Radio 4′s You & Yours today discussed the issues arising from the alleged injury of a client of nutritional therapist Barbara Nash, when Nash put the client onto a ‘detox diet’.
The programme (here and you can listen again here, while it’s still available) includes an interview with registered dietitian Catherine Collins, and the BANT Chair Emma Stiles: extraordinarily, Stiles apparently acknowledges that nutritional therapists do not practise evidence-based medicine. However, the segment began with Mr Page telling the sad story of how this diet – including lots of water and low sodium – progressed. Dawn Page consulted a nutritional therapist because she wanted to lose some weight, but she ended up in intensive care and still suffers from cognitive problems (this case was settled out of court for £810,000; Nash continues to deny responsibility for the injuries to Mrs Page, and due to the settlement there has not been a court finding on this case).
The programme then featured Registered Dietitian Catherine Collins: she pointed out that, while ‘dietitian’ is a protected term, and in order to earn the title one needs to have studied nutrition for at least four years:
The term nutritionist and nutritional therapist are not regulated by law in this country, so [talking to her interviewer] Peter you are a nutritionist or a nutritional therapist if you want to be.
While dietitians in the UK are – due to the protected status of the title – all regulated by the HPC, nutritional therapists are not. For example, Barbara Nash would be quite within her legal rights to continue practising nutritional therapy as before (and her website is still online, suggesting that she may still be practising). We don’t know her current status, but Barbara Nash has been listed as a member of BANT.
Emma Stiles – Chair of the British Association for Applied Nutrition and Nutritional Therapy (BANT) and a practising nutritional therapist – accepted Collins’ definitions of dietitians and nutritional therapists, and stated that BANT have been working towards voluntary regulation of nutritional therapy. Stiles discussed the Skills for Health Competencies Framework. However, as Collins points out
This is the only area of healthcare where the government is allowing enthusiastic amateurs who accept themselves that…they’re really not working to the level they should be, to…have a work in progress.
Clearly, as Collins observes, when one sees a health professional one wants them to be competent and to be properly regulated – it is not sufficient for them to be working towards competence. Some readers may recall Professor David Colquhoun’s experience with Skills for Health and his lack of confidence in their relevance.
The presenter, Peter White, then asked a bold question. He asked Stiles why there was a need for nutritional therapists and if they were, in fact, superfluous: a fair question, given that we already have properly trained and regulated nutrition professionals in the form of dietitians. At this point, I began to feel somewhat sorry for Stiles, who was left arguing that nutritional therapists address a particular niche for those whose issues have not been resolved by recourse to science-based methods.
[We] try to look at the outliers who have been through evidence-based medicine.
It thus sounds like Stiles – speaking as BANT chair – concedes the point that there is not a good evidence-base for some of the treatments that BANT nutritional therapists recommend. This concession appears to remove the putative niche for nutritional therapists: if evidence-based nutrition does not help a particular individual, it will not help to refer them to nutritional therapists who are (by and large) less well-trained than dietitians, inadequately regulated, and working without an adequate evidence base for their work (and, often, without an adequate understanding of what evidence does exist or its significance).
It seems appropriate to close with a quotation attributed to Emma Stiles in Food Habits and Social Change (pdf) March 2008. (A future foundation report for Kelloggs.)
“Everywhere you turn you’ve got Jamie, you’ve got Hugh, you’ve got the Daily Mail, you’ve the food doctor, you’ve got the eating disorder charity, you’ve got all these people and the people who are doing the real good actually have the quietest voice.” Emma Stiles, Chair of the British Association for Applied Nutrition and Nutritional Therapy
Given the inordinately high profile of many self-styled nutritionists and nutritional therapists, one has to imagine that Stiles is referring to registered dietitians. We hope that the quiet voice of the BDA and people like Catherine Collins is given more of a platform and an amplifier in the very near future. As LeeT points out in the comments, a fundamental problem is that not only do the public fail to understand the nature of the difference between a registered dietitian and a nutritional therapist, it seems that nutritional therapists misunderstand the nature of their own qualifications. (JKN’d with comments.)
