Dr A.I. will see you now — The age of Artificial Intelligence in Healthcare

Google DeepMind’s breakthrough might help save the sight of millions around the world.

Rutger Hauer playing Roy Batty in Blade Runner (1982). The Lead Replicant describing his life as both rain and tears flow down his face. Credit: Warner Bros

“I’ve seen things you wouldn’t believe…”

Had he spent more time scrutinising millions of Optical Coherence Tomography (OCT) scans rather than attack ships on fire off the shoulder of Orion, perhaps Dr Roy Batty might have been the most eminent Medical Retina specialist of Ridley Scott’s fictional 2019.

Philip K. Dick’s dystopian vision was penned in 1968 and later adapted into a neo-noir masterpiece by Scott in 1982. The synthetic beings of his tale, outwardly identical to adult humans, have been created in order to replace humans in performing menial or undesirable jobs. Their only deficiencies seemingly being a lack of emotional range and a four-year life span. The themes of humanity and identity continue to resonate despite the decades which have passed since the short story was written.

We are still a long way from androids replacing any profession, let alone doctors or nurses. Nevertheless, a potentially monumental triumph in the application of AI technology in medicine has just materialised, the fruits of which might benefit millions worldwide.

Two London-based teams have collaborated to develop AI technology which can analyse OCT retinal scans and detect a number of eye conditions, then triage those patients who are in need of urgent care. Google’s DeepMind team, spearheaded by Jeffrey De Fauw, have applied a neural network learning system which matches highly experienced doctors and reduces sight loss by minimising the time between detection and treatment. This delay in referral for treatment still causes many people to go blind.

The potential AI-enhanced process to detect eye disease. Credit: DeepMind Health/Moorfields Eye Hospital

Pearse Keane, lead clinician for the project at Moorfields Eye Hospital, describes DeepMind’s algorithm:

“As good, or maybe even a little bit better, than world-leading consultant ophthalmologists at Moorfields in saying what is wrong in these OCT scans”

Artificial Brains — From Chess to Go

Google’s DeepMind, founded in 2010 in the UK and later acquired by Google, seeks to build powerful general-purpose learning algorithms and uncover the mystery of intelligence. Thus-far, its greatest tangible successes had been in defeating humans in games.

Perhaps its landmark gaming victory came in 2016 when DeepMind’s AlphaGo beat high-ranked Go player Lee Sedol 4–1 in a five-game match by using a supervised learning protocol, watching and analysing large numbers of games between humans. Despite the resounding triumph of machine over man in the ancient strategy board game, DeepMind has to thank its ancestor, IBM’s Deep Blue, for the first of such victories.

Garry Kasparov playing chess against IBM’s Deep Blue in 1997. Credit: Peter Morgan/Reuters

In 1996, world chess champion Garry Kasparov beat Deep Blue 4–2. One year later, Deep Blue came back for revenge and beet Kasparov 3½–2½. The message was clear, artificial intelligence was catching up the human intelligence. Yet Deep Blue’s algorithm depended on “brute computational force”, evaluating millions of positions. That works fine for chess, in which there are 20 possible opening moves. Go, a game originating in China almost 2500 years ago, has 361 possible opening moves on its 19×19 grid. It is so large that no AI can currently explore every possibility using Deep Blue’s “brute force” method.

LeeSeDol losing to DeepMind at Go. Credit: Korea Baduk/Reuters

DeepMind’s AlphaGo, on the other hand, works on a combination of different elements which are meant to mimic human decision-making. The algorithm was developed by DeepMind co-founder Demis Hassabis and consists of a number of phases which include supervised learning (being trained by analysing games between human experts), reinforcement learning (playing itself millions of times and maximising expected winning outcomes), “intuition” rollout policy (predicting how a human would play), Value network learning (quantifying the chances of success) and an algorithm which brings all these together called a “Monte Carlo tree search”.

The Age of Scans

A practitioner performing an OCT scan. Credit: Moorfields Eye Hospital

It’s all very good to beat humans at chess or Go, but what about diagnosing diseases? To find a real-world application for the human-like decision making used by DeepMind’s AlphaGo, the team at the company’s Health division looked at Optical Coherence Tomography (OCT) scans. This is a form of three-dimensional eye imaging which slices the retina into different layers, first introduced over two decades ago. OCT machines have come a long way since their inception and have become increasingly complex in how data is generated and presented. Nevertheless, they are used routinely by eye doctors to diagnose diseases such as age-related macular degeneration, diabetic retinopathy and glaucoma.

