Abstract

Objective

To describe food-industry sponsorships of associations active in the field of childhood nutrition and obesity prevention in Spain in 2017-2018.

Method

The associations were located at https://www.google.es/ using the words “society”, “foundation” or “federation” in combination with the terms “nutrition”, “obesity”, “childhood”, “paediatrics” and “diabetes”. Sponsorship was defined as the declaration of funding received or the appearance of a food company logo on an association's website or in the programmes of its congresses or courses. The percentage of sponsored societies and its association with the existence of ethical codes was calculated using MS Excel.

Results

64% of the associations displayed some type of sponsorship, with this being most frequent among paediatric and nutrition societies, 83% and 80% respectively, and non-existent among public health societies. No association was found between the existence of an ethical code and sponsorship (odds ratio: 0.75; 95% confidence interval: 0.14-3.94). The leading corporate sponsors were Nestlé, Coca-Cola and Danone. Whereas the initiatives of sponsored societies were targeted at changing eating individual behaviours, those of unsponsored societies sought to promote changes in the food system and eating environments.

Conclusions

Food industry sponsorship of foundations and scientific societies is very widespread in Spain, except among public health associations. Unlike sponsored associations, those unsponsored propose policies opposed by the food industry, which are aimed at improving the system and food and eating environments.

Keywords:
Conflicts of interest; Scientific societies; Nutrition; Obesity; Childhood; Paediatrics

Resumen

Objetivo

Describir el patrocinio de compañías que comercializan alimentos y bebidas no saludables a sociedades científicas y fundaciones relacionadas con la nutrición y la prevención de la obesidad infantil en España durante 20172018.

Método

Las sociedades y fundaciones fueron localizadas en www.google.es/ usando las palabras clave «sociedad», «fundación» y «federación», combinadas con «nutrición», «obesidad», «infantil», «pediatría» y «diabetes». Se consideró como patrocinio la declaración de financiación o la presencia del logo de la compañía alimentaria en la página web de la asociación o de los programas de congresos o cursos. Se calculó el porcentaje de asociaciones patrocinadas y su asociación con la existencia de código ético usando MS Excel.

Resultados

El 64% de las asociaciones recibieron algún patrocinio de compañías alimentarias, más frecuente en las sociedades de pediatría (83%) y nutrición (80%) e inexistente en las de salud pública. No se encontró asociación entre la existencia de código ético y patrocinio (odds ratio: 0,75; intervalo de confianza del 95%: 0,14-3,94). Las principales compañías patrocinadoras fueron Nestlé, Coca-Cola y Danone. Las iniciativas de las asociaciones patrocinadas se dirigían exclusivamente a cambiar los hábitos individuales, mientras que las sociedades no patrocinadas promovieron cambios en el sistema y el entorno alimentarios.

Conclusiones

El patrocinio de las compañías alimentarias a asociaciones relacionadas con la nutrición y la prevención de la obesidad infantil es común en España, excepto entre las sociedades de salud pública. A diferencia de las sociedades patrocinadas, las no patrocinadas promueven políticas alimentarias dirigidas a modificar el sistema y el entorno alimentarios, a las que se opone la industria alimentaria.

Palabras clave:
Conflictos de intereses; Sociedades científicas; Nutrición; Obesidad; Infancia; Pediatría

