Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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![[Read Rapid Response]](/web/20080511223511im_/http://www.bmj.com/icons/misc/sectionDOWN.gif)
Why no mention of state registered dietitians?
- Paula C Gallon (9 February 2007)
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Register and regulate "nutritionists"
- Andrew Craig (9 February 2007)
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The real junk science
- Jerome Burne (11 February 2007)
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Tell Us the Truth About Nutrition
- Patrick J Holford (11 February 2007)
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Regulation of Nutritional Therapists
- Carol A Granger (12 February 2007)
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Re: The real junk science
- Barton C Massey (12 February 2007)
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Pyramids galore!
- Susan A McGinty, Member British Assoc. Nutritional Therapy (12 February 2007)
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Food sense not nonsense
- Catherine Collins (15 February 2007)
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Re: Regulation of Nutritional Therapists
- Andrew Craig (19 February 2007)
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Tell us the truth about dieticians too
- John P Briffa (24 February 2007)
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Balance of Allopathic and Naturopathic
- Regina Wilshire (26 February 2007)
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Dietitians
- Caroline A. Morrell (26 February 2007)
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Australia fighting the same battle.
- Claire E Hewat (3 March 2007)
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No competing interest?
- David Colquhoun (28 March 2007)
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Competing interests in curry
- Patrick J Holford (17 April 2007)
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Competing interests
- David Colquhoun (18 April 2007)
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Holford's competing interest - shares in a company selling Curcumin (tumeric extract)
- Jon M Mendel (27 April 2007)
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transparency in alternative health
- Catherine M Collins (27 April 2007)
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Fallacy of the worse evil
- Ray G Girvan (19 June 2007)
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Paula C Gallon, Student Dietitian Coventry University CV1 5FB
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I'm a great fan of Ben's writing but it makes me sad that he seems either unaware of the role of the state registered Dietitians, or does not consider it important enought to mention. Dietitians are trained in evidence based nutrition and work very hard in hospitals and the community to give the sort of basic uncomplicated dietary advice that he is calling for. In the current climate of job cuts and post freezing in the NHS, maybe Ben would be willing to call for the government to put more money to fund posts for those of us who have trained very hard for 4 years and are now facing an uncertain job market (along with all other health profession graduates). In the absence of this, I'm sure that the media nutritionists will be happy to fill the void. Competing interests: Student Dietitian |
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Andrew Craig, Health promotion specialist London SW12 8LG
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As a health promotion specialist working in the food industry, I share Ben Goldacre’s views about the confusion “media nutritionism” engenders in an already bemused public whose relationship to food seems to gyrate between disproportionate fears on the one hand and the latest diet fad on the other. Like it or not, there seems to be a robust market for the views of media food pundits: the supply would not exist if there were no demand. This situation is perverse, especially given the UK's looming epidemic of obesity and metabolic disorder. Is there not a readily available remedy through regulation that could help? “Nutritionist” and its variations could be made a registered “protected title”, like dietitian or physiotherapist, under the regulation of the Health Professions Council, see www.hpc-uk.org. Statutory regulation of nutritionists would filter out the worst unqualified offenders and provide a mechanism to discipline unprofessional behaviour in others. Ironically, many people have met bureaucratic indifference when such an apparently sensible change has been proposed in the past. Why is government seemingly resistant to this move? Competing interests: None declared |
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Jerome Burne, medical journalist freelance
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Dr Goldacre’s article must be applauded for identifying a number of the social factors leading to ill-health – inequality, food deserts created by supermarkets, a failure to implement taxes for bad food and the lack of an “enabling environment” to promote exercise. All things certainly worth trying to improve. However it does seem bit unfair to blame “media nutritionists” for failing to tackle them, just as it would be unfair to blame “hard working NHS GP’s for not campaigning for a local cycle track as part of their daily round. More seriously in damning the “media nutritionists” actions, he fails to ask the two most basic questions about any form of treatment – Does it work and is it safe? There are certainly hundreds of thousands of people who would tell him that following dietary changes recommended in books or TV programs benefited them enormously. Not a randomised trial