Update: Corrected the spelling of Emma Styles to Emma Stiles and added in the quotation from the Kellogg’s Report.
Stiles has some comments about the evidence-base for functional foods (pdf).
Consumers appear to be attracted to functional foods as a way of maintaining good health and are used as an illness prevention,” suggests Emma Stiles, Chair of the British Association for Nutritional Therapy. “Taken on a regular basis (daily usually) they act as a peace of mind that the consumer is doing something for promoting good health.”
While there are no specific regulations governing functional foods, it is illegal for manufacturers to make any claim that their products can prevent, treat or cure disease. Despite some sceptics questioning the health claims of some products, however, Stiles is confident of their benefits.
“There is much research around each of the components used in functional foods,” she continues. “Due to the labelling and regulation they do not state how much benefit the products have – with some functional foods, you might only be getting a very small benefit. But it is a benefit none the less.”
We would suggest that it is debatable that that is true of all foods that are promoted as functional and would argue that it overlooks the issue of whether they represent value for money to consumers and support or detract from the idea of an adequately balanced food matrix that meets individuals’ needs and matches their lifestyle.
Update 18 July: BANT has responded to the Your and Yours programme in which they participated (JKN’d).
BANT is, and has always been, ready to comply with the request made in 2006 by the Health Professions Council that the British Dietetic Association, Nutrition Society and BANT work together to progress the regulation of the nutrition profession as a whole. Despite the negative comments in this program about nutritional therapy, BANT would like to reassure the public that BANT members are currently going through a process towards voluntary regulation.
As per the JKN comments, it might have been more useful if BANT were to review their membership requirements and assure the public that they were reviewing their safety procedures and minimal training requirements for membership. After all, this might have been a better use of their discussion time than amending their ethics code to permit commission payments from supplements sales.
Included LeeT’s observation about some nutritional therapists’ misunderstanding about their own qualifications and included a link to David Colquhoun’s assessment of Skills for Health.
Update 22 July: Daily Mail covers the story: Mother winds £800,000 payout after ‘four pints of water a day’ detox diet leaves her brain-damaged. The Times also carries it: Dawn Page receives £800K payout for brain injury caused by high fluid diet. Although both papers give adequate coverage of the story, it might have been helpful for their readers if they had asked the BDA or similar body for appropriate guidance for readers considering a similar “Amazing Hydration diet”. Neither paper used this as a teaching opportunity for their readership to advise them on appropriate credentials for readers who are looking for guidance for weight loss or food-related issues and guide them towards a registered dietitian. To be fair, the Daily Mail does carry a comment from RD Nigel Denby.
July 23: BBC version of the Page-Nash detox story with input from Catherine Collins representing the BDA and Andrew Fadge of the FSA.
Daily Express runs the story Danger of detox diets – doctors issue a warning. Again, a comment from RD Nigel Denby but also, oddly, from Claire Dunt of foodmentor.com who displays a slightly different misunderstanding about her qualification from ION.
Claire founded Food Mentor in 2006 after gaining her Nutritional Therapist’s Diploma from the Institute for Optimum Nutrition, and an FdSc in Nutrition Science from the University of Bedfordshire.
As regular readers know, the DipION/FdSc is the same qualification and FdSc is the abbreviated form of Foundation Degree: the University of Bedfordshire describes if as FdSc/DipION Nutritional Therapy.
The Sun is covering the story with input from Catherine Collins, representing the BDA: Dangers of Detox Diets. They have also, very helpfully, included a link to the BDA for guidance about appropriately-qualified dietitians.
There are currently more than 200 items about this news story but too many of them overlook the obvious opportunity for telling their readership about appropriate sources of advice.
Rose Shapiro has a piece that warns about the dangers of unaccredited nutritional therapists and the typically evidence-free health advice that is bandied about in women’s magazines: Rose Shapiro on how to spot quacks. She also recommends that people who need advice should consult dietitians: “If you want reliable dietary advice it is dietitians, not nutritional therapists, who are properly trained to provide it”. Quite.
