Holford Watch: Patrick Holford, nutritionism and bad science

A recurrent theme among the anonymous commenters is that we need to develop compassion and an open mind when we discuss Patrick Holford and his work. I’m unclear as to whether either of these ought to encompass the acceptance of information that is mis-leading or wrong. More recently, a (named) commenter wrote to tell us how impressed she is by Holford:

I certainly don’t agree with everything alternative medicine has to offer, but some of it does work, so please don’t criticise too much!

Nutritionists (as opposed to dieticians) want to help people towards optimum health - who doesn’t want to feel good? Some of us can’t seem to get the balance right ourselves and, since doctors and buying heavily marketed products often doesn’t help (docs, like dietitians, tend to want to cure rather than prevent), we want to ask someone who knows more than us.

Why is it not appropriate to criticise someone when they are wrong? Or do you think that confusing premature mortality figures of 250,000 for cardiovascular disease when the actual figure should have been 60,000 is neither here nor there? What did you think of the WiFi avoidance advice that would turn your domestic wiring into an aerial? Is it acceptable to extol the virtues of a prophylactic pendant that works by faith and magic rather than science? What about Holford’s fauxrious claim that Watchdog had misrepresented the strength of the research literature for food intolerance tests when he was mistaken?

Holford has removed his fauxrious claims about the Watchdog programme but it still exists on the websites of his supporters. In response to some of Jon’s concerns, he has amended some dietary claims and recommendations on his Food for the Brain website and has now reported that he will ask Health Products for Life to amend advice about folic acid supplements. Holford’s testimonial about the QLink also seems to have disappeared.

Holford Watch hasn’t begun to scratch the surface of what is amiss with some of Holford’s claims or his sometimes inappropriate characterisation of the scientific literature. It is difficult to estimate whether these flaws are minor or might have greater significance: it is also difficult to assess how widespread they are among (say) nutritionists who have trained at ION or any nutritional therapist that one might consult. Catherine Collins gave a robust response to the commenter’s misconceptions about the work and scope of practice of registered dietitians. I would dispute the commenter’s implication that a nutritionist will, by default, always know more than ‘us’.

If Holfordism has persuaded somebody that it is inappropriate to comment on unsubstantiated claims, poor research or bad science, is it harmless?

A commenter recently posted some thoughts, opinions and questions that raised the wider question: Is Holfordism harmless? She obviously has a sufficiently strong interest in nutrition to prompt her to consider dedicating time and money to studying it.

I saw Patrick Holford on tv the other day and was quite impressed. I have also been thinking about studying nutrition and looking at his institute as a place to study.

I certainly don’t agree with everything alternative medicine has to offer, but some of it does work, so please don’t criticise too much!

Nutritionists (as opposed to dieticians) want to help people towards optimum health - who doesn’t want to feel good? Some of us can’t seem to get the balance right ourselves and, since doctors and buying heavily marketed products often doesn’t help (docs, like dietitians, tend to want to cure rather than prevent), we want to ask someone who knows more than us.

Why do you not think that people who have studied the subject for a few years and gained a qualification, are qualified to help people in this way?

Who else would you suggest consulting?

I ask this as someone who both wants nutrition / health advice, and who is considering re-training under the nutrition umbrella.

I was a little taken aback at this characterisation of the work and practice of dietitians; I did wonder what had led this commenter to form such a partial opinion. We were very fortunate to have an excellent and robust response from Registered Dietitian, Catherine Collins.

As a practicing Registered Dietitian (RD), I’m concerned about the biased and inaccurate views that you have of my profession.

I guess you’ve been reading prospectuses from ’self-styled nutritionist’ organisations such as ION or CNELM - or perhaps the pseudo-regulatory organisation BANT, which typically make these inaccurate claims. I guess this is their way of trying to justify their ‘nutrition-lite’ practices to people like yourselves who are thinking of training in this field.

RD’s are basically BSc graduate nutritionists with an extra year of study tagged on to the original 3 years to learn and practice the interface of nutrition with clinical disease. As such it gives us a very broad and deep spectrum of expertise which we can use to work in any arena we like.

In the community we work in private practice, health promotion attached to local education and health authorities, self-help groups and organisations, and increasingly sports nutrition (2012 beckons!). Our skills are valued by the food industry, food retailers, and other businesses related to healthcare - or not.

Alternatively - and as in my case - we have the skills to work with the clinically unwell in a hospital setting. Yes, some aspects of our work are dealing with those who abrogate health and nutrition issues until seriously unwell. But my field of intensive care also deals with those unfortunate individuals in the wrong place/ wrong time, and for whom nutrition treads a fine line of providing fluid, electrolytes,and macronutrients in the presence of multi-organ failure.

I take your point regarding the occasional benefits of non-conventional approaches to illness. Yet in the field of nutrition, you will find that the ‘alternative’ do not use a parallel evidence base (such as TCM does when compared to western medicine)- they just misintepret the SAME clinical evidence to promote their practices and wares - as this excellent site demonstrates.