of course but surely worth considering. Furthermore even their sternest critics have failed to make a serious case that “media nutritionists” kill or maim people. Unlike prescription drugs which, puzzlingly, are never the target of Goldacre’s tirades. This is puzzling because the essence of his assault on all non-drug medicine is that it is unscientific. Look at the charges he levels at “media nutritionists” – they: “wear a cloak of scientific authority”, “make up evidence when it is missing”, “cherry pick the literature”, “only quote favourable studies” . Is he really unable to see that every one of these is regularly done on a far larger scale and with far more damaging effects by the pharmaceutical companies? The concealing of evidence of problems with SSRIs, the marketing and distorting of evidence over Vioxx, the failure to issue warnings over anti-psychotic drugs - to mention just three – not only did harm to innumerable patients but also seriously and deeply “tarnished and undermined the meaningful research work of genuine academics. A major reason why the social factors he is concerned about are regularly pushed to the margins in health policy is because there are heavily marketed drugs that claim to deal with some of damage those factors cause. The reason why large scale trials are rarely done to back up the nutritionists’ claims is because 90% of such trials in this country are run by drug companies. If Dr Goldacre is genuinely concerned about ill health and bad science, he could far more usefully focus his obvious critical abilities on junk science practised by the drug companies. But then perhaps he prefers to remain a “branch of the entertainment industry” poking fun at people who for the most part can’t fight back. Competing interests: I am the author of the recently published book "Food is better medicine than drugs" which advocates nutritional treatments and questions the benefits of drugs as the first line treatment for chronic disease |
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Patrick J Holford, nutritional therapist Carters Yard, London SW18 4JR
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The estimated cost of diet-related diseases to the NHS is in excess of £15 billion, according to the Royal Society.(1) Obesity has become the second most common cause of premature death, with smoking being the first. Type 2 diabetes, a preventable and largely reversible diet-related disease, is predicted to affect approximately one in twenty(2), and possibly one in six people over age 40 by 2010. Prostate cancer, according to the East Anglia Cancer Surveillance Unit at Cambridge University (3) , is predicted to effect 23% of men by 2015 – representing an 83% increase in thirty years – strongly linked in epidemiological studies to high dairy consumption.(4) Clearly, many people in Britain continue to dig their own graves with a knife and fork. The fundamental political issue is how to radically and swiftly change the diet culture in Britain. There is reason to believe that the media will play a major role in encouraging such a culture shift, and that health messages need to be entertaining to achieve impact. Media nutritionists who demonstrate that transformation, weight loss and disease reversal is possible by diet and lifestyle modification should be actively encouraged, not attacked, as Ben Goldacre, a doctor with no apparent speciality in nutrition or research expertise (on PubMed he is second author of just one obscure paper on fMRI), has done in his article ‘Tell us the truth about nutritionists’. In his article, which contains not one single reference to substantiate his claims, he attacks advice to eat turmeric for cancer protection, including that of the prostate. 1834 studies are cited in PubMed on turmeric or curcumin, thought to be the active ingredient in this spice, many of which demonstrate clear anti-inflammatory and immune enhancing properties, 648 of which relate specifically, and consistently, to it’s anti-cancer properties. These include robust in vitro evidence on human cancer cells, and animal studies, described by Goldacre as ‘ speculative laboratory studies on cells, growing (or not growing) in glass dishes’. The evidence is now sufficient to warrant clinical trials and at least a dozen are now underway. The most recent review on turmeric, in the January issue of the Journal of Clinical Immunology (5) , states: “Traditionally known for its an anti-inflammatory effects, curcumin has been shown in the last two decades to be a potent immunomodulatory agent that can modulate the activation of T cells, B cells, macrophages, neutrophils, natural killer cells, and dendritic cells. Curcumin can also downregulate the expression of various proinflammatory cytokines including TNF, IL-1, IL-2, IL-6, IL-8, IL-12, and chemokines, most likely through inactivation of the transcription factor NF-kappaB. Interestingly, however, curcumin at low doses can also enhance antibody responses. This suggests that curcumin's reported beneficial effects in arthritis, allergy, asthma, atherosclerosis, heart disease, Alzheimer's disease, diabetes, and cancer might be due in part to its ability to modulate the immune system. Together, these findings warrant further consideration of curcumin as a therapy for immune disorders.” The safety data on turmeric is exceedingly good. Even if somewhat premature, is it really such a sin to recommend people in Britain to eat this spice on a regular basis, as done in Asian countries where prostate cancer incidence is exceedingly low? Goldacre’s plea to know the truth about nutritionists pales into insignificance in relation for our need to know the truth about nutrition and, most imperatively, to channel more public money into researching foods such as turmeric which, unlike patentable drugs, have no