It’s not so much nutritionists, but dieticians we need to know the truth about
Posted on 23 February 2007
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
Published February 23, 2007 . Filed under: Food and Medical Politics
dear Dr Briffa
you seem to have problems understanding the literature on dietary advice and its potential to treat or modify illnesses. You appear to mock the concept that reducing total and LDL cholesterol reduces cardiovascular risk (refs 2 and 19), yet have missed the point completely by using references on the use of DRUG effectiveness to minimise risk – these were not studies of diet and disease prevention alone. There are around 500 papers on the latter. What a pity you missed them all.
Your low fat/ high carb recommendation for CVD prevention is about 10 years out of date. Perhaps you should read the recommendations which post-date this statement http://heart.bmj.com/cgi/content/full/91/suppl_5/v1. Even if you INSIST you are right, then your ‘high carb’ exhortations is nicely contradicted by your concerns about glycaemic index and glycaemic load on metabolic syndrome, diabetes management etc etc. If you check the free access PubMed on the subject you’ll find a lot more useful and more up to date research in this field.
finally, I see that you seem to think that the BDA have some ulterior motive in not informing you of their industry partners. Could you elaborate? Are you suggesting that the BDA give out dietary recommendations based on how much money they receive from companies? If thats your belief, I think you need to explain a bit further.
.
February 23, 2007 @ 12:46 am
Dear Allan
Thank you for your comments.
Permit me to take them point by point:
\”You appear to mock the concept that reducing total and LDL cholesterol reduces cardiovascular risk (refs 2 and 19),
February 23, 2007 @ 9:06 am
thanks Dr Briffa for your prompt reply. You are of course correct in stating you don’t actually exhort a high carb diet in your blog, but guess i missed the point as you say a lot of what you disagree with, just not a lot of what you recommend.
Ditto also your reply that you ‘were not referring exclusively to cardiovascular disease risk’ when talking about statins. I hadn’t expected that you had based this statement on the use of statins for management of conditions other than CVD. This could be rather confusing for the general public. A bit like saying ‘blood pressure tablets are ineffective (subtext – particularly if you take them for a sore throat). No-one would expect this comparison.
I should have cited ref 18, not 19, in the above when expressing concern of your comments regarding statins.
Apologies
The plethora of papers supporting a complex carb based diet (such as the Mediterranean approach) are readily available on PubMed. I’d have thought as a doctor you would have been able to read them. I don’t think you would want your blog filled with a whole load of clinical references….. but maybe this would be useful? Then interested bloggers could look at the sources you refer to when making your comments?
Finally, it would be interesting to hear your reasons for your views that the BDA have “an obvious conflict of interest here that I believe the public should be aware of”. This does appear that you have some issue with the BDA. There does seem to have been a lot of sniping in the press recently which is the basis for your article above. By not actually stating WHAT your issues are with the BDA it does appear that you are another ‘professional’ trying to establish your position/ credibility by undermining another person/ organisation? Can you give any more details to avoid this apparent position?
February 23, 2007 @ 10:44 am
Dear Allan
Again, let me take your points in turn.
February 23, 2007 @ 11:27 am
Interesting to read your comments re Dr Goldacre, having just recieved an email from Network Dietitians (dietitian’s newsletter) delighting in his comments, (particularly against Gillian McKeith). Patrick Holford has also recently written in his newsletter to defend himself against critics in the medical and dietetic professions.
Maybe I just have a too simple, naive approach to life but I wish medics/dietitians could be less critical of many practioners, who are are frequently well educated and informed about nutrition, and accept that they can also make contributions to health improvement (more Patrick here).
Many ‘media nutritionists’ stole the march on the BDA (& the medics) in terms of media exposure on public health issues such as obesity (why who knows – it should have been a major part of their work!) and often I think criticism & sniping is their way of trying to claw it back. Surely it should be a common goal to help the population look after their health through better nutrition. Wouldn’t it be more productive if a more united front could be presented.
I am a student dietitian, with leaning to and interest in natural health and my o my, my brain gets mashed at times trying to take both sides into account and attempt to formulate my own balanced opinion!
February 23, 2007 @ 4:30 pm
Dear John, I am a frequent visitor to Ben’s bad science web site and much of what he has written is interesting and can be informative. We are all aware that there are nutritionists and there are nutritionists and not all are the same. Patrick Holfords dalience with misrepresentation together with bogus qualifications for Madam McKeith should be enough to ensure that they dont make any more appearances on TV. They give your profession a bad name.
However all that said the biggest issue that struck me on your piece and comments that followed is the blinding ignorance of the so called specialists be they doctors or dieticians .
We live in a world exploding with obesity and Diabetes type 2 but only 30 years ago this was a truely minority sport. Pre 1980s the only diabetics were type 1′s and a few type 2′s who were in middle age or older and had packed on the pounds.