It’s rather ironic of you to agree that “buying heavily marketed products” is not the key to good nutritional health, yet you feel an affinity towards an organisation and an individual which - from this site alone- can be seen to promote products which existing research indicates are futile, or even harmful.

Why should self-styled nutritionists take this approach? I guess it comes down to two reasons -
EITHER
they are unconciously incompetent (so they THINK they know the subject, but they don’t have the ability to translate it accurately or in context for the individual or group)
OR
they are deliberately misleading those who seek their advice…..

But where does that lead dietitians? well, you won’t find us promoting detox or superfoods or megadose vitamins - because ’sexing up’ key nutrition research distorts the context for the public, and we don’t expect our patient to become guinea pigs for future interest - as all the work on high dose vitamins is increasingly demonstrating.

Equally, you won’t find dietitians pestering for column inches and broadcast time. We are well respected in the media because of our sound background, ethical approach and our conduct - incidentally, being the only nutritional professionals regulated by law (HPC Act 2002, formerly the CPSM Act 1980). Just google the term ‘dietitian’/ ‘dietician’ and you can see how we feature ‘out there’.

Finally, I wish you well on whatever nutrition path you take. Check out the dietitians website…or the bona fide Nutritionists website.

You can’t shortcut a route to nutrition, just as you can’t shortcut knowledge of atomic physics - despite what the nutrition-lite lobby will have you believe. If you choose the latter I guess you have to reset your moral compass or ignore the shortfalls in your training when it comes to dealing with the public who trust you……[Minor changes from the original to embed links.]

Depending on your budget, you might also compare and contrast the cost of studying with ION with that of obtaining a Registered Dietitian’s portable qualifications. If you don’t have science qualifications at ‘A’ Level, then ION offers Science Access Courses:

The Science Access courses are designed for those wishing to pursue the Nutritional Therapists’ Diploma/Foundation Degree Course (DipION/FdSc) but having insufficient background in the sciences to support study. The courses concentrate on aspects of these subjects that are relevant to nutrition.

So, you will pay around £3,090 for either the accelerated (3 month) version of this course, or the year-long course (texts and course notes included). You will also need to pick up the travel and maybe accommodation costs of attending the course in Richmond. For the (further) 3 years of the Nutritional Therapy Diploma course, you will need to pay tuition fees of £3,090 per year (I haven’t been able to establish whether the texts etc. are included in this).

If you wish to obtain a BSc in Nutrition Science in association with the University of Luton, you will need to dedicate another year of study and a further £3,000 in fees (if you study full-time, at current prices). I have not yet been able to discover how many ION graduates top-up their diploma with a BSc, nor the degree class that they commonly obtain.

Unlike most tertiary education establishments, ION doesn’t offer an overview of their research facilities, lecturers and researchers online. It would be useful to know the research projects that are in progress at ION and their list of publications. E.g., if I were interested in studying the Sports Nutrition module in Year 3, it might be helpful to know if I could have access to a gas analyser for the study of exhaled breath (e.g., useful for metabolic analysis) or something like one of the latest, very accurate body fat and metabolism analysers; I might want to know if I would be supervised by someone who is certified to conduct blood draws for lactic acid studies or similar. Coracle offers a very interesting overview of research funding in the UK and the research assessment exercise; it would be useful to know if ION is engaged in this sort of academic research .

It might be considerably faster and cheaper to study for a BSc in Nutritional Science; you may be able to qualify as a registered Dietitian in the time that it would take you to study for a Diploma with ION and then top-up to a BSc degree. You can assess for yourself the value of the assurance the DipION/FdSc is accredited by the University of Luton and validated by the British Association of Nutritional Therapists (BANT) and “meets BANT’s stringent requirements for certification of nutritional therapists”.

I’m sure that all of the contributors to Holford Watch wish the commenter well with any future studies and career. However, I am concerned at the role that Holfordism might have played in shaping the mis-perceptions of the role/practice of Registered Dietitians. Further than that, I’m slightly alarmed at the notion that nutritionists have the inside track to ‘feeling good’ or having “optimum health”. To me, this notion not only overlooks the appropriate intervention of professionals such as GPs but it deprecates people’s own commonsense. Is this harmless?

Patrick Holford gives a remarkable overview of history to support his claims for the value of homocysteine testing in helping you “to eliminate your risk of ever having a heart attack”. He swoops from autopsies on egyptian mummies to unsubstantiated opinions on the prevalence of heart disease in late 19th century America via some mangled statistics on the risk of premature death from cardiovascular disease in the UK, before alighting on a study of restenosis to justify his claims.

One of the most common surgical procedures for those with coronary artery disease is angioplasty. It involves inserting catheter tubing containing a small balloon into arteries around the heart. The balloon is inflated to flatten deposits of atherosclerotic plaques blocking the artery, so blood can once again flow to the heart.