Introduction

About one third of all Spanish children and adolescents suffer from overweight, and approximately one out of ten suffers from obesity.¹1. Aranceta-Bartrina J, Gianzo-Citores M, Pérez-Rodrigo C. Prevalence of overweight, obesity and abdominal obesity in the Spanish population aged 3 to 24 years. The ENPE study. Rev Esp Cardiol (Engl Ed). 2020;73:290-9. Although the data indicate that the figures have stabilised in recent years,²2. Ramiro-González MD, Sanz-Barbero B, Royo-Bordonada MA. Childhood excess weight in Spain from 2006 to 2012. Determinants and parental misperception. Rev Esp Cardiol. 2017;70:656-63. Spain, with an estimated prevalence of severe obesity of 2.4% to 4% in children aged 6-9 years, has one of the highest rates in Europe, along with other Mediterranean Basin countries such as Greece and Italy.³3. Spinelli A, Buoncristiano M, Kovacs VA, et al. Prevalence of severe obesity among primary school children in 21 European countries. Obes Facts. 2019;12: 244-58. The main causes of childhood obesity are the Western diet, rich in read and processed meat, refined grains, and saturated fat, the consumption of sugar-sweetened beverages, and sedentarism.⁴4. World Cancer Research Fund International. American Institute for Cancer Research. Diet, nutrition and physical activity: energy balance and body fatness. The determinants of weight gain, overweight and obesity. World Cancer Research Fund/American Institute for Cancer Research. 2018. ISBN 978-1-912259-49-6 (Accessed 29 July 2019). Available at: https://www.wcrf.org/wp-content/uploads/2021/02/Energy-Balance-and-Body-Fatness.pdf
https://www.wcrf.org/wp-content/uploads/... Sedentarism, especially the time devoted to watching television, is associated with a higher consumption of sugar-sweetened beverages and energy-dense snacks.⁵5. Hobbs M, Pearson N, Foster PJ, et al. Sedentary behaviour and diet across the lifespan: an update systematic review. Br J Sports Med. 2014;49:1179-88. Television exerts its principal effect through advertising, which negatively influences children's food preferences, eating behaviours and caloric intake.⁶6. Russell SJ, Croker H, Viner RM. The effect of screen advertising on children's dietary intake: a systematic review and meta-analysis. Obes Rev. 2019;20:554-68.

Scientific societies and foundations active in the field of childhood nutrition and obesity prevention play a crucial role in promoting healthy eating habits and preventing childhood obesity through generating and disseminating scientific knowledge, training professionals in health promotion, nutrition and obesity prevention, establishing population food guidelines, actively fostering and lobbying in favour of healthy food policies, and monitoring them.⁷7. World Health Organization. Report of the commission on ending childhood obesity. Geneva: World Health Organization; 2016. (Accessed 29 July 2019). ISBN 978-92-4-151006-6. Available at: https://apps.who.int/iris/bitstream/handle/10665/204176/?sequence=1
https://apps.who.int/iris/bitstream/hand... There is the possibility, however, that this activity may be unduly affected by potential conflicts of interest deriving from these societies and foundations being funded by companies which market unhealthy products, such as ultra-processed foods and sugar-sweetened beverages.⁸8. Sacks G, Swinburn BA, Cameron AJ. How food companies influence evidence and opinion - straight from the horse's mouth. Crit Public Health. 2018;28:253-6. It has been shown that these conflicts can introduce biases into scientific research, and influence the independence of experts when it comes to drawing up recommendations and guidelines.⁹9. Bes-Rastrollo M, Schulze MB, Ruiz-Canela M, et al. Financial conflicts of interest and reporting bias regarding the association between sugar-sweetened beverages and weight gain: a systematic review of systematic reviews. PLoS Med. 2013;10:e1001578.

10. Mandrioli D, Kearns CE, Bero LA. Relationship between research outcomes and risk of bias, study sponsorship, and author financial conflicts of interest in reviews of the effects of artificially sweetened beverages on weight outcomes: a systematic review of reviews. PLoS One. 2016;11: https://doi.org/10.1371/journal.pone.0162198.
https://doi.org/10.1371/journal.pone.016...

11. Lenzer J. Half of panelists on controversial new cholesterol guideline have current or recent ties to drug manufacturers. BMJ. 2013;347:f6989.^-1212. Cuevas-Casado I, Romero-Fernández MM, Royo-Bordonada MA. Uso del marketing nutricional en productos anunciados por televisión en España. Nutr Hosp. 2012;27:1569-75. Some Spanish scientific societies even collaborate in food industry advertising, by lending their endorsement to unhealthy products.¹³13. Rey-López JP, Gonzalez CA. Research partnerships between Coca-Cola and health organizations in Spain. Eur J Public Health. 2019;29:810-5.

