JDC reports that he “always thought that Dr John Briffa was like a more grown-up version of Patrick Holford” – and until recently I had rather agreed with him. However, Briffa has now taken up some worrying positions on vaccines and autism. Along with Dr Crippen, “I am worried about Dr John Briffa.”
I have just come across some of Briffa’s claims about food sensitivity testing – they are almost Holfordesque. Writing in the Guardian about Irritable Bowel syndrome, Briffa argues that:
Those with IBS can…benefit from identification of problem foods. Several methods of testing exist, such as kinesiology (muscle testing) and dowsing. I believe all such methods have some validity, though those who are more comfortable taking a more ‘scientific’ approach may have their blood tested for IgG antibodies to specific foods. One study published last year in the journal Gut found that elimination of foods identified by this form of testing was beneficial for IBS sufferers.
Now, Patrick Holford has written positively about health dowsing and Applied Kinesiology (AK), but this was quite a while ago. Briffa’s Guardian article was from 2005. As we’re going to find out below, Briffa gets things badly wrong on food sensitivity testing and on recommendations for dealing with (potential) sensitivities.
Applied Kinesiology
John Garrow has shown that AK is not an effective way to diagnose allergy. AK testing thus lacks a plausible mechanism of action, and – in a blinded trial – has failed to do better than one would expect if the practitioners were guessing. Professor Chris Corrigan was thus moved to describe AK – in his testimony to the House of Lords Science and Technology Committee – as
all completely bizarre and, I am afraid, utter nonsense. There is no scientific evidence or mechanistic base to suggest that these tests could be remotely effective.
Putting it politely, this is not a valid way to diagnose food sensitivities.
Dowsing
Quite simply, there is no plausible mechanism through which dowsing might work as a test for food sensitivity, and we have no good evidence that it does work. I cannot see any reason why a competent professional would recommend dowsing for anything other than entertainment.
IgG testing
When recommending IgG testing as a more ‘scientific’ approach to diagnosing food sensitivities, Briffa does point to an article in Gut. Unfortunately, its results indicate that an IgG-guided elimination diet is less effective than a ‘conventional’ elimination diet when you interpret the results using a straightforward Numbers Need to Treat analysis. This is not an effective way to diagnose allergy, intolerance or sensitivity. The House of Lords Science and Technology Committee’s 2007 Report on allergy [PDF, 8.40] have therefore cautioned against the recommendation of IgG testing:
We urge general practitioners, pharmacists and charities not to endorse the use of these products until conclusive proof of their efficacy has been established.
Unfortunate clinical recommendations
This dubious account of food sensitivity testing leads Briffa to make some unfortunate recommendations. Firstly, inaccurate food sensitivity testing can be harmful: both leading patients to avoid foods which they are quite able to eat (false positives) and failing to diagnose genuine allergies and intolerances (false negatives). Secondly, Briffa then suggests a rather haphazard approach to an elimination diet:
there is usually no reason why individuals should not make changes to their diet without testing. I advise trying a diet devoid of wheat (pasta, bread, biscuits, pastries, breakfast cereals) and cows’ milk (another common offender) for a week or two. Better tolerated grains include rice and oats (oat-based muesli, porridge, oatcakes), and rice and oat milks are good swaps for dairy milk, too.
While an elimination diet can be a useful way of diagnosing allergies and intolerances, one would be advised to take a more systematic approach (preferably under medical and/or dietetic supervision). As argued in Allergy: The Unmet Need [PDF, p 53) appropriate advice and supervision is important when a patient is cutting out certain food groups. It is also not entirely clear how Briffa has selected which foods are to be eliminated: for example, while lactose intolerance is relatively common, some milk products (such as some cheeses) contain negligible quantities of lactose.
We should also emphasise that cutting out whole foodgroups from your diet can be harmful, if you fail to adequately substitute alternatives. While eliminating these for 1-2 weeks - as Briffa suggests - is pretty safe in most circumstances, we would have more concerns in the longer term. It is unclear whether Briffa anticipates any kind of challenge protocol being used - for patients to test whether a food which they have eliminated causes problems when reintroduced - or simply expects IBS-sufferers to continue with the exclusion of wheat and cows milk if this exclusion coincides with an improvement in symptoms.