significant commercial return, and hence cannot attract commercial private sector funding. In researching nutritional approaches to common diseases in my book ‘ Food is better Medicines Than Drugs’ (www.foodismedicine.co.uk) I cite several hundred studies, many of which are RCTs. Many doctors, such as Goldacre, are simply unaware how much good quality evidence does exist for nutrition approaches and consequently underestimate the power of optimum nutrition in disease prevention and reversal. As George Bernard Shaw aptly said “Those of you who say it can’t be done should not interrupt those of us who are doing it.” Patrick Holford – media nutritionist and founder of the Institute for Optimum Nutrition (1) S. Fairweather-Tate, ‘Human nutrition and food research: opportunities and challenges in the post-genomic era’ Royal Society, 9 September 2003, pub.on-line (2) YHPHO ‘PBS Diabetes Population Prevalence Model – Phase 2 June 2005, available on line at www.yhpho.org.uk (3) East Anglia Cancer Surveillance Unit, Cambridge University (4) D Ganmaa et al, ‘Incidence and mortality of testicular and prostatic cancers in relation to world dietary practices’, Int J Cancer, 2002, 98 (2): 262-267 (5) Jagetia GC, Aggarwal BB. "Spicing up" of the immune system by curcumin. J Clin Immunol. 2007 Jan;27(1):19-35. Competing interests: None declared |
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Carol A Granger, Registered Nutritional Therapist The Granger Partnership, Midhurst GU29 9LS
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Voluntary regulation of the nutritional therapy profession is now being overseen by the Nutritional Therapy Council (NTC), which works closely with The Princes’ Foundation for Integrated Health (FIH) to provide a national registration scheme for nutritional therapists. The NTC’s mission is to establish, uphold and advance the standards of qualifications, competence and conduct of those who practise nutritional therapy as a profession, in order to protect the public and provide guidance to practitioners. On October 1st 2006 the NTC launched its new national register. Practitioners can apply for registration through the voluntary scheme and will be assessed on their training and experience. If they meet agreed National Occupational Standards and can demonstrate that they provide safe and effective nutritional therapy, they are able to join the register. Maintaining professional standards is a vital element of regulation and practitioners will be required to undertake continuing professional development to ensure that they continue to meet standards. There are many different professions working within the broad field of nutrition. Only practitioners in nutritional therapy and dietitians are trained in clinical practice to give one-on-one personal advice. Dietitians work principally in the National Health Service and are regulated by the Health Professions Council. Their professional body is the British Dietetic Association. The Nutritional Therapy Council registration scheme is for practitioners of nutritional therapy; fully independent practitioners who assess the whole individual and work with the client to achieve and maintain health through nutritional means. The Nutrition Society is a learned society whose aim is to advance the scientific study of nutrition and its application to the maintenance of human and animal health. They hold a register for nutritionists who are qualified to provide general information about food and healthy eating, but are not trained in clinical practice or to give specific information about individual therapeutic diets. Competing interests: Registered nutritional therapist, publicity chair of the Nutritional Therapy Council |
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Barton C Massey, Assoc. Prof. Computer Science Portland State University, Portland OR USA 97207-0751
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No. No it's not "worth considering". For any therapy that has been widely advocated in books or TV programs, I can find you hundreds of thousands of people who would tell you that the therapy has benefited them enormously. This includes obviously crazy stuff. If you want to claim scientific benefit for your therapy, you have to do science.
There are well-studied effects of following this kind of useless advice. Following the advice makes people feel safer. Then they take other kinds of risk. "I can keep smoking all I want: I'm eating turmeric." Following the advice of those who discount or disparage the role of scientific medicine will also undermine their perceived reliability. The number of folks who have let their cancer advance to late stage before seeking a qualified physician because they've been pursuing some alternative "therapy" for their "stomach-ache" is huge. Therapies should be considered ineffective until they are scientifically proven. Ineffective therapies are dangerous therapies. Competing interests: None declared |
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Susan A McGinty, PhD student - nutrigenomics London South Bank University, Member British Assoc. Nutritional Therapy
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So what is basic uncomplicated dietary advice? The UK's Balance of Good Health (plate model) has been around since 1995. Is it perhaps time for a review? In the US, federal law requires that the national dietary guidelines are reviewed (though not necessarily revised) every 5 years to ensure that they are based on the best available evidence. The 2005 US food pyramid (www.mypyramid.gov) carries the banner 'One size doesn't fit all' - an indicator of what is to come in advice according to genotype? The Canadians only last week introduced their new dietary guidelines (www.hc-sc.gc.ca/fn-an/food-guide-aliment/index_e.html). But perhaps the best commentary on this is from Harvard School of Public Health who have produced their own pyramid: http://www.hsph.harvard.edu/nutritionsource/pyramids.html Competing interests: None declared |