A study was recently published about Spanish health-related organisations which received funding from Coca-Cola across the period 2010-2016.¹⁴14. Horel S. Unhappy meal. The European Food Safety Authority's independence problem. Corporate Europe Observatory. 2013 (Accessed 29 July 2019). Available at: https://corporateeurope.org/en/efsa/2013/10/unhappy-meal-european-food-safety-authoritys-independence-problem.
https://corporateeurope.org/en/efsa/2013... It was based on information drawn from the transparency list published by Coca-Cola itself, since scientific societies and foundations are often in the habit of not furnishing information about their funding sources on their websites.¹²12. Cuevas-Casado I, Romero-Fernández MM, Royo-Bordonada MA. Uso del marketing nutricional en productos anunciados por televisión en España. Nutr Hosp. 2012;27:1569-75. To our knowledge, however, there is no information on the funding of Spanish organisations active in the field of childhood nutrition and obesity prevention by other companies that market unhealthy food and drinks.

Accordingly, the aim of this study was to describe sponsorships of Spanish-based scientific societies and foundations active in the field of childhood nutrition and obesity prevention by companies that market unhealthy food and drinks, across the period 2017-2018. Similarly, the relationship between these societies' food-policy initiatives and the existence of sponsorships was also analysed.

Method

Study design and population

Cross-sectional descriptive study of sponsorships granted across the period 2017-2018 by companies that marketed unhealthy food or drinks as defined by the WHO regional nutrient profile model,¹⁵15. WHO Regional Office for Europe. Nutrient profile model. Copenhagen: WHO Regional Office for Europe; 2015. (Accessed 29 July 2019). Available at: https://www.euro.who.int/__data/assets/pdf_file/0005/270716/Nutrient-children_web-new.pdf.
https://www.euro.who.int/__data/assets/p... to any Spanish scientific society and foundation which met the following requirements, namely:

It listed childhood nutrition and obesity among its priority action areas, i.e., any society or foundation active in paediatrics, obesity, diabetes, epidemiology, public health and nutrition (except clinical enteral and parenteral nutrition):

We excluded societies and foundations of clinical nutrition and metabolism, oral health, or enteral and parenteral nutrition. We also excluded Spanish federations of societies or foundations already included individually in this study. To identify the societies and foundations studied, we carried out a search on https://www.google.es/ using the words “society”, “foundation” or “federation” in combination with the terms, “nutrition”, “obesity”, “childhood”, “paediatrics” and “diabetes”. We also checked the directory of scientific foundations at the Ministry of Justice, using the words “nutrition”, “obesity”, “paediatrics” and “diabetes”, and that of scientific societies of the Ministry of Health under the headings of endocrinology and nutrition, paediatrics, and preventive medicine and public health. Of the total of 33 organisations initially located, we excluded three scientific societies active in the field of clinical nutrition and oral health, one state-wide federation of societies, and four regional organisations, thereby leaving a total of 25 organisations.

Data-collection

Information about the existence of sponsorships was obtained from the websites of the societies, foundations and federations included in the study. Congress and course programmes from 2017 and 2018 which were not accessible from the website, were sought on https://www.google.es/ using the words “congress” or “course” combined with the name of the association. A society was deemed to be sponsored by a company which marketed unhealthy foods, in any case where that company was stated to be the source of funding or its logo appeared on the association's website or in the programme of one or more of the society's congresses or courses. We likewise identified the presence on the website of an ethical code or conflict of interest declaration system pertaining to the members of the societies and foundations studied. Lastly, data were also gathered from the websites on advocacy initiatives to promote healthy public food policies, which were classified in line with the Nourishing framework of the World Cancer Research Fund, into the following three pillars or domains of action: food system; change in eating behaviours; and food and eating environment.¹⁶16. Hawkes C, Jewell J, Allen K. A food policy package for healthy diets and the prevention of obesity and diet-related non-communicable diseases: the NOURISHING framework. Obes Rev. 2013;14:159-68. This framework generates recommendations at a global level, with a series of food policies that countries can select according to their local populations and contexts. It thus affords a framework for monitoring food policies around the world, systematically categorising, updating, interpreting and communicating the evidence for policy to policymakers. All data were uniformly collected by the first author (G.G.C). by extensive review of the websites and revised by the last one (M.A.R.B). in case of doubt.

