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)
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.
.
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),…\”
Reference 2 presents the evidence which suggests that, as yet, that statin therapy in the primary prevention setting does not reduce overall mortality. I was not referring exclusively to cardiovascular disease risk, so your point is not valid.
Reference 19 is the email communication I had with the BDA regarding industry partners. I’m not sure what relevance it has to the point you are trying to make. Could you explain?
\”…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\”.
Please see reference 18 Allan. Part of this review analyses studies in which dietary interventions (not drug treatments) were used to reduce cholesterol. Can I suggest you read (or re-read) the paper itself and then we can perhaps have an informed discussion about it.
As for those 500 papers on the subject, could you provide me with a list of relevant references?
\”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.\”
But I never did recommend a low fat and high carbohydrate diet for CVD prevention. Again, could you explain?
\”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.\”
Where, Allan, did I exhort a high carbohydrate diet? Again, could please clarify?
And I don\’t believe I\’m INSISTING I\’m right – just presenting the research and letting it speak for itself.
\”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.”
I believe the point I’m making here is utterly transparent. And no, Allan, I’m not claiming that BDA recommendations are based on industry funding, just that there is an obvious conflict of interest here that I believe the public should be aware of. Does this seem unreasonable to you?
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?
Dear Allan
Again, let me take your points in turn.
“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.”
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.
“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.”
The point I’m making is that statins, in the primary prevention setting, do not reduce overall risk of death. As this applies to the majority of people who take statins, I think this is of enormous relevance, don’t you?
“I should have cited ref 18, not 19, in the above when expressing concern of your comments regarding statins.
Apologies”
Apologies accepted. Now, have you read reference 18 yet and, if so, what are your views on it?
“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?”
The term ‘Mediterranean diet’ encompasses many things. While the diet may be relatively rich in complex carbohydrates, it is also generally rich in other foodstuffs including monounsaturated fat and fish. So, it is impossible to judge the effects of any single food type by looking at evidence on the ‘Mediterranean diet’.
Also, most of the evidence in this area is epidemiological in nature: just because the diet is associated with reduced disease risk that does not prove the diet per se is responsible for that reduced risk.
And finally, it seems odd to me that you would hold a belief about the supposed benefits of a diet rich in complex carbs, and then suggest I provide the evidence for this, That’s for you to do, isn’t it? The fact that comments are enabled on my blog gives you ample right of reply, including the provision of the evidence you feel supports your view.
“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?”
I have no desire to establish my credibility, Allan. I encourage people not to focus on the messenger (me) but the message. With regard to the BDA, yes I do have an issue with this organisation. I’ve answered your question on this once already, and believe my feelings about this will be utterly transparent to anyone who understands the term ‘conflict of interest’.
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!
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>>>>
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.
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??
“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?
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 £2m. This could relate to sponsorship and links with industry. You may well ask, therefore, what links our Doctors have with industry and what is the medical profession not telling us? However this, as with the BDA, is a matter for the BMA and its members to be satisfied about. We trust the BMA to have considered any links with industry in the same manner we have. You should also ask the same question of every profession, the BDA is no different and probably has less income from industry than other organisations.
The Chief Executive
The British Dietetic Association
Thank you ‘Andy’ (bearing in mind you are the BDA’s chief executive and are responding on its behalf do you think it might be a good idea to state your surname on any correspondence?)
I’ll take your comments point by point.
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.
Yes, and the question is why is it “confidential”? Why not just be open and honest about the fact that you receive funding from the food industry?
However the support provided by industry is very minor to our income.
This is not a question of degree, Andy, but that it happens at all and then is undeclared that is the issue. Why refuse to reveal who your ‘partners’ are and to what extent they fund the BDA?
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.
How odd that it is ‘healthy eating messages’ and not ‘healthy eating’ your sponsors seek advice on. Very telling.
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.
Well done you, but this has got nothing to do with the matter in hand: the point is not who does NOT pay you money, Andy, it’s who DOES, and the that fact that this is not transparent.
You will not see any claims or messages related branding of companies from the BDA.
No, of course you don’t, but you do promote certain types of food that have supposed benefits for health, despite there being no good evidence that they are beneficial. Margarine (including cholesterol-reducing ones) is a case in point.
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.
Well, that I suppose depends on what you mean by ‘endorse’. What would you call it when a dietician recommends that someone switches from butter to Benecol or Flora Pro-Activ?
And as regards those messages that are not in the public interest, how about providing the evidence that supports the elements of standard dietetic advice that I took issue with above?
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.
Sorry, but that seems nothing but hot air and rhetoric.
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 £2m. This could relate to sponsorship and links with industry. You may well ask, therefore, what links our Doctors have with industry and what is the medical profession not telling us? However this, as with the BDA, is a matter for the BMA and its members to be satisfied about. We trust the BMA to have considered any links with industry in the same manner we have. You should also ask the same question of every profession, the BDA is no different and probably has less income from industry than other organisations.
I am astonished by these comments. I am almost incredulous that you would contend that “You may well ask, therefore, what links our Doctors have with industry and what is the medical profession not telling us?”, not because I cannot bear for my profession to be questioned with regard to its ethics and integrity (I am frequently critical of my own profession ” see ‘food and medical politics’ on the site), but because it seems you are attempting to deflect attention away from your own potential conflicts of interest to others. Or, perhaps you are somehow claiming that two wrongs DO make a right?
Your comment “You should also ask the same question of every profession, the BDA is no different and probably has less income from industry than other organisations” appears to me to be a desperate attempt to justify your policy on industry funding. Your attitude seems to be ‘We’re all at it, so why pick on us?’.
And then to seem to suggest that the supposed lower levels of income the BDA gets from industry compared to other organisations somehow vindicates you is, I think, quite pathetic.
As the BDA’s chief executive, can you please explain to me in clear and simple terms (I respectfully ask you to avoid using terms like ‘commercially confidential’) why it is that the BDA refuses to reveal the food companies that it ‘partners’ with and/or receives sponsorship from?
Another alternative, of course, is just to declare your industry partners so the public can be satisfied the BDA’s links with the food industry are at least transparent.
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!!
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.
Susan
First of all, I don’t necessarily agree that risk of heart attack or stroke is much greater is cholesterol is not reduced. This statement is based on two main highly flawed arguments:
1. Raised cholesterol levels are associated with an increased risk of heart disease and stroke
This ‘association’ does not prove that high cholesterol causes heart disease and stroke. Also, there is evidence that in later life, high levels of cholesterol are associated with enhanced longevity.
2. Reducing cholesterol with statin drugs reduces the risk of heart disease and stroke
Except that statin drugs have other effects in the body (including an anti-inflammatory effect) that could be the real reason for this observation.
As for the pros and cons of statin therapy, I’ve covered this recently: [click here].
The point I make is that statins are sold to us as some kind of wonderdrug: Some doctors seem to only just stop short of suggesting they should be put in the water supply. But the cold hard facts on statins suggest they have far more limited benefits than we have been ‘sold’. And they’re not without risk either.
To my mind the cholesterol and statin stories have been completely overdone. And if you want some idea why, just follow the money.
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.
Hi Roz, yes it’s a sad reflection of life that your opinions can only be readily responded to (and respected?) if you have medical credentials. There are many intelligent non-medically trained professionals that can contribute. I guess this is just representative of the arrogance of a lot of medics who believe their way is the only way.
On another point, I debated whether to respond as this is not really pivotal to this blog topic but I’d like to make a few points in defence of the RD training programme particularly. I do see where many of the comments are coming from re criticism of dietitians, but I think it is becoming recognized that changes need to be made to the profession to take it forward and these changes are starting to be addressed in the programme content (although there’s a way to go). My course has been rigorous and my cohort has worked very hard to build a firm base on which to develop into effective practioners. I don’t like to see this completely devalued. Whilst I agree that training could include a more detailed study of statistics, the course I have followed has covered critical review of literature (including data analysis), and critical thinking has been an integral part of coursework (albeit largely within the medical model- it could definitely be broader).
