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Resonse to PLOS Medicine paper by Kearns et al.

Posted by Cottrell on 23 Mar 2015 at 10:30 GMT

The paper by Kearns et al.1 contains a number of errors and speculations that merit comment. First, the paper incorrectly claims a role for WSRO in decisions made during the period of time covered by the paper. Second, it misrepresents the decision-making process within WHO. Third the evidence on the best prevention strategies for dental caries is conveniently omitted.
1. The documents examined are reported to relate to the period 1959-1971. It is therefore an incorrect speculation to refer to these as “WSRO related”, since WSRO was not formed until March 1978. This is a substantial inaccuracy by the authors.
2. Equally, the assertion “In 1978, ISRF was reorganised to become WSRO, and SA joined to become a member” is economical with the facts. WSRO was incorporated in England as an entirely separate organisation to ISRF with no American membership. The fact that the Sugar Association became a member later that year does not alter the fact that WSRO was a distinct and independent body, unrelated to ISRF.
3. The repetition in this paper of the canard, attributed to Norum2, that “The World Sugar Research Organisation….successfully blocked the 2003 WHO/FAO joint committee recommendations from becoming WHO policy” ignores the facts. WSRO has no official standing with WHO and was in no position to “block” any WHO proposal. Indeed, the constitution of WHO gives it unparalleled independence from any outside influence, even of its own member governments. At issue during the 2004 World Health Assembly was the initial draft of a “Global Strategy on Diet Physical Activity and Diet” offered to the member governments for their agreement. This draft was extensively based on the policy recommendations of the 2003 committee report (Technical Report Series 916). But it additionally asked the governments to accept a series of quantitative nutrient targets for populations (also taken from the report). All of the text of the draft was accepted, with the exception of the quantitative population targets. The text of the agreed version3 can readily be compared with the report2 to confirm this.
The minor editing of the Global Strategy text was a result of representations from many member governments that the available scientific evidence did not support the quantitative population nutrient targets proposed in the committee report. Since, in the event, the agreed version of the Global Strategy included all the main policy proposals recommended by the committee, it must be questioned why Norum2 and Kearns et al.1 consider the omission of the quantitative population targets so significant.
4. The statement “Despite the overwhelming consensus on the causal role of sugars in tooth decay…” is misleading by omission of a substantial body of evidence. The overwhelming scientific consensus is that all fermentable carbohydrates (i.e. all sources of sugars and starches) contribute to dental decay4,5,6. And since most individual’s diets contain at least as much starches as sugars, the hesitation to assume that simply limiting intake of one source of sugars would solve the problem is perhaps more understandable than Kearns et al. wish the reader to believe. Moreover, there is persuasive evidence that the material practical influence on risk of dental caries is determined by the frequency of consumption, not amount7. To make amount of sugar alone the primary target of dietary advice is therefore illogical and unlikely to be an effective public health strategy. No randomized control evidence has ever been offered to support the proposal that limiting the amount of sugar,or “free sugars”, consumed to the specific targets of 10% or 5% of food energy will materially reduce dental decay8.
5. Speculation as to the motives of those engaged in discussions on dental health research fifty years ago may appeal to historians but has limited relevance to the nutrition policy debates of today. However, the then focus on means of prevention, other than wholesale dietary change for the entire population, might well have been based more on practical14 than venal considerations. What had been established by the 1960s, as a result of the work of Stephan in the 1940s, was that various sugars and cooked starches (the human diet does not generally contain uncooked starches in any important quantity) are capable of leading to acid production by dental plaque and therefore to demineralisation of tooth enamel, a necessary component of the dental caries process. Simply addressing sugar (as was common dental health advice in the 1950s) would, at best, provide only a partial solution.
In addition, the work of Gustafssen et al.7 had shown that frequency of intake of sugar was far more important than amount in the aetiology of caries. Sufficient limitation of the frequency of intake of both starches and sugars (including from fruits and vegetables) for every member of the population might reasonably have been considered impractical14. In the event, a focus on prevention led to the development of fluoride toothpaste (curiously ignored in Kearns. et al.’s analysis), which has been acknowledged to be a highly effective preventative9, if used regularly. Since the introduction of fluoride toothpaste the decay rate in many countries has reduced dramatically. For example, in the UK11 dental decay prevalence (as measured by the standard international comparison of decayed, missing and filled permanent teeth at age twelve, DMFT) has fallen from an average of 4.8 to 0.710.
It is worth noting that Norway has long had a national policy to limit sugar intake to less than 10% of food energy. The implementation of this policy can hardly be accused of being directly influenced by the sugar industry, since Norway has no indigenous sugar production industry. The success of this policy may, perhaps, best be judged by the observation that Norway has a tooth decay rate that is among the worst in Europe and double that of the UK10.
6. With respect to dental decay, Kearns et al. parody our scientific position statement12, which is precisely aligned with that of IOM5 and the EFSA6. They seem to think that WSRO should not emphasise the importance of fluoride toothpaste use, while also acknowledging the role of frequent consumption of fermentable carbohydrates, including sugar. It would be irresponsible not to emphasise fluoride toothpaste’s importance, in common with responsible health educators (e.g. the UK NHS Choices13).
7. To say the WSRO position is “grounded in more than 60 years of protecting industry interests” appears to be an attempt to avoid addressing the full body of scientific evidence by smearing one source, among many4,5,6, of evidence-based opposition to a failed 1950s approach to dental public health. WSRO will continue to argue for sound science and effective public health policy on sugar and health.
1. Kearns CE, Glantz SA, Schmidt LA (2015) Sugar Industry Influence on the Scientific Agenda of the National Institute of Dental Research’s 1971 National Caries Program: A Historical Analysis of Internal Documents. PLoS Med 12(3): e1001798.
2. Norum KR (2005) World Health Organization’s global strategy on diet, physical activity and health: the process behind the scenes. Food Nutr Res 49: 83–88.

