Make you own mind up about the BDA and the dietetics ‘evidence-base’

It’s not like me to be lost for words, but I honestly am not sure where to begin.

On Friday I posted a blog which was a response to an opinion piece in the British Medical Journal in which Dr Ben Goldacre took nutritionists to task. My response focused on the fundamental lack of evidence-base in medicine and dietetics. Also, in his response to his comments about some media nutritionists having lucrative commercial contracts with supermarkets, I drew to his and the public’s attention the fact that the British Dietetic Association receives funding from the food industry but refuses to declare this in a transparent way.

The blog post on Friday has been followed by a lively debate.

If you have the time and inclination I urge you to go back to Friday’s post, and read it in its entirety along with the comments that follow.

However, I know that in this time-poor world that may be asking too much. So, as an alternative, I’m going to use this blog to summarise it as succinctly as I can. To date:

1. No dietician, nor anyone supporting the dietetic approach nor the BDA has provided ANY SCIENCE at all that supports their position

2. No dietician, nor anyone supporting the dietetic approach nor the BDA seems at all concerned about the fact that the BDA receives funding from the food industry that it does not declare openly.

I leave you to draw your own conclusions about this.

26 Responses to Make you own mind up about the BDA and the dietetics ‘evidence-base’

  1. Jules 26 February 2007 at 11:45 am #

    With reference to your comment

    “1. No dietician, nor anyone supporting the dietetic approach nor the BDA has provided ANY SCIENCE at all that supports their position”

    I have now provided some evidence for you in your previous blog (http://www.drbriffa.com/blog/2007/02/23/its-not-so-much-nutritionists-but-dieticians-we-need-to-know-the-truth-about/).

    “2. No dietician, nor anyone supporting the dietetic approach nor the BDA seems at all concerned about the fact that the BDA receives funding from the food industry that it does not declare openly.”

    I am not really sure what you mean here. The majority of the BDA’s income is from dietitians such as myself who pay a subscription. As far as I am aware the BDA is not influenced by food industry as this would be against the Health Professions Council Code of Conduct (plus why would we be swayed by the food industry really? – we are committed to promoting the health of the nation, not lining the pockets of the food indutry). In fact dietitians have put pressure on the food industry to attempt to improve the health of the nation, for example in terms of misleading food labelling, reducing sodium content of foods, food advertisments aimed at children, I could continue but really need to get on with my work now!

  2. Dr John Briffa 26 February 2007 at 12:21 pm #

    Jules

    None of the studies you provided were relevant to original points I made about the lack of evidence-base in dietetics. Please re-read the original post and then, if you wish, provide the evidence to refute the specific claims I made.

    If the BDA has nothing to hide, then why \’hide\’ the details of its funding from the food industry? You and some other dieticians may have no concern about this, but others (including other dieticians) do. Is it not alright for them to judge the facts for themselves?

  3. allan collins 26 February 2007 at 5:16 pm #

    Jules – et al

    You are missing the point here -which is that Dr Briffa is following that old ‘offence is the best form of defence’ issue.

    1. Dr (real one, just like Dr Briffa) Goldacre challenges those with odd perceptions of diet to the veracity of a) their qualifications to do so b) their rationale – ie supporting evidence.
    2. Challenging the ‘nutritionists’ out there is gaining momentum.
    3. Dr Briffa is a medical doctor. He has no formal qualifications in nutrition – and as easily detected by a dietitian – it shows
    4. Dr Briffa seeks to undermine the BDA (hem, Patron: HM the Queen) against his unique and usually non-evidence based recommendations and organisations (hem, Foundation for Integrated Health, Patron: HRH Prince of Wales).
    5. Bottom line – a diversionary approach, in order to make the BDA have to defend its views, whilst he attempts the moral high ground
    6. Conclusion: it hasn’t worked. Assume BDA has had no need to justify its finances to a journo doc with an image to keep amongst Tatlerites and other paying customers, using instead its kudos established over the last 70 years as the professional organisation of the Registered Dietitian.
    7.Await Dr Briffas challenge to the British Medical Association regarding the same – or for more fun, the Foundation for Integrated Health. The former is akin to the BDA for medics, the latter akin to a subsidiary of Solgar……