The diet recommended to diabetics was to reduce your carb intake so that you can reduce your insulin release / dependancy. Very logical. Infact it makes sense as the only foods that really stimulate insulin are carbs especially sugar and starchy carbs.
Suddenly due to some very bad science produced by Ancel Keys and others we all started worrying about fats and the low fat diet madness started. Notwithstanding the fact that the largest heart studies have always shown that there is no correlation between diets high in saturated fats and CVD. Infact in the recent report out of Harvard suggests that woman in the menapause on a low fat diet actually increase thier risk of CVD.
Since the low fat madness arrived our rates of obesity have risen dramatically while …..our calorie consumption has been reduced. Not only that for those out their who think it is to do with a lack of exercise …..PLEASE READ THE SCIENCE…This is a myth created by dieticians and others who simply cant understand why we are getting fatter and fatter while we eat less fat and less calories.
Anyone that goes on a proper carb controlled diet will find that with NO EXERCISE and NO CALORIE COUNTING and NO HUNGER PAINS they will discover thier shape naturally as the body begins to effectively use the food it consumes.
Finally for anyone out thier who is still stupid enough to think that a low fat diet is right ( INCLUDING DIABETES UK) and cant be arsed to read the science ask your self this simple question.
Why did we evolve to eat a HUNTER GATHER DIET. I think we can safely assume that Darwin is basically right. Animals evolve to survive and not die. Our diet for 10,000 year was a high fat high protien low carb diet and that is what you are designed to eat. WE HAVE NOT PHYSICALLY CHANGED SINCE THAT TIME. Please also note that notwithstanding the bollocks we read in our press, Hunter Gatherers were not constantly running about..Take a look at lions..One burst of energy and then lie down for a few days. Think visits to the gym rather than the life of an agricultural worker.
If you want to work in the fields for 16 hours a day then please do go and eat some starchy carbs or sugar. If not, DONT EAT THIS FODDER WHICH WE USE TO FATTEN UP CATTLE. What nutritional benefits are in these foods? Zero is a word that comes to mind.
Finally whilst many doctors can not be bothered to worry about nutrition and diet as they focus on drugs etc we should not leave this important speciality to dieticians who are those were too thick to became nurses. How many dieticians have read the framingham heart study or even understand the rules of thermodynamics.
Finally yes some nutritionists should be thrown out of your growing profession but frankly give me a nutrionists any day to a scarey fat dietician..BY the way have you noticed that most dieticans advocating a low fat diet are actually FAT>>>>
February 23, 2007 @ 4:42 pm
[...] Having a pop at media nutritionists seems to be in vogue right now. In a message to the BMJ (British Medical Journal), the UK’s top nutrition doctor, John Briffa, has come not exactly to their defence, but changes the focus, challenging Dr Ben Goldacre (a high-profile nutritionist critic) and dieticians about their “higher ground”.read more | digg story Filed under: Uncategorized [...]
February 23, 2007 @ 5:23 pm
diet and disease prevention alone. There are around 500 papers on the latter. What a pity you missed them all.
What a pity you seem to have missed the Cochrane Collection review – considered the \”gold standard\” of meta-analysis for evidence-based medicine, concluded in their review Dietary advice for reducing cardiovascular risk that \”Dietary advice appears to be effective in bringing about modest beneficial changes in diet and cardiovascular risk factors over approximately 9 months but longer term effects are not known.\” It\’s noteworthy that their review netted only 23 studies that qualified for inclusion – kind of tells you something about the quality, or lack thereof, of the remaining papers published so many rely on.
Since that review was published, not one study since has brought us compelling data to effectively render the Cochrane review null and void. If anything, a number of studies published leave the question of long-term advice on the dogma of \”proper diet\” for long term health even more questionable. And do note, I said \”dogma\” not \”data\” – that\’s because the evidence is growing that the current dietary recommendations may in fact be flawed at its heart (no pun intended) and may indeed be counter-productive in the longer term for health and prevention of chronic disease.
But, that isn\’t the gist of what Dr. Briffa highlighted in his reply to the BMJ editorial (which I have also read). From my take on what Dr. Briffa has issue with is the wholesale dismissal of \”nutritionists\” because some of them are truly flakes…just as, I think you\’d agree, some medical doctors and registered dietitians are too. A degree only tells us one thing – an individual persevered long enough to get through final exams and a good enough memory to answer the questions as desired.
A degree, whether an MD, ND, DO, RD or what have you tells us nothing about whether an individual has any common sense, critical thinking skills, or the ability to read, understand and interpret statistical data contained within scientific and medical publications. Let us not forget that every graduating medical school has 25% graduating at the bottom of their class who will still be granted a license to practice medicine!
