The authors have declared that no competing interests exist.
Conceived and designed the experiments: CEK SAG LAS. Performed the experiments: CEK. Analyzed the data: CEK SAG LAS. Wrote the first draft of the manuscript: CEK. Contributed to the writing of the manuscript: CEK SAG LAS. Agree with manuscript results and conclusions: CEK SAG LAS. All authors have read, and confirm that they meet, ICMJE criteria for authorship.
In 1966, the National Institute of Dental Research (NIDR) began planning a targeted research program to identify interventions for widespread application to eradicate dental caries (tooth decay) within a decade. In 1971, the NIDR launched the National Caries Program (NCP). The objective of this paper is to explore the sugar industry’s interaction with the NIDR to alter the research priorities of the NIDR NCP.
We used internal cane and beet sugar industry documents from 1959 to 1971 to analyze industry actions related to setting research priorities for the NCP. The sugar industry could not deny the role of sucrose in dental caries given the scientific evidence. They therefore adopted a strategy to deflect attention to public health interventions that would reduce the harms of sugar consumption rather than restricting intake. Industry tactics included the following: funding research in collaboration with allied food industries on enzymes to break up dental plaque and a vaccine against tooth decay with questionable potential for widespread application, cultivation of relationships with the NIDR leadership, consulting of members on an NIDR expert panel, and submission of a report to the NIDR that became the foundation of the first request for proposals issued for the NCP. Seventy-eight percent of the sugar industry submission was incorporated into the NIDR’s call for research applications. Research that could have been harmful to sugar industry interests was omitted from priorities identified at the launch of the NCP. Limitations are that this analysis relies on one source of sugar industry documents and that we could not interview key actors.
The NCP was a missed opportunity to develop a scientific understanding of how to restrict sugar consumption to prevent tooth decay. A key factor was the alignment of research agendas between the NIDR and the sugar industry. This historical example illustrates how industry protects itself from potentially damaging research, which can inform policy makers today. Industry opposition to current policy proposals—including a World Health Organization guideline on sugars proposed in 2014 and changes to the nutrition facts panel on packaged food in the US proposed in 2014 by the US Food and Drug Administration—should be carefully scrutinized to ensure that industry interests do not supersede public health goals.
In a historical analysis of internal documents, Stanton Glantz and colleagues examine the sugar industry influence of the National Institute of Dental Research's 1971 National Caries Program.
Tooth decay (dental caries) is the leading chronic disease of children and adolescents. Although largely preventable, 42% of children in the US have some decay in their baby (primary) teeth, and 59% of adolescents have cavities in their permanent teeth. Tooth decay occurs when the hard enamel covering the tooth surface is damaged by acid, which is produced by bacteria in the mouth. Plaque, a sticky substance of bacteria, food particles, and saliva, constantly forms on teeth. When you eat food—particularly sugary foods and drinks—the bacteria in plaque produce acids that attack the tooth enamel. The stickiness of the plaque keeps the acids in contact with the teeth. Plaque buildup can be prevented by regular brushing and flossing. Dentists can detect tooth decay before it causes toothache through visual examination or by taking dental X-rays, and can treat the condition by removing the decay and plugging the hole with a “dental filling.” However, if the decay has damaged the nerve in the center of the tooth, root canal treatment or removal of the tooth may be necessary.
Experts generally agree that sugars play a causal role in tooth decay. Consequently, in 2014, the World Health Organization (WHO) issued a draft guideline that recommended a daily limit on the consumption of “free” sugars (sugars added to food by manufacturers, cooks, or consumers). Also in 2014, the US Food and Drug Administration (FDA) proposed that the nutrition facts panels on US packaged food products should list added sugars. As with similar proposals made in the past, the World Sugar Research Organisation, a trade organization that represents companies with economic interests in sugar production, is challenging these proposals, arguing that, rather than trying to limit sugar intake, public health interventions to prevent tooth decay should focus on reducing the harms of sugar consumption. Here, the researchers explore how the sugar industry has historically sought to undermine or subvert policies to restrict sugar consumption, by examining internal industry documents related to the launch of a targeted research program to identify interventions to eradicate tooth decay—the National Caries Program (NCP)—by the US National Institute of Dental Research (NIDR) in 1971.