July 26: Daily Mail provides some detail as to the symptoms experienced by Mrs Dawn Page as a result of the hyponatraemia: Water ‘detox’ robbed me of my wife. It seems that Dawn Page experienced epilepsy and psychosis amongst other adverse events: both then and later, it seems to have been both harrowing and gruelling for her and her family.
September 21: Through A Glass Darkly has now posted about the qualifications and career backgrounds of DipION practitioners.
Catherine Collins seems to be the only public face of Dietetics in this country, and she does a very good job even though she is apparently fighting a lone and losing battle. It is a shame the same can’t be said of the the hierachy of the BDA (but that has been done to death over on Quackometer).
I am interested by Sykes argument though – if NTs really are going to look at outliers “who have been through evidence-based medicine” presumably the first thing an NT would do with a prospective patient who has not yet consulted a Registered Dietitian would be advise that they do just that? I can just imagine how short Holford’s GMTV consultations would be if every answer was “see a Registered Dietitian”.
Returning to earth for a second – maybe the fact that these NTs are soon to have formal recognition via the CNHC will mean that the line between RDs and NTs will become even more blurred and more members of the public will end up losing out.
Let’s just hope that the Chief Exec of the BDA resolves his conflict of interests and dalliance with the CNHC and starts ensuring that Dietetians become the first and only port of call for people who need nutrition advice.
“outliers” – what an odd use of language. My dictionary defines the word as “a person or thing situated away or detached from the main body.” Not sure if it is linguistically correct to describe a person with an incurable chronic condition like that.
Perhaps it is BANT and the ION who are the outliers?
I would think that it is very unusual for someone to have been previously referred to a dietitian in the circumstances that Emma Styles outlined.
I don’t understand why faffing round with someone who spouts pseudoscience and provides science-sounding explanations for food and supplement recommendations would work when actual science-based interventions hadn’t.
Are we back to the assumption that what makes the difference is having a 30-60 minute session of talking to someone? Is there social reinforcement for the idea that particular diet restrictions and supplements will do people good and it is therefore a good placebo theatre?
The discussion was interesting in the implicit admissions. It was bizarre that BANT Chair Emma Stiles was trying to argue that protocols and an evidence-base were restrictive and that dietitians do not tailor their advice to the individual.
All the more tragic in the context of a case where Mr Page was effectively saying that the nutritional therapist in question was ‘reassuring’ them with science that he didn’t understand but persuaded them that the symptoms were not untoward. Is that the sort of individual care that Emma Stiles is promoting as the upside of consulting a nutritional therapist?
@Lee – very odd language. However, in this context ION and BANT are more the cowboys of the unregulated Wild West of nutrition, more outlaw than outlier if you will.
@DP – A completely miserable yet realistic prospect. One of my major apprehensions is that the BDA’s PR is so poor while that of the nutritional therapists is excellent – if they are not careful, the new Darzi-hyped polyclinics will give contracts to nutritionists rather than RDs when it comes to putting together their portfolio of services. From what Stiles says, the message seems to be that nutritional therapists are the equivalent if not better than RDs in some contexts, yet the reality is that they can be profoundly ill-equipped in their training and profoundly anti-science – to the point of being dangerous.
Unfortunately, it is not as if fundholders in PCTs etc. can be relied upon to know better.
“From what Stiles says, the message seems to be that nutritional therapists are the equivalent if not better than RDs in some contexts…”
And I’m afraid out in the real world this message is being – literally – bought. Oh dear, going anecdotal again, but a recent conversation with a former nurse highlighted this: I was reproved for defending the notion that someone who has been accepted into and completed an honours degree in human nutrition and whose title is protected (i.e. you’ve got to show evidence of achieving a certain standard to call yourself an RD) could possibly be a better prospect than someone who may only have done a part time correspondence course for which the entry requirements are not stringent.
There is a genuine issue about difficulty in some areas in getting access to a specialised dietitian in cases of suspected food allergy or intolerance. There is a Food Allergy and Intolerance Specialist Group within the BDA (some information about it here: http://www.bsaci.org/dietitians.html ) so perhaps the message needs to be communicated that people with concerns in this area who experience difficulty in accessing an RD should contact the BDA for advice. Interesting to note that BSACI does not have a section for nutritional therapists!