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Catherine Collins, Chief Dietitian St Georges Hospital NHS Trust
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Ben Goldacre asserts “if we excuse their (media nutritionist) silliness, do these characters improve the nation's health? If they do, it comes at a cost: because even the most superficially plausible media nutritionists distort the scientific evidence to justify their profession”. The rapid responses generated demonstrate the veracity of this assertion. Nutrition has a pivotal role in prevention, modification and treatment of disease, but is undermined by the trivial and amateur approach of the self-styled media nutritionist. They engage the vulnerable public with plausible but inaccurate argument, and recommend inappropriate supplements, superfluous blood tests and their own publications to give kudos to their ‘clinical’ approach. They breach basic human rights to a free diet with their unfettered dietary restrictions and exclusions, and leave an imprint of nutrition misinformation and guilt long after the diet has been abandoned. They are self-taught and self-regulated, the only parallel ‘healthcare’ profession allowed to do so (‘holistic’ dentistry, anyone?). The reductionist approach to nutrition - fervently embraced by the self-regulated health food industry –exhorts the vitamin/ mineral/ phytochemical ‘pill for every ill’ whilst denigrating the ‘Big Pharma’ approach of orthodox medicine. Pseudo-prescriptions of these nutritional talismen parallel conventional GP prescriptions confirming to the unsuspecting public the legitimacy of the nutritionist practitioner. Few inroads have been made to protect the public. Extension of the MHRA yellow card scheme has increased public awareness of the limitations of ‘naturally benign’ herbal supplements. The meticulous EVM Report of 2003 highlighted the lack of safety-in-use/ ‘safe upper limit’ data for 20 of the 32 micronutrients currently available on general sale. Scrutiny of media nutritionist practice remain confined to sceptical clinicians, such as Dr Goldacre (www.badscience.net), Professor John Garrow (www.healthwatch-uk.org), and Dr Stephen Barratt (www.quackwatch.com). With regards earlier responses, Registered Dietitians would disagree with nutritional therapist Patrick Holfords example of curcumin as a potent agent against disease, despite the immunology primer provided as evidence. Epidemiological and limited clinical evidence support a potential role for phytochemicals as human cancer chemopreventive agents (1). The effects of polyphenols - such as curcumin - are more pronounced in vitro, using high concentrations which are not physiological in vivo (2). Clinical studies confirm the poor bioavailability of curcumin (3), expoited to afford bowel prophylaxis for FAP adenoma regression (4). A ‘clinical’ dose of 3.6g curcumin is sufficient to achieve in vivo biochemical influence (5). Turmeric powder – a constituent of curry powder - contains 3.1% curcumin by weight (6), so ‘research-to-recipe’ equivalence would require consumption of 110g of turmeric powder daily. Mr Holfords exhortation ‘let the public eat curry’ is thus nutritionally irrelevant in the context of current research, but is recommended by dietitians for the organoleptic and nutritional benefits of the South Asian food matrix evocative of the Mediterranean-style diet (7,8). The interpretation of clinical nutrition research and its application to prevent, treat or manage disease across individuals and populations should be confined to those capable of the practice. Self-regulation of the media nutritionist is clearly inadequate, creating a minefield of misinformation that dietitians later ‘firefight’ for the confused public. For those uncertain of the quality of nutritionists, dietitians have long had an anecdotal way to separate those qualified in nutrition from those not. Avoid the amateur musings of any nutritionist advocating ‘detox’, ‘superfood’, or who recommend multiple food group exclusions at first consultation, or ‘candida overgrowth’ a viable clinical diagnosis. For those considering major dietary exclusions as a blunt tool to correct symptoms, I suggest they recall the quote by Fran Lebowitz, with whom Registered Dietitians would concur, that “Food is an important part of a balanced diet”. Catherine Collins RD
References (1) Thomasset SC et al. Dietary polyphenolic phytochemicals--promising cancer chemopreventive agents in humans? A review of their clinical properties. Int J Cancer. 2007; 120:451-8. (2) Rahman I et al. Regulation of inflammation and redox signaling by dietary polyphenols. Biochem Pharmacol. 2006; 72:1439-52. (3) Garcea G et al. Detection of curcumin and its metabolites in hepatic tissue and portal blood of patients following oral administration. Br J Cancer. 2004; 90:1011-5. (4) Cruz-Correa M et al. Combination treatment with curcumin and quercetin of adenomas in familial adenomatous polyposis. Clin Gastroenterol Hepatol. 2006; 4:1035-8. (5) Sharma RA et al. Phase I clinical trial of oral curcumin: biomarkers of systemic activity and compliance. Clin Cancer Res. 2004; 10:6847-54. (6) Tayyem RF et al. Curcumin content of turmeric and curry powders. Nutr Cancer. 2006; 55:126-31. (7) Ng TP et al. Curry consumption and cognitive function in the elderly. Am J Epidemiol. 2006; 164:898-906. (8) Scarmeas N et al. Mediterranean diet, Alzheimer disease, and vascular mediation. Arch Neurol. 2006; 63:1709-17. Competing interests: None declared |
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Andrew Craig, Health promotion specialist London SW12 8LG
