, that soft drinks are a nutritious alternative to whole fruits would be just as absurd as claiming that 100% fruit juices are.

The authors then attempt to prove that consumption of 100% fruit juice reduces cardiovascular disease. One cited study(10) contained 24 subjects, a sample too small to allow for meaningful conclusions. The other(11) used surrogate markers like atherogenic gene expression, the clinical relevance of which is limited, providing no evidence as to impact on morbidity, mortality, or cardiovascular disease outcomes. Yet, on the basis of these small studies, the document states that “the area of cardiovascular disease appears to show the most convincing evidence from epidemiological and clinical studies for the beneficial effects of fruits and vegetables and their juices.”(2) The reality is there is not a single well designed and well executed study, nor a systematic review or meta-analysis to support the notion that consuming 100% fruit juice reduces cardiovascular disease.

This hawking of bogus science continues with the claim that the “consumption of fruits and vegetables has been shown to be correlated with a reduced risk of becoming overweight or obese”(2). An honest evaluation of the literature shows nothing of the sort. One quoted study(12) only showed correlation, not causation. It was based on a population-based study that relied on self-reported fruit juice consumption and self-reported body weight, data collection methods fraught with potential for error. As well, all individuals with chronic diseases were excluded from the report, eliminating all patients with coronary heart disease, diabetes, or stroke, thus leaning the results squarely in favor of juice consumption. If you take all the people out of the study that may be overweight and obese, like those with diabetes and high risk of heart disease, you eliminate a whole cohort of subjects who may have had their bodyweight negatively impacted by consumption of fruit juice. Effectively you can conclude nothing meaningful from this study.

Nor can you from the second study used by the authors to support their premise(13). Once the study adjusted for confounding factors, only obesity was negatively correlated with fruit juice consumption, and the association came close to non-significance. Interestingly, although they measured 16 potential confounders at baseline, they only adjusted for(13), not controlling for chocolate milk consumption, fat intake, or tea intake. Not doing so with the first two in particular calls into question the conclusions of the study. It is possible that adjusting for these factors, given their impact on total caloric intake, could have eliminated the small relationship shown in the study. Sadly we'll never know because the authors chose not to publish those results. Of course, this is not surprising given that the lead author of the study was an employee of the Juice Products Association.

And let us not forget about diabetes, since this publication was placed inside the envelope containing the Diabetes Communicator. Although the document makes no claims with regards to the appropriateness of fruit juice consumption in diabetes, the CDA implicitly supports consumption of 100% fruit juice in place of fruits and vegetables by including this publication with their own. I could data mine like the authors of The Juicy News and point to one study(14) that shows an increased risk of diabetes in women the higher the consumption of fruit juice. Or another that shows that frequent intake of juice “is associated with an increased risk for development of Type 2 Diabetes”(15).

But I don’t have to. The CDAs very own Just the Basics document, aimed at teaching patients how to make healthy food choices, states that “if you are thirsty, drink water [because] drinking regular pop and fruit juice will raise your blood glucose”(16). The NICE guidelines from Britain don't even mention the word “juice”, only recommending consumption of a variety of fruits and vegetables(17). The International Society for Pediatric and Adolescent Diabetes in their guideline for nutritional management of diabetes in children and adolescents suggests eliminating high sugar and high energy beverages “such as soft drinks and juices”(18).

I can forgive PepsiCo for producing the document they did. They are a profit-driven multinational corporation, their sole purpose being selling products to realize profit. I could even excuse the reviewers of Juicy News, one of which (CS) is an employee of PepsiCo, the other (HS) a consulting dietitian with multiple corporate clients(19). In this case their employment depended on overlooking the blatant data mining and cherry picking of scientific papers.

But I cannot, for the life of me, understand why the Canadian Diabetes Association would approve the placement of this document in an issue of The Diabetes Communicator. The CDA is trusted by Certified Diabetes Educators and other health professionals for evidence- based, professional educational material to advance their knowledge and clinical practices. Presenting this information under that pretense is shameful.

I understand the need for corporate sponsorship but this kind of partnership with corporate donors is inappropriate. The CDA itself makes a stance on their relationship with corporate sponsors stating that they maintain “editorial independence and operational separation from [their] corporate sponsors” and that they make “decisions about information [they] provide without interference from [their] corporate sponsors and none of [their] health information is altered or edited by [their] corporate sponsors at any time”(20) (emphases mine) Placing this document into one of their publications is no different than having PepsiCo edit their health information. Like it or not, doing so suggests that they support the content of the document.

In the future, keep corporate advertorials out of The Diabetes Communicator. They have no place there and their presence threatens the integrity not only of the publication, but of the Association itself.