What I see Dr. Briffa took issue with strongly is the lack of disclosure of what could well be conflict-of-interest by the BDA (the British equivalent of the American Dietetics Association); if someone is to take issue with \”nutritionists\” as Dr. Goldacre did, than perhaps he should also look to see if his side of the street is clean and tidy.
With scandals of failure to disclose potential conflicts-of-interest in multiple medical and scientific journals; leading health organizations refusal to disclose funding levels from corporate interests; and the failure of even those in the media from disclosing source of advertisements and \”segments\” for the news created by corporate interests; and a growing campaign to squash open-access from ever gaining ground….well, Dr. Goldacre appears to be rather simple-minded if he thinks the problem is \”nutritionists\” – or that their very existence \”tarnishes and undermines the meaningful research work of genuine academics studying nutrition.\”
Get real.
Let\’s not forget, earning an RD takes little more than being able to regurgitate the dietary guidelines with absolutely no training along the way in statistics – nothing about how to interpret data, determine of clincial significance of findings from statistically significant findings, calculate out relative and absolute risk from data – nope nothing along the way to really make them evaluate and THINK….instead they\’re trained to rely on what others tell them the data means…if that\’s not dangerous, I don\’t know what is.
February 23, 2007 @ 5:24 pm
1. Ben Goldacre is frequently entertaining, and able to put the boot int easy targets such as GM and PH, but seems to be automatically anti anything non-mainstream. I emailed him once to ask why his Bad Science column didn’t take on the manipulated data behind the promotion of statins, which were a lot less beneficial than touted.
His reply was “what about 4S?” (Simvastatin trial)
I replied that if you looked beyond relative risk, at other equally or more valid ways of assessing benefit, then the results of 4S were positive in a small way towards statins, rather than being a panacea.
He didn’t reply. I can’t say why, but one possibility is that he doesn’t want to look hard at anything that will show the hype for what it is.
He may of course have thought I was a numpty and not worth wasting his time on!
2. Totally agree re the BDA. If they think there is nothing wrong with being partly financed by industry, then no reason not to disclose.
3. Even if dietitians have doubts about what they are taught, and then teach it to the public, they don’t have a lot of choice, apart from to quit and find a new source of income. Ditto for GPs and statins, Diabetes nurses and diabetes diet. You tend not to bite the hand that feeds you!
4.Framingham Heart Study Dr M Eades has a copy of a (or the?) report see here http://www.proteinpower.com/drmike/?p=285 and has summarised and quoted from it. But I’ve never seen any published data/tables etc.anywhere else. In the timeline on this Framingham website http://www.framingham.com/heart/timeline.htm it says that in 1961 “Cholesterol level, blood pressure, and electrocardiogram
abnormalities found to increase the risk of heart disease” A statement which is flatly contradicted by Dr Eades quotes.
Frankly if the trial that is held to be ‘numero uno’ in proving the diet-heart hypothesis actually demonstrates the opposite, then one has to ask why it is so revered in mainstream circles. And if the data is so unequivocal about the risks of cholesterol and saturated fat, why isn’t it easily available to the general public. If it is in fact available at all. Anyone got a link to some genuine data please??
February 23, 2007 @ 9:09 pm
“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 ”
I take this to mean that taking statins as above has no effect on the risk of popping ones clogs, however what I dont understand is whether there is evidence (or not) that taking statins decreases the risk for example of a stroke which leaves people disabled, not dead. This, (what with the deficiencies which include abuse and neglect, re services for older people in our hospitals and nursing homes) – would seem a fate worse than death. The info sheet given by my GP says the risk of stroke or heart attack is much greater if cholesterol is not reduced. If this is the case are there other factors or indicators, for example which GP’s dont routinely test for?
Could Dr Briffa explain?
February 24, 2007 @ 1:03 am
Further to your comments about the BDA and its source of funding from industry, the nature of the links and funding are matters which are commercially confidential to the BDA and its members. We are not a charity or a publicly funded body – the majority of our income comes from our members subscriptions and from advertising and publishing. However the support provided by industry is very minor to our income. Industry sponsors exhibit at our annual conference, they advertise in our magazine and they seek our advice on developing healthy eating messages for consumers and companies. The vast majority of industry collaboration is, however, unpaid because we work with agencies (such as the Dept of Health and FSA) who cannot afford to pay us any money, but who we are happy to work with. You will not see any claims or messages related branding of companies from the BDA. As with most regulated professions we do not endorse products (nor do registered dietitians), messages which are not in the public interest or support individual companies. Our policy on industry sponsorhip is rigorous and we do not work with any industry partner where we are concerned that it would affect the independence of the profession and its members. We do not allow conflicts of interest to arise.