The publication of the work from DeepMind and Moorfields Eye Hospital in Nature this week states categorically that the algorithm performed as well as two leading retina specialists in analysing OCT scans and grading the urgency of a referral for management, with an error rate of only 5.5%. This was despite the algorithm not having access to some extra information, such as patient records, that the doctors had. The algorithm was used on two different types of OCT machines, and was also able to give confidence ratings based on aspects of the scans which it considered suggestive for diagnosis. Importantly, not a single urgent case was missed from the 14,884 scans used in the study.

Real-world application

This is just the first stage of research, although Dr Keane is confident that a final product is not too far away. DeepMind and Moorfields now need to run clinical trials of their OCT system so that doctors have the chance to test it. Mustafa Suleyman, DeepMind co-founder hopes that:

“when this is ready for deployment, which will be several years away, it will end up impacting 300,000 patients per year”

The team hopes that regulators approve a final product based on the immediate tangible benefits of a reduction in time and manpower needed to manually inspect scans, make diagnoses and refer for treatment.

Practical Benefits in the Developing World

PeekVision is a smartphone suite and includes an adapter called Peek Retina which allows the retina to be viewed with a smartphone. Credit: PeekVision.org

AI-powered screening can have an enormous impact in hard-to-reach areas. The ubiquity of smartphones around the world makes adding a portable camera and creating an image acquisition system simple and inexpensive. Already, companies such as UK-based Peek Vision have introduced camera adapters which allow high-quality images to be obtained easily and then analysed remotely.

Companies such as California-based Compact Imaging are currently working to make small form-factor multiple reference OCT (MR-OCT) available for smartphones and wearable technologies. The combination of these compact devices and AI-powered screening software could bridge geographical and economic chasms for many of the 285 million people worldwide living with some form of sight loss.

Sight loss around the world. Credit: DeepMind Health/Moorfields Eye Hospital

Artificial Intelligence elsewhere in health

These developments can act as a blueprint for the development of artificial intelligence elsewhere. DeepMind is currently doing research with University College London to assess whether AI can tell the difference between cancer and healthy tissue in CT and MRI scans. It is also working with Imperial College London to assess whether AI can interpret mammograms and improve accuracy in breast cancer screening.

In all these cases, the most practical benefit of using AI to screen for disease is one of resources — doctors’ time would be freed to spend more time with individual patients, and more time working on and providing treatments.

Pitfalls in AI’s Future

“I did everything, everything you ever asked! I created the perfect system” Clu in Tron Legacy (2010). Credit: Disney

Back to the realms of fiction, where accounts of AI are often littered with depictions of ever-evolving intelligences which strive to be perfect, such as Marvel’s Ultron or Tron’s Clu. These AIs struggle to balance a “human” rationalisation of ethics with the necessity to achieve their goal, with Earth-threatening consequences.

Though we are far from apocalypse scenarios, DeepMind itself has already been embroiled in controversy when it emerged that 1.6 million patient data records had not been adequately safeguarded when shared between London’s Royal Free Hospital and DeepMind. Data sharing agreements between the two had to be rewritten and DeepMind has also created an “Ethics & Society” group to maintain the ethical standards of AI, and ensure that social good is prioritised during the fast-moving evolution of these technologies.

Clearly, there may be obstacles ahead that no one can predict. DeepMind’s co-founder Mustafa Suleyman highlights the extent of the challenge:

“It won’t be easy: the technology sector often falls into reductionist ways of thinking, replacing complex value judgments with a focus on simple metrics that can be tracked and optimised over time….

Getting these things right is not purely a matter of having good intentions. We need to do the hard, practical and messy work of finding out what ethical AI really means.”

A future with everything to play for

Nevertheless, Suleyman describes a future which, with the right guidance, could be aided immensely by artificial intelligence when aligned with human values:

“If we manage to get AI to work for people and the planet, then the effects could be transformational. Right now, there’s everything to play for.”

A future, potentially, riding on AI. Credit: Luca D’Urbino
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The restorative power of hospital gardens

Florence Nightingale asserted in her landmark “Notes on Nursing” that the most challenging ordeal for a feverish patient is:

“not being able to see out of window, and the knots in the wood being the only view.  I shall never forget the rapture of fever patients over a bunch of bright-coloured flowers”.

In 1859, she was emphasizing the value of plants and space in the healing of patients:

“People say the effect is only on the mind. It is no such thing. The effect is on the body too”.