Dietitians are not those that were too thick for nursing, dietetics BSc degree entry is I’m sure at least equivalent (minimum 2 A levels) to that for a nursing degree (or are we as thick as each other?).
As Neil says re ‘biting’ the hand that feeds, I agree, when you draw conclusions that certain dietary guidelines aren’t correct, often the only option is to get out of the NHS. Unless that is, you’re willing to take the barrage of (probably personal) criticism that will come your way.
By the way, I’m not an overweight dietitian, but then I’m personally not a follower of, or a believer in a very low fat diet-so maybe I’m proving you right!
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.
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…
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 £400 of supplements. they couldnt follow it – they came to see me 2 weeks later and it was obvious that she was constipated because of her poor diet. We changed her diet over a period of 3 months – problem solved and altho her diet is not perfect she is well. Need i say more – many nutritionists sell supplements which is a huge money maker. As an RD I cannot do this and will offer impartial advice – thsi is even more apparent in sport.
As a profession we must shout about our achievments – there is so much being done out there. I oversee a project in the south wales valleys and the inroads being made are huge – by Dietitians!
Oh and ps I am not a stick thin or overwt Dietitian either lol
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’t think quoting anecdotes really furthers the debate, though, does it? How would it help, for instance, for me to say that I’ve lost count of the number of patients who have come into my practice claiming something like “I was referred to a dietician for advice on weight loss but she turned out to be fatter than me!”? So in answer to your question ‘need I say more?’, the answer is, in my opinion, ‘yes!’.
Let’s get back to the main themes of my letter to the BMJ, as pertains to dietetics.
1. That it is anything but evidence-based (as is claimed)
2. That your professional body, the BDA, has food industry ‘partners’ that it refuses to declare openly
In the letter I actually list several dietetic ‘gems’ that seem to me to be either unproven or have actually been disproven. What seems utterly curious to me is that not one single dietician nor the BDA has provided the evidence that supports the specific approaches I highlighted.
If you want your profession to be regarded as ‘evidence-based’ and credible then does it not make sense to provide the ‘evidence’? If your office is full of the stuff, please do dig some out and present it here!
And I find it curious that you do not even mention the potential of conflict issue with the BDA. Are you unconcerned about this? Can you tell me what you thought about the response of the chief executive of the BDA?
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!
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.
James Ferris
Let me take you comments point by point:
“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.”
What’s that, James, got to do with this debate? Obviously, Ben Goldacre is entitled to his opinion. And can I ask how you know he has high regard for dieticians? I couldn’t find anything relevant to this on his site. Perhaps you can clarify and, if relevant, point me to appropriate comments Dr Goldacre has made publicly on this issue.
“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.”
She’s entitled to comment. I encourage debate ” that’s why this is a ‘comments enabled’ blog.
“Are you in conflict in the advice you give?”
Maybe, I don’t know. And if we are, can I ask why you think this is important, James? Are two health professionals not allowed to differ in terms of opinion? Please do clarify your position here.
“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?”
Actually, I have issues with many official health bodies and organisations. See ‘Food and Medical Politics’ on my site for more on this. I wouldn’t call it a ‘conspiracy’, but I do think that much information we are subjected to can be influenced by commercial concerns (the pharmaceutical and food industries in particular) and that the public needs to be aware of this. Do you have a problem with this? If so, why? And can you state here, as a member of the public, how you feel about the fact that the BDA receives funding from the food industry but does not declare this openly?
“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.”
And your point is?
“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!”
First of all, I don’t think ‘attack’ is the right word, is it? I just plainly stated the facts.
The rest of your comment seems utterly nonsensical to me. I appreciate that you’re not dietician, but that shouldn’t have let that stop you looking at the BDA’s website and reading (on its home page) its statement that one of its roles is to “promote training and education in the science and practice of dietetics and associated subjects.” I am not aware that the Health Professionals Council in any way directs or contributes to what dieticians learn, and in light of this, can you explain your suggestion that I should direct my comments to this body?
There’s a few questions for you, James, and I’d be very grateful if you would answer them.
Chris Cashin
“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!”
It was an example, Chris, of how anecdotes, in my opinion, are not useful in this debate.
“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”
What do you mean by ‘unfair’? I wrote a piece, he responded, I responded to him and he still has right of reply.
See my comment to ‘Andy’ from the BDA on the issue of ‘endorsement’
“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.”
Where, Chris, did I claim the BDA is a trade union?
“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 !”
Have you ever wondered, Chris, why supposedly self-styled nutritionists exist at all? My sense it because many people regard dietetic advice as wrong, inadequate or irrelevant. If this is the case, is it not natural for them to look elsewhere?
It is interesting that you view that the low-fat/high-carb diet is ‘rubbish’. Here’s an excerpt from an information sheet to be found on the BDA site entitled ‘Food Facts ” Getting the balance right ” A Guide to Healthy Eating’.
In reference to health eating, it states:
In practical terms, this means:
Basing your meals and snacks on starchy foods such as bread,
breakfast cereals, potatoes, rice, noodles, oats, pasta etc. But
be careful not to add or cook them in too much fat.
Having at least 5 portions of fruit and vegetbles each day.
Remember that beans, pulses and fruit juice count towards
your total but only once a day.
Choosing moderate amounts of meat, fish and pulses, removing
the skin from chicken, excess fat from meat and avoiding frying.
Having 2-3 portions of dairy foods each day. A portion is
equivalent to 1/3 pint of milk, a small pot of yogurt or 30g
cheese (small matchbox size). Try to choose reduced fat
versions where you can, eg semi skimmed milk, cottage cheese
etc.
This looks like a low-fat/high-carb diet to me, Chris, what about you?
“Regulation is important – you have none only your medical regulation.\”
I think that you should know that the General Medical Council’s code of conduct states that one of my duties as a doctor is to “Promote and protect the health of patients and the public.”
Could you explain if you believe giving appropriate nutritional advice has not part in this? And if so, can you explain how I might be failing the public in this quest?
And finally, AGAIN, you have not referred to ANY science to support your stance or refute mine.
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?
Neil
Thank you for drawing all of our attentions to the the mention of specific products in BDA literature.
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.
James Ferris
“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.”
I accept that the area of nutrition (as distinct from dietetics) is not without issues, and I make this point in my response. But I also think Dr Goldacre’s piece lacked balance. For instance, he takes nutritionists to task, for instance, for being unscientific. I was keen to point out that this criticism can be levelled at doctors and dieticians too.
And I\\\’m glad you think you know Dr Goldacre well enough to KNOW he will respond. You might want to take note of the post from Neil above which claims Dr Goldacre did not respond tohis query regarding statins.
And you didn’t explain your comment regarding Dr Goldacre allegedly not feeling free to comment on me. Could you now please?
“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.”
You haven’t answered my question, James. WHY is this a concern for YOU?
“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).
I really don’t know. However, I do think that the bodies such as the BDA and WHO should be transparent about it. My issue is the BDA is not transparent about its funding from the food industry. This may not concern you, James, but I can tell you it is of concern to others.
“Are you not \\\”funded\\\” by supplement companies? Would you say this affects your advice?”
I am not ‘funded’ by supplement companies. I am sometimes paid by companies to either produce a piece of writing (though these are never ‘branded’) or give a lecture (though these are not product-specific). In the former case, I have written pieces that appear in, say, the sales catalogue of the company concerned. The link between me and the company is therefore clear for all to see (I assume people will themselves assume I haven’t written the piece for free). Similarly, if I give a talk I always declare the sponsors if this is relevant. What’s important here is transparency. The public can see the link and are in an informed position to judge the veracity of my 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.”
James, can we not allow members of the public to judge for themselves whether the fact that the BDA takes funding from the food industry and does not declare the details of this openly concerns THEM.
“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?”
Yes, it may be your suspicion that this is free, but we don’t know that do we? And even if it is, how do you think it would look if the companies concerned turn out to fund the BDA? Again, we don’t know. And the only people that can answer these questions are within the BDA or the food companies concerned.