The researchers analyzed an archive of 319 internal sugar industry documents from 1959 to 1971 (the “Roger Adams papers”) and NIDR documents to explore how the sugar industry sought to influence the setting of research priorities for the NCP. Their analysis indicates that, as early as 1950, sugar industry trade organizations had accepted that sugar damaged teeth and had recognized that the dental community favored restricting sugar intake as a key way to control caries. The sugar industry therefore adopted a strategy to deflect attention towards public health interventions that would reduce the harms of sugar consumption. This strategy included tactics such as funding research into enzymes that break up dental plaque and into a vaccine against tooth decay, and cultivating relationships with the NIDR leadership. Notably, 78% of a report submitted to the NIDR by the sugar industry was directly incorporated into the NIDR’s first request for research proposals for the NCP, and research that could have been harmful to sugar industry interests (specifically, research into methods to measure the propensity of specific foods to cause caries) was omitted from the research priorities identified at the launch of the NCP.
These findings, although limited by the researchers’ reliance on a single source of industry documents and by the absence of interviews with key actors in the launch of the NCP, reveal an alignment of research agendas between the NIDR and the sugar industry in the early 1970s. The findings also suggest that the NCP was a missed opportunity to develop a scientific understanding of how to restrict sugar consumption to prevent tooth decay. Indeed, although tooth decay declined by 20% between 1971/1973 and 1980, 64% of children still developed caries a decade after the NCP was launched. Most importantly, these findings illustrate how the sugar industry has protected itself from potentially damaging research in the past; a similar approach has also been taken by the tobacco industry. These findings highlight the need to carefully scrutinize industry opposition to the proposed WHO and FDA guidelines on sugar intake and labeling, respectively, to ensure that industry interests do not interfere with current efforts to improve dental public health.
Please access these websites via the online version of this summary at
The US National Institute of Dental and Craniofacial Research (the successor to the NIDR) provides detailed information on
The US Centers for Disease Control and Prevention also provides information on
The UK National Health Service Choices website provides detailed information about all aspects of
MedlinePlus provides links to additional information about
Information about the
Despite overwhelming consensus on the causal role of sugars in tooth decay [
Publications about food industry influence on public health policy are growing [
We analyzed previously unexplored sugar industry documents to trace industry interactions with the US National Institute of Dental Research (NIDR, which changed its name to the National Institute of Dental and Craniofacial Research [NIDCR] in 1998) between 1966 and 1971, a critical period for dental caries control policy when the NIDR planned the launch of the National Caries Program (NCP) with the goal of eradicating dental caries within one decade [
This study drew substantially on previously unexplored WSRO-related internal documents from between 1959 and 1971 [
In 1943, SRF was founded in New York, New York. In 1949, SA was created to oversee the research activities of SRF (the research arm) and the newly created Sugar Information (the public relations arm). In 1968, SRF dissociated from SA and was reorganized as ISRF. SA joined ISRF as a member (shown as a dotted line). In 1973, SA discontinued Sugar Information because there was no longer a meaningful separation of duties between SA and Sugar Information. In 1978, ISRF was reorganized to become WSRO, and SA joined WSRO as a member.
