Holford Watch: Patrick Holford, nutritionism and bad science

Dr Dave Gorski has sparked off an interesting discussion on the topic: Death by “alternative” medicine: Who’s to blame?. A patient with early stage breast cancer is advised on a course of medical intervention but elects to pursue alternative healing modalities. After 3 years she then re-presents to the original diagnostician. Unfortunately, the tumour had progressed “from a highly curable clinical Stage I to a difficult to cure clinical stage IIIC”. Despite this, the patient was not willing to accept any medical intervention.

The patient is a fully competent, autonomous adult who is exercising her right to choose her treatments. Does the responsibility for this perceived failure lie with anyone but the patient in question? Could her doctors have done more to dissuade her while maintaining a therapeutic alliance with her?

There is some robust discussion in the comments and some commenters advocate the strategy of ‘telling it like it is’ as a means of persuasion. E.g., Dr Kim Atwood suggests:

[I]f there was a failure of the medical profession, it may have been that her doctors were not judgmental enough. Not of her, per se, but of her choices and of those who provided those choices. Did her doctors tell her that those methods are worthless quackery and that their practitioners are either charlatans or know-nothing ditzes?

However, in his response, Gorski accurately characterises the likely and potentially harmful outcome of adopting such an approach as damaging to the therapeutic alliance.

In my experience, the quickest and surest way to alienate such a patient and to guarantee that she will not listen to a thing that you say after that is to start attacking her current practitioners in such a nakedly judgmental way. Because the patient chose those practitioners, she will almost inevitably interpret such attacks on her practitioners, no matter how justified, how well-argued, or how true, as attacks on herself. Indeed, calling the practitioners “quacks” and “charlatans,” particularly on the first visit, is about as counterproductive a strategy as I can imagine (it’s rarely such a great idea later on, either, after the patient has invested a great deal in the woo in question), and I must strongly disagree with the last part of your statement, at least initially. It may be appropriate at some point to drop the “Q-bomb” (perhaps later on, after her tumor had grown), but telling when that point is is very difficult and fraught with peril. More often than not, such characterizations will not help the physician attain his goal of persuading the patient to let him try to save her life.

If in some forms alt-med are indeed “cults,” as you characterize them, ask yourself this: What’s the usual reaction of cult members to direct attacks on their beliefs or their cult leader? It ain’t to say, “Oh, yes, you’re quite right. How could I have been so stupid?” It’s to circle the wagons, view the attacker as an enemy and infidel, and to push back or run away.

All of us use the shortcuts that were so well described by Robert Cialdini in Influence*.

The evidence suggests that the ever-accelerating pace and informational crush of modern life will make this particular form of unthinking compliance [shortcuts] more and more prevalent in the future (introduction, p. x.)

When New Age or folk nostrums and practices are given credulous coverage or even approbation in leading news organisations then many of these tactics come into play and we can be alarmingly vulnerable to irrational factors that have been created by others. rjstan gave an example of this in her discussion of Peggy Orenstein’s Cancer Diary in the NYT where Orenstein was clearly using different research standards when she was assessing both the medical and CAM interventions that she was using.

In pages 55-8 of his book, Cialdini recounts the story of the time that he and a logician friend attended an introductory lecture to Transcendental Meditation. At the Q&A section at the end of the lecture, the friend:

pointed out precisely where and why the lecturers’ complex argument was contradictory, illogical , and unsupportable. The effect on the discussion leaders was devastating…
[Audience members crowded to sign up for the course. The recruiters were delighted but taken aback; Cialdini was puzzled.]
I chalked up the audience response to a failure to understand the logic of my colleague’s arguments…
[Cialdini questioned some of the people who had signed up.]
[T]hinking that [they] must have signed up because they hadn’t understood the points made by my logician friend, I began to question them about aspects of his argument. To my surprise, I found that they had understood his comments quite well; in fact, all too well. It was precisely the cogency of his argument that drove them to sign up for the programe on the spot…
These were people with real problems, and they were desperately searching for a way to solve those problems. They were seekers who…had found a potential solution…
Now, in the form of my colleague, intrudes the voice of reason, showing the theory underlying their newfound solution to be unsound. Panic! Something must be done at once before logic takes its toll and leaves them without hope once again…[W]alls against reason are needed; and it doesn’t matter that the fortress to be erected is a foolish one…”Quick, a hiding place from thought!…No need to think about the issues any longer.” The decision has been made, and from now on the consistency tape can be played whenever necessary…
If, as it appears, automatic consistency functions as a shield against thought, it should not be surprising that such consistency can also be exploited by those who would prefer that we respond to their requests without thinking…[Quotations from pp. 57-8.]