“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.”
I don’t understand this comment – it doesn’t appear to make sense.
“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.”
Are you aware that I posted my response to Dr Goldacre’s piece in the ‘rapid response’ section of the British Medical Journal?
And why shouldn’t the public have access to this debate, exactly?
And I\\\’m much less concerned with the \\\’Briffa brand\\\’ than with doing what I can to ensure that people get accurate information and advice with which to make truly informed decisions about their diet, lifestlye and medical treatment, should they wish to.
“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.”
I don’t have a detailed knowledge of Patrick Holford’s work, so can’t possibly comment. Your question is a bit like asking a Christian what his views on the Bible are. Could you perhaps be a bit more specific about what aspects of his beliefs or work you would like my opinion on? As long as I am familiar with his specific views or information he provides, I’ll gladly give my opinion of them.
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.
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.
Chris Cashin
“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.”
Oh, I see, endorsing one product is a no-no, but multiple, simultaneous endorsements are OK, now, are they?!
“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.”
I will gladly look at the website, but let it not deflect from the apparent issues with the BDA and the profession in general.
“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 “
No, I don’t endorse these sorts of foods. And can I remind you that it was you who described the low-fat/high-carb diet as ‘rubbish’? I just pointed out that your own opinion seems to be at loggerheads with that of the BDA.
“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!”
Maybe, maybe not. Got any proof that they are useless? Because I reckon I have plenty of good evidence that much of dietetic dogma is unproven or disproven. And YET AGAIN YOU’VE PROVIDED NO EVIDENCE TO SUPPORT YOUR STANCE OR REFUTE MINE.
“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.”
What I am is SHOCKED and SADDENED that no-one from your profession or anyone pro-dietetics has even attempted to provide any evidence that vindicates the advice generally given out by dieticians or is in the least bit concerned that the BDA takes money from food companies but is not transparent about this.
“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.”
I would beg to differ on this. So we’ll have to agree to disagree on this one.
“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.”
Even if dieticians are hard-working and ethical and dieticians are the centre of the nutritional universe in South Wales that doesn’t mean the advice they generally give is evidence-based, correct or effective, right? And neither does it absolve the BDA of the need for transparency with regard to funding.
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!
james not sure who you are but I like you!
I think this siite is answered by cronies
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
Chris,
I’m nobody’s crony except perhaps my wife’s 🙂 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.
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.
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’
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’m sure you would agree that much of the data is weak (largely due to the inherent difficulties in studying the effect of nutritional interventions to the exclusion of other confounding factors) and inconclusive. In particular there is a lack of large scale, long term randomised controlled trials in many areas of nutritional research.
In your original article/blog you have suggested that the cornerstone of dietetic advice to aid weight loss is via “low-fat eating” / “a diet low in fat and high in carbohydrate”. I would contest that is strictly true that this is what is promoted by dietitians and is certainly an over-simplification of what is endorsed. Furthermore that phrase does not account for the complexity in the aetiology, prevention and treatment of obesity and you have not actually defined precisely what you mean by “low-fat eating” / “a diet low in fat and high in carbohydrate”.
In fact a number of strategies are undertaken for example including, portion size control (1-2), increasing high fibre / wholegrain choices and reducing intake of refined carbohydrates/simple sugars (3-7) and incorporating physical activity (8-9). I would also offer advice to help the client reduce overall fat intake (10-11), as this will aid a reduction in energy density of overall intake. This would involve, as Chris Cashin has already said, encouraging the client to cutting down/out chips, pasties, biscuits, cakes, etc (depending upon their usual intake) and coming up with alternatives that are acceptable to the client. However I would not say this is necessarily meaning a ‘low-fat’ diet, just a ‘lower fat’ diet. The ultimate aim, in crude terms, is to reduce ‘calories in’ and increase ‘calories out’ (a very simple formula really!!).
Furthermore, with overweight clients, it is not just about ‘reducing weight’, it is also about improving health outcomes, for example reducing cardiovascular risk and the risk of developing type 2 diabetes. Such advice may focus on altering balance of fat quality (i.e. unsaturated fat, esp monounsaturated in place of saturated fat) (12-16), increasing intake of fruit and vegetables (17-19), reducing intake of sodium (20-21) and encouraging intake of oily fish/n-3 LC-PUFA (22-24). Furthermore, it is now recognised that reducing body fat stores, particularly abdominal, are desirable for health whether accompanied by weight loss or not (easily monitored via waist circumference).
The most important aspect is that dietitians undertake a holistic approach whereby the client’s individual circumstances (e.g. usual intake, cooking facilities, ability to cook, income levels, proximity to shops, available transport, physical limitations, living alone / with partner / with family, etc), barriers to change and indeed readiness to change are considered.
References (PS ” I could have given more, but I thought this post was already a little bit on the long side!!)
1. Rolls, B.J.; Roe, L.S. and Meengs, J.S. (2006) Larger portion sizes lead to a sustained increase in energy intake over 2 days. Journal of the American Dietetic Association 106(4): 543-549
2. Rolls, B.J.; Roe, L.S. and Meengs, J.S. (2006) Reductions in portion size and energy density of foods are additive and lead to sustained decreases in energy intake. American Journal of Clinical Nutrition 83(1): 11-17
3. Burton-Freeman, B. (2000) Dietary fiber and energy regulation. Journal of Nutrition, 130: 272S-275S.
4. Delzenne, N. M. and Cani, P. D. (2005) A place for dietary fibre in the management of the metabolic syndrome. Current Opinion in Clinical Nutrition and Metabolic Care, 8: 636-640.
5. Melanson, K. J.; Angelopoulos, T. J.; Nguyen et al (2006) Consumption of whole-grain cereals during weight loss: Effects on dietary quality, dietary fiber, magnesium, vitamin B-6, and obesity. Journal of the American Dietetic Association, 106, 1380-1388.
6. Slavin, J. L. (2005) Dietary fiber and body weight. Nutrition, 21, 411-418.
7. Koh-Banerjee, P.; Rimm, E.B. (2003) Whole grain consumption and weight gain: a review of the epidemiological evidence, potential mechanisms and opportunities for future research. Proceedings of the Nutrition Society 62(1): 25-29.
8. Ross, R. and Janssen, I. (2001) Physical activity, total and regional obesity: dose-response considerations. Medicine and Science in Sports and Exercise. 33 (Suppl 6): S521-S527.
9. Kay, S.J. and Fiatarone Singh, M.A. (2006) The influence of physical activity on abdominal fat: a systematic review of the literature. Obesity Reviews 7(2): 183-200.
10. Avenell, A.; Brown, T.J.; McGee, M.A. et al (2004) What are the long-term benefits of weight reducing diets in adults? A systematic review of randomized controlled trials. Journal of Human Nutrition and Dietetics 17(4): 317-335.
11. Avenell, A.; Broom, J.; Brown, T.J. et al (2004) Systematic review of the long-term effects and economic consequences of treatments for obesity and implications for health improvement. Health Technology Assessment 8 (21): iii-iv, 1-458
12. Denke MA (2006) Dietary fats, fatty acids, and their effects on lipoproteins. Current Atherosclerosis Reports 8(6): 466-471.
13. Hooper, L.; Summerbell, C.D.; Higgins, J.P. et al (2001) Reduced or modified dietary fat for preventing cardiovascular disease. Cochrane Database of Systematic Reviews 3: CD002137.
14. Truswell, A.S. (2005) Some problems with Cochrane reviews of diet and chronic disease. European Journal of Clinical Nutrition 59 (Suppl 1): S150-S154.
15. Williams, C.M.; Francis-Knapper, J.A.; Webb, D. (1999) Cholesterol reduction using manufactured foods high in monounsaturated fatty acids: a randomized crossover study. British Journal of Nutrition 81(6): 439-446.
16. Allman-Farinelli, M.A.; Gomes, K.; Favaloro, E.J. and Petocz, P. (2005) A diet rich in high-oleic-acid sunflower oil favorably alters low-density lipoprotein cholesterol, triglycerides, and factor VII coagulant activity. Journal of the American Dietetic Association 105(7): 1071-1079.
