A couple of weeks ago an opinion piece entitled ‘Tell us the truth about nutritionists’ appeared the British Medical Journal which asked serious questions of about ‘media nutritionists’. It’s author, Dr Ben Goldacre, is a practising doctor and man behind the website www.badscience.net, the aim of which is to expose ‘pseudoscience’ and those he feels peddle it (including nutritionists). Unless you subscribe to the BMJ (I suspect few of you do) I cannot link to the article within the BMJ itself, so I’ve linked to it at Ben Goldacre’s own site here.
Read it, and you’ll see Dr Ben seems to have an exceedingly dim view of nutritionists. In my view he scores some ‘easy hits’ by exposing some silly thinking and taking them to task over their supposedly slopping and money-motivated handling of the science.
But are nutritionists really that bad? The BMJ allows individuals to send electronic responses to articles, so I submitted on yesterday that should (unless the BMJ decides to censure it) appear some time today. For ease, I’ve pasted it here below. Read it, and you’ll quickly realise the medical profession (of which he and I are a part) is most certainly not above question. But more relevantly, there are serious questions to be asked about ‘state registered’ dieticians and their professional body in the UK, the British Dietetic Association.
I recommend you read both pieces and make your own mind up about who the real villains of the peace are here.
Tell us the truth about dieticians too
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].
Dr Goldacre speaks of lucrative commercial contracts that some media nutritionists have with supermarkets, but at least these are on display for the public to see and judge. That’s quite different from the situation in dietetics: The BDA has multiple food industry ‘partners’, the details of which are not to be found on its website. And when I recently asked the BDA to tell me who its partners are and to what extent they funded the BDA my request was declined [19]. The BDA and the dieticians it represents hold themselves up as portals for unbiased, independent nutritional advice. But the fact that the BDA is in bed with food companies is a clear conflict of interest. And the fact that such associations are not declared publicly should give us all even more cause for concern.
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)
It seems that my posts can only be loaded up from my yahoo email address, not my university address. Does this website have a block on academic e-mails (afraid we may give too much evidence for you?!)
First of to those of you who are not familiar with the process of blogging, comments by those not registered with the site are held for ‘moderation’, and if I’m not in front of my computer, I can’t enable them. So that’s one reason for delay between you ‘posting’ and your comments appearing.
Actually, I was walking the dog.
Another is that comments sometimes end up in the spam filter, and this has been the case in the last few hours for both Chris and Jules.
Jules
I appreciate your comments about the inadequaces of the the scientific method. I COMPLETELY agree with you. But if dietetics is not evidence-based partly because of such deficiencies, let’s not say it is. If you are committed to evidence-based practice, you may need to look for a new profession, though I have not idea what this might be.
I commend you for providing all those studies, but not one of them refutes or rebuts the specifics of my original post.
No, I’m not concerned that you will provide too much evidence. But I would like you to provide evidence relevant to the original piece.
With regard to accountability, I am bound by the code of conduct set out by the General Medical Council. Do you feel I ahve transgressed? If so, how?
And as for my work that falls outside clinical practice, I regularly look at the evidence (or lack of it) and believe this speaks for itself. If you have an issue with the veracity of my opinions from a scientific perspective, then take me to task. But please stick to studies that are germaine to the points I made in my original post about low fat diets and weight loss, dairy and bones, cholesterol-reduction etc…
OK it now seems the blog liked my posts rather a lot of times – apologies for the multiple posts say the same things, but I assure you I did allow a lot of time in between attempts to load them up, so not really sure what has happened here….
Interesting reading.
In truth I have rarely seen a Dieiitian who advocates a HIGH carbohydrate diet for weight loss. I believe that to be a myth or poor practice in less up to date Dietitians. I am in the fortunate position of being qualified in both “camps” and am quite enjoying reading.
John, you are correct I’m not really used to blogs, so apologies once again for the multiple posts!
You state ” commend you for providing all those studies, but not one of them refutes or rebuts the specifics of my original post.”
What do you mean? It is clear from what I stated in my post that I do not agree with you original post where you state that the cornerstone of dietetic advice to aid weight loss is via “low-fat eating” / “a diet low in fat and high in carbohydrate”. so why would I try to prove something that I don’t agree I do. I therefore provided relevent and up-to-date references to support the type of dietetic advice that I would use. I suggest you read them before dismissing them. Many involve RCTs and RCT meta-analyses so what is wrong with them.
I also found it somewhat patronising that you said “I commend you for providing all those studies” – you can’t have your cake and eat it. You asked for references and got them. Because they are not what you want then you dismiss them.
In response to “With regard to accountability, I am bound by the code of conduct set out by the General Medical Council. Do you feel I ahve transgressed? If so, how?”