Like bypass surgery, angioplasty is often not a permanent cure, and after surgery the arteries may reclog in the treated area – a very undesirable condition called restenosis…

Restenosis of the coronaries is much more likely if your H score is high, according to research at the Swiss Cardiovascular Centre in Bern. (4) In a nutshell, this means the higher your H score, the faster your coronary arteries will narrow again after surgery, so there’s little point having an angioplasty without testing for and treating high homocysteine.

Unfortunately, this is only part of the story; the role of homocysteine levels in predicting restenosis is not that straightforward. Holford has frequently expressed his concern about the mis-citing of research literature and possible suppression of inconvenient findings, so it seems appropriate to look at the research literature for homocysteine and restenosis in a little more detail to see if he is representing the literature in an evenhanded way.

Back in 2000, Dr. Steven Miner and his colleagues published an interesting study into possible correlations between homocysteine concentrations and restenosis following angioplasty. This was a well-designed, prospective study. The authors were confident in their conclusion that raised homocysteine levels do not predict the likelihood of restenosis.

The range of plasma homocysteine concentrations in this study is consistent with that seen in other studies,[refs] as is the trend toward an increased mean homocysteine concentration in homozygotes for the MTHFR 677T genotype.[ref] However, ours is the first published study to investigate the possible correlation between homocysteine concentrations and restenosis after PTCA and clearly shows the absence of any positive correlation. This lack of effect is apparent in patients undergoing PTCA alone and in with those receiving adjuvant stenting. No threshold effect is apparent. The adequate sample size, near complete follow-up, and the trend toward a negative correlation makes the possibility of a false-negative study extremely unlikely. [Emphasis added.]

There are several other studies that do not find a signficant relationship for homocysteine and restenosis:

2002 Relation of homocysteine, vitamin B(12), and folate to coronary in-stent restenosis “These results suggest that homocysteine, folate, and vitamin B(12) are not related to the angiographically determined rate of coronary in-stent restenosis after 6 months.”

2005 Clinician Update Homocysteine and Its Effects on In-Stent Restenosis cites a number of earlier clinical trials that fail to show a relationship between high homocysteine levels and restenosis. They note that several trials are in progress and conclude: “Until complete results of these studies become available, screening for hyperhomocystinemia in patients undergoing coronary stenting is only recommended in the case of premature atherosclerotic disease (patients homocysteine-lowering therapy might have a deleterious effect in patients treated with stent implantation“. [Emphasis added.]

2006 A prospective patient observational study of the role of hyperhomocysteinemia in restenosis in patients undergoing infrainguinal angioplasty or bypass procedures. “This study does not support the hypothesis that HHCy is associated with an increased risk of restenosis after vascular intervention.”

2006 Effect of folic acid supplementation on risk of cardiovascular diseases: a meta-analysis of randomized controlled trials. This is one of the studies that Holford acknowledges and disputes; however, the authors conclude: “Folic acid supplementation has not been shown to reduce risk of cardiovascular diseases or all-cause mortality among participants with prior history of vascular disease. Several ongoing trials with large sample sizes might provide a definitive answer to this important clinical and public health question”.

2006 Efficacy of folic acid therapy for prevention of in-stent restenosis: a randomized clinical trial. “Treatment with folic acid does not decrease the rate of restenosis and need for revascularization of the target lesion after stent-percutaneous coronary angioplasty.”

2006 Post-interventional homocysteine levels: failure as a predictive biomarker of in-stent restenosis. “[W]e hypothesise that homocysteine may not serve as a safe and independent biomarker of in-stent restenosis after a six months period following percutaneous coronary stenting.”

Holford uses a restenosis study that is not validated by other researchers to assemble a supporting platform of evidence to demonstrate the value of widespread testing of homocysteine levels.

Holford and Braly claim that homocysteine levels are a “chemical crystal ball”. It would be profoundly useful and cost-effective if homocysteine levels were capable of predicting the need for restenosis or could function as a simple index of your current and future health. Unfortunately, it doesn’t seem as if a homocysteine test can bear the mantle of so much responsibility: there isn’t even a consensus of opinion as to whether or not it has a predictive role for restenosis although the evidence is increasingly against it.

Regular homocysteine tests (as recommended 2-3 times a year to establish your baseline levels and tweak/maintain them with vitamin supplements) cost money; from around £70-75 per test. The recommended H Factors vitamin supplement will cost from £41.60 for 90 days to £41.60 for 30 days, depending on the recommended dose. There is no information about the bioavailability of the contents, so I don’t know if it is appropriate to expect your GP or Practice Nurse to advise you on your H Factors dosage; you might need to pay to consult a nutritionist or similar. A nutritionist might base his/her recommendations on an inappropriate interpretation of research and some unsupported beliefs.