We located sources related to the NIDR NCP through searches of PubMed and WorldCat, and by contacting NIDCR directly. Materials included NCP primary publications [
Findings were assembled chronologically into a narrative case study. Part of the analysis called for systematically comparing two key reports for similarities: (1)
Key Dates | NIDR | SRF and ISRF |
---|---|---|
1959 | Roger Adams becomes member of SRF Scientific Advisory Board [ |
|
June 1966 | NIDR Director Seymour Kreshover initiates planning for what would become NCP [ |
|
1967 | SRF funds Project 269 to develop dextranase enzyme and vaccine [ |
|
June 1968 | Announcement of Caries Task Force [ |
Philip Ross (with ties to the US National Institutes of Health) elected ISRF president [ |
June 1969 | Symposium on the Status of Research in Sucrochemistry, Diet and Heart Disease, Obesity, Dental Caries, and Clinical Nutrition held; Prof. G. Neil Jenkins speaks on “Sugar and Dental Caries” [ |
|
Sept. 1969 | Symposium held: Seeking New Approaches to Old Problems; the NIDR’s Richard Greulich speaks on “The Future of Caries Control” [ |
|
Oct. 1969 | Caries Task Force Steering Committee meeting on research priorities; planning for Role of Human Foodstuffs in Caries Workshop Conference [ |
ISRF convenes Panel Meeting of the Dental Caries Task Force—members of the NIDR Caries Task Force Steering Committee participate [ |
Late 1969 | Submission of ISRF report |
|
Jan. 1970 | NIDR Laboratory of Microbiology chief Henry Scherp submits |
|
Feb. 1970 | President Nixon endorses NCP [ |
Celebratory |
March 1970 | Caries Task Force holds Role of Human Foodstuffs in Caries Workshop Conference [ |
|
March 1971 | NCP becomes operational [ |
In June 1966, President Lyndon Johnson initiated a major reappraisal of National Institutes of Health (NIH) research agendas, requesting that directors of NIH institutes submit their programs’ “priorities and objectives in the national attack on disease and disability” [
The threat of the NIDR’s dental research program to the sugar industry began to crystallize in July 1967, after the president praised Kreshover’s report [
In October 1967, the NIDR’s National Dental Advisory Council identified three main areas of emphasis to inform research priorities to eradicate caries: reducing the virulence of bacteria once exposed to sugars, fluoride delivery, and, of most concern to the sugar industry, dietary modification [
There have been a great many observations, discussions, and controversies published in the literature concerning the role of different foods and particularly sweets in the etiology [of dental caries]. However…there seems to be little controlled experimental proof to show which foods are cariogenic and which noncariogenic in humans. [
Stephan had initiated work to develop an animal model that could “evaluate cariogenicity and anticariogenicity of different foods and beverages that people like and commonly consume” [
At least as early as 1950, SRF knew its product damaged teeth and appreciated that both the scientific evidence and the dental community favored restricting sugar intake as a key way to control caries [
The ultimate aim of the Foundation in dental research has been to discover effective means of controlling tooth decay
The 1950 SRF annual report also shows that industry research was selected as part of a strategy to deflect attention away from sugar restriction as a means to control caries [
Consistent with a deflection strategy, between 1967 and 1970, SRF funded Project 269 to bolster research on interventions not requiring sugar restriction to control dental caries [
SRF allocated US$12,000 (US$85,455 in 2014 dollars) to Project 269 between 1967 and 1970 [
Funding from SRF and the chocolate and confectionary industry allowed Cohen to create a new laboratory to use monkeys for the development of dextranases and a tooth decay vaccine for human application [
At a June 1968 press conference, NIDR Director Kreshover announced the creation of the Caries Task Force chaired by NIDR Laboratory of Microbiology chief Henry Scherp to develop the NCP [
Name | Affiliation | NIDR Caries Task Force Steering Committee, 1969 [ |
ISRF Panel Meeting of Dental Caries Task Force, October 20, 1969 [ |
---|---|---|---|
Basil G. Bibby | Director, Eastman Dental Center | X | X |