Statistical analysis

We calculated the percentage of sponsored associations and foundations, both overall and by thematic area, e.g., paediatrics, nutrition, obesity and diabetes, epidemiology and public health. To analyse the association between the existence of an ethical code and sponsorship, the probability of sponsorship was compared as between societies having and not having evidence of an ethical code or a conflict of interest declaration system, using the odds ratio and its 95% confidence intervals. Similarly, we quantified the number and percentage of associations funded by the leading corporate sponsors. All analyses were performed using the MS Excel computer software programme (Redmond, Washington, USA).

Results

Table 1 shows the distribution of the different modalities of food industry sponsorship of scientific societies and foundations active in the field of childhood nutrition and obesity in Spain. Collaboration in congresses was the most frequent form of sponsorship, with nine associations (36%), followed by the presence of the corporate logo on the website, with six associations (24%). In the case of the Spanish Society of Community Nutrition (Sociedad Española de Nutrición Comunitaria) and Spanish Diabetes Federation (Federación Española de Diabetes) sponsorship was displayed on congress websites and programmes. Of the nine associations in which the existence of an ethical code or declaration of interests could be established, five (56%) enjoyed some type of sponsorship: in the case of the remaining 16, 10 (62.5%) enjoyed some type of sponsorship (odds ratio: 0.75; 95% confidence interval: 0.14-3.94).

A total of 64% of the societies and foundations studied reported receiving some type of sponsorship from food companies that market unhealthy products (Table 2). This percentage was highest for paediatric societies, with a figure of 83%, and nutrition societies, with a figure of 80%, whereas none of the epidemiology and public health societies reported receiving any sponsorships from food and drink companies. The leading food industry companies which sponsored scientific societies and foundations active in the field of childhood nutrition and obesity in Spain were Nestlé, which sponsored 36%, Coca-Cola which sponsored 32%, and Danone which sponsored 24% of the societies and foundations studied (Table 3). While Nestlé displayed a preference for paediatric societies, which accounted for 55.6% of the societies sponsored by the company, and Danone displayed a preference for nutrition societies, with a figure of 66.7%, Coca-Cola, which displayed a certain preference for nutrition societies, with a figure of 37.5%, showed a more uniform distribution of its sponsorships.

Table 4 shows that all the initiatives with proposals to improve the ‘food system' and ‘food and eating environment' pillars in line with the Nourishing framework, were launched by societies having no type of sponsorship; in contrast, the initiatives launched by sponsored societies were targeted exclusively at the ‘changing eating behaviour' pillar, with proposals for improving population information and awareness about the importance of food and nutrition.

Discussion

Almost two-thirds of scientific societies and foundations active in the field of childhood nutrition and obesity in Spain, regardless of whether or not they had an ethical code, received some type of food industry sponsorship, with this phenomenon being more widespread among nutrition and paediatric societies, a finding that is in marked contrast to the lack of sponsorship of epidemiology and public health societies. The leading corporate sponsors were Nestlé, Coca-Cola and Danone. Whereas scientific societies with no type of sponsorship launched initiatives with proposals for improving the ‘food system' and ‘food and eating environment' pillars of the Nourishing framework, those launched by societies or foundations sponsored by the food industry sought to promote educational and awareness-raising measures to stimulate a change in eating behaviours at an individual level.

