Healthy Skepticism Library item: 7499

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Publication type: Newspaper Article

Santora M
In diabetes fight, raising cash and keeping trust.
NY Times (Print). 2006 Nov 25
http://www.nytimes.com/2006/11/25/health/25ada.html?ex=1322110800&en=ad4022aad8735011&ei=5088&partner=rssnyt&emc=rss

Keywords:
Publication Types: Newspaper Article MeSH Terms: Advertising/ethics Advisory Committees Biomedical Research/economics Conflict of Interest*/economics Diabetes Mellitus, Type 2*/drug therapy Drug Industry*/economics Financial Support/ethics* Food Industry*/economics Humans Voluntary Health Agencies/economics* Voluntary Health Agencies/ethics*

Full text:

SnackWell’s Sugar-Free Lemon Creme cookies have nearly as many calories as some sugar-rich cookies. Yet until recently the box featured an American Diabetes Association logo, advertising the cookie as a “proud sponsor” of the charity’s efforts on behalf of the nation’s 21 million diabetics.

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Diabetes Panel’s Relationship With Drug Companies Foods like the Sugar-Freedom Eskimo Pie and Frosted Shredded Wheat have also sported the American Diabetes Association logo over the years. The companies paid the A.D.A. to be associated with a respected voice for healthful eating. The association wanted the money to finance its uphill battle against a widening epidemic of Type 2 diabetes, which is associated with obesity.

But in the last year the A.D.A. began rethinking how it raises money from companies, especially from those whose primary business is selling foods and beverages that are high in calories, even if they have created some sugar-free items.

The group has allowed some food company deals to expire and has turned down millions of dollars in new sponsorships.

Many public health charities, from the American Heart Association to the Lupus Foundation of America, raise money from businesses. But for the A.D.A., and some other charities, the effort has increasingly become an exercise in balancing the need to raise money with core matters of conscience.

“We tightened things up,” Dr. Richard Kahn, a top A.D.A. executive, said of the association’s new guidelines for corporate fund-raising, “because we were beginning to be bombarded by all kinds of food companies selling all kinds of products with requests to be a ‘proud sponsor’ or to advertise.”

Some consumer and food activists say the guidelines, while good, do not go far enough.

They say the A.D.A. remains too wedded to benefactors in the food and pharmaceutical industries, who provided more than $23 million last year.

Of particular concern: a three-year, $1.5 million sponsorship deal with Cadbury-Schweppes, the world’s largest confectioner. Under the deal, which meets the new guidelines, Cadbury is promoted as an A.D.A. sponsor in several settings, and has permission to use the A.D.A. logo on its Diet-Rite sodas, Snapple unsweetened tea and Mott’s Apple Sauce, among other products.

Critics say the A.D.A. affiliation has helped Cadbury pose as a concerned corporate citizen, even as it supplies grocery stores with sugary and fattening foods like Dr Pepper and the Cadbury Creme Egg.

“Maybe the American Diabetes Association should rename itself the American Junk Food Association,” said Gary Ruskin, director of Commercial Alert, a consumer advocacy group.

Others remain concerned about the A.D.A.’s relationships with pharmaceutical companies. Their presence is evident throughout the charity, from its annual convention, which is largely underwritten by drug makers, to its board meetings, where pharmaceutical executives have served on the volunteer committees that set policy.

The A.D.A. says its independence is evident because it has often acted against the interests of the pharmaceutical industry. Last month, for example, a panel it appointed to study how to treat people at heightened risk of developing diabetes decided against recommending the use of higher-priced brand-name drugs.

But critics say the drug industry’s influence can be seen in the A.D.A.’s emphasis on the treatment of diabetics, which often involves drug therapy, over efforts to persuade people to change the way they live so that the disease can be prevented in the first place.

“I’m glad the A.D.A. finally took its logos off of sugary cereals,” said Marion Nestle, a professor of nutrition and food studies at New York University. “Nevertheless, the A.D.A. still needs to pay more attention to prevention. Right now, it puts way more resources into treatment.”

Companies say they give to the A.D.A. because they share the goal of helping people lead healthier lives. Drug makers say their products work hand in hand with A.D.A. efforts to better treat diabetics. Food company executives say they hope to give consumers greater choice by drawing attention to new, healthier products, which are increasingly popular.

