Introduction

About one third of all Spanish children and adolescents suffer from overweight, and approximately one out of ten suffers from obesity.¹ Although the data indicate that the figures have stabilised in recent years,² 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.³ 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.⁴Sedentarism, especially the time devoted to watching television, is associated with a higher consumption of sugar-sweetened beverages and energy-dense snacks.⁵ Television exerts its principal effect through advertising, which negatively influences children's food preferences, eating behaviours and caloric intake.⁶

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.⁷ 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.⁸ 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.^9-12 Some Spanish scientific societies even collaborate in food industry advertising, by lending their endorsement to unhealthy products.¹³

A study was recently published about Spanish health-related organisations which received funding from Coca-Cola across the period 2010-2016.¹⁴ 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.¹² 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

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.¹⁷ 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.¹⁸ 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.¹⁴ 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.¹⁹

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,⁸ 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.²⁰ 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.^21,22 Recent research shows that this is also the case with studies funded by the food industry,^9,10,23 which have presumably copied the tactics of the tobacco industry.^24,25 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,¹⁴ 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.²⁶ 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.²⁷ 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.²⁸ 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,²⁹ substances linked to metabolic alterations, obesity, diabetes and cardiovascular disease.³⁰

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.²⁵ 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,³¹ 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».³² This was despite the fact that such studies had already been published at the time.³³ 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.³⁴ 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,^19,27 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.³⁵

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.^19,25 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.