George W. Burnett | Professor of Microbiology, School of Dentistry, Medical College of Georgia | X | X |
James P. Carlos | Chief, Biometry Section, NIDR | X | |
Charles J. Donnelly | Chief, Dental Caries and Hard Tissues Program, Extramural Programs, NIDR | X | X |
Robert J. Fitzgerald | Laboratory of Microbiology, NIDR | X | |
John C. Greene | Deputy Director, Division of Dental Health, Bureau of Health Professions, Education of Manpower Training, NIH | X | X |
Robert S. Harris | Professor of Nutritional Biochemistry, Massachusetts Institute of Technology | X | X |
John Knutson | Professor of Preventive Dentistry, School of Dentistry, University of California, Los Angeles | X | X |
Bo Krasse | Professor of Cariology and Dean, Faculty of Odontology, University of Gothenburg, Sweden | X | |
Seymour Kreshover | Director, NIDR and Caries Task Force Steering Committee | X | X |
Henry W. Scherp | Chief, Laboratory of Microbiology, NIDR, Chairman Caries Task Force | X | X |
In 1968, SRF reorganized as ISRF to carry on SRF’s research mission at the global level [
As the NIDR Caries Task Force Steering Committee began meeting to discuss research priorities in 1969, ISRF scheduled a series of meetings to select “the areas of research that [ISRF] should be attacking” [
Feasible Interventions to Eradicate Dental Caries | (A) Prof. G. Neil Jenkins address to ISRF, “Sugar and Dental Caries,” June 1969 [ |
(B) NIDR’s Richard Greulich address to ISRF, “The Future of Caries Control,” September 1969 [ |
(C) NIDR Caries Task Force Steering Committee, October 1969 [ |
(D) ISRF Panel Meeting of the Dental Caries Task Force, October 1969 [ |
(E) ISRF Submission to the NIDR: |
(F) NIDR Caries Task Force Role of Human Foodstuffs in Caries Workshop Conference, March 1970 [ |
(G) NIDR Request for Contracts, |
---|---|---|---|---|---|---|---|
Cariogenic potential of foods | Deferred to March 1970 meeting | X | |||||
Dietary phosphates | X | X | X | X | X | X | X |
Invert sugars | X | X | X | X | |||
Dietary trace elements | X | X | X | X | X | ||
Dextranase | X | X | X | X | X | N/A | X |
Low molecular weight dextrans | X | X | X | N/A | X | ||
Antimicrobial agents | X | X | X | N/A | X | ||
Antibiotics | X | X | N/A | X | |||
Immunization | X | X | X | X | N/A | X | |
Water fluoridation | X | X | X | X | N/A | ||
Topical application of fluoride | X | X | X | N/A | X | ||
Addition of fluoride to sugar, salt, flour | X | X | X | N/A | |||
Sealants | X | X | X | X | N/A | X | |
N/A | |||||||
Dental epidemiology | X | N/A | |||||
Education for motivation | X | N/A |
N/A, not applicable.
ISRF launched its critical review of dental caries by inviting Dr. G. Neil Jenkins, a professor at the University of Newcastle Dental School, to speak at an ISRF symposium in London in June 1969 [
Several lines of evidence have tended to emphasize, and perhaps exaggerate, the importance of dextrans.…As an enzyme its instability would limit its application, and the whole basis of this idea depends on the unresolved question of the importance of dextrans. [
On the caries vaccine Jenkins noted, that while “a successful preliminary experiment along these lines has been reported in three monkeys,” the promise of this result was limited because “it is admitted that the organisms used in the above experiment would be unsuitable for human use and it is not yet possible to incriminate any individual species [of bacteria] as the sole cause of human caries” [
ISRF got a preview of the NIDR’s research priorities for the NCP at the second ISRF symposium in September 1969 in Bethesda [
From a public health point of view, we do not feel confident that fluoride is the only answer; and biologically speaking, it obviously is not because we have not talked to the other enterprises here. We have mentioned a host factor as represented or reflected by fluoridation. We have not talked to the microbes; we have not talked to the substrate or to nutrition. [
Greulich’s symposium presentation downplayed the value of limiting sucrose consumption as a means to control dental caries:
One could say, on logical grounds and good evidence, that if we could eliminate the consumption of sucrose, we could eliminate the problem—because we would be denying these pathogens their primary source of nutrient. We are realists, however, and we recognize the value of sucrose to nutrition. So