The companies that pay us, do so in ways which are identical to other professional associations. Our income from industry partners based on non-advertising is about 5% of our income. This is not significant in relation to our core income streams. As a comparator, the British Medical Association had ‘other income’ in 2006 (un related to publishing, etc..) in excess of
February 24, 2007 @ 7:36 am
Thank you
February 24, 2007 @ 8:49 am
Well done John!! At least with your medical credentials you are entitled to respond the way you did and I thank you!!! I have always been deeply concerned about (Dr!) Gillian Mckeith and that terrible programme she has on TV – the misinformation that pours from her mouth beggars belief and does nothing for those of us with good credentials and years of experience. I have been working with medical doctors for years and whenever I meet a new one I have to start from the basics to reassure them that I won’t come in burning incense and dangling crystals at them!
I’m also Vice Chair for the ION and at times we have to do a lot of firefighting to save our reputation, but thankfully the new Grandparenting and regulation with registration should sift the chaff from the straw, or is it wheat – I’m not sure!!
February 24, 2007 @ 9:25 am
Andy wrote “Our income from industry partners based on non-advertising is about 5% of our income. This is not significant in relation to our core income streams”
Income from industry advertising is still income, why not include that income as well. And then there is the reasonable inference that ANY publisher would be less inclined to be critical of an advertisers products.
Still seems that either the BDA or their sponsors are afraid of full disclosure here. Lord knows why! And I firmly believe that every organisation that advises the public on health issues should be fully transparent regarding any source of income and potential influence.
February 24, 2007 @ 2:50 pm
Susan
First of all, I don
February 24, 2007 @ 3:14 pm
Susan: From The Great Cholesterol Con by Dr Malcolm Kendrick.
” In 1995 The Lancet published a massive study that looked at 450,000 people over a period of 16 years, who suffered between them 13,000 strokes……the conclusions thereof ‘There was no association between blood cholesterol and stroke’.
More recently a pan-European study known as EUROSTROKE published in 2002 ….’This analysis of the EUROSTROKE project could not disclose an association of total cholesterol with fatal, non-fatal, haemorrhagic or ischaemic stroke’ ”
Therefore, cholesterol levels are unrelated to the incidence of stroke.
It is true that statins reduce the risk of stroke.
It is also true that statins have NOT been shown to reduce overall mortality (dying of any cause) in women.
It is true that statins do not reduce overall mortality in men without heart disease.
Therefore, statins do not reduce overall mortality in over 95% of the population.
Well over 200 ‘risk factors’ have been identified as being associated with heart disease. ‘Associated with’ does not mean ’caused by’. A common explanation of this is that firemen are strongly associated with major fires, but are not the cause of those fires. Even if high cholesterol is associated with heart disease, this most emphatically does not mean that it causes heart disease.
February 24, 2007 @ 3:57 pm
Hi Roz, yes it
February 24, 2007 @ 5:48 pm
Sam
Thanks for both your posts, which I think are pertinent, balanced and intelligent.
I don’t agree with your point about qualifications – as I’ve said before, we should be concentrating on the message (not the messenger). Several posts that have really contributed to the debate and I think are very well informed seem to have come from individuals with NO nutritional or science-based qualifications.
Compare that to those of Allan Collins from the pro-dietetic camp and the BDA itself. No wonder your profession is feeling increasingly discredited!
I am very pleased that things are changing – not a moment too soon I say.
And can I say that if more dieticians had your seeming balance, clarity and wisdom, this debate wouldn’t need to happen at all.
I genuinely wish you well in your chosen career.
February 24, 2007 @ 6:30 pm
I’ve just noticed an error I made in my original post numbered ’4′.
I had written: “Take a browse through my blog and you will see that I write regularly about the general benefits of carbohydrates that have considerble capacity to disrupt glycaemic control”.
This should have read “Take a browse through my blog and you will see that I write regularly about the general benefits of cutting back on carbohydrates that have considerble capacity to disrupt glycaemic control” and is now amended.
As my original post and letter to the BMJ states, I do make mistakes…
February 25, 2007 @ 11:15 am
Hi – i am a Dietitian with over 20 years experience. This debate has been raging since i qualified and I feel it may be coming to a head. Just to note i work freelance but also work for some GPS in south wales and I am a sports dietitian
On a daily basis I work with people form all walks of life. The science is one thing and we can all quote one study after another – lord knows my office is full of the stuff! BUT when it comes down to it getting it over to patients is the important thing. THis is where DIetitians excell – if you knew how we are trained then you would understand . Here is an example I have a family I affectionatly call the chip family – they eat chips for every meal – now how do you go about changing their really unhealthy lifestyle! Telling them to take supplements and gojo berries would go down like a lead balloon. I now have them on chips once a day so we are getting there but this has taken 4 months! It has taken alot of time and teaching on my part! Dietitians are very skilled at this SO STOP KNOCKING THEM. Most of you really do not have a clue about our skills and perhaps some of it is our own fault or has been in the past – we do not praise ourselves enough.