Both milk and wheat are significant sources of calories for many children and adults in the UK. Milk is a significant source of calcium, and some wheat-based products (such as certain fortified breakfast cereals) are a significant source of fibre for many people. Also, fortified wheat-based breakfast cereals and breads can be a useful source of a number of vitamins and minerals. One should therefore not exclude these food groups from the diet without finding suitable alternatives. There are particular concerns with children: Allergy observes [PDF, p11] that “it is harmful to put a child on an extensive exclusion diet that has no scientific basis, because of the risk of nutritional compromise and poor growth.”
This is all rather worrying. Briffa manages to recommend three inappropriate approaches to testing for food sensitivity, and then suggest an haphazard approach to an elimination diet. His clinical recommendations are also unfortunate – failing to take into account the potential harm caused by eliminating whole food groups if this course of action is continued for some time and without appropriate advice and supervision.
As Dr Crippen might put it, this is wibble – damaging wibble.
Gimpy – I like Orac’s classic line about boosting the immune system when discussing Airborne.
As ever, if there are upsides, there are probably downsides. Boost an immune system and notionally you may be pushing towards auto-immune diseases. Downplay appropriate inflammatory responses and there goes the neighbourhood with ‘simple’ illnesses.
Dr Aust – it is all true but why is it that visions of codger-dom come to mind whenever you say that, “Remarkably – yes, it is all true. Don’t smoke. Alcohol in moderation ditto food. Eat your fruit and veg, not neglecting your greens. If you don’t like formal exercise and don’t own a dog, behave as if you have a dog and go for a walk at least twice a day. Cultivate your family and friends. Have some past-times that you practice regularly and enjoy”.
I saw snippets of two episodes in series 12 of ER and both of them stuck with me because they gave explanations that made them sound very exciting, plausible, simple or dramatic (in various permutations). One of them starred James Wood and he gave a thrilling lecture about ATP (season 12:13 but can’t find the YouTube for this part of Body and Soul). The other involved a surgeon (Dubenko) who was grilling the residents about free radicals during a code and later started writing out some processes on the nearest lightbox and then the wall. Part of his explanation soundbites were: “The difference between a physician and a witch doctor is an appreciation of the science beneath the disease” (8:30-8:35); and “Free radicals are the link to so many disease processes in the human body – ischaemia, cancer, ageing – they form after tissue is deprived of oxygen. Why are they bad?…What happens when a radical encounters the mitochondria of a healthy cell, Lockhart?…Everything that we do in ER, every intervention, ultimately operates at a molecular level. I don’t understand how any of you expects to affect the complex machinery of the human body if you don’t understand the basics.” (2:00-2:25).
Simple explanations for complex events that worked well in a TV drama. Probably riddled with so many inaccuracies that it made people who know something weep. Even I wondered why ageing could be so blithely referred to as a disease. The sort of material that would probably be flayed if anyone ever analysed it like Scott Morrison does for House at Polite Dissent.
Gimpy, i believe he was suggesting that reducing IL1 IL6 TNF NFKB peroxinitrite only if these molecules are elevated. I totally agree that you would never want to do this otherwise and i assume plummer is fully aware of this. From what i can remember he was looking at dealing with factors that raise these levels. poor adrenal function, digestive issues, low antioxidant status ie glutatione P and SOD levels, RA allergy asthma.
Sorry, the 3 main cytokines were the ones i originally mentioned (not the 3 main one whatsoever, very badly worded)
Much of his lecture was concerning diet, life style, stress maagement.
I will find the notes today and show yo the refs to see what you think
Gimpey, you seem a little angry, im not sure why. Im not disputing what you are saying and value Holfordwatch opinion. I said i will post the refs when i have time to dig them out.
I pass no comment on this set of Bad Science awards (nothing to do with Ben Goldacre). Apparently, Victor Herbert, M.D., J.D. and Tracy Stopler Kasdan, M.S., R.D. wrote:
These Bad Science award people say:
Over-stated but it is one of those things that feels as if it has a kernel of something useful at its core. However, you could probably make the same broadstroke judgment about anyone who is dedicated to an idea.
Being a die-hard fan, I remember both episodes of ER very well, Wulfstan.
I remember finding the Dubenko free radicals exposition particularly funny, since a surgeon would never, ever, say these sorts of things to the junior doctors. On the whole, it is the basic scientists that believe the Dubenko line (“we need to know and understand the underlying molecular events”) , while clinicians view this sort of “waaaay down there underlying molecule stuff” stuff as fairly irrelevant to clinical medicine, and pass this view on to their juniors.