Similar to the approaches the sugar industry was promoting, Greulich identified interventions targeting bacteria as promising to the NIDR (
Beyond its focus on decay-causing bacteria, Greulich told ISRF that the NIDR was investigating ways to modify sugar to reduce its harmful effects [
In October 1969, the NIDR Caries Task Force Steering Committee met to identify research priorities [
In October 1969, the same month the Caries Task Force Steering Committee was evaluating research priorities to eradicate dental caries (
ISRF’s summary of the ISRF Panel Meeting of the Dental Caries Task Force indicates that the ISRF panel “recommended that a study be made of the cariogenicity of carbohydrate-containing foodstuffs” but did not mention studying the tooth-decay-causing potential of foods in its final “major approaches to caries” [
ISRF submitted the findings from its series of meetings to the NIDR Caries Task Force late in 1969 in a report titled
During fall 1969, the Nixon administration focused on biomedical research policy and showed signs of interest in supporting the NCP [
During his February 1970 budget message, President Nixon announced support for “substantial increases in research on cancer, heart disease, serious childhood illnesses, and dental health—where current findings promise significant advances for the future” [
In February 1970, after President Nixon’s public endorsement of the NCP but before the NIDR officially released the NCP research priorities, ISRF mailed its report
Dental caries has been a constant worry to many consumers of sugar and sugar products. To some scientists, dental caries and sugar are considered almost “synonymous.” ISRF, in its concern about this image, has supported research to uncover many of the unknowns, and has kept in close communication with other institutions which concentrate on such research. The National Institute of Dental Research, of the U.S. Public Health Service’s National Institutes of Health, is the most prominent U. S. organization conducting dental caries research on a broad scale. Last year the Institute formed a Dental Caries Task Force to work “toward the goal of virtually eliminating tooth decay in the United States.” Dr. Philip Ross, ISRF President, met with the Dental Caries Task Force and has worked closely with its Chairman, Dr. Henry W. Scherp.
The NIDR Caries Task Force held its conference on dietary research priorities one month later (
Soon after Nixon’s February 1970 endorsement of the NCP, Scherp began operational planning for program implementation at the NIDR [
The research priorities in the 1971 NCP RFC largely reflected the research priorities identified at the October 1969 NIDR Caries Task Force Steering Committee meeting (compare columns C and G in
Comparison of the research priorities identified by ISRF and submitted to the NIDR in 1969 (
This study analyzes a series of papers discussing previously undocumented cane and beet sugar industry activities between 1959 and 1971 regarding strategies to influence the research priorities of the NIDR’s 1971 NCP. The documents show that the sugar industry knew that sugar caused dental caries as early as 1950 and did not attempt to deny the causative role of sucrose in tooth decay. Instead, through trade associations, the sugar industry adopted a strategy to deflect attention to public health interventions that would reduce the harm of sugar consumption, rather than restricting intake.
After the NIDR announced it was considering a research program to eradicate dental caries in 1966, the sugar industry used tactics designed to protect sucrose sales. In collaboration with the chocolate and confectionary industries, SRF funded research that supported the idea that enzymes and a tooth decay vaccine could be developed that could eradicate dental decay without requiring sugar restrictions. ISRF conducted reviews of the dental caries literature to identify potential interventions that might reduce the health harms of sugar consumption other than by restricting sugar intake. ISRF cultivated relationships with the NIDR leadership through meetings with the Caries Task Force chairman and through a consultation with members of the NCP steering committee charged with selecting research priorities. A sugar industry report submitted to the NIDR became the basis for the research priorities published in the first NCP RFC.