17. Dauchet, L.; Amouyel, P.; Hercberg, S. and Dallongeville, J. (2006) Fruit and vegetable consumption and risk of coronary heart disease: a meta-analysis of cohort studies. Journal of Nutrition 136(10): 2588-2593.
18. Liu, S.; Manson, J.E.; Lee, I.M. et al (2000) Fruit and vegetable intake and risk of cardiovascular disease: the Women’s Health Study. American Journal of Clinical Nutrition 72(4): 922-8.
19. Bes-Rastrollo M, Martinez-Gonzalez MA, Sanchez-Villegas A et al (2006) Association of fiber intake and fruit/vegetable consumption with weight gain in a Mediterranean population. Nutrition 22(5): 504-11.
20. Scientific Advisory Committee on Nutrition (2003) Salt and Health. The Stationary Office (http://www.sacn.gov.uk/pdfs/sacn_salt_final.pdf)
21. O’Shaughnessy, K.M. (2006) Role of diet in hypertension management. Current Hypertension Reports 8(4): 292-297
22. Scientific Advisory Committee on Nutrition (2004) Advice on Fish Consumption: Benefits and Risks. The Stationary Office (http://www.sacn.gov.uk/pdfs/fics_sacn_advice_fish.pdf)
23. Griffin, M.D.; Sanders, T.A.; Davies, I.G. et al (2006) Effects of altering the ratio of dietary n-6 to n-3 fatty acids on insulin sensitivity, lipoprotein size, and postprandial lipemia in men and postmenopausal women aged 45-70 y: the OPTILIP Study. American Journal of Clinical Nutrition 84(6): 1290-8.
24. Moore, C.S.; Bryant, S.P.; Mishra, G.D. et al (2006) Oily fish reduces plasma triacylglycerols: a primary prevention study in overweight men and women. Nutrition 22(10): 1012-2
James
“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.”
Give me an example of where I have ‘set upon’ someone? I’ve just repeatedly stated my case, asked for you and others to refute it properly, and when you haven’t, I’ve asked again.
“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.”
What’s ‘odd’ about it? Practitioners disagree all the time in the real world.
“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.”
I’m not implying anything. You said you were sure he would respond, but I have questioned how you could be so sure.
“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?”
I did give that quote re 100 % Health and stand by it. I do think that generally, the information and advice he gives is sound and useful. His book based on the low glycaemic load diet is an example of this. I think the ION course is generally good from what I can tell, and I believe many individuals who have studied here have made very good and effective practitioners. I haven’t read the studies Patrick Holford quotes in support of his vit C/AZT comments. Also, I do not know what claims Patrick Holford has made.
If the studies Patrick Holford has used to back his claim are in vitro studies, and if he has claimed that this means vit C is more clinically useful than AZT, then my opinion is Dr Goldacre’s comments are valid.
“john you are very good at twisting words.”
Where have I ‘twisted 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.”
Yes, I do see patients. The ‘I don’t have the time’ line is, in my opinion, a cop-out.
“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.”
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’s not the expression of opinion that bothers you, but that fact that it differs from your own.
“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”
And neither do nutritionists claim to have these skills either.
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’m sure you would agree that much of the data is weak (largely due to the inherent difficulties in studying the effect of nutritional interventions to the exclusion of other confounding factors) and inconclusive. In particular there is a lack of large scale, long term randomised controlled trials in many areas of nutritional research.
In your original article/blog you have suggested that the cornerstone of dietetic advice to aid weight loss is via “low-fat eating” / “a diet low in fat and high in carbohydrate”. I would contest that is strictly true that this is what is promoted by dietitians and is certainly an over-simplification of what is endorsed. Furthermore that phrase does not account for the complexity in the aetiology, prevention and treatment of obesity and you have not actually defined precisely what you mean by “low-fat eating” / “a diet low in fat and high in carbohydrate”.
In fact a number of strategies are undertaken for example including, portion size control (1-2), increasing high fibre / wholegrain choices and reducing intake of refined carbohydrates/simple sugars (3-7) and incorporating physical activity (8-9). I would also offer advice to help the client reduce overall fat intake (10-11), as this will aid a reduction in energy density of overall intake. This would involve, as Chris Cashin has already said, encouraging the client to cutting down/out chips, pasties, biscuits, cakes, etc (depending upon their usual intake) and coming up with alternatives that are acceptable to the client. However I would not say this is necessarily meaning a ‘low-fat’ diet, just a ‘lower fat’ diet. The ultimate aim, in crude terms, is to reduce ‘calories in’ and increase ‘calories out’ (a very simple formula really!!).
Furthermore, with overweight clients, it is not just about ‘reducing weight’, it is also about improving health outcomes, for example reducing cardiovascular risk and the risk of developing type 2 diabetes. Such advice may focus on altering balance of fat quality (i.e. unsaturated fat, esp monounsaturated in place of saturated fat) (12-16), increasing intake of fruit and vegetables (17-19), reducing intake of sodium (20-21) and encouraging intake of oily fish/n-3 LC-PUFA (22-24). Furthermore, it is now recognised that reducing body fat stores, particularly abdominal, are desirable for health whether accompanied by weight loss or not (easily monitored via waist circumference).
The most important aspect is that dietitians undertake a holistic approach whereby the client’s individual circumstances (e.g. usual intake, cooking facilities, ability to cook, income levels, proximity to shops, available transport, physical limitations, living alone / with partner / with family, etc), barriers to change and indeed readiness to change are considered.
Furthermore, as Chris has just said, while the nutritional interventions for the treatment of obesity and diabetes is an important aspect of dietetics, dietitians are also experts in nutritional interventions for many clinical conditions, including renal, oncology, haematology, mental illness, neurorehabilitation, stroke, eating disorders, gastroenterology (including Crohn’s Disease, Ulcerative Colitis, Coeliac Disease, IBS), Cystic Fibrosis, food allergy and intolerance, immunosuppressed states (e.g. HIV) to name a few. And no cannot provide references for all of these too as I have to get on with my work now!!
References (PS ” I could have given more, but I thought this post was already a little bit on the long side plus I have already spent far too long writing this)
1. Rolls, B.J.; Roe, L.S. and Meengs, J.S. (2006) Larger portion sizes lead to a sustained increase in energy intake over 2 days. Journal of the American Dietetic Association 106(4): 543-549
2. Rolls, B.J.; Roe, L.S. and Meengs, J.S. (2006) Reductions in portion size and energy density of foods are additive and lead to sustained decreases in energy intake. American Journal of Clinical Nutrition 83(1): 11-17
3. Burton-Freeman, B. (2000) Dietary fiber and energy regulation. Journal of Nutrition, 130: 272S-275S.
4. Delzenne, N. M. and Cani, P. D. (2005) A place for dietary fibre in the management of the metabolic syndrome. Current Opinion in Clinical Nutrition and Metabolic Care, 8: 636-640.
5. Melanson, K. J.; Angelopoulos, T. J.; Nguyen et al (2006) Consumption of whole-grain cereals during weight loss: Effects on dietary quality, dietary fiber, magnesium, vitamin B-6, and obesity. Journal of the American Dietetic Association, 106, 1380-1388.
6. Slavin, J. L. (2005) Dietary fiber and body weight. Nutrition, 21, 411-418.
7. Koh-Banerjee, P.; Rimm, E.B. (2003) Whole grain consumption and weight gain: a review of the epidemiological evidence, potential mechanisms and opportunities for future research. Proceedings of the Nutrition Society 62(1): 25-29.
8. Ross, R. and Janssen, I. (2001) Physical activity, total and regional obesity: dose-response considerations. Medicine and Science in Sports and Exercise. 33 (Suppl 6): S521-S527.
9. Kay, S.J. and Fiatarone Singh, M.A. (2006) The influence of physical activity on abdominal fat: a systematic review of the literature. Obesity Reviews 7(2): 183-200.
