Is Sports Nutrition for Sale?
Tommy Boone, PhD, MPH, FASEP, EPC
Professor and Chair
Department of Exercise Physiology
The College of St. Scholastica
Duluth, MN 55811

"We are governed not by ethics and straight thinking but by the bottom line." -- William T. Boone

In 2002, PEPonline became the first electronic journal to publish exercise physiology articles that expressed the concern about the link between sports nutrition, the supplement industry, and exercise physiologists [1].  No longer was sports nutrition about sound nutrition and the athlete’s nutritional needs through better training methods.  No longer were some exercise physiologists interested in finding the truth through statistical testing.  Sports nutrition research, in particular, took on a new meaning.  Ethical thinking was driven by the bottom line of business decisions.  Everyone figured out that there is money (and a lot of it) in business and relatively little in education. 

CEOs of supplement companies realized the potential in marketing their products to improve physical performance [and] their business bottom line.  It is not very difficult therefore to understand why failure to disclose financial ties with sports supplement companies is a problem in academic exercise physiology.  And, this is certainly not an unheard of conflict in academic medicine [2] that has become equally common and problematic.  Conflict-of-interest policies on the part of the investigators conducting sports supplement research have not been developed in exercise physiology.  Frankly, it is obvious that university-based investigators should be prohibited from holding decision-making positions in sports supplement companies that may affect the research findings.

Clearly, when nutritional and/or fitness products are marketed with the idea to make the companies rich, there is almost no way to ensure that the public is going to get the truth in advertising.  This is a serious problem, both from an ethical and athletic points of view.  Unfortunately, at the present time, the entrenched interest of exercise physiologists in sports nutrition is at the public’s expense.  Continuing efforts to find [the] nutrient supplement to enhance physical performance make little sense.  At the same time, there are too few exercise physiologists who object to the financial associations to companies that make products related to the articles they publish.  Yet, as an example, in spite of their beliefs that increased protein is required for athletes, “…most athletes consume much more protein (from food alone) than they require.” [3]  To a large degree, to consume more than 1.5 to 2.0 grams of protein per kilogram of body weight [4, 5] is unnecessary since this amount of protein is easily obtained from one’s regular diet.

This apparent sports medicine policy, if not a "planned" financial movement, that nutrition and sport supplements are vital to athletics is by no means unique to exercise physiology.  Coaches, players, trainers, and others are routinely encouraging the use of drugs and supplements.  The sports medicine exercise physiologists are now so intertwined with the supplement and biotechnology companies that many are professional consultants for hire.  Their job is to write articles to support the products.  The grants for the purchase of laboratory equipment is increasingly very popular among these investigators. Obviously, the money is used to help buy expensive equipment and, strangely enough, few exercise physiologists seem to question the overlap in articles they publish and the products they are paid as consultants to support. 

No one knows how many of these investigators have stock and/or stock options in the companies that sponsor the research!  And, therefore, the time-honored custom of research is expected to be the highest possible, right?  Perhaps, this is exactly the problem.  Maybe not all exercise physiologists are healthcare professionals.  Just maybe they are paid employees of the industry, which is worrisome since they are in an excellent position to undermine public trust.  More discussion and research are needed on the harms and benefits of the relationship between academics and industry.  Increasingly, until more is known, it is prudent for universities and faculty to monitor sports nutritionists who are responsible to the industry, especially when their conferences are sponsored by the time-honored objective of companies to make money. 

It may be that it is time for exercise physiologists to answer the question:  “Where does good business begin and conflict-of-interest stop?”  Part of the answer is that separation of academic research programs with direct partnerships with supplement companies is imperative.  The fact that money is involved, equipment is purchased, and technology is linked is the potential for real compromise in data analysis and reporting.  While academic institutions are responsible for the purchase of equipment and technology, good research is not about marketing industry-sponsored products.  Imagine how difficult it is for the researchers to remain nonbiased.  However, the lack of equipment itself and thus specifics types of research should not be driven by the availability of industry funding.  It is not enough for the researchers to say, “I would never be influenced by supplement companies.”  Their outrage at the idea is part of the problem, too.  They want the industry funding and the freedom to do as they will along with their ties to industry, and they want professional recognition as well.