  4. Dr John Briffa 26 February 2007 at 9:05 pm #

    “Dr Briffa is a medical doctor. He has no formal qualifications in nutrition – and as easily detected by a dietitian – it shows”

    How does it ‘show’, Allan? I don’t see one thing you have ‘contributed’ that has in any way refuted my original post. I referenced my letter with the evidence to support my opinion that much of dietetic practice lacks an evidence base. If you have evidence to the contrary, please present it.

    “Dr Briffa seeks to undermine the BDA (hem, Patron: HM the Queen) against his unique and usually non-evidence based recommendations and organisations (hem, Foundation for Integrated Health, Patron: HRH Prince of Wales).”

    I have never claimed that my work is evidence-based. But the point is, neither is dietetics. Neither is medicine for that matter. Let’s all be clear and honest about this and not blind the public with our professional-sounding rhetoric.

    “Assume BDA has had no need to justify its finances to a journo doc…”

    It’s not to me that I feel the BDA needs to justify its failures regarding the transparency of its funding, it’s to the general public. Personally, I am saddened at how many in the dietetic profession claim not to see this clear potential conflict of interest as an issue.

  5. Seany 26 February 2007 at 10:44 pm #

    Hey Dr J.

    I’ve read the various posts and I’m just a bit surprised at the way your response comes across. No doubt unintentionally, my reading of what you said was “nutritionists don’t deserve close scrutiny, and even if some of them are obvious quacks we should ignore them because, erm, the rest of medicine is just as bad”.

    Do you not want to see the highest standards of practice in your chosen field? Are you not pleased that someone is taking on the charlatans? Don’t the likes of McKeith and Holford drag you down by association?

  6. Dr John Briffa 26 February 2007 at 11:06 pm #

    Thanks Seany

    I don’t think nutritionists should not be put under scrutiny. To my mind, though, it’s an easy hit for Ben Goldacre to ‘rubbish’ nutritionists by focusing on the likes of Gillian McKeith.

    And I did find his piece lacked balance.

    If his opinion is that ‘nutritionism’ lacks validity because it is not evidence-based, then he should also be aware that this is true of mainstream practice (including medicine and dietetics) too.

    So, my letter/blog was really an attempt to put some balance back into the debate. All is not completely in order in the world of ‘nutritionism’, but let’s at least level criticism with an even hand.

    Yes, of course I want to see the highest standards of practice in nutritionism. And I’m hoping that this debate will help that in some way. Just as I hope the debate might ultimately have a positive impact on dietetic practice too. We shall see…

  7. Seany 27 February 2007 at 12:02 am #

    The whole balance thing was where I was coming from.

    McKeith has massive exposure and as a figurehead for ‘nutritionism’ it is frankly quite scary what she gets away with. Goldacre’s BMJ piece and Guardian article are necessary to try to redress the balance but unfortunately will get nowhere near the same level of exposure.

    Would a more balanced approach on your part be to applaud the debunking of pseudonutrionists and address any issues you have with dietitians /medicine completely separately?

    After all, we could argue the toss about the evidence for evidence-based medicine (and the interpretation of statistics or the difference between practice and treatment, viz http://www.clinicalevidence.com/ceweb/about/knowledge.jsp)
    but what we can be clear about is that medicine has done a pretty good job in figuring out how the body works and has a lot of good evidence-based chemistry at its disposal. Can the same be said of the rogue nutritionists?

  8. Neil 27 February 2007 at 12:19 am #

    can i tell a joke?

    St Peter was showing a newly arrived agnostic around Heaven

    He says, you can join any group you like, the Catholics are over to your left, the Muslims are over to your right playing football with the Hare Krishnas (etc etc)

    Thanks says the agnostic. But tell me St Peter, whats behind that high brick wall??