3. (2003) Joint WHO/FAO expert consultation on Diet, Nutrition and the Prevention of Chronic Diseases. WHO Technical Report Series No. 916.

4. FAO/WHO Report of a Joint FAO/WHO Expert Consultation. FAO Rome (1997)
Carbohydrates in Human Nutrition. FAO Food and Nutrition Paper No 66.

5. Institute of Medicine (2005) Dietary reference intakes for energy, carbohydrate, fiber, fat, fatty acids, cholesterol, proteins, and amino acids. National academies Press, Washington, USA. accessed 12/3/15

6. European Food Safety Authority (2010) Scientific opinion on dietary reference
values for carbohydrates and dietary fibre. EFSA Panel on Dietetic Products,
Nutrition and Allergies. EFSA Journal 2010; 8(3):1462.

7. Gustafsson BE, Quensel CE, Lanke LS et al (1953) The effect of different levels
of carbohydrate intake on caries activity in 436 individuals observed for five years.
Acta Odontologica Scandinavica 11: 232-364.

8. Moynihan PJ, Kelly SAM (2013) Effect on Caries of Restricting Sugars Intake:
Systematic Review to Inform WHO Guidelines. Journal of Dental Research 93: 8-18.

9. Kay EJ (1998) Caries prevention : based on evidence? Or an act of faith? British
Dental Journal 185:432-3.

10. Data are displayed graphically (with their original source) at accessed 12/3/15

11. Cottrell RC. (2013) Dental Disease: Etiology and Epidemiology. In: Caballero B. (ed.) Encyclopedia of Human Nutrition, third edition, vol. 2, pp. 10-16. Waltham, MA:
Academic Press.

12. accessed 12/3/15

13. accessed 12/3/15
14. Carlos JP (1982) The prevention of dental caries: ten years later. Journal of the American Dental Association: 104: 193-197.