I do not know if you have transgressed from the GMC code of conduct. My point was that the nutritional advice you provide is not regulated, which as far as I am aware is not an area that the GMC would particularly consider. Furthermore, you were suggesting that dietitians are not accountable and I gave evidence that they are – to the Health Professions Council.
In response to “But please stick to studies that are germaine to the points I made in my original post about low fat diets and weight loss, dairy and bones, cholesterol-reduction etc…” – I have given my thoughts on ‘low fat diets’ already and if you REALLY want could do so for the other areas you have mentioned. However you will just dismiss what I present to you as you have obviously not taken a look at the references I have given.
Also, could you please clarify what you mean by “cholesterol reduction” – are you refering to dietary cholesterol or plasma cholesterol? If it is the latter are you talking about total cholesterol or HDL, LDL, VLDL-cholesterol – as it makes a difference if you are just talking about total cholesterol. What are your thoughts on triacylglycerol levels? How about the atherogenoc lipoprotein profile?
a little astounded by the “too thick to be nurses” comment. Ignorant. A pointless comment.
In an age where many nurses still have no degree?
I did not train here but can tell you the qualifying score for Dietetics was/is equal to that for medicine which is also a postgraduate course.
Neil
Yes, NHS dietitians are “allowed” to advise a low carbohydrate diet if it is appropriate for the patient.
Contrary to some of the views here, we do not advise the same diet for every person as we treat everyone as an individual. At the end of the day, although we adhere to a code of conduct, we are autonomous practitioners and have a responsibility to keep up to date with current research. In our training we were taught how to critically appraise and do not just accept what we are told we should believe. We then pass this knowledge on to patients to help them choose what they should eat – we do not dictate to them. We see people with a wide range of conditions, as Chris has said and although I do not doubt that there are some “bad” dietitians out there, just as there are “bad” doctors, dentists etc, please do not tar us all with the same brush.
well said karen
Further to the postings and the discussions about the BDA and where its industry support comes from, I have held off from further comments as: the discussions have been very interesting; and, there was a need to reflect on the comments made.
I won’t respond to all the individual points as many are really petty ones, correcting perceptions, responding to specific points, etc…. Details of who supports our campaigns and healthy eating messages is available on the BDA website (www.bda.uk.com) – just go into the area with campaigns info and look at the Partnerships for the Food First campaign. You can also find our annual report on the website which details some of the activities and the companies we have worked with. I don’t know why there is a perception that we are not open about our links when there is info on our website? If anyone wants to know more about industry partners connected with advertising they are welcome to apply for BDA membership, receive our publications, attend our annual conference and meet those companies who exhibit. Again, membership info is available to all on our website.
I don’t know why the issue of the BDA’s links with industry has arisen, other than through Ben Goldacre’s article. In some ways I am bemused that such an issue has been raised about the BDA. The basic principle is that this is a matter between the industry partner, the BDA and our membership. The issue of ‘transparency’ or accountability is one that our members alone need to be satisfied about, as in the case of other professional associations. We are accountable to our members for the our actions, we have no need to justify our actions to anyone else other than our primary stakeholders.
I am pleased to see the comments from dietitians and others about the profession of dietetics and the scientific knowledge and principles that underpin it. I am not a dietitian so am not able to comment further.
If anyone wants to ask specific questions about the BDA then (as per usual!) contact details can be found on the BDA website. I can’t add any more to what has been posted to date.
Against my better judgement I have decided to respond.
Chris – you may not know who I am but I looked you up. Am really pleased someone with your background thinks my comments are valid.
Neil – I agree the power wielded by Pharm co’s is wide and powerful but lets think this through logically.
On the one hand you have dietitians who (mostly I believe) work in the NHS on poor money, giving out advice to people with no impact on their wage from recommending any products. On top of that you have the NHS which is also trying to cut costs at every level (why would the NHS used expensive drugs if “natural” cures were available).
On the other hand you have nutritionist such as “Dr” Gillian, Holford and Dr Briffa, all of whom have direct income from supplement companies (the Pharm co’s) and the media. I know “Dr” Gillian has her own brands and John has products he has developed (I hope that is the right term John). Logic tells me that one group has a personal gain from recommending supplements, the other does not.
Even more like the Pharm industry, those recommending supplements can do so on the understanding that they have got someone hooked for life, what I would call a cash cow.
So which one do you trust? The one who benefits personally or the one who is independent (even if the BDA is not (which I don’t believe) its member will not gain a financial advantage from their advice). The logic just doesn’t add up.
John – On a plus side, I am pleased you do believe in conventional medicine to treat HIV. I wish you would focus your attention on the very dangerous views of Holford rather than attack NHS professionals (why have you not looking into his research?). I think your efforts would be much better served there and you may gain more respect in your field (I have not seen any support for you from any health professionals). How you can take his views in isolation is beyond me.