On a weekly basis I see patients or private clients who have seen psuedo nutritionists and the advice is frighteningly bad and completly unpractical. As students we just didnt study the theory but the practical too – cooking, weighing food so u know what a portion actually is, taking food histories – not as simple as it sounds.
This industry needs regulating – if I read a book on surgery would I be able to call myself a surgeon – i dont think so! Here is a recent example – a liitle girl who had allergy tests by a practitioner, a photocopied diet sheet was given to her with a list of foods to avoid – mum was asked to purchase
February 25, 2007 @ 12:31 pm
Hello Chris
Thank you for your comments.
I have not doubt that there are some dieticians out there doing very good work, just I am convinced that the same is true for nutritionists.
I don
February 25, 2007 @ 1:31 pm
John, interesting that you talk about Dr Goldacre, I understand he has high regard for Dietitians and I assume he works alongside a number of them in his NHS role. I also understand you work alongside a Dietitian at one of your private hospitals (St John and St Elizabeth). I would be interested to hear her comments on your blog. Are you in conflict in the advice you give? Are you also in conflict with the WHO whom I believe support the advice of dietitians. Is there a world consipricy on nutrition whereby only private practitioners who support widespread use of supplements are telling the truth?
There is also the hint on Dr Goldacre’s website (not from him) that he has not been able to comment about you due to his links with the Guardian Group.
Also, isn’t the BDA just (in affect) a trade union? Should your attack not be on the Health Professionals Council who Dietians have to be registered with?
Sorry for anything that is incorrect re the BDA etc, I’m not a Dietian, I’m an accountant!
February 25, 2007 @ 1:47 pm
gosh this is throwing up quite alot of conflict .
Anecdotal notes I think are important – I wish there was a way of reporting this to someone.
It is interesting your rather childish comment on overwt dietitians – i know a few but just a few!
I think you have been rather unfair to Andy – the staff at the bda are actually matched by loads of dietitians giving up their own time to further the profession.= – me included.The BDA is not in the pockets of the food industry – in fact if you knew anything about our code of conduct we are not allowed to be. Most of its income is from the likes of me and some advertising – alot from job adverts. Just remember that some of the advertising and trade stands are not from food based companies but clinical products like supplement drinks, enteral feeds etc. This is actually very useful as a source of info at exhibitions. The bda does not endorse products and in the nhs most are not allowed to give out info from companies either
How little you know – the BDA is not a trade union per se – it is affliated to the trade union but is a completely different side to the professional side. We need representing too – dietitians need help at times with work related problems and can join another union if you want to..
It is important to consider one point here – would u prefer a free for all in the nhs and let everyone loose on patients because if regulation of dietitians and others like physios was not in place the that is what you will get. Dietitians are not the only profession to suffer physios are being invaded by sports therapists etc – again no control.
Dietitians do look at evidence and adjust dietary advice – I think we just give honest and simple advice that people can follow – not low fat / high carb rubbish. I feel as a Dietitian our existence is being threatened from all sides – maybe I’ll be a pseudo doctor or accountant because one thing for sure the whole world is an expert !
Regulation is important – you have none only your medical regulation.
February 25, 2007 @ 2:24 pm
James Ferris
Let me take you comments point by point:
February 25, 2007 @ 2:58 pm
Chris Cashin
February 25, 2007 @ 3:36 pm
Chris Cashin said
” The bda does not endorse products…..”
How about this from Functional Foods pdf leaflet on the BDA website
” You will find a number of foods containing prebiotics on your supermarket shelves such as Rice Krispies Muddles, Warburton’s Healthy Inside bread and Muller Vitality yoghurts and yoghurt drinks”
Flora, Benecol, Danone, St Ivel and others all get plugs.
Looks like a free advert to me.
Open question, can anyone tell me if an NHS dietitian would be allowed to recommend a low carbohydrate diet to a patient?
February 25, 2007 @ 4:38 pm
Neil
Thank you for drawing all of our attentions to the the mention of specific products in BDA literature.
February 25, 2007 @ 5:18 pm
John
My points on Dr Goldacre are revelant as you are stating he shouldn’t be concerned with Patrick Holford et al, but should focus on the BDA. I’m sure if you, or anyone else asks Dr Goldacre a question on the BDA or any other subject, he will respond.
Addressing some of your other issues:
Re the Dietian you work with:
If you are working alongside another health professional and your views are conflicting I think this is a concern, hence my comment on your colleague.
Re your comments on world health organisations:
I really don’t understand why you have a concern. Do you really believe that the WHO (and others such as the BDA) are influenced by the food industry to the point that they give bad health advice? I have no issue at all about the BDA being funded by the food industry (if they are). Are you not “funded” by supplement companies? Would you say this affects your advice?