This take is actually understandable, in the sense that it is clinical trials that ultimately tell doctors what works on people, not whether the underlying basic science can provide a mechanistic explanation. The science is most useful in complex cases when there is little or no clinical “evidence base” to help. In those settings reasoning from underlying basic science principles gives you a starting point.
In the antioxidant context, many antioxidants were tested in clinical trials for all sorts of disease states, and shown to be ineffective, while science types like me were still struggling to work out the intricacies of the test-tube-ery on “what do oxidants and anti-oxidants do to cells?”
The Nutri-bollocks gang have, of course, exploited this by keying on (i) that the doctors aren’t interested in tons of confusing biochemistry; and (ii) that cells-in-a-dish studies and human trials often don’t give the same answer. The Nutritionista crew have used these two things to sell supplements “around” the barrier posed by their ineffectiveness in controlled trials.
dvnutrix says:
“Dr. Plummer developed and manufactured the very first human-use commercial probiotic derived from indigenous lactic acid bacteria”
think that attribute in th 20th century goes to Metchnikoff – or if you want to define ‘manufacture’ on a commercial basis then Dr Minoru Shirota takes the prize for Yakult
Professor UKdietitian – always a pleasure even if it is for a mild rebuke.
dvnutrix quoted the bio which said…
However, I should have made that plainer. What can I say? I was over-awed by the number of areas in which one person can claim world expertise. Particularly when other slackers can devote an entire career to one tiny, specific area of any one of those topics – nowhere near being able to claim expertise in several complete areas.
I can only hope that people like
PaulMark* Levine are abashed (albeit that is vitamin C). What have the Romans and people like Levine ever done for us, eh? Comparatively speaking…Edited *see jdc325 comment. [blush]
“I can only hope that people like Paul Levine are abashed (albeit that is vitamin C).”
Re Paul Levine and Vit C: isn’t P Levine into epidemiology and cancer rather than vitamin C? Pretty sure it’s Mark Levine who is well known for his work on vit C research.
You are right, jdc325 – mixed them up because I’m working on a post (that involves both although I will reference neither) about antioxidants.
I was also thinking about Dr Aust’s words of wisdom on Experts.
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Fascinating topic and sadly one that I can’t get into in any detail.
It was not at the cellular level (of course) but one of the reasons that pinks disease took so long to identify was that people were prepared to hand wave the underlying causative principles and didn’t examine the arguments of those who proposed causes (including that of Warkany, the paediatrician and teratologist who did recognise it for what it was).
One of the on-going arguments seems to be that homeopathy etc. will continue to be eligible for clinical trials because people claim results, despite the lack of plausibility for any underlying biological mechanism. But, LCN put up a good argument about that and SBM writes about it regularly.
Yes, I like the science-based medicine “prior probability” take on trials for Alt Therapy. It is far too easy for folk like John Briffa to employ a kind of catch-all get-out by saying (I’m paraphrasing slightly):
“Oh but applied kinesiology for diagnosing food intolerance hasn’t been tested systematically, so you can’t say it’s rubbish”
(Apply to Alt daftness of your choice)
I wouldn’t say trials of such things weren’t needed – Edzard Ernst does a great job rounding up the trials and showing how think the evidence for almost any Alt modality is – but for inherently utterly biologically implausible things, the evidence to rule them out does not have to be as strong (at least for me) as for things that have some claim to plausibility. The obvious contrast is the (oft-confused) homeopathy and herbal.
Re. the Dubenko thing, as a basic scientist I obviously believe in looking for mechanism. It is just that sometimes you have mechanisms in both directions, and the one that biologically “ought” to win doesn’t. Beta blockers in heart failure (which the physiology really says should be a terrible idea) is an example. And another one (which I have some personal acquaintance with) is the antioxidant one. I used to do antioxidant research in the context of chronic pancreatitis, and there is still reasonable evidence that oxidative stress is part of the (poorly understood) pathophysiology. But antioxidants were tried extensively and did bugger all for the chronic panc patients. This obviously tended to mean that most of the pancreatic physicians and surgeons couldn’t see why we were bothering to keep on with the research… and from where they stood you could see what they meant.
Oops – meant “how thin the evidence…”
The interesting thing is that even when these approaches are tested (for example, Garrow’s blinded test of Applied Kinesiology which showed it to work about as well as guessing) this is still not seen as convincing if it gives the ‘wrong’ result.
Quite, Jon.
I specifically picked applied kinesiology as an example since it is in the post title and John Briffa commented on it recently on his blog along the “no evidence either way” line… but he didn’t mention Garrow – quelle surprise.