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The registration efforts of the Nutrition Society and the Nutritional Therapy Council while laudable have a common and fatal flaw - they are voluntary. Those who are least in need of regulation will probably be most likely to register; while those who need to be controlled will not apply: yet another manifestation of the inverse care law. The trend in professional regulation is away from self-regulation and nutrition practice should reflect this, given the credence ascribed to it by the public. The only way to safeguard the public is through independent regulation and that means the Health Professions Council. The list of those professional groups applying for such status shows that they value it. We should expect nothing less from "nutritionists". Competing interests: None declared |
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John P Briffa, Doctor and health writer Woolaston House, 25 Southwood Lane, Highgate, London N6 5ED
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Dr Goldacre’s opinion piece [1] takes a broad swipe at media nutritionists by focusing on some silly thinking and the ‘pseudoscience’ that undoubtedly can sometimes be found in the area. The author takes particular exception to Gillian McKeith’s claim that chlorophyll is rich in oxygen and that eating plenty of it will help to oxygenate the blood. In respect to this, Dr Goldacre comments “as any 14 year old biology student could tell you, plants only make oxygen in light: it's very dark in your bowel; and even if, to prove a point, you put a searchlight up your bottom, you probably wouldn't absorb too much oxygen through the gut wall.” Fair enough, but I wonder how many of us (doctors included) have beliefs and, where relevant, employ clinical approaches that in their entirely would stand up to scrutiny. Take, for example, Dr Goldacre’s own suggestion to test the oxygen-producing capacity of chlorophyll in the gut by illuminating the large bowel: this hypothetical test, albeit tongue-in- cheek, is flawed because the process of digestion would render chlorophyll biologically inactive by the time it reaches the colon. On the face of it, some of Dr Goldacre’s own musings here might be regarded as nonsensical at those of McKeith. Dr Goldacre appears to give the impression that much what media nutritionists do is unvalidated mumbo-jumbo. Yet, many nutritionists do refer to the research and scientifically reference their work. The accusations of misinterpretation, cherry-picking, inappropriate extrapolation of data and conflict of interest can be made, but these can also be levelled at the medical and scientific establishments too: The widespread promotion of statins despite there being no evidence that these are effective in reducing mortality in the primary prevention setting is a case in point [2,3]. The area of nutrition is an emerging field, and thus many nutritionists will advocate approaches that may not have been formally studied, but do seem to be of broad benefit in practice. It seems that for Dr Goldacre such clinical experience does not count for much. Is he of the mind, then, that everything health professionals do be properly studied and validated before implementation. If that’s the case, we doctors should pack up and go home now: only 15 per cent of medical practice has been proven effective, and most of what we do is of unknown effectiveness, is unlikely to be beneficial, or has been shown to be positively harmful [4]. Dr Goldacre expresses his belief that nutritionists have deliberately over-complicated their approaches and adds, “Basic, uncomplicated dietary advice is effective and promotes health.” Given his attachment to scientific rigour, it seems appropriate to ask Dr Goldacre what evidence there is for this assertion. If anything, the evidence is to the contrary. For example, the perhaps most pervasive nutritional message that has sunk deep into the population’s psyche is certainly a simple one: that we should eat a diet low in fat and high in carbohydrate. And despite this easy-to-understand piece of advice, rates of chronic conditions such as obesity and Type 2 diabetes in the UK continue to soar. And the evidence for the ineffectiveness of low-fat eating is not merely anecdotal. Studies show that this oft-touted ‘healthy’ way of eating is, for instance, thoroughly ineffective for the purposes of weight loss in the long term [5,6]. It is perhaps worth bearing in mind that the ‘low-fat high-carb’ dictum is not generally popularised by media nutritionists, but instead by dieticians and the professional bodies to which they are affiliated, notably the British Dietetic Association (BDA). Other dietetic ‘gems’ that come from the dietetic establishment include the notion that plenty of calcium and dairy products in the diet are somehow ‘essential’ to bone health in children and adults [7-9], that artificial sweeteners are preferred to sugar for those seeking to lose weight (not one single randomised, placebo-controlled study assessing the effects of artificial sweeteners on weight is to be found in the scientific literature), that diabetics should make starchy carbohydrates a cornerstone of their diet (many of these release sugar relatively quickly into the bloodstream and tend to disrupt glycaemic control, and eating less of such foods has been shown to improve biochemical markers including those of glycaemic control) [10-17], and that taking dietary steps to reduce cholesterol saves lives [18]. I accept that media ‘nutritionists’ may get it wrong sometimes (myself included) and some make a tidy living from their efforts. But if Dr Goldacre’s cry is for more accountability in the area, I reckon he should put the spotlight of scrutiny less on media nutritionists, and more on dieticians and the BDA. References: 1. Goldacre B. Tell us the truth about nutritionists. BMJ 2007;334:292 2. Abramson J, Wright JM. Are lipid-lowering guidelines evidence- based? Lancet 2007;369:168-169 3. Jauca C, Wright JM. Therapuetics letter: update on statin therapy. Int Soc Drug Bull Newsletter. 