Nightingale was not alone in her appraisal of gardens and green spaces as therapeutic tools which were indispensable in the recovery process. Throughout Victorian and Edwardian periods, green spaces in hospitals were championed as havens for healing.  In the succeeding decades, this notion appears to have been forgotten as priorities in hospital construction were directed elsewhere, with little attention given to green spaces, and the replacement of park areas by car park areas.

Perhaps a renaissance was provoked following a 1984 study by American psychologist Roger Ulrich, who demonstrated that patients with views of trees and animals from their wards recovered faster after gallbladder surgery, and spent less time in hospital than those who had no such views.  In the UK, we are in the midst of re-appraising the role of gardens and green spaces, not just for patients but for staff and visitors as well.  The British Medical Association stressed in 2011 that hospital design should always make allowances for the important therapeutic role of gardens.

The Ninewells Community Garden isn’t just a space for rest and relaxation, but also provides a source of community spirit amongst volunteers, be they patients, staff or visitors. Credit: Ninewells Hospital Dundee

Remembering the history of these beautiful spaces, including the unique roles of specific colours and scents in therapy, helps guide the design of future hospital green spaces. In her book “Therapeutic Landscapes”, medical historian Dr Clare Hickman summarises how importantly hospital gardens were regarded, and the plans for new well-designed green spaces in the future, for example the upcoming Horatio’s Garden at Stoke Mandeville Hospital in Aylesbury.  

Painting classes at Horatio’s Garden with artist-in-residence Miranda Creswell. Credit: Horatio’s Garden, Salisbury

Whether they deliver a natural and calming scene from a patient’s bed, an accessible treat for the senses of a waiting visitor, or some relaxation, freedom and privacy for a staff nurse away from the wards, these spaces are once again being seen as crucial for health and wellbeing.   It is no surprise that a reclaimed boiler-house roof, now showpiece garden at Great Ormond Street Hospital designed by Chris Beardshaw, won a Gold Medal at last year’s RHS Chelsea Flower Show.

Hospital gardens need not be highly conceptualized spaces occupied by incongruous abstract sculptures and with little space to walk.  They can be triumphs if they are peaceful, interesting, accessible, well-maintained and engage the senses (though not too strongly).  Here are some beautiful, functional and peaceful hospital gardens across the UK.

                      Ten Hospital Gardens around the United Kingdom

The Morgan Stanley Garden for Great Ormond Street Hospital

The Morgan Stanley Garden for Great Ormond Street Hospital. Credit: JOHN CAMPBELL

Constructed by renowned garden designer Chris Beardshaw, this woodland-themed garden was transplanted from the RHS Chelsea Flower Show (where it won a Gold medal) to a disused roof space, surrounded by tall hospital buildings that look onto it.  The garden provides a quiet and peaceful space for childern and families, with a roof designed such that summer mornings will light up the sculpture of a child which is the centrepiece of the garden.

Horatio’s Garden at Salisbury District Hospital

A path for the senses at Horatio’s Garden, Salisbury. Credit: HORATIO’S GARDEN

Horatio’s Garden is a charity which makes gardens of sanctuary in centres for spinal injury. The gardens are named after Horatio Chapple, who came up with the idea alongside his father whilst volunteering in Salisbury. Horatio was tragically killed aged only 17, but his legacy endures in these beautiful gardens which combine a sensory and aesthetic feast with events and activities. For example, painting the scenic garden with artist-in-residence Miranda Creswell at Salisbury Hospital adds the extra element of creative and expressive arts therapy for patients suffering from spinal injuries.

Ninewells Community Garden, Dundee

A community spirit in action. Credit: NINEWELLS HOSPITAL

This huge community garden is overlooked by the Ninewells Hospital, and emphasizes a spirit of volunteer gardening for patients, staff and the local community.  The garden’s vegetable and sensory gardens, orchard, wildlife habitat and play areas offer a multitude of options for people to de-stress, recuperate and exercise. 

John Radcliffe Hospital Women’s Centre Garden, Oxford

Credit: John Radcliffe Hospital Women’s Centre Garden, Oxford

This discarded area adjacent to the Women’s Centre was transformed into an open space with a compact walking area and two subtle sculptures in the centre. Instead of the previous drab view in front of the building, the colourful array of flowers and scents of thyme and lavender provide a welcome area for female patients and staff to relax during the course of the day.