Competing interests declared: Dr Richard Cottrell is employed as Director General of the World Sugar Research Organisation, a scientific research and information organisation funded by the sugar industry.

RE: Resonse to PLOS Medicine paper by Kearns et al.

glantz replied to Cottrell on 30 Mar 2015 at 20:58 GMT

The World Sugar Research Organization’s (WSRO) response [1] to our paper Sugar Industry Influence on the Scientific Agenda of the National Institute of Dental Research’s 1971 National Caries Program: A Historical Analysis of Internal Documents [2] illustrates how the sugar industry continues to try to protect itself from potentially damaging research.

None of the criticisms in the WSRO letter contest the substantive results of our analysis of internal sugar industry documents.

The criticisms instead seek to distance WSRO from the industry efforts to influence taxpayer-funded research on sugar documented in our paper. This letter in fact provides an excellent illustration of the industry’s continuing efforts to shift attention away from sugar’s role in promoting tooth decay, the same strategies that we document from a half-century ago.

First, WSRO claims that it is unrelated to the International Sugar Research Foundation (ISRF), which spearheaded efforts to influence National Institute of Dental Research (now the National Institute of Dental and Craniofacial Research) science in the late 1960s. This claim is false. As documented in our paper, WSRO was formed from ISRF [3]. In a 1978 internal industry document, the President of the Sugar Association described the relationship between ISRF and WSRO as follows:

This past month [March 1978], 'ISRF has become WSRO' (World Sugar Research Organisation). The first meeting of this new organization was held in London in March and it would seem that it is now progressing along the lines recommended by the Sugar Association membership. Basically this means that the new WSRO will be acting as a clearing house for research information and a meeting place for world sugar organizations. [3] [emphasis added]

Furthermore, as described in March 1978 by KC Sinclair, Chief Executive of the British Sugar Corporation, [4] the last ISRF meeting and first WSRO meeting were one in the same:

At the Annual Meeting of the International Sugar Research Foundation held in London in March 1978 one day was devoted to a discussion of Nutritional Guidance, and in particular as it relates to Government involvement. A panel of four speakers introduced the subject and a full discussion followed. In view of the importance and great interest in nutrition these days and strong and sometimes mistaken views held by many on this subject a full report of the meeting was made. It is available in typescript to members, on demand.

'The meeting was held under the auspices of the International Sugar Research Foundation which is being replaced by the World Sugar Research Foundation.' This report may therefore be regarded as the last publication of the ISRF and the first of the new WSRO. It is hoped that this summary of addresses will be of value to those concerned with advising what we eat and that it may be a worthy successor to the high standard reports of the ISRF. [5] [emphasis added]

WSRO’s disavowal of any relationship to ISRF also contradicts its 2011 publication titled, A Guide for Members:

Shortly after the Second World War, the Sugar Research Foundation (SRF) was created by the US Sugar Association as its ‘research arm’. The Foundation supported projects at leading institutions and universities initially in the US and later in the UK. The main areas of research were sugar technology, non-food applications and health aspects of sugar. In 1970, when Tate & Lyle, the British Sugar Corporation and the Belgian company Raffinerie Tirlmontoise joined the SRF it became the International Sugar Research Foundation.

In the seventies, ‘sugar and health’ issues were becoming important in the US and emphasis on non-food applications was therefore reduced. In view of the consequent divergence of research objectives amongst the members of the ISRF, a new co-operative venture resulted which led to the creation in 1978 of the World Sugar Research Organisation (WSRO). Its members then included the US Sugar Association, the British Sugar Bureau, Tate & Lyle, the South African Sugar Association and a number of sugar companies in Canada, Europe and Latin-America.