    Ah says St Peter, thats the ******** , they don’t think anybody else is here.

    Well, I tried

  9. Dr John Briffa 27 February 2007 at 7:39 am #

    Seany
    “Would a more balanced approach on your part be to applaud the debunking of pseudonutrionists and address any issues you have with dietitians /medicine completely separately?”

    Not in my mind. I felt the piece was not a fair portrayal of nutritionsism in general. The sub-text seemed to be that mainstream practice can claim the ‘scientific’ higher-ground. My point (and I do think this is very important and should be more widely recognised) is that it can’t.

    Let me clarify, are you saying all nutritionists are ‘rogue’?

    Let’s be clear, a lot of nutritonists used quite a lot if science in their approach. When blood nutrients levels are assessed and deficiencies correct through diet and supplementation, is that not chemistry? When stool analysis reveals a parasite that is then eradicated with anti-parasitic agents, is this not microbiology? When blood testing reveals IgG antibodies to foods is this not immunology? Please don’t make the mistake of writing off nutritionism on the basis of the images and emotions Gillian McKeith (and her like) conjure up for you.

  10. Dr John Briffa 27 February 2007 at 7:51 am #

    Thank you Neil – always love a gag!

    And it’s a good opportunity to pause for thought.

    I get the sense this debate is not moving on much. There are clearly strong emotions on both sides, and right now there seems little room to meet in the middle.

    This is a shame, I think, as both dieticians and nutritionists seem to share the same ideal of improving the health of the nation.

    I think we’re going to need to take this debate to another level. Something more constructive needs to be done, I think.

    I’m going to spend a day or two thinking about this. In the meantime, I would obviously welcome any suggestions (constructive, please) about the issues raised over the last few days regarding nutritionists and dieticians may be debated and some sort of progress made.

  11. marina 27 February 2007 at 9:56 am #

    On giving this some thought, I can actually see where you are coming from with the concept of evidence based practice. Let me be anecdotal for this entry. I shall try not to make too many sweeping generalisations and shall base comments on personal experience.
    As I have said, I fall into both camps.
    I see that Dietitian’s are heavily focussed on throwing the “evidence based” line out, usually in conflict with nutritionists.
    It is clear that the point that you are making may be about what we consider to BE a strong evidence base and as Seany has mentioned above, we could argue the toss with the best.
    The point is that Dietitians are trained in critically examining the evidence base and working with the strength of that base but are also able to work within an ethical framework to question and develop benchmarking practice.
    In my experience, SOME non university trained nutritionists do not work to this level but more on a “google” basis. I have recently met a chap who has never heard of medline and gets all his information from one text and dubious websites.
    I have been amazed at the lack of understanding of what Dietitian’s training has been in critical reading and research.
    I have been amazed at the lack of depth of research that has been evident in the parctice of some “nutritionists”.
    I understand what you are saying, I think Dietitian’s need to think further about what they mean by “evidence based” and show that we do not mean that we are a sheep – like profession blinded by the notion that we have a flawless formula to work on for specific nutrition interventions, following a didactic line. I think Dietitians maybe need to be more broad in their description of what we base our practice on and more generous with themselves about the forward thiking aspects of the profession.
    I also think that other groups need to realise what Dietitan’s training does encompass so much more. I myself, was amazed and impressed.

  12. Seany 27 February 2007 at 10:45 am #

    I wasn’t writing off all nutritionists and I certainly didn’t say that all nutritionists are ‘rogue’, which is why I used the word ‘pseudonutritionist’.

    I think you hit the nail on the head when you said nutritionism shouldn’t be written off “on the basis of the images and emotions Gillian McKeith (and her like) conjure up”. But this is what people are likely to do when she talks nonsense without being held publicly accountable or even censured by members of her own profession.

    Whilst there are pseudonutritionists out there using quack diagnostic techniques (the McKeith stool / tongue analysis, blood cell analysis, iridology, kinesiology, phrenology, Kirlean photgraphy etc), who are free to use the term ‘clinical nutritionist’ without any form of training and do not have to belong to a single recognised regulatory body that has powers of censure, then I do feel that ‘mainstream practice’ has the scientific highground.