Although food industry sponsorship of societies active in the field of childhood nutrition and obesity is very widespread, it is less common than that observed for medical societies sponsored by pharmaceutical and health technology industries in a similar study that was recently undertaken in Italy.¹⁷17. Fabbri A, Gregoraci G, Tedesco D, et al. Conflict of interest between professional medical societies and industry: a cross-sectional study of Italian medical societies' websites. BMJ Open. 2016;6:e011124. Although we do not have similar data for Spain, one ongoing study shows that medical societies received D 130.5 million from the pharmaceutical industry in 2017, mainly for congresses.¹⁸18. Belmonte E, Bernardo A. 18 médicos recibieron más de 50.000 euros cada uno de una sola farmacéutica en 2017. Civio, 9 de octubre de 2018. (Accessed 29 July 2019). Available at: https://civio.es/medicamentalia/2018/10/09/18-medicos-recibieron-mas-de-50000-euros-de-una-sola-farmaceutica-en-2017/.
https://civio.es/medicamentalia/2018/10/... If our analysis were to be

restricted to scientific nutrition, paediatrics, obesity and diabetes societies, then sponsorship frequency would be shown to be similar in Spain and Italy. As with our study here in Spain, sponsorships in Italy were found to be independent of the existence of an ethical code. Coca-Cola was one of the largest sponsors of all types of societies and foundations across the period 2017-2018, with a certain preference for nutrition societies. This result is in line with data obtained from the transparency list published by Coca-Cola itself, which sponsored 74 health organisations in Spain across the period 2010-2016: of these, cardiology and nutrition societies received the greatest funding.¹⁴14. Horel S. Unhappy meal. The European Food Safety Authority's independence problem. Corporate Europe Observatory. 2013 (Accessed 29 July 2019). Available at: https://corporateeurope.org/en/efsa/2013/10/unhappy-meal-european-food-safety-authoritys-independence-problem.
https://corporateeurope.org/en/efsa/2013... In both studies, attention should be drawn to the absence of sponsorship of public health organisations and societies, unlike what is seen in the USA.¹⁹19. Aaron DG, Siegel MB. Sponsorship of national health organizations by two major soda companies. Am J Prev Med. 2017;52:20-30.