You may well be comforted at the thought that your homocysteine levels are low or within bounds; however, it might be helpful if you are confident that there is good quality research to support the value of this. In subsequent parts of the review of Holford’s claims for homocysteine, we will look at trials that report that homocysteine levels can be reduced by vitamin supplementation but that this has no affect on clinical outcomes; e.g., you might spend between £700-1000 per year and successfully lower your homocysteine levels but still have raised blood pressure.

Patrick Holford and Dr. James Braly wrote a book about homocysteine and assert that it is “the best single indicator of whether you are likely to live long or die young: The H-Factor Solution. According to Holford and Braly, homocysteine is:

[l]ike a chemical crystal ball, it reveals exactly what we should be doing to guarantee our future health…your H score predicts your risk of more than 100 diseases and medical conditions-including increased risk of premature death from all common causes.

Holford and Braly’s claims for the value of homocysteine are extraordinary. However, the proof that Holford offers is less impressive; particularly against the background of an article about homocysteine and coronary vascular disease (CVD) in which he substantially overstates the risk of premature death from CVD.

You might expect that any claims would be based on a balanced overview of all the research literature about homocysteine: any causal links to clinical conditions; its predictive value; whether it is possible to lower homocysteine levels with a therapeutic intervention; whether lowering homocysteine levels reduces the risk of disease, or poor outcomes in disease. I can’t comment on the book, but Holford does not do this in relevant articles on his website.

Holford is enthusiastic about the homocysteine test. The test is a significant part of his claims that you can follow his advice and learn How to Eliminate Your Risk of Ever Having a Heart Attack. I should emphasise that your homocysteine level is not a diagnostic test: it is not something like a cardiac enzyme study that can determine whether you’ve recently had a heart attack. If it’s not diagnostic, is it predictive? Does this test tell you something about your risk profile that is more meaningful than other sources of information such as a physical examination alongside a detailed family history? According to Holford:

[t]he single greatest risk of a heart attack comes from having a high homocysteine level. Homocysteine is a naturally-occurring protein that’s found in the blood. If you’ve had a heart attack, the chances that you have an unacceptably high homocysteine score (over 9 units) are well above 50 per cent. About 30 per cent of you will have a level above 15 units, which is very high. Very conservatively, I estimate that at least 8 million people in Britain have dangerously high homocysteine, increasing their risk of a heart attack by at least 50 per cent.

I’m going to go out on a limb and say that your “single greatest risk of a heart attack” is whether or not you’ve already had a heart attack, followed by your age (67% of deaths from CHD occur in those aged 75 and above figures calculated from British Heart Foundation statistics report (pdf)). I’m also going to say that there are some conditions, such as familial hyperlipidaemia that would raise a red flag and should be fully investigated before considering the need for a homocysteine test.

Gene Sherpa, Dr. Steve Murphy, provides fascinating insights into the role of genetics in personalised medicine. He emphasises the research that shows time and again that a good family clinical history is the best and cheapest genetic risk assessment that trumps most offerings from a direct-to-consumer testing service. He has recently commented on the importance of family history when estimating the risk of stroke. Murphy outlines research into a genetic variation that might affect homocysteine/folate/one carbon metabolism and raises questions about whether vitamin status plays a role. This might look like a showcase example of the need for nutrigenomics: how the appropriate diet and supplements can reduce risks attributable to individual variation. However, Murphy cautions that all is not as it seems:

1. Homocysteine is only poorly linked to heart disease in asymptomatic patients
2. There is some literature which states that B vitamin supplementation in patients with prior heart attack can cause WORSE outcomes.
3. This is a replicated study, but not on a heterogeneous population………..

Basing his advice on the current state of knowledge, Murphy counsels that people who have already had a heart attack should not supplement B vitamins.

The following are some of the causes or proposed correlates of elevated homocysteine levels:

1. defect in the transsulfuration pathway / deficiency in cystathionine B-synthase
2. defect in the remethylation pathway / defective methylcobalamin synthesis or abnormality in MTHFR
3. Proposed sources of abnormalities

genetic predisposition

1. genetic predisposition exacerbated by co-morbid conditions and/or nutritional and environmental factors:
1. abnormal MTHFR
2. chronic renal failure
3. hypothyroidism
4. methotrexate therapy
5. oral contraceptive use
6. malignancies of breast, ovary, and psoriasis
7. smoking
8. high alcohol consumption
9. age

For most of these, you would need a skilled interpretation of your homocysteine levels alongside your clinical history: it might be very unwise to self-medicate to adjust homocysteine levels without allowing for relevant clinical details.

If the question about homocysteine measurement is, “For the general population, does this test tell you something about your risk profile for heart attacks that is more meaningful than other sources of information such as a physical examination alongside a detailed medical and family history?”, the answer would seem to be “No”. Holford and Braly may well have been right when they likened homocysteine to a “chemical crystal ball”; it is a matter of judgment for readers to decide whether or not they consider a “crystal ball” to be a reliable source of information.