    Nutritionism is science, plain and simple. By regulating the profession and insisting on standards of qualification in order to practice, you would weed out the charlatans and quack science. This would not only improve the public’s perception of the profession but it would give you an equal status with dietitians and lend more weight to any nutrition-based argument you have with ‘mainstream practice’.

  13. Neil 27 February 2007 at 3:29 pm #

    Marina wrote

    ” I think Dietitian’s need to think further about what they mean by “evidence based”

    I would apply that to ALL our health professions Marina. There is an underlying assumption among health professionals that because a large study or trial has been conducted on behalf of government or industry, it is good quality research. This plainly is not the case
    How many professionals have the time to read much more than the abstracts of the myriads of papers that exist?
    Equally, how much relevance has a trial that enrols twenty people and a dog for a 3 week multiple intervention ‘trial’?

    It is difficult, but important that we all keep our critical faculties when looking at evidence.

  14. Dr John Briffa 27 February 2007 at 3:36 pm #

    Seany
    I don’t agree that ‘nutritonism is science, pure and simple’, just like medicine and dietetics are not either in my opinion.
    Are you a health professional?

  15. Catherine Collins RD 27 February 2007 at 4:41 pm #

    Is it worth it? (to misquote L’Oreal!)

    I would suggest that this whole thread – and the preamble – do not foster genuine debate regarding the relative roles of dietitians/ nutritionists/bloggers but IMHO merely serve as a piece of rather unpleasant media self-promotion by Dr Briffa.

    These recent threads appear – for the first time visitor – to have been solely for the purpose of Dr Briffa to undermine the practice of dietetics, Registered Dietitians (ie the sole nutritional professionals regulated to practice nutrition within a legal framework in the UK) in general, and the dietetic professional association – The BDA – in particular.

    One has to wonder – at a time when ‘nutritionism’ is under media scrutiny – why such vitriol from a member of the GMC, and from an individual with no apparent qualification in the subject? – although I am happy to stand corrected by Dr Briffa on this.

    And just how ‘professional’ is it for a so-called ‘medical doctor’ to insult a profession about which it is clear he knows so little about? Does the GMC code of conduct endorse such vile and unjustified comments by its members?

    I have to conclude that the sole reason must be that Dr Briffa – a medical doctor yet self-styled nutritionist – considers himself ‘in competition’ with dietitians for media and commercial exposure, especially after the furore raised by Dr Ben Goldacres ‘Bad Science’ columns in the Guardian.

    It is clear from his website that Dr Briffa considers himself quite a nutritionist, and as a dietitian I have no issue with him promoting his unique approach to the subject. However, his condescending and frankly insulting replies to the comments of RDs and the BDA proves he knows has a limited nutritional repertoire typical of the ‘alt-nutritionist’ genre – quick to dismiss ‘evidence based’ approaches, eager to undermine perceived potential detractors, yet apparently unable to place his patronising comments into context of any useful advice for the public to take.

    I will assume that Dr Briffa will post a reply to this note, but please be assured that my initial interest in how Dr Briffa presents himself to the public has been satisfied, and I have no further need for this site.

    I would suggest that fellow RDs also do not waste time, effort and consideration on the futile practice of attempting a debate with Dr Briffa. I would, however, strongly recommend sampling Dr Ben Goldacres highly interesting debates on his blog, at http://www.badscience.net.

    Dr Briffa may keep his coterie of likeminded nutritionists keen on his brand of nutritionism. As a dietitian, I will continue to practice dietetics.

    Each to their own.

    And if the public are confused about the status of nutritionism-medicine, I would suggest contemplating the following.

    I trust my gynaecologist and my dentist. But I would not want them to swap ends…..

  16. Dr John Briffa 27 February 2007 at 4:58 pm #

    Catherine
    I was hoping that we might be able to raise the debate somewhat. I appreciate you may not be keen to do that, but for all those reading this please do not that let that put you off offering contructive comment.