The ethics of this type of conflict-of-interest should be evaluated.  Academic institutions should adopt guidelines to monitor industry-supported conferences, honorariums, consulting fees, and research grants.  Exercise physiologists with an interest in sports nutrition should commit to the professional development of exercise physiology by sharing with the public that it is not for sale.  The clinging to supplement companies to get a cut of the action is not a shared expectation of all professional exercise physiologists.  Also, it should be known that commercializing exercise physiology via sports nutrition is not in the best interest of exercise physiologists as healthcare practitioners.  Those who publish sports nutrition supplement articles have a special responsibility to hold themselves accountable to the scholarly and ethical standards of exercise physiology.  They have an obligation to get involved in the shared practice of ethical thinking to help all exercise physiologists to uphold the highest standards of the profession.  In most instances, since exercise physiologists are expected to have high ethical standards and try not to allow personal interest to interfere with their research decisions, the  infusion of industry dollars into an industry-investigator partnership has not resulted in producing data of poor quality.

In short, however, the competiton for the industry dollar is a concern that must be dealt with by exercise physiologists.  The changes and growth in the professional development of exercise physiology will be slower than originally thought.  If, for no other reason, since many of the exercise physiologists with an interest in sports nutrition are friends, it is important to rethink the likelihood of a real exploitation of exercise physiology with the over-commercialization of supplement research.  The issue here should be a balanced perspective on behalf of the students future.  Presently, the impact of no controls or guidelines on sports nutrition reearch is simply too much of a widespread problem .  The challenge is therefore to bring the research and ties to the industry under some control and shared responsibility of all exercise physiologists.  And, yet it is no surprise that this suggestion will seem as a violation of the rights of some sports nutritionists/exercise physiologists.  This concern is likely to be most pronounced in collaborative relationships between academia and industry. 

Regardless, it is well documented that an unhealthy alliance between academic and corporate America exists [6].  If medical doctors believe the presence of industry in the patient-doctor relationship is a “serious threat” to safety of subjects in clinical trails [7], shouldn’t exercise physiologists be concerned about the health and safety of athletes who are encouraged to use supplements?  This concern is most pronounced with young and college aged athletes.  The price is too high for athletes (and their parents) as well as society.  The quick research payoff of academic publishing is at an expense of the athlete’s moral character.  It is unbelievable that the inherit value of sport nutrition from an exercise physiologist’s view is lost by nurturing conflicts of interest and, in some cases, unethical behavior. 

A critical question is how much exercise physiology is willing to give up if sports nutritionists are dead set on unrestricted support of their research by the supplement industry?  What will be the end result on the professional development of exercise physiology?  For certain, these are important questions and exercise physiologists need answers.  This is especially the case when industry funded research data fails to support the company’s large sum of money dedicated for equipment and the authors set out to publish the paper.  Will the company attempt to block the publication process?  Will the company seeks damages?  [8]   Also, equally important, will colleagues believe the research findings?  Are they credible?

This connection between supplement companies and universities will ultimately be viewed in a highly negative way in the not too distant future.  Once the public and other professions realize that it is possible that sports nutritionists may have allowed the industry to influence academic research and university educational programs, they will recognize the threat to scientific integrity.  Scientific research is by design regulated.  The public’s trust in research is a synthesis of ethical thinking.  Conflicts of interest require disclosure of financial interest (including consulting fees and honoraria) as well the researcher’s bias.  Exercise physiologists must not approach their research with foregone conclusions.  Here, it seems, is a serious conflict by sports nutritionists who have an established conviction that supplements are a necessary part of athletics.  Rather than finding that a supplement does not work and concluding the same in a published paper, it is all too common to observe the researchers’ conclusions in favor of the supplement [9].  This conflict of conviction is undeniably a threat to the integrity of the scientific inquiry and the credibility of exercise physiology.

“Strong and consistent evidence shows that industry-sponsored research tends to draw pro-industry conclusions.” --  Justin E. Bekelman, Yan Li, and Cary P. Gross [10]

The answer to this dilemma is the provision for explicit learning experiences in professionalism, which is also true for undergraduate medical education [11] and other healthcare professions.  The industry’s transformation of sports nutrition in the United States undermines the decades of sports nutrition research.  The rise of supplement usage has led a lot of parents and others to be concerned about the athlete’s attitudes and behavior towards sports and life.  The erosion of professionalism is reflected in the unchallenged use of performance-enhancing supplements and drugs.  As a result, there is a growing concern among some academic exercise physiologists that to promote the professional development of exercise physiologists, departments of exercise physiology should provide academic experiences in professionalism.  Unfortunately, the majority of schools do not address professionalism or incorporate a lecture or two in introductory exercise science courses.  To stop the sale of sports nutrition, exercise physiologists must teach professional values [12] and behaviors along with ethical thinking.  Role modeling and experiential learning are important to developing professional behaviors of students. 