Sponsorship of scientific societies and foundations active in the field of childhood nutrition and obesity, by an industry that markets ultra-processed foods and sugar-sweetened beverages causes a conflict of interests among the professionals of these organisations,⁸8. Sacks G, Swinburn BA, Cameron AJ. How food companies influence evidence and opinion - straight from the horse's mouth. Crit Public Health. 2018;28:253-6. with the ensuing risk that their professional judgement or actions may be unduly influenced by non-health-related interests, due to feelings of gratitude or reciprocity, which may be unconsciously induced by even the smallest gifts.²⁰20. Dana J, Loewenstein G. A social science perspective on gifts to physicians from industry. JAMA. 2003;290:252-5. These conflicts can cause biases in scientific research, since it has been repeatedly shown that studies funded by pharmaceutical and tobacco industries produce more favourable results about the latter's products than do independent studies.²¹21. Bero L. Industry sponsorship and research outcome: a Cochrane review. JAMA Intern Med. 2013;173:580-1.^,2222. Barnes DE. Why review articles on the health effects of passive smoking reach different conclusions. JAMA. 1998;279:1566-70. Recent research shows that this is also the case with studies funded by the food industry,⁹9. Bes-Rastrollo M, Schulze MB, Ruiz-Canela M, et al. Financial conflicts of interest and reporting bias regarding the association between sugar-sweetened beverages and weight gain: a systematic review of systematic reviews. PLoS Med. 2013;10:e1001578.^,1010. Mandrioli D, Kearns CE, Bero LA. Relationship between research outcomes and risk of bias, study sponsorship, and author financial conflicts of interest in reviews of the effects of artificially sweetened beverages on weight outcomes: a systematic review of reviews. PLoS One. 2016;11: https://doi.org/10.1371/journal.pone.0162198.
https://doi.org/10.1371/journal.pone.016... ^,2323. Mozaffarian D. Conflict of interest and the role of the food industry in nutrition research. JAMA. 2017;317:1755-6. which have presumably copied the tactics of the tobacco industry.²⁴24. Brownell K, Warner KE. The perils of ignoring history: big tobacco played dirty and millions died. How similar is big food? Milbank Quarterly. 2009;87:259-94.^,2525. Capewell S, Lloyd-Williams F. The role of the food industry in health: lessons from tobacco? Br Med Bull. 2018;125:131-43. Although sponsored researchers routinely state that the funder has had no influence on the design, analysis and publication of their results, the data nonetheless suggest that studies funded by Coca-Cola in Spain serve its commercial goals,¹⁴14. Horel S. Unhappy meal. The European Food Safety Authority's independence problem. Corporate Europe Observatory. 2013 (Accessed 29 July 2019). Available at: https://corporateeurope.org/en/efsa/2013/10/unhappy-meal-european-food-safety-authoritys-independence-problem.
https://corporateeurope.org/en/efsa/2013... and a recent analysis of the company's research funding agreements with US and Canadian public institutions highlighted the fact that at times these agreements specified that Coca-Cola had the final say about any publication, though there was no evidence to show that it had indeed exercised this power.²⁶26. Steele S, Ruskin G, McKee M, et al. "Always read the small print": a case study of commercial research funding, disclosure and agreements with Coca-Cola. J Public Health Policy. 2019;40:273-85. Furthermore, an analysis of Coca-Cola's internal documents has revealed that the company's intention in funding the Global Energy Balance Network (Red Global del Balance Energético) was none other than to defend its own interests, on presenting obesity as a mere question of a lack of balance between energy intake and exercise, in order to divert attention from the effect of sugar-sweetened beverages.²⁷27. Barlow P, Serôdio P, Ruskin G, et al. Science organisations and Coca-Cola's 'war' with the public health community: insights from an internal industry document. J Epidemiol Community Health. 2018;72:761-3. However, the influence of the unhealthy food and drink industry can be extended to other levels, such as the drawing-up of recommendations and guidelines by sponsored scientific societies.²⁸28. Royo-Bordonada MA. Captura corporativa de la salud pública. Revista de Bioética y Derecho. 2019;45:25-41. Thus, in its hydration guidelines for the Spanish population, the Spanish Society for Community Nutrition (Sociedad Española de Nutrición Comunitaria) which received almost D 300,000 from CocaCola between 2010 and 2016, recommends daily consumption of sugar-free soft drinks (with non-caloric sweeteners), sports drinks and commercial fruit-based juices, and weekly consumption of soft drinks sweetened with sugar or fructose,²⁹29. Aranceta J, de Torres ML, López Rocha A, et al. Guía para una hidratación saludable. La declaración de Zaragoza. SENC, 2008. Rev Esp Nutr Comunitaria. 2009;15:225-30. substances linked to metabolic alterations, obesity, diabetes and cardiovascular disease.³⁰30. Malik VS, Hu FB. Fructose and cardiometabolic health: what the evidence from sugar-sweetened beverages tells us. J Am Coll Cardiol. 2015;66:1615-24.