The A.D.A., more than many other charities, already has a tough time raising money. Type 2 diabetics, frequently old and overweight and judged by some as partly responsible for their own plight, do not generate as much sympathy, or contributions, as many other sick people.

Faced with financial pressures, A.D.A. officials say they try to focus on practical solutions, like treatment options, more than lifestyle modifications. It is not favoritism toward pharmaceutical companies, as some suggest, Dr. Kahn said. It is skepticism toward the notion that many Type 2 diabetics have the discipline to eat less and exercise more.

“Ninety percent of the people out there still can’t lose 10 percent of their body weight and keep it off for four years,” he said. Nonetheless, he said, the A.D.A. will continue education efforts to reverse the tide of obesity.

With the emergence of Type 2 diabetes as the nation’s fastest growing health problem, increasing by 80 percent in the last decade, this is an important time for the A.D.A. The 66-year-old charity, based in Alexandria, Va., is the primary coordinator for the national response to the disease and directs much of the lobbying, treatment guidelines and education efforts that address the major forms: Type 1, a genetic disorder that usually surfaces in children, and Type 2, a far more prevalent illness in which genetics plays a role, but in which obesity and inactivity are the key risk factors.

Each year, diabetes causes hundreds of thousands of Americans to suffer heart failure, lose limbs, go blind, or die. Yet even with corporate support and substantial grass-roots fund-raising, the A.D.A.’s $210 million budget is stretched by its many missions: educating legislators, publishing medical journals, running camps for diabetics across the country.

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Diabetes Panel’s Relationship With Drug Companies From the A.D.A.’s perspective, no charity is more rigorous about ethical standards or more transparent about where its executives earn and invest their money. Even unpaid volunteers must detail their income and financial holdings.

“I want to be able to sleep at night,” said Vaneeda Bennett, the A.D.A.’s chief fund-raiser, “knowing that we are doing the right thing for people with diabetes, not doing anything that could, in any way, jeopardize that trust.”

Dr. Peter Lurie, deputy director of the Health Research Group of Public Citizen, the government watchdog group, said the influence of pharmaceutical money can be very subtle.

“The question is what happens in the close calls,” he said. “If you are at more cocktail parties, if you have more mugs from the company in your kitchen, you are just going to be more receptive.”

A.D.A. officials cited an event from several years ago to illustrate their resistance to such influence. An A.D.A. panel found that antipsychotic drugs could help fuel diabetes. The announcement angered a drug manufacturer, Eli Lilly and Company, a longstanding A.D.A. benefactor that stood to lose hundreds of millions of dollars in lawsuits.

Some A.D.A. officials said they believed the company became so angry it sought to have Dr. Kahn fired, a charge the company denies.

Either way, nothing happened. Dr. Kahn, the association’s chief scientific officer, kept his job.

“Show me one instance where money has caused us to do something that is wrong,” Dr. Kahn said in an interview. “You can’t.”

Corporate Friends

When the A.D.A.’s executive committee met at the W Hotel in Seattle in 2003, a special handout circulated around the room.

It outlined a business deal so sensitive it had not been listed on the official agenda and the handouts were collected at the meeting’s end.

Two words on the handout stood out.

Burger King.

Even within an organization that had made deals with food companies, the fast-food business was different.

Like McDonald’s, Burger King had become a lightning rod for criticism of junk food and its impact on childhood obesity.

But Burger King told the A.D.A. that it was coming out with more healthful products, like a grilled sandwich and a side of vegetables, and hoped the charity would consider a partnership.

“They assured us that this was not just something they were doing to respond to the criticism over their role in the obesity epidemic,” said Nancy Stinson-Harris, the A.D.A.’s managing director for corporate alliance and cause-related marketing.

To review the A.D.A.’s dealings with Burger King is to understand its struggle to raise money and preach health without crossing lines or demonizing foods.

“There are some within A.D.A. who say no fast food whatsoever and there are some that say that eating healthy is about choice and people need to make good choices,” said Ms. Bennett. “We want to embrace the healthy choices and work from within the tent.”