2003;17:7-9 4. http://www.clinicalevidence.com/ceweb/about/knowledge.jsp 5. Pirozzo S, et al. Advice on low-fat diets for obesity. Cochrane Database Syst Rev. 2002;(2):CD003640 6. Willett C, et al. Dietary fat is not a major determinant of body fat. Am J Med. 2002;113(9B):47S-59S 7. Lanou AJ, et al. Calcium, dairy products, and bone health in children and young adults: a reevaluation of the evidence. Pediatrics. 2005;115(3):736-43 8. Winzenberg T, et al. Effects of calcium supplementation on bone density in healthy children: meta-analysis of randomised controlled trials. BMJ 2006;333:775-778 9. Feskanich D, et al. Calcium, vitamin D, milk consumption, and hip fractures: a prospective study among postmenopausal women. American Journal of Clinical Nutrition 2003 77(2):504-511 10. Collier GR, et al. Low glycemic index starchy foods improve glucose control and lower serum cholesterol in diabetic children. Diabetes Nutr Metab 1988;1:11-19 11. Fontvieille AM, et al. A moderate switch from high to low glycemic-index foods for 3 weeks improves metabolic control of type I (IDDM) diabetic subjects. Diabetes Nutr Metab 1988;1:139-43 12. Jenkins DJ, et al. Low-glycemic-index starchy foods in the diabetic diet. Am J Clin Nutr 1988;48:248–54 13. Wolever TM, et al. Beneficial effect of a low glycaemic index diet in type 2 diabetes. Diabet Med 1992;9:451–8 14. Wolever TM, et al. Beneficial effect of low-glycemic index diet in overweight NIDDM subjects. Diabetes Care 1992;15:562–4 15. Brand JC, et al. Low-glycemic index foods improve long-term glycemic control in NIDDM. Diabetes Care 1991;14:95–101 16. Fontvieille AM, et al. The use of low glycaemic index foods improves metabolic control of diabetic patients over five weeks. Diabet Med 1992;9:444–50 17. Frost G, et al. Dietary advice based on the glycaemic index improves dietary profile and metabolic control in type 2 diabetic patients. Diabet Med 1994;11:397–401 18. Studer M, et al. Effect of different antilipidemic agents and diets on mortality. Archives of Internal Medicine. 2005;165:725-730 19. Email communication (available on request) contact: john@drbriffa.com Competing interests: I am a private-practising doctor and health writer with a special interest in nutrition |
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Regina Wilshire, ND Candidate 65203
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"...to anyone who's interested in science, it's simply offensive to find newspapers and television channels filled with people who adopt a cloak of scientific authority while apparently misunderstanding the most basic aspects of biology." It's just as offensive that a "hard working NHS doctor" has this much time to write a diatribe, attempting to convince readers of BMJ that only a wholesale dismissal of an entire profession is not just rational, but necessary. "...even the most superficially plausible media nutritionists distort the scientific evidence to justify their profession." It seems the good doctor is just as guilty; does he seriously believe that a nutritionist is so powerful that their mere existence in the public view "tarnishes and undermines the meaningful research work of genuine academics studying nutrition." I'd like to know, how, exactly a nutritionist advising fruits and vegetables in the diet is tarnishing the work of thousands of researchers who've reached the conclusion that a diet rich with fruits and vegetables is protective? How, exactly, is a nutritionist advising fish oil as part of the diet "undermining meaningful research" when scientists the world over keep finding benefit from EPA and DHA in fish oil? Perhaps his arguement is convincing because he violates the very spirit of evidence-based medicine he accuses nutritionists of - "...they cherry pick the literature, selecting only favourable studies and ignoring the overall picture." - when he himself cherry picks the media, finds those examples favorable to his arguement and then reasons we should all fear nutritionists, all the while he ignores the overall picture of the complementary nature allopathic and naturopathic can offer together if given opportunity to do so. "...most corrosive is the way they misrepresent, from their position of dominance in the mainstream media, what scientific evidence for a clinical assertion would actually look like. Food gurus extrapolate wildly, creating hypotheses from metabolism flow charts or interesting theoretical laboratory bench data, and then using them to justify a clinical intervention." We all know this happens in conventional medicine too, yet few are railing against all medicine because a few cranks exist among the ranks of licensed physicians. "Nutrition is one of the few areas where the notion of scientific evidence for health interventions is popularly discussed: the nutritionists take this opportunity and use it to promote the public misunderstanding of science, laying fertile ground for health scares and a misled population...most offensive to me, as a hard working NHS doctor, is the way that media nutritionists assume the moral high ground, as if they were somehow the source of all that is right and good in the management of lifestyle risk factors for cardiovascular disease and cancer." So we're to accept the notion that the views of conventional medicine and established consensus on diet are the only "right" and "good" for us and everything else, anything that is not scientifically "proven" is wrong, misguided, distorted, and even dangerous to consider in the management of risk factors? If you ask me, a rational and reasonable person can and will see the value of both conventional medicine and naturopathic approaches to well-being; neither on their own provides a balaced view; but when allopathic and naturopathic are taken together a very powerful, and underutilized way to prevent and treat risks emerges to provide balance and options, where before there was only this or that, there is now this and that. Perhaps Dr. Goldacre will agree that over the years much of our newly accumulated knowledge in the area of nutrition is specifically because much of the "old wives tales" of yore are being sceintifically scrutinized and found to have merit? Funny how that happens when something seems to work and a researcher somewhere hears about it and decides to give the best science can offer in an attempt to prove/disprove its efficacy! Competing interests: ND Candidate |