Horatio’s Garden at the Scottish National Spinal Injuries Unit, Glasgow

Credit: Horatio’s Garden, Glasgow

The second Horatio’s Garden on this list was inaugurated in August 2016, with views of the stunning woodland garden (above) from the hospital wards.  The garden has six distinct spaces, all of which serve to stimulate different senses, and a greenhouse which is surrounded by areas used for horticultural therapy activities.

Chase Farm Hospital Rehabilitation Gardens, Enfield

Credit: Chase Farm Hospital

Chase Farm Hospital has just renovated two of its areas into specialist therapeutic gardens aimed for the specific needs of patients, but open to staff and visitors. One of the gardens supports dementia patients, whilst the other (above) support stroke and rehabilitation patients. Based on a Japanese design, it provides a very compact but tranquil sanctuary within the hospital.

Guy’s Hospital Courtyard Garden, London

Credit: Guy’s Hospital, London

The contemporary feel of the courtyard garden at Guy’s Hospital in London is accentuated by the number of sitting areas amidst the shrubs and hedges, with the vindicated expectation that the garden was designed that the garden would become a preferred spot for having lunch or sitting with family outside the wards.

Bournemouth Hospital Orchard Garden, Bournemouth

A desolate tarmac courtyard in the hospital has only recently been revamped into a three-segmented garden: a therapeutic courtyard garden outside the chemotherapy suite (above), a sensory garden linking the courtyard to a lakeside garden, giving patients and visitors not only options for their retreat of choice, but also a large area to walk around and exercise in.

Chapel Garden, Norfolk and Norwich University Hospital, Norwich

A bland lightwell was transformed into this chapel garden, featuring a central “wish tree” and a number of water features such as a vertical water fountain and a water rill giving the impression of water moving continually throughout the garden.  The calming flow of water and illusion of space allow for, once again, a small and previously unused area becoming a peaceful reservation amidst the hospital.

Dick Vet Hospital Gardens, University of Edinburgh

Credit: University of Edinburgh

Animals, animal-owners and animal-lovers should not be excluded from the healing power of gardens.  This luscious retreat at the University of Edinburgh’s Easter Bush Campus provides ample space and quiet, together with several benches. It is capped off by the Path of Memories, a path lined by granite stones which can be engraved with an animal’s name.

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Seeing Things

An Art Exhibition inspired by the hallucinations of Charles Bonnet Syndrome

Visual Hallucinations

It was a pleasure to attend the first day of the Seeing Things interactive art exhibition, which is taking place at the lovely Forum in Norwich over the next two weeks.

Charles Bonnet Syndrome is a type of visual hallucination which people can experience after sight loss. In comparison with other types of hallucination, those who experience these know that they are just a creation of the brain as a reaction to visual loss.

 Fascinating paintings depicting some of these hallucinations. Source: Own photo

 

The Art of Charles Bonnet

This art exhibition, set up by the NNAB, features art from people who suffer from the syndrome, as well as other visual artists who have been inspired from speaking to those who experience these vivid hallucinations, which have their own unique attributes in comparison with other types of hallucinations.

To the left – a bear statue in front of some upside-down cupcakes. Strange faces can also be a feature of the condition. Source: Own photo

Experiences

Dominic Ffytche, a world expert in the condition, gave a fantastic lecture about the Syndrome, and it was indeed fascinating to listen to the experienced of sufferers from the condition. The audience comprised of people who suffered from the condition, people who had not previously heard of the syndrome and clinicians, such as myself, who are aware about the condition but want to understand more and gain perspective.

I was particularly intrigued by the number of people who experience hallucinations of old period clothing from different eras, which seems to be a consistent feature of the syndrome. Interestingly, even when the syndrome was first described 250 years ago — the literature describes sufferers talking about people wearing period dress of the time. Perhaps 18th century formal-wear has a hallucinatory quality to it?

 Dr Dominic Ffytche, an expert in the condition, shows images of certain visual hallucinations that people experience. Source: own photo

Gaps

Even though Charles Bonnet Syndrome was first described 250 years ago, by a Swiss philosopher who was writing about his grandfather’s experiences having lost his sight to cataracts, we still do not know why exactly it happens. Certainly, we suspect that the brain fills in the gaps generated from visual loss by producing new fantastic pictures or old images which it might have stored. For many people, these hallucinations are not a problem but for some they can, understandably, be distressing. Certainly, it helps to understand these hallucinations and it is useful for both sufferers, the public and clinicians (such as yours truly) to be aware and understand this fascinating condition.