For the A.D.A., working within the tent has meant choosing persuasion over protest. Critics say the organization is too silent on vanguard issues like special taxes on foods like soda. But the A.D.A. says it will take more than shouting to change America’s eating habits. It will take focused efforts to prod mainstream manufacturers toward offering healthier products.

To that end, the association signed deals with more than a dozen food companies over the years, including Bird’s Eye, Campbell’s, General Mills and Coca-Cola.

Each deal was distinct, but generally the companies financed an A.D.A. health campaign and were recognized as sponsors. Some received permission to use the A.D.A. logo on select products, generally sugar-free and diet brands.

Kraft, for example, as part of a four-year, $1 million deal that expired this year, was recognized as an A.D.A. sponsor and could post the A.D.A. logo on products like SnackWell’s cookies, Post Raisin Bran, Cream of Wheat cereal and Sugar-Free Jell-O.

In some cases, the products that had permission to use the logo were only slightly healthier than those that did not.

Kraft, for example, never used the logo on Cool Whip Lite, but it had permission, even though the topping had just five fewer calories per serving than regular Cool Whip.

In Burger King’s case, negotiations toward a deal stretched on for nearly a year. Then the A.D.A. learned that the company was coming out with another new product. “It was a burger that would have the most fat that has ever been on the market,” Ms. Stinson-Harris recalled. Burger King did not respond to several requests for comment.

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Diabetes Panel’s Relationship With Drug Companies The A.D.A. dropped negotiations at that point. But officials of the charity seized the opportunity to create a more formal set of policies about corporate fund-raising. The guidelines installed this year are 54 pages long and cover the gamut of corporations, from food manufacturers to drug makers.

“The association,” they say, “should refrain from associating with companies that have the potential to damage A.D.A.’s image because of the nature of the companies’ products, services or reputation.”

Because of the guidelines, several deals with food companies that expired could not be renewed, officials said. Hershey and the A.D.A., for example, could not come to terms on renewing an agreement, worth more than $200,000 a year. A.D.A. officials said they would not agree to the use of their logo on a sugar-free chocolate candy because of its fat content.

“Now the first thing we do is look at the content, the label,” Ms. Bennett said. “In the past we didn’t. The fat was not a consideration.”

The A.D.A., which took in more than $3 million from food companies last year, has not signed a new agreement with a national food company since the guidelines took effect. One obstacle is that the guidelines set a minimum contribution of $500,000 for any company that would seek permission to use the A.D.A. logo, a new provision borne of the organization’s belief that an association with its name has undeniably high value.

“There are still some people who are pained by the fact that we cannot do a deal on this or that because of the guidelines,” said Dr. John Buse, the incoming A.D.A. president.

Though they often present the most difficult choices, food companies represent a small segment of the A.D.A.’s corporate support. Pharmaceutical companies remain the largest corporate contributors, but the guidelines have not affected them as much because the A.D.A. has never allowed its logo to be put on specific medicines.

And for all the scrutiny the new guidelines are said to have brought, critics are quick to note that they did nothing to block the A.D.A. from doing business with Cadbury, a $12 billion-a-year empire built on the consumption of sweets.

“This isn’t really rocket science,” said Mr. Ruskin, the consumer activist. “This is damage to their integrity. And this is a serious matter.”

Cadbury officials say their association with the A.D.A. is a good-faith effort to promote health. At one point last year, Dr. Kahn also tried to defend the Cadbury deal by telling an online publication: “There is not a shred of evidence that sugar, per se, has anything to do with diabetes.” To Dr. Kahn it was a matter of basic science. Though diabetics should watch their sugar intake, many foods, not just sugar, he said, carry the kinds of calories that can lead to obesity and ultimately diabetes.

But the remark struck some as careless, given concerns about excess sugar in many diets.

Ms. Bennett acknowledged that negotiating deals like the Cadbury agreement are difficult “when a good company offers several ‘good for you’ as well as ‘bad for you’ products.” In the end, she said, Cadbury improved the deal by agreeing to use its own advertising budget to promote the A.D.A.’s new Weight Loss Matters program.

More than a year into the arrangement, the A.D.A. says it is happy with how it turned out. At a meeting this fall, it honored Cadbury with a corporate recognition award.