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Caroline A. Morrell, Community Dietitian. BSc in Dietetics, HPC Registered, Cert MHS Greater Manchester M16 OPQ
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I am responding to the letter written by Dr John P. Briffa which could lead to misunderstandings in the medical world of the Dietetic Profession. The title of Dietitian or Dietician is protected by law and only those practitioners registered with the Health Professions Council (HPC) can use either spelling of this title. Unathorised use of the title Dietitian can result in prosecution. Any Dietitian who works in clinical practice has to be registered with the HPC. This gives the public the protection of knowing that the Dietitian they are seeing is bone fide and fit to practice. HPC registration for a Dietitian such as myself means that I have to follow the HPC Code of Conduct. Failure to do so means I can face action by the HPC, with the ultimate sanction of being struck off. Every two years I have to declare that I have undertaken Continuous Professional Development (CPD) and there is now a requirement that I have to supply proof of my CPD if asked by the HPC. Failure to so will result in a warning and ultimately being taken off the register. This means that Dietitians have to be evidence based in their practice and need to keep up to date with the latest evidence and change their practice accordingly if required. It is simply not in our interests to fail to meet the requirements asked of us. The introduction of the Knowledge and Skills framework (KSF) as part of Agenda for Change (AfC) also means we are required to provide evidence of our CPD to our employer to be able to progress up our pay bands and through our band gateways. Being a Dietitian takes a lot of dedication and hard work in what is currently a very turbulent NHS climate. Competing interests: None declared |
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Claire E Hewat, Executive Director, Dietitians Association of Australia 1/8 Phipps Close Deakin ACT 2600 Australia
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As dietitians in Australia read Ben Goldacre’s recent article in the BMJ ‘Tell us the truth about nutritionists’ we knew we were fighting the same battle: addressing mis-information in the media provided by unqualified ‘experts’. Many of our Accredited Practising Dietitians (APDs) work tirelessly with the media providing accurate and practical comments and advice on nutrition topics. We are successfully influencing the quality of nutrition stories in Australia and we are often able to squash poor ideas before they get past being a twinkle in the producers eye. We encourage both media and consumers to look for the APD credential which is the only credential for dietitians recognised in Australian. However with no government recognised credential for ‘nutritionists’ the media and consumers should always check media nutritionists’ credentials. DAA has spoken to network executives in Australia about Gillian McKeith’s You Are What You Eat program, however with Australian’s fascination with the nutritionally horrible, we have been unsuccessful in convincing them to pull the program. Claire Hewat APD
Competing interests: None declared |
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David Colquhoun, Professor of Pharmacology University College London, Gower Street, London WC1E 6BT
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I'm a little puzzled about how it can be that Patrick Holford's comment is labelled 'No competing interests'. Being the sole shareholder in Health Products for Life ( http://www.healthproductsforlife.com/content.asp?id_Content=418 ) might be thought of by the sceptical as constituting a rather large financial interest in promotion of nutritional supplements. Competing interests: None declared |
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Patrick J Holford, nutritional therapist Carters Yard, London SW18 4JR
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In reference to Professor David Colquhoun’s comments viz my competing interests, the BMJ defines competing interests as: “A competing interest exists when professional judgment concerning a primary interest (in this case the validity of research) may be influenced by a secondary interest (such as financial gain or personal rivalry).” In this particular case I was pointing out that the scientific data for turmeric – found in curry - having a beneficial effect was substantial and that it was hardly a sin for a media nutritionist to recommend people to eat it. I also stated that there is a large body of solid scientific research that supports a nutritional medicine approach for many chronic diseases. Since I don’t run an Indian restaurant I didn’t feel there were any conflicts involved in recommending curry. Neither do I run a fruit and vegetable store nor a gymnasium so a large part of the nutritional and