  17. Dr John Briffa 27 February 2007 at 5:04 pm #

    Partly as a result of Catherine Collins’ above, I have taken the decision not to allow posts that do not seem to further the debate or add constructively to it.

    Again, let me reiterate I am genuinely willing to hear from anyone who feels they have suggestions to make about the way forward. You can comment, or contact me via the contact button above.

  18. Steve 2 March 2007 at 3:48 pm #

    I thought it was the job of the health professions to listen…

    I thought science was based upon evidence not emotions…

    To be become qualified to speak on a subject, you have to answer the question you are being asked not the one you want to answer..

  19. Julia 3 March 2007 at 10:57 am #

    I suspect that the reason this debate (and many others like it in medicine and elsewhere) seems not to be moving forward is that it is genuinely impossible. Do any of you know of an open debate amongst professionals on the internet which has moved things forward in their arena?

    I originally studied anthropology, and although I never practiced, and therefore have no qualifications to comment, this debate has looked to me like a ritual of the sort you see in all cultures. If you set up a ritual in a “closed” way, where only certain things can be said and done, then you can control the result to a large extent. That control isn’t here, so people are welcome to use it as they wish, and usually that means an attempt to achieve each individual’s goal – for power, exposure, status, money, or whatever it happens to be. Very few academics believe in the existence of altruism, so informed, constructive debate to advance to public good necessarily takes a back seat to these other agendas.

    I don’t mean to criticise any of you in this. I don’t see how anything else could have happened.

    If you really want to try to achieve a constructive debate, you could try an eGroup with heavy moderation. The moderator needs to be someone “outside” the debate who has an understanding of the subject and the respect of those posting. Posting needs to be controlled by the moderator according to publicly stated rules (e.g. only those with certain qualifications can post, all “personal” remarks rejected, evidence always cited – and the lack of it duly noted – etc). The moderator has the final decision about what to post and what to reject. And finally – absolutely all posts must be anonymous and untraceable to their writers. If you can manage that, you will get closer to constructive debate. People will still push their professional agenda, of course, but you can eliminate the purpose of a lot of the personal posturing.

  20. Thea 3 March 2007 at 9:44 pm #

    As a new mother I have found your nutritional advice (Healthy Kids book) wonderful. Using nutritional advice I overcame a yeast overgrowth and lost a stone in weight having been given antibiotics after birth. My daughter developed eczema after I introduced dairy – yet when cutting out cows milk it disappeared. But when seeking the advice of doctors, health visitors and dieticians – they just offered steroid cream and “you must give her cows milk, for healthy bones etc”. I’ve wanted to thank you for your advice for a while as my daughter is now 2 and very healthy. I think you’re doing a great job and see you as a very important spokesperson for health. Keep up the excellent work! Why not have your own TV show like Gillian McKeith?!

  21. Natalija 4 March 2007 at 12:03 am #

    Well just to illustrate British dieticians good doing:

    16 years ago at the age of 25 I cam to this Country, stable weight, healthy.
    After some time I decided that to be even more healthy I should follow up British dietitians society recommendation for healthy eating: a lots of carbohydrates, low fat, etc.

    Result 30 kg extra within a year. Completely disturbed life patern. Problems loosing weight, tiredness, sleepiness, bloatidness, candida…

    And do not tell me it is something else, I went to British GP-s for years to find out what is wrong, and they could not find any “thyroid” or other disturbance. I was accused of eating “loads of chips”.
    For you information I loath chips, and the only adjustment to my original diet (I come from Mediterranean country) is to follow instructions of BDA, hoping to be even healthier than I was.
    Now I am stuffed, and the only way I found myself functioning is following my old eating habits which ar enot very different of what Dr Briffa is advoacting. However the health and the looks have been ruined by your advice, further toped by GP-s disinterest to help!
    So. please do not make coments like above, because really it is depressing. You should try to learn something new.