Valuable Advice

At a Chicago hotel last month, the A.D.A. brought together seven medical experts, widely viewed as stars in their field, to consider an issue that could radically alter the way people at heightened risk of developing diabetes are treated. It also had bearing on the fortunes of at least one A.D.A. benefactor.

For years, doctors have debated whether to use drugs to treat people who are prediabetic, meaning their blood sugar is elevated, but not to the level considered diabetic.

An estimated 41 million people in America are viewed as prediabetic, in danger of developing the disease. One drug manufacturer, GlaxoSmithKline, recently completed trials of a new drug to treat this potentially huge market and, in several months, the A.D.A. panel will publish its recommendation on whether drug treatment for prediabetes is warranted.

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Diabetes Panel’s Relationship With Drug Companies A.D.A. rules prohibit such panels from reviewing the efficacy of an individual brand. But the A.D.A.’s perspective on whether a class of drugs should be used in treatment often carries great weight with the Food and Drug Administration, which must approve the Glaxo drug for use, and with doctors who write prescriptions.

So the appointed panel’s perspective is likely to be closely watched by Glaxo, which donated more than $1 million to the A.D.A. last year.

All but one member of the panel reported receiving fees or research funding from pharmaceutical companies on their A.D.A. financial disclosure forms. Three reported direct compensation from Glaxo, though no amounts were listed.

Few in medical care believe such payments disqualify experts from serving on panels. Many research scientists receive such funding.

They are, nonetheless, representative of the sort of complications that arise when the work of charities and corporations become significantly intertwined.

The A.D.A.’s relationship with drug companies dates to 1940, when 26 doctors met at Schrafft’s Restaurant in Manhattan to create the association, using a $1,000 gift from the drug maker Eli Lilly. Twice in the past decade, the A.D.A.’s 12-member Executive Committee has been led by the former top executives of drug or medical equipment companies. Today the A.D.A.’s treasurer is the director of investor relations for Johnson & Johnson.

Pharmaceutical companies sell $15 billion worth of diabetes drugs in the United States each year and the A.D.A. is now a fixture in their marketing strategy. The companies advertise in A.D.A. journals and announce new medicines at A.D.A. conventions, where a coming-out party for a touted new drug can drive a stock higher.

The convention, known as the Annual Scientific Sessions, routinely draws some 15,000 doctors, health care workers and experts to a conference center where everything from the water bottles to the chartered buses are plastered with ads from drug companies.

“It’s not quite brainwashing, but they have a way of influencing your thinking,” Dr. Buse said of the companies. He said some companies sent hundreds of employees to the convention, nearly all of them there to promote new medicines.

Dr. Buse said he did not believe that the money, or the manpower, ultimately influences A.D.A. policy. But he said the level of fraternization made him uncomfortable, and might hurt the A.D.A.’s image. He said it was one of the more pressing issues facing public health charities, who have come to rely on pharmaceutical money for a large portion of their budget.

“It is a real problem,” he said.

One of its members of the A.D.A. panel studying prediabetes, Dr. Ralph A. DeFronzo, chief of the diabetes division at the University of Texas Health Science Center, said the panel had decided to recommend lifestyle interventions and some use of a generic drug for prediabetics, but had stopped short of advocating the use of newer, brand-name drugs, such as the one being developed by Glaxo.

The decision can potentially affect billions of dollars in sales because the prediabetic market is so large and the difference in price so great between generic and “branded” drugs. The generic drug the panel recommended, for example, metformin, costs about $240 a year, just a fifth to a tenth of what a branded drug prescribed in the same setting might cost, experts said.

“I think the panel’s recommendation was really quite conservative,” Dr. DeFronzo said.

In the past year, Dr. DeFronzo has received compensation from seven drug companies, though not Glaxo. The companies either financed his research or paid him for work as a speaker or as a consultant, according to his disclosure form. He said he was confident that such support never influenced his judgment.

“To be honest,” he said, “if you are the best person in the world, why wouldn’t a company, why wouldn’t the A.D.A., want you on a panel?”

Dr. Kahn said that, even with extensive safeguards, he and his staff ultimately must rely on the integrity of the people they appoint. It becomes an act of faith, and like all acts of faith, he said, there may well be nonbelievers when the panel’s report comes out.

“We have no choice,” he said. “There will always be a few people who think that we are biased.”