I was disappointed in the quality of evidence that Patrick Holford put forward to support his claims that we could learn, How to Eliminate Your Risk of Ever Having a Heart Attack. Since then, I’ve been reading through the intervention trials that have experimented with lowering homocysteine levels through supplementation etc. and whether they have succeeded in lowering those levels, but not the incidence of clinical disease. Ultimately, it is more relevant to consider whether you have decreased the incidence of disease or reduced its severity rather than concentrating on a particular measurement. When you alter a particular measurement such as a cholesterol or homocysteine level, but you don’t reduce the incidence of (say) heart attacks or strokes, then it raises the suspicion that you have identified a false surrogate endpoint.

So, I was more than a little interested when I came across Holford’s article, Homocysteine: Helpful or Hoax? I don’t fully agree with his conclusions but it is a shame that he doesn’t link to this less dogmatic article from the one where he claims that

Lowering your H score…dramatically reduces the risk of death from all causes, not just heart attacks.

Holford is aware of trials that don’t support his conclusions and discusses those results with particular reference to the objections made by Dr. Helga Refsum. This discussion does, of course, include the use of a rhetorical device:

So was this a cover-up of the sort all too common with inconvenient findings in drug trials?

Somewhere in there, the fine nuance of Refsum’s arguments is lost. Holford quotes Refsum:

If we are going to optimise treatment for heart disease patients we need to discover what works for them and what doesn’t…The problem is that the trials so far are too small to come forward with definite advice.

It could also be argued that the trials, so far, are insufficient to support Holford’s broad recommendation for testing and supplementation in asymptomatic individuals.

In the light of his recent objections and comments about folate fortification (here and here), it is worth mentioning that Holford quotes Refsum on this:

The business of folate fortification…may also be affecting the results. Since it was introduced, stroke rates in North America have dropped significantly - by 10% in the USA and by 15% in Canada. “Translated into British terms,” says Dr Refsum, “those figures suggest that adding folate to the diet could actually save more than 5000 lives a year.” [Emphasis added.]

There is considerably more to say on the matter but it may well be premature (at best) to recommend that large-scale homocysteine screening and ‘corrective’ supplementation would “eliminate your risk of ever having a heart attack”. The evidence isn’t satisfactory or sufficient for people who have already had heart attacks and it has certainly not been adequately established for people who are asymptomatic. Helpful or hoax - who knows? Overhyped on the basis of current evidence - that’s a different question.

The wonderful skepchick blog has now put up the Skeptic’s Circle blog carnival. Lot’s of good reading there, and a very cute duck picture. I especially like the Skeptical Alchemist’s critique of a dubious ashtma ‘cure’, Hand-Boniakowski’s account of the ‘alternative’ ethics sometimes practice in alternative medicine, and Autism Street’s impressively thorough fisking of a journal article on autism and mercury.

So, with all this hot air blowing around about the inevitability of our imminent deaths due to mobiles and Wi-Fi, it is no surprise that Patrick starts using his extensive physics knowledge to keep us safe from the evils of the ‘New Big Pharma’, the mobile-wifi-EMR conspiracy of ‘Vested Interests’. Patrick rids his home of Wi-Fi and in doing so starts a new experiment in the dangers of EMR - but that is to come.

Patrick has sent his latest missive from 100% Health e-news, entitled ‘Wi-Fi Health Warnings: Is Your Broadband Harming Your Health?‘. The short answer ought to be of course, ‘No’, but instead Patrick subjects his subscribers to his flaky knowledge of electromagnetic theory. Let’s pull his email apart…

At the heart of his email is the message that ‘most people don’t realise how easy it is to create an EMR free home.’ Obviously, EMR is a big evil that your family needs to avoid. Patrick begins his email,

The more research I read on the dangers of electromagnetic radiation (EMR), from mobile phones and especially from wireless networks (wLANs, otherwise known as Wi-Fi) installed at home, the more convinced I am of the importance of creating an electromagnetic free home environment.

Now that would be quite a feat in that electromagnetic radiation pervades the universe. There is no escape from it. But of course, let’s not be pedantic, Patrick is just concerned about removing from our houses the frequencies that have been implicated in mobile phone causing cancer, wi-fi worries and electrosensitivity induced by domestic appliances. Why this broad range of frequencies is dangerous to human health is of course at the heart of the controversy. Patrick has obviously seen enough evidence to convince him that something is afoot. Many of us are going to need a little more convincing.

In order to free of us of dangerous EMR, Patrick proposed we get rid of our wireless broadband networks and replace them with something allegedly less dangerous. However, in doing so, Patrick displays a remarkable lack of knowledge about the issues. He says,

The big problem with wLANs is that, unlike your mobile phone, they are on and broadcasting, 24 hours a day. The signal also has to be very strong, which is why you can often pick up a wireless network from two houses away, and it gives off radiation similar to emissions from mobile phones and phone masts.