I share DVN’s concern about the BDA’s PR failure and her worries about future provision of healthcare via commercial organisations, which I’m sure the manufacturers of supplements, home tests etc are eyeing with interest.
Part of the problem seems to be that many Dip IONs rather worryingly don’t understand the level of qualification they have obtained. It is actually equivalent to a HND or foundation degree. Some of them seem to think they have undergone post-graduate training in nutrition. See for example:-
http://www.nationalnutritionclinic.com/hannah-love-profile.htm “This led to her embarking on a three year post-graduate course to become a nutrition therapist”
http://www.naturallynutrition.co.uk/Profile.html “with a postgraduate diploma from Patrick Holford’s world-renowned Institute of Optimum Nutrition.”
I followed Lee T’s first link (thank you) and found this:
http://www.nationalnutritionclinic.com/allergy-screening.htm
“An Allergy Screening With Instant Results
Thanks to our latest bio-dermal clinical screening technology, we can identify your allergies without taking blood and give you the results immediately.
All you do is hold a metal probe in each hand while we send a signal for each of the allergens listed below. If you are sensitive to that allergen, it will show up on your report.
The whole process takes just 45 minutes, and we discuss the findings with you to agree what to do next.
What Allergies Do We Screen You For?
We screen for 136 allergens in your 45 minute session. Just click on each of the categories below for a full list of the allergens you will be tested for:
Allergen Sensitivity
Air Pollutants
Animal Danders
Chemicals
Clothing Materials
Food Sensitivity
Fossil Fuels
Harmful Energies
Heavy Metals
Pests
Pollen Mix …”
head>>desk
“Thanks to our latest bio-dermal clinical screening technology, we can identify your allergies without taking blood and give you the results immediately.
All you do is hold a metal probe in each hand while we send a signal for each of the allergens listed below. If you are sensitive to that allergen, it will show up on your report.”
Crikey. Diagnostic electro-dowsing! Or should that be “bioelectric applied kinesiology”?
In fact it is an updated version of a time-honoured Alt.Reality quack electro-device, the “Vega-test” system. Plus ca change…
PS Loved LeeT’s quote from someone calling the IoN “world-renowned”. It’s a bit like someone calling the late Herr Hitler a “world-renowned political leader”.
PS Oops – forgot to include a URL for teh Vega-test quackery: a good one is here.
I wonder what the therapy for “Harmful Energies” is – exorcism?
Listened again last night. Thought Catherine Collins came across well. Good questions from Peter White too – particularly the one prompting the admission that Nutritional Therapy (I mean as practised by unregulated, partially-trained nutritionists rather than referring to dietetics) is not evidence-based.
I thought Emma Stiles sounded nice actually and it was certainly brave of the BANT chair to agree to the debate – given the way some high profile NTs refuse to engage in debate (or even to discuss their ideas) and the fact she was, essentially, defending the indefensible.
@ JDC, I’m sure most nutritional therapists are very nice, well-meaning people but I’ve been looking at some of the websites given in BANT’s find a practitioner service (follow link given in post; click on the button in l-hand sidebar), and quite a few so far appear to offer unvalidated allergy/intolerance testing, e.g. here:
http://www.homeopathinessex.co.uk/
Obviously, I have no idea if this sites I have looked at are representative of BANT members’ knowledge of allergy/intolerance testing in general, given I don’t have time to look at all of them and many don’t have website links. But what I’ve seen so far concerns me.
Indeed. In other words, hobbyists and daydreamers who like to play at being doctors for pocket money. BANT, being their representative organisation, are also hobbyists as evidenced by the meaningless fake code of ethics. ION is a hobby.
If ever anyone needed a finer example of a cargo cult!