Tony Nickonchuk, BSc. Pharm., RPh., CDE, APA

1 Canadian Diabetes Association [homepage on the internet]. The Association: Toronto; [cited Nov 8 2012]. The Diabetes Communicator; Available from: http://www.diabetes.ca/publications/tdc/

2 Smith H, Saunders C. Juicy News. PepsiCo Canada [homepage on the internet] Fall 2012 [cited Nov 8 2012]. Available from: http://pepsico.ca/en/downloads/Juicy%20News%20ENGLISH.pdf

3 Eating Well with Canada’s Food Guide [homepage on the Internet]. Health Canada: Ottawa; [cited Nov 8 2012]. Available from: http://www.hc-sc.gc.ca/fn-an/food-guide-aliment/index-eng.php

4 National Health Services [homepage on the internet]. [cited Nov 8 2012]. 5 a day: What Counts? Available from: http://www.nhs.uk/Livewell/5ADAY/Pages/Whatcounts.aspx

5 Department of Health and Children, Ireland [homepage on the internet]. [cited Nov 8 2012]. Your Guide to Healthy Eating Using the Food Pyramid. Available from: http://www.dohc.ie/publications/pdf/ YourGuide_HealthyEating_FoodPyramid.pdf?direct=1

6 Fruit Juice Consumption by Nation [homepage on the internet] [cited Nov 8 2012]. Available from: http:// www.nationmaster.com/graph/foo_fru_jui_con-food-fruit-juice-consumption

7 Dietitians of Canada [homepage on the internet] [cited Nov 8 2012]. Eatracker. Available from: http:// www.eatracker.ca/food_search.aspx?current=1&text=grapes

8 Tropicana [homepage on the internet] [cited Nov 8 2012]. Tropicana Pure Premium Original Nutrition Facts. Available from: http://www.tropicana.ca/EN/products_pure.php

9 PepsiCo Canada [homepage on the internet] [cited Nov 8 2012]. Pepsi Soft Drink Nutrition Facts. Available from: http://pepsico.ca/en/Brands/Pepsi_Cola-Brands.html#Pepsi_reg_soft_drink_fb

10 Morand C, Dubray C, Milenkovic D, Lioger D, Martin JF, Scalbert A, Mazur A. Hesperidin contributes to the vascular protective effects of orange juice: a randomized crossover study in healthy volunteers. Am J Clin Nutr. 2011;93(1):73-80.

11 Milenkovic D, Deval C, Dubray C, Mazur A, Morand C. Hesperidin displays relevant role in the nutrigenomic effect of orange juice on blood leukocytes in human volunteers: a randomized controlled cross-over study. PLoS One. 2011;6(11):e26669.

12 Akhtar-Danesh N, Dehghan M. Association between fruit juice consumption and self-reported body mass index among adult Canadians. J Hum Nutr Diet. 2010 Apr;23(2):162-8.

13 Pereira MA, Fulgoni VL III. Consumption of 100% fruit juice and risk of obesity and metabolic syndrome: findings from the national health and nutrition examination survey 1999-2004. J Am Coll Nutr. 2010 Dec;29(6):625-9.

14 Bazzano LA, Li TY, Joshipura KJ, Hu FB. Intake of fruit, vegetables, and fruit juices and risk of diabetes in women. Diabetes Care. 2008 Jul;31(7):1311-7.

15 Odegaard AO, Koh WP, Arakawa K, Yu MC, Pereira MA. Soft drink and juice consumption and risk of physician-diagnosed incident type 2 diabetes: the Singapore Chinese Health Study. Am J Epidemiol. 2010 Mar 15;171(6):701-8.

16 Canadian Diabetes Association [homepage on the internet]. The Association: Toronto; [cited Nov 8 2012]. Just the Basics; Available from: http://www.diabetes.ca/files/jtb17x_11_cpgo3_1103.pdf

17 National Institute for Clinical Excellence [homepage on the internet]. [cited Nov 8 2012]. Type 2 diabetes: National clinical guideline for management in primary and secondary care (update). Available from: http://www.nice.org.uk/nicemedia/live/11983/40803/40803.pdf

18 Smart C, Aslander-van Vliet E, Waldron S. Nutritional management in children and adolescents with diabetes. Pediatric Diabetes 2009;10(s12):100-17-

19 Heidi Smith Nutrition. [homepage on the internet] [cited Nov 8 2012]. About Heidi. Available from: http:// www.heidismithnutrition.com/Home10.html

20 Canadian Diabetes Association [homepage on the internet] The Association: Toronto [cited Nov 8 2012]. Disclaimer: Advertising and Editorial Independence. Available from: http://www.diabetes.ca/about- us/policies/disclaimer/