I also have a regulating body and have no idea how they are funded outside of subscription but would expect that the large accountancy firms fund them through adverts etc and I do not see this as sinister in anyway at all. In response to Neil’s point on the free advertising (which I would suspect is just that – free) I think the most likely explanation is that these are products that people know of and hence the BDA is trying to help people identify products to help them lead a healthy lifestyle. Why is this an issue?
I hope that answers the majority of the points/questions, although as a member of the public I think it should really be for me to ask the questions and the health professionals answering.
And yes, I do think it is an attack, if you were after a debate you could do this in a forum for health professionals/medics (of which I am sure there are loads). I think your approach is very unprofessional and only serves to generate hype around the “Briffa” brand.
Finally, I have a simple yes/no questions for you:
Do you support Patrick Holford’s views on nutrition? Your article says that the BDA is a better target for Dr Goldacre but you do not say whether you agree with his views on media nutritionists and I am interested in your opinion on Holford in particular.
February 25, 2007 @ 7:10 pm
James Ferris
February 25, 2007 @ 8:35 pm
James,
putting my member of the public hat on for a minute, I assume that the BDA is an impartial objective organisation. Any product or manufacturer that is referred to (unless being criticised) is being endorsed and given free advertising. Even if the intention is to be helpful, ( and there’s no proof either way) it’s still endorsement and free advertising and beneficial to the companies concerned. As a member of the public, I would tend to trust the ‘endorsement’ of the BDA and be more likely to buy the ‘endorsed’ products.
The public, IMHO is far too trusting of what those in authority tell them.
I wholeheartedly agree with debunking bad science in all it’s facets, I just wish people with Ben Goldacre’s abilities and influence would also look at mainstream medicine ( which has a far greater potential for harm) with the same critical eye that he casts over ‘alternative ‘ practitioners.
February 25, 2007 @ 9:23 pm
well – I guess apart from a few nice comments – this is dedicated to bashing dietitians.
These comments are not in any particular order.
1) The Bda does not endorse products – where a product is referred to it is an example and is given with several others!
Once it did and the members went nuts – it was dropped quite quickly.
2) The HPC does regulate courses and hospital placements- it ensures a standard is met. Self regulation is not an option – it can be flawed. It is a requirement to have a portfolio and prove your competancy. Look at the website.
3) You cherry pick bits of info – the important thing is to get rid of the fat rubbish – pies chips – or are u endorsing these types of foods
4) Most psuedo nutritionists and therapists sell vast amounts of supplements that may be completely useless. Dietitians offer impartial advice as they cannot sell them. I do not dismiss them but many are useless!
5) I think this debate has rattled you rather than dietitians as you have no standards to maintain and no accountablity – hide behind the medical side – would you get on the nutrition society register or uk sport reg of nutritionists. Who is supervising your practise or setting standards of care. This not you in particular but anyone who calls themselves a nutritionist
6) the reason people turn to others is the shortage of dietitians and long waiting times . To give an example i dont have a waiting list in my gp sessions but the local hospital has a waiting time of three months – far to long. I do not have a problem with people turning to others as long as they are suitably qaulified and regulated. And there in lies the problem!I am overwhelmed with private clients.
Most Dietitians are very ethical and hard working – so stop knocking them !
I work in wales and dietitians are at the heart of what is going on here in terms of nutrition – maybe you english should look to us for example. I certainly do not feel undervalued and we are the shakers and movers within Wales.
February 25, 2007 @ 10:06 pm
Chris Cashin
February 25, 2007 @ 10:47 pm
John
This will be my final comment, as your site appears to be an ego trip whereby anyone who questions you is set upon and your tone is increasingly aggressive and unprofessional.
Why would I have a concern over you and your colleague disagreeing on nutritional advice? I think that is obvious as people who are treated in the same hospital could be given conflicting advice? Does it truely concern me, myself? Not really, I just think it’s a bit odd.
I am not sure what you are implying with the comments on Dr Goldacre but I have no connection with him, I emailed him once and he responded!! Hence, if he’s willing to write to a nobody I thought he would reply! Nothing sinister, I thought as you had brought him into the debate I would state my experience of interacting with him. With your reaction I wish I hadn’t mentioned it.
On the subject of Patrick Holford, I really don’t get the comment on the bible…but surely you know his work enough to say “Quite simply, 100% Health is essential reading for anyone living in today’s world”. Did you not give this quote in the Daily Mail? I feel you are giving a politicians answer to hedge your bets. I ask a straight question and get a bent answer. I will try to clarify:
Would you recommend Holford’s books to people looking for nutritional advice? Do you think the ION (generally) gives good advice on nutrition? Do you think the comments on badscience on Holford are valid?