10. Avenell, A.; Brown, T.J.; McGee, M.A. et al (2004) What are the long-term benefits of weight reducing diets in adults? A systematic review of randomized controlled trials. Journal of Human Nutrition and Dietetics 17(4): 317-335.
11. Avenell, A.; Broom, J.; Brown, T.J. et al (2004) Systematic review of the long-term effects and economic consequences of treatments for obesity and implications for health improvement. Health Technology Assessment 8 (21): iii-iv, 1-458
12. Denke MA (2006) Dietary fats, fatty acids, and their effects on lipoproteins. Current Atherosclerosis Reports 8(6): 466-471.
13. Hooper, L.; Summerbell, C.D.; Higgins, J.P. et al (2001) Reduced or modified dietary fat for preventing cardiovascular disease. Cochrane Database of Systematic Reviews 3: CD002137.
14. Truswell, A.S. (2005) Some problems with Cochrane reviews of diet and chronic disease. European Journal of Clinical Nutrition 59 (Suppl 1): S150-S154.
15. Williams, C.M.; Francis-Knapper, J.A.; Webb, D. (1999) Cholesterol reduction using manufactured foods high in monounsaturated fatty acids: a randomized crossover study. British Journal of Nutrition 81(6): 439-446.
16. Allman-Farinelli, M.A.; Gomes, K.; Favaloro, E.J. and Petocz, P. (2005) A diet rich in high-oleic-acid sunflower oil favorably alters low-density lipoprotein cholesterol, triglycerides, and factor VII coagulant activity. Journal of the American Dietetic Association 105(7): 1071-1079.
17. Dauchet, L.; Amouyel, P.; Hercberg, S. and Dallongeville, J. (2006) Fruit and vegetable consumption and risk of coronary heart disease: a meta-analysis of cohort studies. Journal of Nutrition 136(10): 2588-2593.
18. Liu, S.; Manson, J.E.; Lee, I.M. et al (2000) Fruit and vegetable intake and risk of cardiovascular disease: the Women’s Health Study. American Journal of Clinical Nutrition 72(4): 922-8.
19. Bes-Rastrollo M, Martinez-Gonzalez MA, Sanchez-Villegas A et al (2006) Association of fiber intake and fruit/vegetable consumption with weight gain in a Mediterranean population. Nutrition 22(5): 504-11.
20. Scientific Advisory Committee on Nutrition (2003) Salt and Health. The Stationary Office (http://www.sacn.gov.uk/pdfs/sacn_salt_final.pdf)
21. O’Shaughnessy, K.M. (2006) Role of diet in hypertension management. Current Hypertension Reports 8(4): 292-297
22. Scientific Advisory Committee on Nutrition (2004) Advice on Fish Consumption: Benefits and Risks. The Stationary Office (http://www.sacn.gov.uk/pdfs/fics_sacn_advice_fish.pdf)
23. Griffin, M.D.; Sanders, T.A.; Davies, I.G. et al (2006) Effects of altering the ratio of dietary n-6 to n-3 fatty acids on insulin sensitivity, lipoprotein size, and postprandial lipemia in men and postmenopausal women aged 45-70 y: the OPTILIP Study. American Journal of Clinical Nutrition 84(6): 1290-1298.
24. Moore, C.S.; Bryant, S.P.; Mishra, G.D. et al (2006) Oily fish reduces plasma triacylglycerols: a primary prevention study in overweight men and women. Nutrition 22(10): 1012-1024.
In response to a comment made in post #8 (by Regina Wilshire):
“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”
Where on earth have you formed this opinion??? It is certainly untrue, at least where I trained (University of Surrey).
If all I had done in my Nutrition and Dietetics degree course was to “regurgitate the dietary guidelines with absolutely no training along the way in statistics” then I would have definitely failed!! Certainly we were made aware of the dietary guidelines and how they were reached, however we also considered the limitations of these guidelines (e.g. limited data, particularly for certain population groups, the fact they do not account for genetic variation, etc). Furthermore, our course included a module on statistics, which focused on those stat methods that are used by Biological Scientists and we undertook a research project which usually involved data collection and interpretation (including the use of statisical analyses).
We were also required to carry out critical reviews of given scientific papers of varying quality, which included evaluating the statistical methods used and drawing conclusions about the quality of data presented and research carried out. This formed an integral part of core coursework on what was an extremely tough and far-reaching undergraduate course.
Therefore, I totally disagree that we were taught “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”
And I ask you, Regina, how would you even know what is in our course unless you have been on it!?!
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’m sure you would agree that much of the data is weak (largely due to the inherent difficulties in studying the effect of nutritional interventions to the exclusion of other confounding factors) and inconclusive. In particular there is a lack of large scale, long term randomised controlled trials in many areas of nutritional research.
In your original article/blog you have suggested that the cornerstone of dietetic advice to aid weight loss is via “low-fat eating” / “a diet low in fat and high in carbohydrate”. I would contest that is strictly true that this is what is promoted by dietitians and is certainly an over-simplification of what is endorsed. Furthermore that phrase does not account for the complexity in the aetiology, prevention and treatment of obesity and you have not actually defined precisely what you mean by “low-fat eating” / “a diet low in fat and high in carbohydrate”.
In fact a number of strategies are undertaken for example including, portion size control (1-2), increasing high fibre / wholegrain choices and reducing intake of refined carbohydrates/simple sugars (3-7) and incorporating physical activity (8-9). I would also offer advice to help the client reduce overall fat intake (10-11), as this will aid a reduction in energy density of overall intake. This would involve, as Chris Cashin has already said, encouraging the client to cutting down/out chips, pasties, biscuits, cakes, etc (depending upon their usual intake) and coming up with alternatives that are acceptable to the client. However I would not say this is necessarily meaning a ‘low-fat’ diet, just a ‘lower fat’ diet. The ultimate aim, in crude terms, is to reduce ‘calories in’ and increase ‘calories out’ (a very simple formula really!!).
Furthermore, with overweight clients, it is not just about ‘reducing weight’, it is also about improving health outcomes, for example reducing cardiovascular risk and the risk of developing type 2 diabetes. Such advice may focus on altering balance of fat quality (i.e. unsaturated fat, esp monounsaturated in place of saturated fat) (12-16), increasing intake of fruit and vegetables (17-19), reducing intake of sodium (20-21) and encouraging intake of oily fish/n-3 LC-PUFA (22-24). Furthermore, it is now recognised that reducing body fat stores, particularly abdominal, are desirable for health whether accompanied by weight loss or not (easily monitored via waist circumference).
The most important aspect is that dietitians undertake a holistic approach whereby the client’s individual circumstances (e.g. usual intake, cooking facilities, ability to cook, income levels, proximity to shops, available transport, physical limitations, living alone / with partner / with family, etc), barriers to change and indeed readiness to change are considered.
Furthermore, as Chris has just said, while the nutritional interventions for the treatment of obesity and diabetes is an important aspect of dietetics, dietitians are also experts in nutritional interventions for many clinical conditions, including renal, oncology, haematology, mental illness, neurorehabilitation, stroke, eating disorders, gastroenterology (including Crohn’s Disease, Ulcerative Colitis, Coeliac Disease, IBS), Cystic Fibrosis, food allergy and intolerance, immunosuppressed states (e.g. HIV) to name a few. And no cannot provide references for all of these too as I have to get on with my work now!!
References (PS ” I could have given more, but I thought this post was already a little bit on the long side plus I have already spent far too long writing this….)
1. Rolls, B.J.; Roe, L.S. and Meengs, J.S. (2006) Larger portion sizes lead to a sustained increase in energy intake over 2 days. Journal of the American Dietetic Association 106(4): 543-549
2. Rolls, B.J.; Roe, L.S. and Meengs, J.S. (2006) Reductions in portion size and energy density of foods are additive and lead to sustained decreases in energy intake. American Journal of Clinical Nutrition 83(1): 11-17
3. Burton-Freeman, B. (2000) Dietary fiber and energy regulation. Journal of Nutrition, 130: 272S-275S.
4. Delzenne, N. M. and Cani, P. D. (2005) A place for dietary fibre in the management of the metabolic syndrome. Current Opinion in Clinical Nutrition and Metabolic Care, 8: 636-640.