“I’m sure most nutritional therapists are very nice, well-meaning people but…”
Ha – yes, I think perhaps the appeal to niceness should be recognised as a logical fallacy. I was trying not to be critical of the person while criticising their actions [sort of 'love the sinner, hate the sin' if you will] rather than trying to defend her. I remember Sue McGinty on Rise of the Lifestyle Nutritionists – she came across as being very nice and very reasonable and she was willing to go on a programme about nutritionists presented by someone who has been critical of nutritionism and debate the subject. Despite this, I still found some of her comments amusing. I can’t find the programme she was on now (part one is still on ‘listen again’, part two is not as far as I can tell), but if there is a transcript of the prog anywhere (I can’t find one) I should say that her definition of ‘phenotype’ is worth keeping an eye out for.
Admin: you’re right, Part 2 does seem to be down at present, we have emailed the BBC to ask if this is permanent.
Upate 21 July, Part 2 is now live again.
Well thank you, Holfordwatchers, for maintaining your usual high standard of critique regarding a Patrick Holford/ self-styled nutritionist story.
As a London based dietitian it’s relatively easy for the media to find me for comment. But my fellow dietitians up and down the country also contribute to the wider public debate about nutrition, as we can see from our cuttings agency figures. Despite having a miniscule PR team (compared to Mr Holfords empire) at BDA HO their ‘backroom’ activities generate much of our press interest – which ultimately lead to our opinions being heard. Increasingly so, as journalists realise that poor quality comments from self-styled experts can negatively impact on their future commissions.
So thank you for all your sterling work. There is much to be learnt from your critical reviews and supporting evidence when faced with the musings of ‘enthusiastic amateurs’. And may the media continue to use RDs as their primary source of sound nutritional opinion!
Claire
I have analysed all the websites of Dip ION therapists that I could find – about eighty. Following a bit of spreadsheet meta-analysis I have to report that a large minority of them: (1) are either bonkers or (2) do not understand the nature of the qualification they have or (3) do not come from a science background
I’ll publish my research once my Word Press/blogging skills are a bit better and when some one offers me a PhD for my work.
Lee – will look forward to the post :)
JDC325 wrote:
I agree – she did come across as pretty nice, and relatively up-front about the limitations of nutritional therapy and nutritional therapists. The problem I have is with the approach to nutritional therapy that Stiles was defending…
It is all very sad – most nutritional therapists are not quacks or crooks. Most of them are intelligent and enthusiastic. What they need is better leadership. Here is what I propose:-
(1) The ION distances itself from Patrick Holford and, like the University of Teeside, asks him to stop visiting
(2) The ION asks the BDA to take a critical look at its curriculum
(3) It is made clear to all Dip IONs that their diploma/foundation degree MUST be converted to an honours degree within two years or they will no longer be able to practice
(4) Whilst studying for the honours degree they will be closely monitored in terms of the clients they deal with
(5) In the first two years after graduation they will be operating under licence, possibly under the supervision of a dietitian. After that period, like other helath professionals, they will be committed to continuing professional development which will consist of more than attending Patrick Holford seminars or sales conferences by vitamin pill salesman.
LeeT
now thats an interesting idea.
A simpler way way forward, hypothetically, would I suggest be that -
1) Dept of Health ‘donate’ a sum equivalent to that already given to woo therapy (to ‘regulate’ themselves), but this time for a large PR campaign about how to spot a nutriquack. (Come to think of it, even half of thast £800k would do nicely).
2) The practice of clinical nutrition for the prevention and management of disease (ie dietetics) becomes protected to those qualified in the subject. (Note parallels with the protection of role for the medical profession, with self-styled doctors ending up with prison sentences for fraud)
3) The sterling work of the ASA in highlighting fraudulent marketing claims should combine with the DoH to scrutinise what is actually going on at these nutritional madrassahs. That should lead to closure of most – if not all – of the current ‘Institutes’ and ‘Schools’.
This will also prevent those interested in the subject from being mislead about where exactly their diplomas and certificates will lead them when they ‘qualify’. ie not into clinical nutrition areas that they are currently incompetent to practice in, but by necessity into their own private practice.
4) those enthusiastic about the subject will then be trained in any of the legit universities offering dietetic degrees. Both graduates and their patients find it a rewarding experience.
*btw – do we know what the ION has done to ensure that the substandard training on ‘nutritional pharmacology’ has been addressed by the 2001 – 2007 cohort of ‘dipION’ graduates?