Second, in its critique of our study, WSRO dismisses its role in ensuring that the quantitative limit for free sugars of less than 10% of total calories recommended by the Joint WHO/FAO Expert Consultation on Diet, Nutrition and the Prevention of Chronic Diseases in 2003 [7] was omitted from the 2004 WHO Global Strategy on Diet, Physical, Activity and Health [8], as documented by Norum [9] In its letter, WSRO claims that because it has no official standing with the WHO, it was in no position to block any WHO proposal. This statement ignores the fact that the WHO, one of many specialized agencies within the United Nations [10], works with other UN agencies, including the Food and Agriculture Organization (FAO), to develop and implement policies that concern both agencies [11]. The 2011 WSRO A Guide to Members describes WSRO’s relationships to UN agencies, including its official standing with the FAO and Codex Alimentarious Commission. In particular, the Guide lists numerous successful collaborations between the WSRO and the WHO and FAO, which include:


World Level Relationships

WSRO collaborates with such world-wide bodies as the Food and Agriculture Organisation (FAO) and the World Health Organisation (WHO) of the United Nations and the International Life Sciences Institute (ILSI).

WSRO has an International Non-Governmental Organisation (INGO) liaison status with the FAO and has represented its Members at FAO meetings, especially the Committee on Agriculture.

WSRO has Observer status with the Codex Alimentarius Commission and has represented its Members in many Codex meetings on topics related to nutrition labelling and health claims.

'Collaborative programmes with FAO and WHO include:'

WSRO has completed a collaborative programme with WHO on “Oral Health,” referring to the fluoridation of sugar and involving research projects in several countries. The programme resulted in a series of research papers published in Advances in Dental Research, volume 9, 1995.

The “Carbohydrate Expert Consultation” programme with the FAO/WHO, initiated in 1996, resulted in a report: Report of a Joint Food and Agriculture Organisation / World Health Organisation Expert Consultation (1998). Carbohydrates in Human Nutrition. FAO Food and Nutrition Paper No 66. FAO, Rome.

The “Obesity Expert Consultation” programme with WHO, initiated in 1996, has resulted in a WHO Technical Report 894, “Obesity - Preventing and Managing the Global Epidemic”. WHO 2000.

WSRO was among a number of organizations invited to comment on the Draft of WHO/FAO Technical Report 916 “Diet, Nutrition and the Prevention of Chronic Diseases” in 2002. Its comments were published on the WHO web site.

Third, while WSRO dismisses the importance of the omission of the quantitative limit on free sugars from the 2004 WHO Global Strategy on Diet, Physical, Activity and Health, it clearly understands the potential adverse effect on sugar sales if the 10% quantitative limit had been implemented. The May 9, 2013 edition of the Sugar Association newsletter Sugar E-News reports that:

WSRO commissioned an analysis quantifying the impact of this WHO recommendation. 'If a 10% sugar limit were adopted worldwide, the year-2005 global demand for sugar would be nearly 23 million tons lower than year-2000 global demand.' [12] [emphasis added]

The WSRO’s remaining criticisms of our paper fail to address anything specific to our analysis. They simply represent a continuation of the strategy, documented in our paper, whereby the sugar industry tries to deflect attention away from the clear need for public health measures that reduce sugar consumption to prevent dental caries.

Finally, WSRO dismisses our analysis, suggesting that the historical events uncovered have no relevance to nutrition debates today. This claim, in fact, echoes the statement Brown and Williamson Tobacco issued in 1995 in response to the first research papers [13,14,15,16,17] that analyzed internal tobacco industry documents:

Lifting single phrases or sentences from 30 year-old documents and using that information to distort and misrepresent B&W's position on a number of issues is clearly what is occurring ... We continue to believe that nicotine is not addictive because over 40 million Americans have quit smoking, 90 percent of them without any help at all. [18]

Nothing in the WSRO letter contradicts the evidence we present. In fact, this letter reinforces our point that “the sugar industry’s current position—that public health recommendations to reduce dental caries risk should focus on sugar harm reduction as opposed to sugar restrictions—is grounded in more than 60 years of protecting industry interests.” This letter from WSRO underscores the importance of our historical analysis and its relevance to today’s nutrition policy debate. Industry opposition to current policy proposals to restrict sugar intake should be carefully scrutinized to ensure that industry interests do not supersede public health goals.