5. Melanson, K. J.; Angelopoulos, T. J.; Nguyen et al (2006) Consumption of whole-grain cereals during weight loss: Effects on dietary quality, dietary fiber, magnesium, vitamin B-6, and obesity. Journal of the American Dietetic Association, 106, 1380-1388.
6. Slavin, J. L. (2005) Dietary fiber and body weight. Nutrition, 21, 411-418.
7. Koh-Banerjee, P.; Rimm, E.B. (2003) Whole grain consumption and weight gain: a review of the epidemiological evidence, potential mechanisms and opportunities for future research. Proceedings of the Nutrition Society 62(1): 25-29.
8. Ross, R. and Janssen, I. (2001) Physical activity, total and regional obesity: dose-response considerations. Medicine and Science in Sports and Exercise. 33 (Suppl 6): S521-S527.
9. Kay, S.J. and Fiatarone Singh, M.A. (2006) The influence of physical activity on abdominal fat: a systematic review of the literature. Obesity Reviews 7(2): 183-200.
10. Avenell, A.; Brown, T.J.; McGee, M.A. et al (2004) What are the long-term benefits of weight reducing diets in adults? A systematic review of randomized controlled trials. Journal of Human Nutrition and Dietetics 17(4): 317-335.
11. Avenell, A.; Broom, J.; Brown, T.J. et al (2004) Systematic review of the long-term effects and economic consequences of treatments for obesity and implications for health improvement. Health Technology Assessment 8 (21): iii-iv, 1-458
12. Denke MA (2006) Dietary fats, fatty acids, and their effects on lipoproteins. Current Atherosclerosis Reports 8(6): 466-471.
13. Hooper, L.; Summerbell, C.D.; Higgins, J.P. et al (2001) Reduced or modified dietary fat for preventing cardiovascular disease. Cochrane Database of Systematic Reviews 3: CD002137.
14. Truswell, A.S. (2005) Some problems with Cochrane reviews of diet and chronic disease. European Journal of Clinical Nutrition 59 (Suppl 1): S150-S154.
15. Williams, C.M.; Francis-Knapper, J.A.; Webb, D. (1999) Cholesterol reduction using manufactured foods high in monounsaturated fatty acids: a randomized crossover study. British Journal of Nutrition 81(6): 439-446.
16. Allman-Farinelli, M.A.; Gomes, K.; Favaloro, E.J. and Petocz, P. (2005) A diet rich in high-oleic-acid sunflower oil favorably alters low-density lipoprotein cholesterol, triglycerides, and factor VII coagulant activity. Journal of the American Dietetic Association 105(7): 1071-1079.
17. Dauchet, L.; Amouyel, P.; Hercberg, S. and Dallongeville, J. (2006) Fruit and vegetable consumption and risk of coronary heart disease: a meta-analysis of cohort studies. Journal of Nutrition 136(10): 2588-2593.
18. Liu, S.; Manson, J.E.; Lee, I.M. et al (2000) Fruit and vegetable intake and risk of cardiovascular disease: the Women’s Health Study. American Journal of Clinical Nutrition 72(4): 922-8.
19. Bes-Rastrollo M, Martinez-Gonzalez MA, Sanchez-Villegas A et al (2006) Association of fiber intake and fruit/vegetable consumption with weight gain in a Mediterranean population. Nutrition 22(5): 504-11.
20. Scientific Advisory Committee on Nutrition (2003) Salt and Health. The Stationary Office (http://www.sacn.gov.uk/pdfs/sacn_salt_final.pdf)
21. O’Shaughnessy, K.M. (2006) Role of diet in hypertension management. Current Hypertension Reports 8(4): 292-297
22. Scientific Advisory Committee on Nutrition (2004) Advice on Fish Consumption: Benefits and Risks. The Stationary Office (http://www.sacn.gov.uk/pdfs/fics_sacn_advice_fish.pdf)
23. Griffin, M.D.; Sanders, T.A.; Davies, I.G. et al (2006) Effects of altering the ratio of dietary n-6 to n-3 fatty acids on insulin sensitivity, lipoprotein size, and postprandial lipemia in men and postmenopausal women aged 45-70 y: the OPTILIP Study. American Journal of Clinical Nutrition 84(6): 1290-1298.
24. Moore, C.S.; Bryant, S.P.; Mishra, G.D. et al (2006) Oily fish reduces plasma triacylglycerols: a primary prevention study in overweight men and women. Nutrition 22(10): 1012-1024.
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’s not the expression of opinion that bothers you, but that fact that it differs from your own. ”
I’m sure most dietitians could not agree more. And we ARE ACCOUNTABLE – to the Health Professions Council (http://www.hpc-uk.org/). We follow a strict code of conduct and need to provide evidence to prove we meet the various criteria. We would not be able to register with the HPC otherwise and would therefore not be able to call ourselves “Dietitian” or “Dietician” (both are protected titles in an attempt to avoid further mis-leading the public about who is best qualified and informed to impart nutritional advice).
I would bounce the statement back to you – What accountability is there for the nutritional advice that a Medical Doctor with an ‘interest in Nutrition’ provides?
Thanks
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!
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’m sure you would agree that much of the data is weak (largely due to the inherent difficulties in studying the effect of nutritional interventions to the exclusion of other confounding factors) and inconclusive. In particular there is a lack of large scale, long term randomised controlled trials in many areas of nutritional research.
In your original article/blog you have suggested that the cornerstone of dietetic advice to aid weight loss is via “low-fat eating” / “a diet low in fat and high in carbohydrate”. I would contest that is strictly true that this is what is promoted by dietitians and is certainly an over-simplification of what is endorsed. Furthermore that phrase does not account for the complexity in the aetiology, prevention and treatment of obesity and you have not actually defined precisely what you mean by “low-fat eating” / “a diet low in fat and high in carbohydrate”.
In fact a number of strategies are undertaken for example including, portion size control (1-2), increasing high fibre / wholegrain choices and reducing intake of refined carbohydrates/simple sugars (3-7) and incorporating physical activity (8-9). I would also offer advice to help the client reduce overall fat intake (10-11), as this will aid a reduction in energy density of overall intake. This would involve, as Chris Cashin has already said, encouraging the client to cutting down/out chips, pasties, biscuits, cakes, etc (depending upon their usual intake) and coming up with alternatives that are acceptable to the client. However I would not say this is necessarily meaning a ‘low-fat’ diet, just a ‘lower fat’ diet. The ultimate aim, in crude terms, is to reduce ‘calories in’ and increase ‘calories out’ (a very simple formula really!!).
Furthermore, with overweight clients, it is not just about ‘reducing weight’, it is also about improving health outcomes, for example reducing cardiovascular risk and the risk of developing type 2 diabetes. Such advice may focus on altering balance of fat quality (i.e. unsaturated fat, esp monounsaturated in place of saturated fat) (12-16), increasing intake of fruit and vegetables (17-19), reducing intake of sodium (20-21) and encouraging intake of oily fish/n-3 LC-PUFA (22-24). Furthermore, it is now recognised that reducing body fat stores, particularly abdominal, are desirable for health whether accompanied by weight loss or not (easily monitored via waist circumference).
The most important aspect is that dietitians undertake a holistic approach whereby the client’s individual circumstances (e.g. usual intake, cooking facilities, ability to cook, income levels, proximity to shops, available transport, physical limitations, living alone / with partner / with family, etc), barriers to change and indeed readiness to change are considered.
Furthermore, as Chris has just said, while the nutritional interventions for the treatment of obesity and diabetes is an important aspect of dietetics, dietitians are also experts in nutritional interventions for many clinical conditions, including renal, oncology, haematology, mental illness, neurorehabilitation, stroke, eating disorders, gastroenterology (including Crohn’s Disease, Ulcerative Colitis, Coeliac Disease, IBS), Cystic Fibrosis, food allergy and intolerance, immunosuppressed states (e.g. HIV) to name a few. And no cannot provide references for all of these too as I have to get on with my work now!!