lifestyle advice I offer involves no conflict either. It is true that for some conditions I recommend vitamins and supplements and that I have shares in a company that sells supplements, although since there is no patent on these products anyone taking my advice is free to obtain supplements from many other sources. The rules on conflicts of interest in the BMJ were formulated specifically to deal with the blatant distortion of data engaged in by some researchers writing up drug trials, which do involve patented products and which are also supported by hundreds of millions of pounds of marketing. The amount I earn from vitamin sales would barely support the lifestyle of a single drug rep. I rather feel we are comparing pea shooters with pump action shotguns here. However, in order to avoid any possible confusions or accusations in the future I shall make clear the fact that I benefit – modestly – from supplement sales whenever I cite studies supporting their use. Unlike drug companies, I do not set up such trials, pay the researchers who conduct them and then sometimes refuse to publish the data if it is not favourable. I notice that Professor David Colquhoun has so far not felt it relevant to mention his own competing interests and financial involvements with the pharmaceutical industry when knocking non-drug approaches to diseases. I assume that in the future he will also want to be forthright and state his own interests. Competing interests: formulator of supplements, shares in Health Products for Life Ltd, author of Food is Better Medicine Than Drugs |
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David Colquhoun, Professor of Pharmacology UCL WC1E 6BT
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Oh dear, Patrick Holford really should check before saying things like "I notice that Professor David Colquhoun has so far not felt it relevant to mention his own competing interests and financial involvements with the pharmaceutical industry". Unlike Holford, when I said "no competing interests", I meant it. My research has never been funded by the drug industry, but always by the Medical Research Council or by the Wellcome Trust. Neither have I accepted hospitality or travel to conferences from them. That is because I would never want to run the risk of judgements being clouded by money. The only time I have ever taken money from industry is in the form of modest fees that I got for giving a series of lectures on the basic mathematical principles of drug-receptor interaction, a few years ago. One more small correction. I don't believe that I am "knocking non- drug approaches to diseases". All I am knocking is claims, whether for ordinary drugs of for nutrition, that are not backed by good evidence. Competing interests: None declared |
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Jon M Mendel, PhD Student Durham, DH1 3LE
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Patrick Holford argues that he did not need to declare any competing interests in his first rapid response to this article because he does not "run an Indian restaurant [and therefore] didn’t feel there were any conflicts involved in recommending curry". However, Holford does acknowledge that he owns shares in Health Products for Life (a company which sells Curcumin, extracted from tumeric - http://www.healthproductsforlife.com/content.asp?id_Content=1714&id;_Content_Parent_Override=764) In his first rapid response, Holford states that "1834 studies are cited in PubMed on turmeric or curcumin, thought to be the active ingredient in this spice, many of which demonstrate clear anti- inflammatory and immune enhancing properties, 648 of which relate specifically, and consistently, to it’s anti-cancer properties". I would therefore argue that shares in a company that sells curcumin supplements are a competing interest - and should have been declared as such from the start. Competing interests: Editor of www.HolfordWatch.info blog |
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Catherine M Collins, Chief Dietitian St Georges Hospital NHS Trust
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I note with interest the above discussion from Professor Colquhuon and Mr Holford regarding declarations of interest. Mr Holford states categorically that he does not own a curry house, so exhorting the public to 'eat curry' is not a conflict of interest. I agree. But exhorting the benefits of the active ingredient of turmeric -curcumin - whilst selling such supplements from your website surely is? http://www.healthproductsforlife.com/content.asp?id_Content=1714&id;_Content_Parent_Override=764 Perhaps Mr Holford would be kind enough to clarify. Competing interests: None declared |
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Ray G Girvan, Technical writer Exeter, Devon, EX3 0ES
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It's disappointing to see three of the respondents here arguing the classic fallacy that "we should not make efforts against X because Y is a similar/worse evil". The existence of problems with mainstream medicine or dieticians or "big pharma" does not refute or diminish the argument that there is a problem with media nutritionists. Certainly there are nutritionists who operate on the basis of sound science, but the wider field appears not to have a corresponding scientific ethos and infrastructure: one with a vigorous and open mechanism for testing and weeding out false and unproven claims. If, as in science in general, we saw nutritionists more ready to apply critical analysis to factually untrue claims made by colleagues in the media under the banner of nutrition, it would give the field far more credibility as a science. Competing interests: Bad Science participant / sceptical blogger |
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