Point to Neil – do you really think the medical world is against us? I just can’t see it myself, millions of people around the world working in the hope of conning people into eating bread, rice and pasta? Feeding cancer patient pills just to keep the corporates happy? Maybe I’m one of the blind sheep, I know one of us must be wrong.
Signing off now. I’ve got a bet on that my questions on Holford aren’t answered with simple yes and no!
February 25, 2007 @ 10:49 pm
james not sure who you are but I like you!
I think this siite is answered by cronies
February 25, 2007 @ 11:03 pm
john you are very good at twisting words.
I am slightly confused about you do you just write or do you see real people. I see real people and adjust dietary intake to their particular lifestyles. I am not going to spend hours filing ref on here – beacuse at the end of the day dont have the time.
Nutrition needs some control – obviously u think otherwise. I have been i touch with the bda and I hope they respond. This is typical of alot of sites on the internet – dominated by a few self opiniated people.
Dietitians do not just see overwt and people who have high cholesterol levels – they are experts in clinical nutritionand specialise in cancer care , itu etc – pseudo nutririonists do not have this skill
Oh and ps i do hope your pop at wales was in jest – you obviously have a problem with dietitians
February 25, 2007 @ 11:41 pm
Chris,
I wouldn’t presume to question the integrity of any dietitian. My problem is that they are saddled with conforming to the current ‘saturated So, any thoughts on whether an NHS dietitian would be allowed to advise a low carbohydrate diet ?(I won’t use the ‘A’ word as I haven’t read any of the books etc). I am genuinely curious, I know that as a nurse, I wouldn’t dare go against the accepted thinking, I still owe too much on the mortgage.
I’m nobody’s crony except perhaps my wife’s
James,
I don’t think the medical world is against us, in fact I have worked as a colleague of ordinary Doctors and Nurses for 30 years. I merely believe that the power wielded by pharmaceutical companies has grown to excess in the influence they have over research and prescribing habits. They are not out to get us either, they are out to make money the same as any commercial enterprise. They are pretty good at it too.
February 26, 2007 @ 12:42 am
Sorry, anyone who reads this. Gremlins in the PC
Should have read ‘current Saturated Fat/High Cholesterol is bad hypothesis. The evidence to contradict this is out there, but rarely is seen and usually dismissed when it does make it to the media. The mainstream thinkers usually seem to cut short the ‘debate’ when challenged to take a hard look at the evidence’
February 26, 2007 @ 12:48 am
Dear Dr Briffa
I have just recently qualified as a dietitian, and am currently studying towards a PhD and am, along with the majority of my dietetic colleagues, committed to evidence based practice.
Even with my limited clinical experience I have formed my own opinions based on current available evidence as to the best way to approach the various clinical and public health problems that a dietitian may encounter. However, as you must well know, the area of nutrition, diet and health is an extremely complex one to investigate, and as such one must critically evaluate all data presented in papers, to ensure that one agrees the authors conclusions are valid. Furthermore, although there is a great deal of published data available, I
February 26, 2007 @ 2:09 am
James
February 26, 2007 @ 8:54 am
February 26, 2007 @ 9:09 am
Dear Dr Briffa
I have just recently qualified as a dietitian, and am currently studying towards a PhD and am, along with the majority of my dietetic colleagues, committed to evidence based practice.
Even with my limited clinical experience I have formed my own opinions based on current available evidence as to the best way to approach the various clinical and public health problems that a dietitian may encounter. However, as you must well know, the area of nutrition, diet and health is an extremely complex one to investigate, and as such one must critically evaluate all data presented in papers, to ensure that one agrees the authors conclusions are valid. Furthermore, although there is a great deal of published data available, I
February 26, 2007 @ 9:09 am
In response to a comment made in post #8 (by Regina Wilshire):
February 26, 2007 @ 9:15 am
Dear Dr Briffa
I have just recently qualified as a dietitian, and am currently studying towards a PhD and am, along with the majority of my dietetic colleagues, committed to evidence based practice.
Even with my limited clinical experience I have formed my own opinions based on current available evidence as to the best way to approach the various clinical and public health problems that a dietitian may encounter. However, as you must well know, the area of nutrition, diet and health is an extremely complex one to investigate, and as such one must critically evaluate all data presented in papers, to ensure that one agrees the authors conclusions are valid. Furthermore, although there is a great deal of published data available, I
February 26, 2007 @ 9:24 am
Dr Briffa, you state in #39 “What I think we need is not so much control, but ACCOUNTABILITY. And is it so bad that someone has an opinion? I suspect it
February 26, 2007 @ 9:40 am
john – I beg to differ – if you look at nutr therapist websites they claim to treat absolutely everything!
they are trained mainly by weekends and alot of correspondence.