Now, Wi-Fi is not a strong signal. It broadcasts at less less than 0.1W. Compare this with the EMR given out by a light bulb at 100W, or the million watts output by a TV transmitter. Wi-Fi does not need strong signals, it just needs to broadcast locally, usually within a building. A mobile on the other hand, needs to transmit many hundreds of metres. Even then it can do this on incredibly low power consumption. The battery in a mobile is tiny. This is made possible because modern electronics can be very sensitive. You just do not need strong signals to do the job. Take the transmitters in the Voyager spacecraft, now on the limits of the solar system. They broadcast back to Earth with much less than 300W of power - that is, enough power to light a living room. The fact that Wi-Fi barely gets next door, just shows how low-power the transmission is. These tiny radio power levels are one the main reasons scientist are so sceptical of the dangers of Wi-Fi and mobiles. But more on this later.

Patrick proposes the following:

Instead of wLAN you can use ‘dLAN’. This safe alternative is simply a box that plugs into any mains socket, with a lead that plugs straight into your computer. In effect it turns your household mains wiring into a hi-speed network.

These dLans, made by companies like Devolo, are rather quite neat. Many people use them because data rates can be much higher than Wi-Fi, they are much cheaper than installing dedicated wiring, and signals can get through thick walls easily.

dLans work by sending signals through your mains circuits and to specially adapted plugs. In slightly technical terms, the a/c current is modulated with a high frequency signal to carry the digital data. The frequencies are so high that your iron and Corby trouser press do not notice. However, and this is the important bit, electrical engineers have a technical name for long lengths of wire with modulated signals on them - aerials.

Yes, Patrick has turned the rings mains in his home into one mighty big aerial, spraying digital data EMR all over the place. It is an inevitable consequence of the physics of using a dLan. So, instead of ‘no invisible EMR zapping your family’, Patrick is adding a whole new frequency range of EMR into his house. He adds,

I’m now working on converting my neighbours, with their wireless networks, to convert to dLAN so we can create an EMR free street!

Uh no, Patrick. You are just adding to the EMR noise in your street. Hi Fi buffs are well aware of this problem and spend a small fortune ‘cleaning’ their mains to prevent interference problems. The mains is a high voltage, high power transmitter, and is very noisy. One of Patrick’s radiation detectors ought to tell him that.

Devolo actually discuss this problem on their web site as they have anticipated their more electrically aware customers might have questions about it. In fact, the problem is so severe that it is quite a security risk as a baddy in the street, with appropriate inexpensive receiving equipment, could pick up the EMR from the mains and snoop on your network. As a result, all network traffic on the mains should have a high level of encryption applied to prevent electronic evesdropping.

Devolo point out that the EMR from their network is somewhat lower than from a mobile phone, but is not too much different from a Wi-Fi network power. However, as Patrick points out, the network is going to be on all the time, and if Patrick is downloading dodgy bit-torrent files 24 hours a day, the total exposure could be ’significant’. The frequencies associated with the dLan are closer to a mobile too.

Let’s use the electrosensitivy lobbies arguments here and see how they go. (Tongue firmly in cheek from now on, if you don’t pick up irony…)

First, do we trust the Devolo web site? They have a huge vested interest after all? Also, Devolo say the EMR power from their dLan is very low and no thermal effects can be expected. Trust them to say that. We all know that it is the non-thermal effects that we need to be worried about. Studies on stork nesting habits and sperm mobility prove it. The frequencies emitted by the dLan could well have subtle non-thermal effects on delicate cell structures, inter-cellular signalling, brain membranes and the immune system. Cancer is a possibility that cannot be ruled out.

It is also worth noting that Devolo can provide absolutely no evidence that their dLan is completely safe. There have been no long term studies on human health on exposure to the frequencies emitted by their networks. We at HolfordWatch call for more research to be done and the government should call a moratorium on rolling out such networks to schools.

If Patrick wants to use his family, and his neighbours, as a trial into the safety of such networks, then fine by us. But don’t impose this unknown and unproven technology and its EMR burden on the rest of us.

Holford has e-mailed me about folic acid fortification - objecting to some of the content of this post - and I’d therefore like to explain my position in more detail. I’m grateful to Holford for raising some interesting points, and will take this opportunity to respond to a few of them:

• Holford argues that problems are “already occurring in the US where flour is fortified with folate at half the level proposed for the UK”. This is, technically, correct - the FSA plans to fortify UK bread flour with higher levels of folic acid than is mandatory in the US. However, the FDA insists that a wider range of US staple foods (e.g. rice and grits) are also fortified - meaning that the average folic acid intake in the US increased by 215-240mcg/day following mandatory fortification. It is estimated that fortifying UK bread flour as planned by the FSA will lead to the average folic acid intake by c. 78mcg/day [PDF file, p.7]*.
• Holford argues that there is “no reason for us not to expect [similar problems] in Britain”. However, given that the FSA’s plans will increase UK folic acid consumption by just over 1/3 of what was achieved by compulsory fortification in the US, there is a very good reason to expect that any problems will be less pronounced.
• Holford argues that “[t]he real issue we have to deal with is how to educate and nourish young women.” Certainly, this is important - there have been problems getting across the message that women who are (trying to become) pregnant should generally supplement with folic acid. However, I’m sure that Holford would agree that good nutrition is important for other groups, too. I’d also argue that folate consumption is valuable for the general population, as it may be linked to a reduced risk of cardiovascular disease and cancer (and a good folate intake is definitely important for older women with higher-risk pregnancies). While greens do not oxygenate your blood, the fact that some are a good source of folate is therefore another good reason to eat your greens.
  Holford states that “I do not recommend and continue to be opposed to folate supplementation on its own to any individual or group at risk of B12 deficiency”. I’m glad to hear this - it seems a pretty sensible position on folate supplementation. I would, however, suggest that Holford makes the risks of this clear on his website and web-store: I have e-mailed him to advise that he does so.
• Holford argues that I mis-represent Morris et al’s AJCN paper. I fail to see how this is the case: I note, pretty uncontroversially I would think, that the paper finds that “high folic acid intake combined with inadequate B12 intake is related to cognitive impairment in older people”. To be very precise, the Morris et al paper concludes that “In seniors with low vitamin B-12 status, high serum folate was associated with anemia and cognitive impairment.” All the evidence suggests that eating more folate will - at least to a point - increase your serum folate level. An increase of c. 78mcg/day in folic acid consumption (caused by fortification) will not, in itself, lead to high folic acid consumption and will not in itself lead to high serum folate levels. My argument that “it is very unlikely the modest supplementation supported by the FSA is going to be a significant problem in itself” is therefore correct, and is also perfectly compatible with a reasonable interpretation of the Morris et all paper.
• Holford argues that the problems caused by high folic acid consumption have “nothing to do with the source of folate, whether from diet, fortification or supplements, but to blood levels”. I’d note that the Morris et al paper focused on blood levels of folate - and was therefore only likely to show those risks/benefits associated with different blood levels. I’d acknowledge that there are certain risks associated with high serum folate levels - whatever way these are achieved. However, supplement use can play a very significant part in high folate intake levels: for example, Mulligan et al’s recent article has found (albeit in a relatively small sample) that 94% of the over-60s in their sample group with high folate intake used supplements. There’s an obvious link between eating lots of folate and high serum folate levels - supplements provide an easy means of eating lots of folate.

There are a few more issues around this which I might go into later - but this post is already a bit too long. At any rate, I hope it’s clear from the above why I would stand by my criticisms of the Guardian article on folate fortification. As John Nichols of the Royal College of General Practitioners puts it, I would acknowledge that “[t]here may be a case to be made against folic-acid fortification of bread and flour, but the stream of misinformation in [the Guardian] article is not it”.

* I haven’t had time to check these figures, but they seem about right and the FSA is clearly a reliable source.

Patrick Holford has e-mailed me, asking me to put his response to my post on folic acid and my letter in The Guardian on this blog. I’m happy to oblige, and welcome this opportunity to look at issues around folic acid supplementation and fortification in more depth. I’ve quoted his reply in full below, and I have also written a 2nd post to look at the issues around folic acid fortification and supplementation in more detail.

Jon – you’ve misrepresented the results of the research, published in the American Journal of Clinical Nutrition by Dr Martha Morris (http://www.ajcn.org/cgi/content/abstract/85/1/193), which clearly shows that those elderly in the US who have high serum folate levels, but are B12 deficient - estimated to be 4% of the elderly population - are already showing increased incidence of cognitive decline. This is a direct consequence of folate fortification, and is already occurring in the US where flour is fortified with folate at half the level proposed for the UK. So there is no reason for us not to expect the same thing in Britain. This has nothing to do with the source of folate, whether from diet, fortification or supplements, but to blood levels. It is quite wrong to imply that the risk would only relate to high dose supplements, but not to fortified food. Any doctor knows that folate can mask B12 deficiency and now we know that folate can exacerbate B12 deficiency associated cognitive decline. For that reason, I do not recommend and continue to be opposed to folate supplementation on its own to any individual or group at risk of B12 deficiency, however it has many benefits in combination with B12. The real issue we have to deal with is how to educate and nourish young women.

On another note, as you continue to attack my apparent lack of qualification to call myself a nutritionist despite 30 years in this field, perhaps you would care to explain what your qualifications are. I’m sure readers of your website would appreciate knowing.

Patrick Holford

11Joanna Blythman was writing in Friday’s Guardian, discussing concerns about plans FDA to fortify UK bread with folic acid11. Discussing it badly. Really, really badly. And - to add to the excitement - using Patrick Holford as a source. I’m going to look at the article - and Holford’s contribution here.