References (PS ” I could have given more, but I thought this post was already a little bit on the long side plus I have already spent far too long writing this)
1. Rolls, B.J.; Roe, L.S. and Meengs, J.S. (2006) Larger portion sizes lead to a sustained increase in energy intake over 2 days. Journal of the American Dietetic Association 106(4): 543-549
2. Rolls, B.J.; Roe, L.S. and Meengs, J.S. (2006) Reductions in portion size and energy density of foods are additive and lead to sustained decreases in energy intake. American Journal of Clinical Nutrition 83(1): 11-17
3. Burton-Freeman, B. (2000) Dietary fiber and energy regulation. Journal of Nutrition, 130: 272S-275S.
4. Delzenne, N. M. and Cani, P. D. (2005) A place for dietary fibre in the management of the metabolic syndrome. Current Opinion in Clinical Nutrition and Metabolic Care, 8: 636-640.
5. Melanson, K. J.; Angelopoulos, T. J.; Nguyen et al (2006) Consumption of whole-grain cereals during weight loss: Effects on dietary quality, dietary fiber, magnesium, vitamin B-6, and obesity. Journal of the American Dietetic Association, 106, 1380-1388.
6. Slavin, J. L. (2005) Dietary fiber and body weight. Nutrition, 21, 411-418.
7. Koh-Banerjee, P.; Rimm, E.B. (2003) Whole grain consumption and weight gain: a review of the epidemiological evidence, potential mechanisms and opportunities for future research. Proceedings of the Nutrition Society 62(1): 25-29.
8. Ross, R. and Janssen, I. (2001) Physical activity, total and regional obesity: dose-response considerations. Medicine and Science in Sports and Exercise. 33 (Suppl 6): S521-S527.
9. Kay, S.J. and Fiatarone Singh, M.A. (2006) The influence of physical activity on abdominal fat: a systematic review of the literature. Obesity Reviews 7(2): 183-200.
10. Avenell, A.; Brown, T.J.; McGee, M.A. et al (2004) What are the long-term benefits of weight reducing diets in adults? A systematic review of randomized controlled trials. Journal of Human Nutrition and Dietetics 17(4): 317-335.
11. Avenell, A.; Broom, J.; Brown, T.J. et al (2004) Systematic review of the long-term effects and economic consequences of treatments for obesity and implications for health improvement. Health Technology Assessment 8 (21): iii-iv, 1-458
12. Denke MA (2006) Dietary fats, fatty acids, and their effects on lipoproteins. Current Atherosclerosis Reports 8(6): 466-471.
13. Hooper, L.; Summerbell, C.D.; Higgins, J.P. et al (2001) Reduced or modified dietary fat for preventing cardiovascular disease. Cochrane Database of Systematic Reviews 3: CD002137.
14. Truswell, A.S. (2005) Some problems with Cochrane reviews of diet and chronic disease. European Journal of Clinical Nutrition 59 (Suppl 1): S150-S154.
15. Williams, C.M.; Francis-Knapper, J.A.; Webb, D. (1999) Cholesterol reduction using manufactured foods high in monounsaturated fatty acids: a randomized crossover study. British Journal of Nutrition 81(6): 439-446.
16. Allman-Farinelli, M.A.; Gomes, K.; Favaloro, E.J. and Petocz, P. (2005) A diet rich in high-oleic-acid sunflower oil favorably alters low-density lipoprotein cholesterol, triglycerides, and factor VII coagulant activity. Journal of the American Dietetic Association 105(7): 1071-1079.
17. Dauchet, L.; Amouyel, P.; Hercberg, S. and Dallongeville, J. (2006) Fruit and vegetable consumption and risk of coronary heart disease: a meta-analysis of cohort studies. Journal of Nutrition 136(10): 2588-2593.
18. Liu, S.; Manson, J.E.; Lee, I.M. et al (2000) Fruit and vegetable intake and risk of cardiovascular disease: the Women’s Health Study. American Journal of Clinical Nutrition 72(4): 922-8.
19. Bes-Rastrollo M, Martinez-Gonzalez MA, Sanchez-Villegas A et al (2006) Association of fiber intake and fruit/vegetable consumption with weight gain in a Mediterranean population. Nutrition 22(5): 504-11.
20. Scientific Advisory Committee on Nutrition (2003) Salt and Health. The Stationary Office (http://www.sacn.gov.uk/pdfs/sacn_salt_final.pdf)
21. O’Shaughnessy, K.M. (2006) Role of diet in hypertension management. Current Hypertension Reports 8(4): 292-297
22. Scientific Advisory Committee on Nutrition (2004) Advice on Fish Consumption: Benefits and Risks. The Stationary Office (http://www.sacn.gov.uk/pdfs/fics_sacn_advice_fish.pdf)
23. Griffin, M.D.; Sanders, T.A.; Davies, I.G. et al (2006) Effects of altering the ratio of dietary n-6 to n-3 fatty acids on insulin sensitivity, lipoprotein size, and postprandial lipemia in men and postmenopausal women aged 45-70 y: the OPTILIP Study. American Journal of Clinical Nutrition 84(6): 1290-1298.
24.Moore, C.S.; Bryant, S.P.; Mishra, G.D. et al (2006) Oily fish reduces plasma triacylglycerols: a primary prevention study in overweight men and women. Nutrition 22(10): 1012-1024.
I have posted twice on here and am wondering have they been removed
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?????
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’m sure you would agree that much of the data is weak (largely due to the inherent difficulties in studying the effect of nutritional interventions to the exclusion of other confounding factors) and inconclusive. In particular there is a lack of large scale, long term randomised controlled trials in many areas of nutritional research.
In your original article/blog you have suggested that the cornerstone of dietetic advice to aid weight loss is via “low-fat eating” / “a diet low in fat and high in carbohydrate”. I would contest that is strictly true that this is what is promoted by dietitians and is certainly an over-simplification of what is endorsed. Furthermore that phrase does not account for the complexity in the aetiology, prevention and treatment of obesity and you have not actually defined precisely what you mean by “low-fat eating” / “a diet low in fat and high in carbohydrate”.
In fact a number of strategies are undertaken for example including, portion size control (1-2), increasing high fibre / wholegrain choices and reducing intake of refined carbohydrates/simple sugars (3-7) and incorporating physical activity (8-9). I would also offer advice to help the client reduce overall fat intake (10-11), as this will aid a reduction in energy density of overall intake. This would involve, as Chris Cashin has already said, encouraging the client to cutting down/out chips, pasties, biscuits, cakes, etc (depending upon their usual intake) and coming up with alternatives that are acceptable to the client. However I would not say this is necessarily meaning a ‘low-fat’ diet, just a ‘lower fat’ diet. The ultimate aim, in crude terms, is to reduce ‘calories in’ and increase ‘calories out’ (a very simple formula really!!).
Furthermore, with overweight clients, it is not just about ‘reducing weight’, it is also about improving health outcomes, for example reducing cardiovascular risk and the risk of developing type 2 diabetes. Such advice may focus on altering balance of fat quality (i.e. unsaturated fat, esp monounsaturated in place of saturated fat) (12-16), increasing intake of fruit and vegetables (17-19), reducing intake of sodium (20-21) and encouraging intake of oily fish/n-3 LC-PUFA (22-24). Furthermore, it is now recognised that reducing body fat stores, particularly abdominal, are desirable for health whether accompanied by weight loss or not (easily monitored via waist circumference).
The most important aspect is that dietitians undertake a holistic approach whereby the client’s individual circumstances (e.g. usual intake, cooking facilities, ability to cook, income levels, proximity to shops, available transport, physical limitations, living alone / with partner / with family, etc), barriers to change and indeed readiness to change are considered.