While not officially recognized as participating in the NIDR Caries Task Force, the sugar industry effectively contributed to the research priorities developed for the launch of the NCP. Research priorities identified in the first NIDR NCP RFC focused on sugar harm reduction strategies, as opposed to sugar restriction, and were strongly aligned with sugar industry research priorities. The NIDR, like ISRF, took the position that sugar restriction was impractical.
The first policies related to the declaration of conflicts of interest for federal advisory committees were implemented in the early 1960s [
The majority of the research priorities promoted by the sugar industry and those selected for the 1971 NCP RFC failed to lead to widespread application [
The most successful interventions selected for funding following the 1971 NCP RFP were topical fluoride and sealants [
It is not clear why the NIDR adopted the position in 1969 that reducing sugar intake as a public health measure was impractical. Proposals centered on ways to limit sucrose consumption were just around the corner. In its multi-year review of foods generally recognized as safe initiated in 1969, the FDA deemed sucrose consumption at 1976 levels as unsafe for teeth [
When reflecting on the NCP in 1990, Basil Bibby, a member of the Caries Task Force Steering Committee, noted that the NIDR approved only “one or two small research grants” related to food cariogenicity compared to the “hundreds of generous awards [that] were made for investigations with so-called high scientific content” [
In 1977, the NIDR finally moved to develop a standardized animal model to identify the tooth-decay-causing potential of foods “with the objective of its being widely accepted in industry, and in regulatory agencies and in academic research, as a basis for distinguishing cariogenic from non-cariogenic snacks” [
With industry input, consensus was finally achieved on a standard method to screen foods for cariogenicity at a conference sponsored by the Foods, Nutrition and Dental Health Program of the American Dental Association in 1985, but only to support claims that food products were safe for teeth [
With the implementation of the nutrition facts panel on packaged food products in 1993, the FDA required the declaration of total sugars [
The sugar industry formed SRF in 1943 to fund research that supported the industry position [
At the same time that the NIDR was planning the NCP, the National Cancer Institute (NCI) was pursuing its Smoking and Health Program [
The tobacco industry used its involvement in the TWG to oppose funding of projects, such as smoking cessation programs, that were seen as a threat to industry interests [
Litigation against tobacco companies has been a major factor in achieving meaningful policy change. Successful litigation could not have been achieved without industry documents research illuminating the strategies and tactics of tobacco companies. This analysis demonstrates that sugar industry documents research has the potential to define industry strategies and tactics, which may potentially prove useful in future litigation.
While we were fortunate to discover the Roger Adams papers, we recognize that it provides a narrow window into the activities of just one sugar industry trade association, particularly because other industries had an interest in the outcome of the NCP, including the chocolate and confectionary industries, the pharmaceutical industry, and food companies interested in developing food additives and sugar substitutes. To help compensate for limited access to industry documents, we used other historical materials to cross-validate findings as they emerged throughout the analysis. Another limitation was that we could not interview key actors.
This historical example illustrates how industry protects itself from potentially damaging research, which can inform policy makers today. While it may be valuable in theory for the industry to contribute data about their products to the research community, industry should not have the opportunity to influence public health research priorities [
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We thank Ernest Newbrun, Aubrey Sheiham, Ben Chaffee, Lauren Lempert, Rachel Barry, Lauren Dutra, Margaret Kulik, Randy Uang, and Clayton Velicer for helpful comments on the manuscript. We thank Linda Stahnke, Cara Bertram, and Willam Maher at the University of Illinois Archives for their assistance with the Roger Adams papers. We thank George Coy for his assistance locating documents related to the NCP at NIDCR.
Food and Agriculture Organization
Food and Drug Administration
International Sugar Research Foundation
National Cancer Institute
National Caries Program
National Institute of Dental Research
National Institute of Dental and Craniofacial Research
National Institutes of Health
request for contracts
the Sugar Association
Sugar Research Foundation
Tobacco Industry Research Committee
Tobacco Working Group
World Health Organization
World Sugar Research Organisation