Perhaps if any of you really understood what and how dietitians are trained then you would have more of an open mind. Dietitians are accountable / controlled – twist on words but there are alot of very ropey nutr therapists out there – I have encountered alot. Also look at adverts – in my local yellow pages nutritionists range from the local fireman to me. So yes i believe the term nutritionist needs protecting – like ther term doctor , dietitians and physio.
I am not coping out at all but the one thing trials and studies which often contradict themselves does not do is turn advice into food on the plate – and at the moment that is my mission in life! Do u teach people how to cook or shop – well i do quite regularly – i reent;y did a work shop with some elite athletes – 18-20y ear olds who have never cooked a thing – my shock at seeing a medical student chopping an onion with the skin on! All the studies in the world will have NO IMPACt if people cannot cook or do not even know what a carbohydrate is!
In ans to an earlier comment – yes dietitians do prescribe low carb diets if they feel it is required . however if any of you have actually tried to live on 20g carbs then you will know how difficult it is. A study being undertaken in the west country is looking at this and they have aimed for 60g carbs but compliance is the big issue – most patients haven migrated upwards.
I have often argued with dietitians that patients should be seen in the community – if they are ill and in hospital they are worried and do not take things on board. There are some fab projects going on in the community – something you chose to ignore in an earlier comment.
One last point dietitians do not have a problem with saturated fat and do not advice people on very low fat diets. The one thing they do is actively discourage all the junk we are eating. i have 100s of food diaries and the meat, milk, butter etc are not the problem – it is all the crisps, chips, pastry and sugar -or are u advoacting those products.
Patients often say to me – its alright for you you don’y have a problem with your wt – well i tell them that is beacuse i do not eat very much junk – so what i tell them to do is what I do myself!
February 26, 2007 @ 10:29 am
Dear Dr Briffa
I have just recently qualified as a dietitian, and am currently studying towards a PhD and am, along with the majority of my dietetic colleagues, committed to evidence based practice.
Even with my limited clinical experience I have formed my own opinions based on current available evidence as to the best way to approach the various clinical and public health problems that a dietitian may encounter. However, as you must well know, the area of nutrition, diet and health is an extremely complex one to investigate, and as such one must critically evaluate all data presented in papers, to ensure that one agrees the authors conclusions are valid. Furthermore, although there is a great deal of published data available, I
February 26, 2007 @ 10:34 am
I have posted twice on here and am wondering have they been removed
February 26, 2007 @ 11:18 am
I have tried to post with lots of evidence for you John, but my posts do not seem to be loading up. I wonder why?????
February 26, 2007 @ 11:23 am
I will try again:
Dear Dr Briffa
I have just recently qualified as a dietitian, and am currently studying towards a PhD and am, along with the majority of my dietetic colleagues, committed to evidence based practice.
Even with my limited clinical experience I have formed my own opinions based on current available evidence as to the best way to approach the various clinical and public health problems that a dietitian may encounter. However, as you must well know, the area of nutrition, diet and health is an extremely complex one to investigate, and as such one must critically evaluate all data presented in papers, to ensure that one agrees the authors conclusions are valid. Furthermore, although there is a great deal of published data available, I
February 26, 2007 @ 11:24 am
In response to a comment made in post #8 (by Regina Wilshire):
February 26, 2007 @ 11:25 am
Dr Birffa, you state in #39 “What I think we need is not so much control, but ACCOUNTABILITY. And is it so bad that someone has an opinion? I suspect it
February 26, 2007 @ 11:25 am
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?!)
February 26, 2007 @ 11:26 am
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…
February 26, 2007 @ 11:54 am
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….
February 26, 2007 @ 12:02 pm
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.
February 26, 2007 @ 12:05 pm
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
February 26, 2007 @ 12:18 pm
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.
February 26, 2007 @ 12:28 pm
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.
February 26, 2007 @ 1:02 pm
well said karen
February 26, 2007 @ 1:16 pm
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.
February 26, 2007 @ 2:54 pm
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?
February 26, 2007 @ 3:18 pm
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.
February 26, 2007 @ 6:13 pm
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.
February 27, 2007 @ 12:10 am
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.
February 27, 2007 @ 8:57 am
” 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
February 27, 2007 @ 3:08 pm
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.
February 27, 2007 @ 4:42 pm
Thanks again Marina
February 28, 2007 @ 12:47 am
[...] Briffa, has come not exactly to their defence, but changes the focus, challenging Dr Ben Goldacre ahttp://www.drbriffa.com/blog/2007/02/23/its-not-so-much-nutritionists-but-dieticians-we-need-to-know…British Journal of Nutrition – September 2007, Volume 98, Issue 3British journal of Nutrition. [...]
May 29, 2008 @ 9:08 pm