    Perhaps instead insullting, you should try to cooperate with and learn from other people. Why not disclose you close asociations with food industry.

  22. helen 4 March 2007 at 10:28 pm #

    wow don’t some people get their knickers in a knot? From what I can hear dietitians spout the politically correct party line – eat low fat & consume around 60 to 70% of your diet from grains & high sugar fruits & green leafy veggies, eat little meat & avoid saturated fats.
    While I have nothing against the green leafy vegetables I do consider their advice flawed when all you have to do is look at what fat people are eating – pasta, bread, rice, margarine, sugary low fat products & prepackaged foods of course the low fat ones, margarine instead of butter, low fat milk & cheese & of course the biggest health myth of all soy!!
    This is what all these dietitians are saying is what we must eat & it is what all the fat people are eating! only they must be lying because fat people eat the wrong things, right?

  23. Helen 5 March 2007 at 9:10 pm #

    Having just read this blog I feel a little saddened. If everyone put all the energy they have used to belittle each others qualifications into helping each other & working together to understand each others specialities wouldn’t we all be better off?

    From what I have read, dieticians, nutritionists & nutritional therapists all differ from each other in what they study & how they practice. Reading this blog it seems to me that many people assume nutritionists & nutritional therapists are the same thing. It’s my understanding that they are not.

    I am currently studying nutritional therapy & I understand that in order to practice once qualified I will need to be registered with BANT – only those obtaining a qualification that covers all the required theory plus a substantial amount of clinical practice will be able to register & obtain insurance etc. I would strongly advice anyone thinking of consulting a nutritional therapist to check that the person is BANT registered. Unfortunately these regulations are relatively new & there are people out there, including McKeith, who do not have the required level of qualification to register. That, I believe, is why Ms McKeith calls herself a ‘clinical nutritionist’ because she is not qualified to call herself a ‘nutritional therapist’.

    Nutritional therapy is termed as a complemetary therapy because it complements other types of therapies & medical practices. This by definition means it does not need to exclude them.

    So let’s stop stepping on each others toes & instead let’s start working together to share our knowledge in order to help people, each in our own way.

  24. Sophie 23 March 2007 at 8:54 pm #

    i’ve watched the comments on this topic with mild interest and bemusement and the amazing level of ignorance of some people out there, i realise it has been a while since anyone has posted but still for some peculiar reason i found the need to comment.

    as a dietitian the whole dietitian/nutritionist comment has been ongoing since i began as a student, personally i see our roles and interests different and have a great deal of respect for the main practising nutritional therapists out there giving sound advice to clients, its a shame there is so many cranks (most of whom appear to be on tv or running cranky websites) who ruin there reputation.

    there seems to be the misconception that dietitans only deal with weight loss, diabetics and the odd supposed food intolerance, all of which i could not have less time for personally.

    i get far more satisfaction helpingf patients with a clinicl condition that greatly affects there quality of life, be it cancer, renal disease, crohns, inflammatory bowel, dysphagia or many of the important clinical conditions where we can have a massive impact on imprving someones quality of life.

    the focus on overweight and obese people in the press drives me INSANE its about time someone paid attention to the 1000s of undernourished people out there, the kind of people who i see every day that are far more in need of our care and advice and who cost the NHS twice the amount that overweight people do.

    so to all you ignorant people out there who feel you can coment on dietetic practice, go fing out what we REALLY do, which is sound evidence based regulated practice, leave the weight loss advice to the nutritionists if they like doing it so much, they are welcome to it.

  25. Andy 2 April 2007 at 11:25 pm #

    Helen, could you or anyone reference where a nutritional therapist must be BANT registered?

    BANT say that NTs must be regsitered with the Nutritional Therapy Council. But the NTC say that such people do not ‘warrant statutory regulation’.

    http://www.nutritionaltherapycouncil.org.uk/ntcstatus.htm

    Looks like there is a lot of confusion out there. All these organisaitons trying to make nutritionists look like a regulated profession when indeed they are not!

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