Furthermore, as Chris has just said, while the nutritional interventions for the treatment of obesity and diabetes is an important aspect of dietetics, dietitians are also experts in nutritional interventions for many clinical conditions, including renal, oncology, haematology, mental illness, neurorehabilitation, stroke, eating disorders, gastroenterology (including Crohn’s Disease, Ulcerative Colitis, Coeliac Disease, IBS), Cystic Fibrosis, food allergy and intolerance, immunosuppressed states (e.g. HIV) to name a few. And no cannot provide references for all of these too as I have to get on with my work now!!
References (PS ” I could have given more, but I thought this post was already a little bit on the long side plus I have already spent far too long writing this)
1. Rolls, B.J.; Roe, L.S. and Meengs, J.S. (2006) Larger portion sizes lead to a sustained increase in energy intake over 2 days. Journal of the American Dietetic Association 106(4): 543-549
2. Rolls, B.J.; Roe, L.S. and Meengs, J.S. (2006) Reductions in portion size and energy density of foods are additive and lead to sustained decreases in energy intake. American Journal of Clinical Nutrition 83(1): 11-17
3. Burton-Freeman, B. (2000) Dietary fiber and energy regulation. Journal of Nutrition, 130: 272S-275S.
4. Delzenne, N. M. and Cani, P. D. (2005) A place for dietary fibre in the management of the metabolic syndrome. Current Opinion in Clinical Nutrition and Metabolic Care, 8: 636-640.
5. Melanson, K. J.; Angelopoulos, T. J.; Nguyen et al (2006) Consumption of whole-grain cereals during weight loss: Effects on dietary quality, dietary fiber, magnesium, vitamin B-6, and obesity. Journal of the American Dietetic Association, 106, 1380-1388.
6. Slavin, J. L. (2005) Dietary fiber and body weight. Nutrition, 21, 411-418.
7. Koh-Banerjee, P.; Rimm, E.B. (2003) Whole grain consumption and weight gain: a review of the epidemiological evidence, potential mechanisms and opportunities for future research. Proceedings of the Nutrition Society 62(1): 25-29.
8. Ross, R. and Janssen, I. (2001) Physical activity, total and regional obesity: dose-response considerations. Medicine and Science in Sports and Exercise. 33 (Suppl 6): S521-S527.
9. Kay, S.J. and Fiatarone Singh, M.A. (2006) The influence of physical activity on abdominal fat: a systematic review of the literature. Obesity Reviews 7(2): 183-200.
10. Avenell, A.; Brown, T.J.; McGee, M.A. et al (2004) What are the long-term benefits of weight reducing diets in adults? A systematic review of randomized controlled trials. Journal of Human Nutrition and Dietetics 17(4): 317-335.
11. Avenell, A.; Broom, J.; Brown, T.J. et al (2004) Systematic review of the long-term effects and economic consequences of treatments for obesity and implications for health improvement. Health Technology Assessment 8 (21): iii-iv, 1-458
12. Denke MA (2006) Dietary fats, fatty acids, and their effects on lipoproteins. Current Atherosclerosis Reports 8(6): 466-471.
13. Hooper, L.; Summerbell, C.D.; Higgins, J.P. et al (2001) Reduced or modified dietary fat for preventing cardiovascular disease. Cochrane Database of Systematic Reviews 3: CD002137.
14. Truswell, A.S. (2005) Some problems with Cochrane reviews of diet and chronic disease. European Journal of Clinical Nutrition 59 (Suppl 1): S150-S154.
15. Williams, C.M.; Francis-Knapper, J.A.; Webb, D. (1999) Cholesterol reduction using manufactured foods high in monounsaturated fatty acids: a randomized crossover study. British Journal of Nutrition 81(6): 439-446.
16. Allman-Farinelli, M.A.; Gomes, K.; Favaloro, E.J. and Petocz, P. (2005) A diet rich in high-oleic-acid sunflower oil favorably alters low-density lipoprotein cholesterol, triglycerides, and factor VII coagulant activity. Journal of the American Dietetic Association 105(7): 1071-1079.
17. Dauchet, L.; Amouyel, P.; Hercberg, S. and Dallongeville, J. (2006) Fruit and vegetable consumption and risk of coronary heart disease: a meta-analysis of cohort studies. Journal of Nutrition 136(10): 2588-2593.
18. Liu, S.; Manson, J.E.; Lee, I.M. et al (2000) Fruit and vegetable intake and risk of cardiovascular disease: the Women’s Health Study. American Journal of Clinical Nutrition 72(4): 922-8.
19. Bes-Rastrollo M, Martinez-Gonzalez MA, Sanchez-Villegas A et al (2006) Association of fiber intake and fruit/vegetable consumption with weight gain in a Mediterranean population. Nutrition 22(5): 504-11.
20. Scientific Advisory Committee on Nutrition (2003) Salt and Health. The Stationary Office (http://www.sacn.gov.uk/pdfs/sacn_salt_final.pdf)
21. O’Shaughnessy, K.M. (2006) Role of diet in hypertension management. Current Hypertension Reports 8(4): 292-297
22. Scientific Advisory Committee on Nutrition (2004) Advice on Fish Consumption: Benefits and Risks. The Stationary Office (http://www.sacn.gov.uk/pdfs/fics_sacn_advice_fish.pdf)
23. Griffin, M.D.; Sanders, T.A.; Davies, I.G. et al (2006) Effects of altering the ratio of dietary n-6 to n-3 fatty acids on insulin sensitivity, lipoprotein size, and postprandial lipemia in men and postmenopausal women aged 45-70 y: the OPTILIP Study. American Journal of Clinical Nutrition 84(6): 1290-1298.
24. Moore, C.S.; Bryant, S.P.; Mishra, G.D. et al (2006) Oily fish reduces plasma triacylglycerols: a primary prevention study in overweight men and women. Nutrition 22(10): 1012-1024.
In response to a comment made in post #8 (by Regina Wilshire):
“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”
Where on earth have you formed this opinion??? It is certainly untrue, at least where I trained (University of Surrey).
If all I had done in my Nutrition and Dietetics degree course was to “regurgitate the dietary guidelines with absolutely no training along the way in statistics” then I would have definitely failed!! Certainly we were made aware of the dietary guidelines and how they were reached, however we also considered the limitations of these guidelines (e.g. limited data, particularly for certain population groups, the fact they do not account for genetic variation, etc). Furthermore, our course included a module on statistics, which focused on those stat methods that are used by Biological Scientists and we undertook a research project which usually involved data collection and interpretation (including the use of statisical analyses).
We were also required to carry out critical reviews of given scientific papers of varying quality, which included evaluating the statistical methods used and drawing conclusions about the quality of data presented and research carried out.
Therefore, I totally disagree that we were taught “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”
And I ask you, Regina, how would you even know what is in our course unless you have been on it!?!
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’s not the expression of opinion that bothers you, but that fact that it differs from your own. ”
I’m sure most dietitians could not agree more. And we ARE ACCOUNTABLE – to the Health Professions Council (http://www.hpc-uk.org/). We follow a strict code of conduct and need to provide evidence to prove we meet the various criteria. We would not be able to register with the HPC otherwise and would therefore not be able to call ourselves “Dietitian” or “Dietician” (both are protected titles in an attempt to avoid further mis-leading the public about who is best qualified and informed to impart nutritional advice).
I would bounce the statement back to you – What accountability is there for the nutritional advice that a Medical Doctor with an ‘interest in Nutrition’ provides?
Thanks
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
Just read most of the posts here. Only really want to say that as a patient in my own experience and being a borderline diabetic and with high cholesterol NHS Dieticians have given me in my opinion bad dietary advice (eg: ;do any diet you wish to lose weight and if you feel dizzy or heady have some sugar to raise your glucose…..if your peckish between meals have some dried fruits to nibble on…..eat what you normally eat, just have smaller portions) – and on the other hand I have been given some excellent advice from Nutritionalists (eg: eat little and often to keep your blood sugars even……cut out refined foods……eat healthy with lots of veg, nuts, seeds, fresh stuff, cut down on carbs, but do not cut out any main food groups completely, etc)