Cialdini extends his argument to say that after we have made a small commitment, it can alter our self-image in ways that lead us to accept or acquiesce to actions that we might have rejected previously. We might accept these actions because they are consistent with our new self-image.

Breast cancer is an extreme case where someone might opt for CAM. It might be interesting to learn whether there is something distinctive about particular illnesses that so influence self-image that people are prepared to countenance a course of action that they might previously have rejected or dissociate from a lifestyle and medical culture that now seems to have contributed to an illness.

However, in circumstances that are ostensibly less serious than breast cancer, there is a tendency for people who seek CAM to have self-diagnosed a deficiency or disease. E.g., it is unlikely that someone has consulted a nutritionist because s/he is seeking advice about a gluten-free diet because s/he has been newly diagnosed with coeliac disease. S/he would be more likely to be referred to a Registered Dietitian as part of the NHS service, not least because they would be given advice on what is available to them by prescription. It is more likely that someone consults a nutritionist from a general feeling of malaise or self-diagnosis with food intolerance or a hypothyroidism or a sub-clinical deficiency of some vitamin or mineral.

Is it possible that when somebody has self-diagnosed and had that diagnosis reinforced or extended by a sympathetic person, then the sense of consistency is enhanced and leads to defensiveness if (say) a GP were to object that blood tests show that thyroid levels are normal? Does being open to persuasion on this issue pre-suppose a good therapeutic relationship between the GP and patient? Would Cialdini predict that commitment and consistency would make it difficult for either party to change their mind? (See also Crichton’s review of Groopman’s How Doctors Think which describes how doctors are also vulnerable to confirmation bias and consistency.)

So far in the SBM discussion, overshoot has offered a pragmatic strategy.

This is what I advise you to do, but whatever you decide please come back every to monitor progress and discuss how you’re doing” relationship.

I can see how this might be possible in the circumstances that Gorski outlines. However, books and articles by people such as Patrick Holford or Jonny Bowden decry the knowledge of medical doctors or qualified RDs and state that they don’t recommend supplements or appropriate action plans for (say) food intolerance or hypothyroidism because they didn’t receive the appropriate education or haven’t kept up to date. E.g., Bowden wrote the following about his disagreement with an article written by Jane Brody of the NYT:

I frequently find myself stifling some of my more pugilistic tendencies when it comes to speaking out against public idiocy, largely out of an ill-advised desire to remain ‘objective’, ‘impartial’, ‘above-the-fray’ and ‘respectable’…

The truth is this: When it comes to nutrition, Jane Brody is an idiot. She is a know-nothing who repeats any crap the American Dietetic Association tells her, she’s incapable of reading or understanding complexity of thought, and she’s not much better than a paid shill for the worst elements of the dietary establishment and the American Medical Association. She’s basically the Nutritional Antichrist.

And, who can forget the extraordinary, mis-guided and unjustified attack that former Visiting Professor Patrick Holford who is still Head of Science and Education at Biocare made on the integrity of the authors of a systematic review of Omega 3 for mortality, cardiovascular disease and cancer.

If people buy into the arguments of self-styled experts such as Holford and Bowden because it holds out a promise of relief of present discomfort or distressing MUPS (medically-unexplained physical symptoms), does that eventually erode their confidence in the competence, expertise and judgment of qualified health professionals? Is the quintessential problem of nutritionism not only that it can lead to serious problems in the hands of practitioners who may not understand the limits of their competence, but also that it is a trojan horse for pseudo-science? Is this the pernicious phenomenon that the Hoofnagle brothers styled as crank magnetism but Damian Thompson more elegantly termed counterknowledge?

I would once have thought that that trojan horse argument was over-stated. However, in the past year, I’m surprised at the number of times that people who advocate nutritionism are also anti-vaccination or flirting with germ-theory denialism or Aids denialism or question the relevance or efficacy of evidence-based medicine.

Such beliefs can reflect personal preferences such as counter-cultural beliefs and a desire to mark oneself as distinct from dissociative reference groups. They might indicate a strategy for coping with, or making sense of, psychological threats caused by feeling powerless in the face of MUPS or distress.

When several of these beliefs occur together, it may lead to such distortions about the basics of science that it undermines the public understanding of science and leads to a cynical rather than sceptical attitude to medicine. On an individual level, the consequences of this might not substantial, depending on individual circumstances. However, the impact might be more pernicious where personal circumstances are rather more adverse, or where there are implications for public spending priorities. It is plausible that commitment and consistency may influence both individuals and wider groups to actions that would otherwise seem irrational.

* Cialdini, RB. 2000. Influence: Science and Practice. 4th edition. Allyn & Bacon.

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