Kassirer [13] concluded in 1997 that, “When physicians have financial incentives to minimize the expense of care, competing forces tug at them.”  It stands to reason that the same scenario is true for exercise physiologists/sports nutritionists.  The rationales for compromise choices vary: in one case the exercise physiologist chooses to tell an athlete to supplement his diet with protein with expectation that it will enhance his performance, in another the athlete is told about the assumed benefits of a supplement from a company that funds the exercise physiologist’s laboratory, and in yet another, the athlete is told that there are no side effects to a particular supplement.  In each scenario, what the athlete is told is driven by the exercise physiologist’s personal agenda.  This, it seems to most on-lookers, is not in the best interest of the athlete.  At the very least, the athlete should know that most supplements do not work and those that do are likely to be questioned in due time by athletic officials.

Kassierer also wrote, “For some, however, personal financial considerations can erode the ethical fire wall.  These physicians may eventually convince themselves that the low-cost care they are providing is of high quality when in fact it is substandard.  These are the doctors to worry about, because this corruption of their integrity undermines their professionalism and threatens the quality of their care.” [13, p. 1666]  Why, then, should exercise physiologists take issue with the content of this article?  Are exercise physiologists with an interest in sports nutrition better than physicians?  Are sports nutritionists exempt from upholding the integrity of their association with athletes?  Of course, if professionalism is to grow, it can only do so when exercise physiologists take their association with the public sector as important as a physician is expected to.  At what point sports nutritionists/exercise physiologists will come to recognize their inevitable professional responsibility to caring for the athlete beyond the concept of winning at all cost remains to be seen.  Perhaps, stated somewhat differently, at what point will the exercise physiologist define him- or herself as a professional separate of the athlete’s addiction to win.  Whatever the answer, exercise physiologists must come to grips with these difficult professional issues.  The athlete’s physical health and mental well being must be placed above the self-interest of the exercise physiologist.
 

References
1. Boone, T. (2002). Exercise Physiology Quackery and Consumer Fraud. Professionalization of Exercise Physiologyonline. 5:5:May [Online]. http://www.asep.org/asep/asep/ExercisePhysiologyQuackery.html
2. Angell, M. (2000). Editorial. Is Academic Medicine for Sale? New England Journal of Medicine. 342:20:1516-1518.
3. Benardot, D. (2000).  Nutrition for Serious Athletes. Champaign, IL: Human Kinetics, p. 17.
4. Butterfield, G.E., Cady, C., and Moynihan, S. (1992). Effect of Increasing Protein Intake on Nitrogen Balance in Recreational Weight Lifters. Medicine and Science in Sport & Exercise. 24:S71 (abstr).
5. Tarnopolsky, M.A., MacDougall, J.D., and Atkinson, S.A. (1988). Influence of Protein Intake and Training Status on Nitrogen Balance and Lean Body Mass. Journal of Applied Physiology. 64:1:187-193.
6. Andreopoulos, S. (2001). The Unhealthy Alliance Between Academia and Corporate America. West Journal of Medicine. 175:225-226.
7. Ross, L.F. (2000). Is Academic Medicine for Sale? [letter] New England Journal of Medicine. 343:508-510.
8. Russell, S. (2000). Firm That Paid for UCSF Study Seeks Damages. San Francisco Chronicle. [November], p. A3.
9. Boone, T. (2003). The Sports Supplements Disagreement: A Call for a Dialogue About Values and Obligations of University Teachers. Professionalization of Exercise Physiologyonline. 6:8:August [Online]. http://www.asep.org/asep/asep/TheSportsSupplementsDisagreement.html
10. Bekelman, J.E., Li, Y., and Gross, C.P. (2003). Scope and Impact of Financial Conflicts of Interest in Biomedical Research. Journal of American Medical Association. 289:4:454-465, p. 7.
11. Swick, H.M., Szenas, P. Danoff, D., and Whitcomb, M.E. (1999).  Teaching Professionalism in Undergraduate Medical Education. Journal of the American Medical Association. 282:9:830-832.
12. Boone, T. (2003). Values Clarification in Exercise Physiology. Professionalization of Exercise Physiologyonline. 6:6:June [Online]. http://www.asep.org/asep/asep/ValuesClarificationANDExercisePhysiology.html
13. Kassirer, J.P. (1997). Editorial: Our Endangered Integrity – It Can Only Get Worse.  New England Journal of Medicine. 336:23:1666-1667, p. 1667.