 An interesting hallucination — bear and inverse cupcakes. Source: own photo

To this end, it is fantastic to have an art exhibition which both raises awareness and bewitches us, humbling us as clinicians into realising there is still so much about the eyes and the brain that we don’t yet understand. Do you have any experience of this condition? Please feel free to comment below.

Links:
Royal National Institute of Blind People
Norfolk and Norwich Association for the Blind
NHS Charles Bonnet Syndrome Information

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The Destruction of the NHS: A Dialogue at Breaking Point

The Destruction of the NHS: A Dialogue at Breaking Point

by Nima Ghadiri

Is the NHS at breaking point?

Yes, it really is. As things stand, it will not exist in five to ten years time, and different elements of our Health Service will be apportioned as Dialysis-Plus East Coast, CrossCancer, Virgin Maternity, or whatever other word-pasticcio the “brand positioner” regorges.

With consecutive governments in seemingly total denial about the state of the NHS, the phrase “crisis point” is an understatement. We need to do something now, every month which passes brings the death sentence closer.

Ok, just…. just chill out there for a second. Are things really THAT BAD?

Chucking about numbers is often a precursor to a well-known Disraeli quote, paraphrased by Mark Twain. Nevertheless, sometimes they are needed so people can grasp what is happening.

Since 2011, there has been a 504% increase in the number of patients waiting over four hours in A&E Departments across the country, forcing Secretary of State for Health Jeremy Hunt to ditch the target.   23 hospitals were simultaneously on black alert earlier this year, which means that they “are unable to guarantee life-saving emergency care”. This included Jeremy Hunt’s own local hospital The Royal Surrey, which had 27 patients urgently needing a bed but no space.

Waiting times for surgery have been getting much longer, and 4093 urgent operations were cancelled in 2016, an increase of 27% in just two years.  Knee and hip operations are now being rationed only for those who aren’t able to sleep because of agony, using bogus “pain tests” as a differentiator.

Cancer treatment targets have been missed for four consecutive years, and services are now failing.  Mental health services are being rationed, so people who suffer are dying in their homes, unable to care for themselves.

These are frightening figures, it’s no wonder the Red Cross (who stepped in early in the year to help with a shortage of ambulances) has declared the NHS a humanitarian crisis, as people are dying needlessly in the world’s fifth-richest country…

Stop, I get the idea, things are looking gloomy all round. Surely, we have the MONEY to stop this?

Source: BMA

Astonishingly, as demand has risen hugely, funding has been cut.  Our spending on the NHS as a percentage of our GDP has plummeted below 10%.  This is a lot less than France and Germany, and amongst the lowest in the developed world.

If our national health funding matched the average amount that Europe’s 10 leading economies spend on their healthcare, perhaps we could lose this uncoveted accolade:

Source: BMA

Yes, we need more NURSES and DOCTORS!

And we are getting far less.  Medical school applications have plummeted, the proportion of med school graduates who become first year doctors has gone down from 70% to 50%, with phrases such as “in droves” and “en masse” describing the number of junior doctors leaving the United Kingdom.  Enormous rota gaps are now ubiquitous, GP vacancies have skyrocketed from 2% in 2011 to 12.2% now, and 84% of general practitioners now say that their workload is affecting patient care.

Nursing applications have fallen by 23% over the last year, and the removal of bursary funding for student nurses and midwives has sent one clear message “We don’t value you”, underlined by years of below-inflation 0% and 1% pay rises.  By 2019, NHS workers will have seen their pay capped for nine consecutive years, and nurses will have seen their pay reduced by 12%.

To add salt into these raw and gaping wounds, the Secretary of State for Health massively over-estimated nurses’ average pay this month when he was asked why so many nurses are having to use food banks.

Source: British Medical Journal

So they want things to fail, is this all about PRIVATISATION?

We don’t need to speculate about this, it’s all there in numbers, contracts, even a book with Jeremy Hunt’s name on it, calling for the de-nationalisation of the NHS.  There has been an increase in spending on “independent sector providers” of a third between 2014 and 2016, and an estimated 500% more contracts have gone private since 2012.

Source: BMA

The plan for privatising the National Health Service isn’t exclusive to one party.  The groundwork was done by the previous government, with poorly conceived “public service reforms” leading to unfettered introduction of private corporations into commissioning. It has accelerated over recent years, however.