As a passing comment, I cannot believe you do not understand that your USE OF CAPITALS, is rude, aggressive and unprofessional I hope your bedside manner is less agressive.
You won’t believe me, but a serious question based on a comment above, do you give your dog supplements?
wow – this debater has moved on while I ahve been in work.
James the BDA really is funded by its members and some income from job adverts and advertising in our journal. I t was founded over 60 years ago by the first Dietitians.
Now the interesting thing is that dietitians really do work for the benefit of the profession and for nothing! There are may sub groups like local branches and specialist groups – sport nutrition .,diabetes , paediatrics etc. Thet are run by elected commitees and are unpaid except for expenses and that is fair enough. Sometimes the BDA will pay a trust for time spent away from the job. The daily functions are carried out by paid staff – some of whom are dietitians. i myself am on the commitee of sport nutriton and am a member of the Welsh Board. These groups and comittees do alot of work develping policies, position statements etc.
For a professional Dietitian the BDA is vital to develop practice. Study days are also part of this remit – CPD is now compulsory and all portfolios can be viewed by the HPC. Hope this makes sense.
The BDA also funds the yearly weight wise campaign and I was involved last year. Dietitians across the UK worked with teenagers and the intervention working with the families prooved to be very beneficial – my teenager lost over 2 stone and is continuing to lose wt – again with the right input.
The weight wise websites that recieved some govt funding has proved to be very successful and offers sensible impartial advice .
The thing is that many of the statements re diet made by the non dietitians have been cherry picked and are not worth much on their own!
I am looking forward to more comments.
Sincere thanks to all who have clarified re dietitians’ freedom of advice when interacting with patients and the wide scope of practice.
Re chips pies pasties cakes and biscuits. Good to limit all of these I agree (whilst not offending one’s spouse and relatives)
Again, open question, what aspects of chips are not good from a dietitians perspective? Personally, I try not to eat much of them because they are a starchy vegetable cooked in a polyunsaturated
oil ( at a guess probably soy oil as its cheap). Pretty moreish too if the cook is good.
Goodnight all
Re cherry picking advice.
Chris, this is rife whether mainstream of alternative. Crap science abounds. One easily findable example is Ancel Key’ Seven Countries study half a century ago, which really kicked off the whole ‘Saturated Fat is bad’ for real.
When I started nursing in the 1978, I got a severe bollockingon my first ward from a Ward Sister for letting an MI patient use a commode rather than perch on a bedpan. Bedrest was de rigeur for these patients back then. Now, bedrest is held to be harmful for them. Which is right? If current practice is best, then it’s likely that over a period, many people died from what was then ‘best’ practice.
I accept that the mention of products and companies on the BDA website are not ‘plugs’, presuming that none of the companies are sponsors? Call me cynical, or anything else you want to, but isn’t this is very close to what I believe is called ‘product placement’ on TV and more overtly, in films??
Promise I’ll check out some of Jules references, though there’s a lot to choose from, so if any are thought to be particularly worthy, I wouldn’t say no to a pointer.
As regards P Holford and G McKeith, IMHO, both have areas of sensible advice with an overlay of shall we say dubiousness. I’m not well up on supplements, but in the interests of disclosure. I take a moderate amount of Vit C, and Zinc/Selenium when I remember which isn’t very often.
Nutrition and diet I agree is very complex, I suspect the more we know, the more we realise we don’t know.
Another open question, as i understand it there are 3 basic foods (disregarding vits and minerals) I know that fats and protein is essential in so far as without enough of them, we eventually die, but that carbohydrates are not essential on those terms. (I am not advocating not eating carbohydrate btw I’m not a closet traditional Inuit or Masai). So then, is there a carbohydrate that is essential for life? I don’t believe so, but if there is, I’d be interested to know.
Regina Wilshire is from the USA and has her own blog in which she primarily looks at published research and health advice given to the public. I’ve no idea whether an American dietitian is the same as one from this side of the channel.
Just to answer that personal query- Personally I do not favour chips due to three main features – fat content is only one minor part. I find that in practice, when people have chips (and it can be 4-5 times a week in this area), it involves over half the plate. I do not advocate such a large portion of carbohydrate (and potatoes are not the best choice in terms of GI). It also usually means, in the case of my clients, that there are no vegetables on the plate at all.
” when people have chips (and it can be 4-5 times a week in this area)”
Like my wife’s best friend!!
Thanks for replying Marina
btw neil, on reading back I noticed your question regarding low carbohydrate diets and know that there are NHS Dietitians in the UK currently using low carbohydrate diets for their clients.
Thanks again Marina