I thought the article was so bad that I wrote a letter to the Guardian criticising it. And - credit where credit’s due - the Guardian has published the letter today. Read my letter here22 (along with an excellent letter from John Nichols of the Royal College of General Practitioners).

Naturally, I’m grateful that the Guardian published the letter - but there are more problems with the article than I could fit into a single letter to the paper (and - while whoever was editing the letter did a good job on it - they did edit out a little of what I had to say). I’ve also been in touch with Holford since the publication of the article (and since after I wrote the letter) and he’s kindly clarified a few of his points. I’m therefore going to use this post to outline some of the problems with Holford’s position, and to go into more detail about some of the points raised in my letter.

Firstly, if the Guardian wants to run an article on adding ‘chemicals’ to our food, it might help if they made sure that their writers know what a ‘chemical’ is. The article certainly appears confused about this (rather central) point: for example, Blythman refers to adding the “controversial chemical” flouride to our water supply.

My God! Chemicals in water! Next you’ll be telling me that there’s hydrogen in there, or even - shudder - dihydrogen monoxide33. One would hope that someone writing for The Guardian would know that water is a chemical (H2O) and that without access to such chemicals we would all die pretty quickly. We need chemicals all the time, not just daily.

Looking for a good source to quote on folic acid and fortification, Blythman chose to quote Holford - listing him as a “nutritionist”. I know Holford doesn’t have any accredited university degrees in nutrition - but ‘nutritionist’ isn’t a accredited title (I could quite legally market the duck in my local park as a ‘nutritionist’) so I’ll let that pass. However, Holford does have a number of competing interests in this area and it would have been appropriate to at least mention this - so that readers could take this into account when judging Holford’s statements. Especially given that Blythman has written at length44 about the distorting effects of the commercial interests of the supermarkets, it’s surprising that she doesn’t think that Holford’s commercial interests are worth mentioning.

Of course, if Holford’s science was sound then his commercial interests wouldn’t be so…well…interesting. However, I’ve got real problems with his arguments - problems which are exacerbated by the fact the Holford’s Health Products for Life makes money from selling folic acid supplements.

In the article, Holford argues that “We already know that folic acid, given without B12, is creating problems for the elderly…And that’s at half the amount that the FSA is proposing to add to British flour.” However, the FSA is proposing55 [PDF file; see p7] to add folic acid to our flour at pretty low levels: 300mcg/100g of flour; after the cooking of bread is taken into account, this “will increase the average folic acid intake of the population by about 78[mcg/day]“.

A high folic acid intake can mask the symptoms of B12 deficiency - something which, as Holford is right to note, is a particular problem for older people. However, the Scientific Advisory Committee on Nutrition has found that66 [PDF file; see p.53] “folic acid intakes up to 1mg/day are not associated with delayed diagnosis of vitamin B12 deficiency in older people.” The American Journal of Clinical Nutrition has found77 that high folic acid intake combined with inadequate B12 intake is related to cognitive impairment in older people (although good folic acid intake, alongside good B12 intake, brings cognitive benefits). However, although David Smith (writing in the same journal) urges caution88, it is very unlikely the modest supplementation supported by the FSA is going to be a significant problem in itself.

This is where Holford’s commercial interests become interesting. The SACN report99 argues that, at current levels of consumption, fortification of bread will increase “the number of people aged 65 years and over with low vitamin B12 status consuming more than 1mg/day of folic acid.” Supplement pills will play a key role here - anyone who wanted to shovel down enough (unfortified) food to eat 1mg of folic acid every day would need the constitution of an ox and a freakish love of spinach. An obvious way to avoid this risk is therefore for people to take fewer supplements. One likely consequence of the move to fortify bread flour is thus more prominent warnings about the need to avoid over-supplementation.

Holford’s Health Products for Life sells1010 folic acid pills (without B12). Holford advises that some people seeking to reduce their risk of Alzheimer’s should supplement with 2mg of folic acid per day1111. This is despite the fact that the Expert Group on Vitamins and Minerals has set1212 [PDF file] a safe Upper Limit (UL) for folic acid supplementation of 1mg/day (though a few groups - e.g. women with high risk pregnancies - may be advised to take more). 2mg/day is, however, not advisable for most of us.

So - Holford is quoted in a Guardian article emphasising the dangers of bread fortification (which could have a negative impact on Health Products for Life sales) but not even mentioning the much more significant risks from folic acid supplementation (Holford has a commercial interest in selling folic acid). Of course, one can’t know why Holford gives the advice he does - and had he given a balanced assessment of the evidence, I would not even need to be asking about him making money from pill sales. However, the rather skewed advice he was quoted giving does appear to serve his commercial interests surprisingly well - and I would therefore argue that the Guardian article should have made his commercial interests clear, in order to allow readers to decide for themselves whether they are relevant.

A note on measurement
1g = 1000 mg (milligrams) = 1,000,000 mcg (micrograms)