Cristin Kearns, DDS, MBA
Stanton Glantz, PhD
Laura Schmidt, PhD

University of California, San Francisco


1. Cottrell RC (2015) Response to PLOS Medicine paper by Kearns et al.; Available: http://www.plosmedicine.o.... Accessed 26 March 2015.

2. Kearns CE, Glantz SA, Schmidt LA (2015) Sugar Industry Influence on the Scientific Agenda of the National Institute of Dental Research’s 1971 National Caries Program: A Historical Analysis of Internal Documents. PLoS Med 12: e1001798.

3. The Sugar Association (1978) The Sugar Association, Inc. Annual Meeting of Members May 11, 1978, Washington, D.C. Records of the Great Western Sugar Company. Fort Collins (Colorado): Agricultural and Natural Resources Archive, Colorado State University.

4. International Sugar Research Foundation (1975) Planning the Research Effort: I. Identification of Priorities II. Specific Recommendations, September 11 & 12, 1975. Records of the Great Western Sugar Company. Fort Collins (Colorado): Agricultural and Natural Resources Archive, Colorado State University.

5. International Sugar Research Foundation/World Sugar Research Organisation (1978) International Sugar Research Foundation/World Sugar Research Organisation symposium, March 1978. London: International Sugar Research Foundation/World Sugar Research Organisation.

6. World Sugar Research Organisation (2011) World Sugar Research Organisation: A Guide to Members. Accessed at: on 13 February 2013.

7. Joint WHO/FAO Expert Consultation on Diet Nutrition and the Prevention of Chronic Disease (2003) WHO Technical Report Series, No. 916 (TRS 916): Diet, nutrition and the prevention of chronic diseases: Report of the joint WHO/FAO expert consultation, Geneva 28 January - 1 February 2002. Available: Accessed 20 October 2014.

8. World Health Organization (2004) Global Strategy on Diet, Physical Activity, and Health. Available: Accessed 19 December 2014.

9. Norum KR (2005) World Health Organization’s global strategy on diet, physical activity and health: the process behind the scenes. Food & Nutrition Research 49: 83-88.

10. United Nations (2015) Funds, Programmes, Specialized Agencies and Others. Available: Accessed 26 March 2015.

11. Food and Agriculture Organization of the United Nations World Health Organization (2007) FAO/WHO Framework for the Provision of Scientific Advice on Food Safety and Nutrition. Available: Accessed 26 March 2015.

12. The Sugar Association Inc. (2003) Sugar E-News Vol. 6#18 May 9, 2003. Available: Accessed 26 March 2015.

13. Glantz SA, Barnes DE, Bero L, Hanauer P, Slade J (1995) Looking through a keyhole at the tobacco industry. The Brown and Williamson documents. Jama 274: 219-224.

14. Slade J, Bero LA, Hanauer P, Barnes DE, Glantz SA (1995) Nicotine and addiction. The Brown and Williamson documents. Jama 274: 225-233.

15. Hanauer P, Slade J, Barnes DE, Bero L, Glantz SA (1995) Lawyer control of internal scientific research to protect against products liability lawsuits. The Brown and Williamson documents. Jama 274: 234-240.

16. Bero L, Barnes DE, Hanauer P, Slade J, Glantz SA (1995) Lawyer control of the tobacco industry's external research program. The Brown and Williamson documents. Jama 274: 241-247.

17. Barnes DE, Hanauer P, Slade J, Bero LA, Glantz SA (1995) Environmental tobacco smoke. The Brown and Williamson documents. Jama 274: 248-253.

18. Graham T (1995) The Brown and Williamson documents: The company's response. JAMA 274: 254-255.

No competing interests declared.