To promote healthier food and eating environments, societies not sponsored by the industry advocate measures such as taxes and the regulation of advertising and food sold in public spaces, all of which the food industry opposes.²⁵25. Capewell S, Lloyd-Williams F. The role of the food industry in health: lessons from tobacco? Br Med Bull. 2018;125:131-43. In contrast, the initiatives of sponsored societies are limited to information and awareness-raising proposals, goals more in line with the industry's position. While the Federation of Public Health Associations supported the ministerial initiative to implement the Nutri-Score in Spain from the outset,³¹31. Sociedad Española de Salud Pública y Administración Sanitaria. SESPAS apoya la decisión del Ministerio de Sanidad de aplicar el sistema de etiquetado NutriScore en España. SESPAS, 19 de noviembre de 2018. (Accessed 29 July 2019). Available at: https://sespas.es/.
https://sespas.es/... the Spanish Federation of Nutrition, Food and Dietetics Societies brought out a press release opposing it, in which its Chairperson stated: «There are no scientific studies that back the Nutri-Score's performance».³²32. Federación Española de Sociedades de Nutrición, Alimentación y Dietética. FESNAD recuerda que NutriScore no cuenta con el aval de las sociedades científicas del sector alimentario en España. FESNAD, 28 de noviembre de 2018. (Accessed 29 July 2019). Available at: http://www.fesnad.org/resources/files/notaPrensa.pdf.
http://www.fesnad.org/resources/files/no... This was despite the fact that such studies had already been published at the time.³³33. Chantal J, Etilé F, Hercberg S. Front-of-pack Nutri-Score labelling in France: an evidence-based policy. Lancet Public Health. 2018;3:e164. The industry is also trying to slow down the implementation of the Nutri-Score in Spain. To this end, it is conducting an aggressive campaign in Europe to implement its alternative nutritional labelling proposal, with the dissemination of a presentation video and a communiqué.³⁴34. Mondeléz International, Nestlé, PepsiCo, The Coca-Cola Company, Unilever. Plan trials of the Evolved Nutrition Label (ENL) in selected EU Member States. Brussels, 3 May 2018. (Accessed 29 July 2019). Available at: https://gastronomiaycia.republica.com/wp-content/uploads/2018/05/etiquetado_semaforo_industria.pdf.
https://gastronomiaycia.republica.com/wp... This alignment between some scientific societies' positions on public health interventions and those of their industrial sponsors who strongly oppose policies to promote healthy food and eating environments,¹⁹19. Aaron DG, Siegel MB. Sponsorship of national health organizations by two major soda companies. Am J Prev Med. 2017;52:20-30.^,2727. Barlow P, Serôdio P, Ruskin G, et al. Science organisations and Coca-Cola's 'war' with the public health community: insights from an internal industry document. J Epidemiol Community Health. 2018;72:761-3. might be yet another undesirable consequence of the financial conflicts of interest to which such societies are subject. In line with our results, a recent systematic review found that industry founded organizations generally supported policy positions that favour sponsors' interest.³⁵35. Fabbri A, Parker L, Colombo C, et al. Industry funding of patient and health consumer organisations: systematic review with meta-analysis. BMJ. 2020;368:l6925.

This study has a number of limitations. Firstly, it is a crosssectional study, which means that we are unable to establish causal relationships. Secondly, it is difficult to ascertain the real scope of food industry sponsorship, due to the fact that scientific societies and foundations are not always given to declaring funding sources on their websites and forthcoming with information about the content of the agreements with their funders.¹⁹19. Aaron DG, Siegel MB. Sponsorship of national health organizations by two major soda companies. Am J Prev Med. 2017;52:20-30.^,2525. Capewell S, Lloyd-Williams F. The role of the food industry in health: lessons from tobacco? Br Med Bull. 2018;125:131-43. It is also possible that information on initiatives to promote healthy food policies or the existence of ethical codes might not always be available on the websites, though the existence of such codes would not appear to act as a bar to societies receiving funding from the food industry. Thirdly, we have no information on the amount of the sponsorships, whether in absolute terms or in relation to the overall budget of societies and foundations, or on the terms and conditions of the funding agreements, data which could be relevant as regards possible undue influence of the industry on societies

and foundations. That said, however, our study's findings serve to highlight the influence which conflicts of interest with the food industry can have on scientific societies and foundations active in the sphere of childhood nutrition and obesity in Spain. It is desirable that total transparency surrounds the financial contributions which this industry makes to these organisations. What is more, politi cal authorities, scientific community and civil society organisations should work jointly to create ethical codes targeted at avoiding this undue influence, which can have negative consequences for child public health.

In conclusion, with the single exception of public health societies, most scientific societies and foundations active in the field of childhood nutrition and obesity in Spain are sponsored by the food industry, with the ensuing financial conflicts of interest. While unsponsored scientific societies promote initiatives with proposals which seek to improve the food and eating environment, and to which the industry objects, the initiatives promoted by sponsored societies or foundations, with educational and awareness-raising measures, are in line with the proposals of the industry, which bases its action on measures of a merely individual scope. To avoid the public health risks of these conflicts of interest, it would be best not to accept sponsorships from industries which market unhealthy products and whose interests clash with those of public health, and instead publicly declare the sums received under and the conditions stipulated in the funding agreements concluded with the industry.

References

Publication Dates

History