The dishonesty argument is also relevant. If applied kinesiology does “reveal” anything, it seems highly likely it has to do with psychology, and expectations, and the practitioner’s ability to pick up on them – a bit like various kinds of cold reading – and nothing to do with real physiological effects .
One suspects that the more intelligent practitioners – certainly any of them with medical degrees – must know this, but conceal it to keep the hocus-pocus intact and the mystique potent. “Smoke and mirrors”, as the phrase is.
Couldn’t agree more. Failing any demonstration of plausible mechanism, a complete lack of replicable bench results, no decent animal studies etc. then there is absolutely no justification for spending more money on homeopathy trials. Some of the herbals are a completely different matter.
Re: beta-blockers, it is wrong of me but I am fascinated by ideas that have a firm logical underpinning but for some reason, in the real world and the human body, the outcomes are different. One of my favourites is giving a blood transfusion after cardiac surgery which seemed to be commonsense. However, clinical testing discredited the practice and revealed that it was linked with a higher risk of ischaemic events, leading to higher rates of kidney impairment, strokes, and heart attacks.
Re: the anti-oxidants and chronic pancreatitis, I’m about to raise one of the current topics we’ve been researching for a while. Holford and other ‘visionaries’ are wibbling on about the brave new world of nutrigenomics (as if Berthelot’s notion of food pharmacies had not anticipated them a century and more ago, but, obviously not with the genetics component).
Do you have any expectation that genetic profiling will identify groups of people who do benefit from particular interventions? Or, is shovelling anti-oxidants into someone going to be far too broad an intervention if you are not sure what you might be up-regulating or down-regulating?
I’ve seen teachers use it – not in a Brain Gym way. They use it (and pendulum swinging) to demostrate ideomotor movement (for the latter) and how a set of beliefs about something can change muscle tone etc. without you being aware of it. The AK in that case is good fun. The children are asked to think of a food they like and one they dislike (just think, it isn’t present) and note the difference in muscle tone as they think of each one. They try several more like-dislike combinations and then they are asked to consider whether the attitude that they have about something can affect their experience of it. This usually creates quite a strong argument as the children discuss perception – the difference in taste receptors- how context can change experience and perception etc.
Somewhere (no idea where), I have a copy of Ian Rowland’s cold reading book and it is a very interesting read. I must excavate it from wherever it is.
No specific expertise, but on the whole I suspect the latter, unless you can find people with a very specific major “genetic antioxidant defence defect”. And any such would presumably be rare as it would hardly be a genetic plus..!
On the whole I am rather cynical about “nutrigenomics “… as indeed I am about “toxicogenomics” and “pharmacogenomics” – they all have possibilities, clearly, and there is certainly a lot of money and drive behind it all, but the hype is tremendous. Of course, if I worked on polymorphisms in GST, or CYPs, or some other detoxifying enzyme, or even on antioxidant enzymes, I would no doubt be talking up the “genetic profiling” ideas too.
The other big caveat is the “adaptability” you describe. One of the things that comes clearly out of even the crudest array experiments is what vast numbers of genes change their expression when you perturb cells or tissues. And this message also comes out (at the organism level) from gene knockout studies. I have lost count of the seminars I have sat through where the person say “errm… we knocked out A.N. Other gene… and to our surprise the mice were fine”. Nature is rather amazingly adaptable, which explains why we are all here.
PS Agree about it not being new as an idea. Benecol, whether you believe it or no, is targetted at those with slightly dodgy lipid levels. Such folk may well have a decent element of familial genetics to their lipid profile… ergo: genetically-tailored functional food.
Of course, it is a pretty safe bet that long before gene profiling and tailored drugs/foods/supplements are a widespread reality, we are going to have loads of folk trying to sell us things they say are “tailored XYZ”. I won’t place a bet on whether it will be the PharmaCos, the Consumer ProductCos like Unilever, or the nutri-pill gang first. They all have a pretty obvious financial motive.
The functional food Cos are already pushing the nutrigenomics idea e.g. here from the FoodNavigator site (my favourite source of reports about nutritionally-enhanced junk food!):
http://www.foodnavigator.com/news/ng.asp?id=79205-chr-hansen-nutrigenomics-r-d
“…Chr Hansen regards nutrigenomics as technology to underlie the food industry’s future away from one-size-fits-all nutrition, and has placed exploration of this area high-up on its R&D agenda…”