So what are the POLITICIANS saying?

Absolutely the wrong things. For a National Health Service which is quite visibly starving, Jeremy Hunt said: “The NHS needs to go on a 10-year diet”.

Theresa May also didn’t like the Red Cross assessment of the NHS, calling them “irresponsible” and “overblown”.

The BMA has identified five key issues for the future of the NHS, and it would indeed be “irresponsible” if politicians did not address these:

Source: BMA

Are you subtly telling me which way to VOTE?

No, it’s not for me to instruct you, and people don’t like being told what to do.  Nevertheless, it’s currently very easy for the mainstream media and tabloid press to distract the general population and report on fake scandals rather than one which is very real, and affects all of us.

As long as you are aware of what is happening and can make up your own mind, then that’s already very important. If you can spread the word to others, even better.  Over the next few months we will see an increase in grass-roots movements in social media and the streets, in support of the National Health Service.  There will be a nurses’ summer of protest activity, a show of anger against pay-rise caps and maltreatment which has left 40,000 posts unfilled.

Battling a Murdoch and Dacre Press which has vested interests against the NHS will be challenging, and no doubt lies will be spun which confuse and subvert.  Tabloid journalism had a pivotal role in the Junior Doctor contracts dispute, and may do so against the nurses too. It is crucial to appreciate that supporting our nurses means supporting our National Health Service.

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[MUST READ] Coca-Cola’s secret influence on medical and science journalists

Please read this article from the British Medical Journal: http://www.bmj.com/content/357/bmj.j1638

 

This is a very important argument, and it is essential for healthcare professionals, journalists and politicians alike to make a concerted and aggressive effort to kick these sugar-peddling companies out of the sphere of academic influence.

The more overt “More Doctors smoke…” advertisements of yesteryear are thankfully a thing of the past, but the covert influence of sugar-saturated food companies is no less a threat to our health. Aaron and Siegel (1) report that from 2011 to 2015, the Coca-Cola Company and PepsiCo were found to sponsor 95 national health organizations, many medical and public health institutions amongst them. They also lobbied against 29 public health bills intended to reduce soda consumption or improve nutrition.

The British Nutrition Foundation, for example, lists amongst “Sustaining Members” Coca-Cola, PepsiCo, Kellogg, Nestle, Tate & Lyle and has “Corporate Members” British Sugar plc, Mars UK, KP Snacks, McDonalds, United Biscuits, Weetabix, Ocean Spray and many more. Although it is open to companies and corporations from a variety of backgrounds including healthcare and fitness, the actual members who have provided support read as a Who’s Who of Sugar Salesmen (2), making their promise of a “a focus on objective nutrition science interpretation and delivery” open to scrutiny. The American Society for Nutrition is no different, with an almost-identical list of names cropping up (3) for this group, which publishes the Journal of Nutrition.

Indeed, the editorial boards of top nutrition journals are littered by corporate affiliations with sweetie companies – The American Journal of Clinical Nutrition, for example, lists the likes of Mars, Coca-Cola, PepsiCo, Nestle, McDonald’s  and Ferrero amongst companies who have a relationship with members of their board (4). The ambassador’s reception may also be overflowing with hazelnut-and-wafer spherical treats at many other nutrition journals, who often  home of the Journal of Nutrition Education and Behavior, who have eight “corporate patron friends” and four “corporate sustaining friends.  (5)

It would be interesting to note how these journals consider submissions which report a detriment to health from these companies’ products, but when some of the largest nutrition journals display such a conflict of interest it must become clear to all that the Honey Pot relationship between “Big Food” and academia is poisonous and needs to be dealt with.

References:

(1) Sponsorship of National Health Organizations by Two Major Soda Companies. Aaron, Daniel G. et al. American Journal of Preventive Medicine , Volume 52 , Issue 1 , 20 – 30

(2) “Member Organisations – British Nutrition Foundation”. Nutrition.org.uk. N.p., 2017. Web. 10 Apr. 2017.

(3) “American Society For Nutrition – Our Sustaining Partners”. Nutrition.org. N.p., 2017. Web. 10 Apr. 2017.

(4) AJCN Editor Conflict of Interest Statement. (2017). Ajcn.nutrition.org. http://ajcn.nutrition.org/site/misc/EditorCOI.xhtml Web, 10 April. 2017.

(5) Nestle, Marion. Food Politics. 1st ed. Berkeley, Calif.: University of California Press, 2013. P112. Print.

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