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.
……….and
5) Patrick can ‘come out’ as the fully fledged vitamin pill pusher that he is, without the need for convoluted and contortional Holfordisms about nutrition to support his musings. There will be no more missives from the master, and Holfordwatchers can take that well deserved holiday.
I actually feel that I am owe some apology along these lines to my brain cells having subjected them to Holford’s vaccination, salvestrols and other bits of thought abuse.
I don’t think that I can answer *btw, Prof UK dietitian, but we may have some information on the way ahead for the ION that we might post later as everything else we want to write about is pretty intricate (Holford is wrong but he has mixed up some things that make this hard to disentangle) and we are waiting for responses from various academics, researchers etc.
UK Dietitian
Take a look at the following on the ION website:
http://www.ion.ac.uk/Grandparenting/GP_ION_Notice_of_Assessment_for_Course_Mapping_Route_C.doc
“All ION graduates from 2001-2007 applying for Route C are recommended to purchase Dr Cliff Whelan’s 2005 lecture: Therapeutic Module: Pharmacokineticys. This will help to rectify areas of this subject missing from the course. LO3/5”
I assume what diplomates (note I don’t use the word graduate) from 2001-2007 will have to do is order a recording of Dr Whelan’s lecture and then sign a bit of paper confirming that they have listened to it.
If anyone can prove to me that they actually have do anything substantial I’ll eat a page of “The Optimum Nutrition Bible”.
Lee – it’s not your fault but you have made me very sad. It looks like they sign to say that they have listened to a lecture? But then again, as UK dietitian hints, it is plausible that ION lacks any appropriately active clinical staff who would be capable of setting/marking an adequate exam. The same might be true of clinical supervision.
Ben Goldacre reveals that The Telegraph lost its science editor and its science correspondent in two months.
That is a sad reflection on UK journalism and probably demonstrates Nick Davis’ argument about what is happening to specialist journalists and the rise of churnalism. Riffing off your previous post about science blogging and journalism, maybe it an opportunity for The Telegraph to do something interesting and radical like consulting a few science bloggers and the BDA to beef up their coverage?
I think that they do need to employ specialist journalists but this would be a good experiment and its boldness would seem novel for that newspaper.
Mary
It is not all bad. Some Dip IONs are actually very highly qualified. Take a look at the following two websites:-
http://www.fitwithfood.co.uk/about.html
http://www.nutritionandallergyclinic.co.uk/aboutme.asp
An old friend of mine trained as a nutrtion therapist. She has a good science degree from a good university and I would not describe her as a quack.
The challenge is to harness all the enthusiasm and passion they have for nutrition for the service of evidence-based science.
Lee
Sorry, Lee T – but I fail to see how someone ‘very highly qualified with a PhD in Physiology’ + ‘interest in food’ = ‘highly qualified nutrition professional’.
Actually, they’re not. They are a clever individual who knows a lot about how the body ticks. With a PhD behind them that will mean they have a lot of knowledge about a teeny weeny little part of how the body works.
This ABSOLUTELY does NOT mean that they have more than a rudimentary knowledge of nutrition, and of how dietary manipulation can influence bioavailability and cell functioning. They will have ABSOLUTELY NO knowledge of the medical conditions, management and how diet can interfere or positively interact with health.
I’m sure they’re a very nice, clever person. But having seen plenty of physiologists, graduate nutritionists, and biochemists who have all decided to retrain as dietitians they would be the first to tell you that their first or higher degrees provided a mere background to their current studies.
Afraid a lovely personality doesn’t cut the mustard, so to speak. if you or your friend think otherwise, afraid you’re both sadly deluded.
@UKD – No, I was not suggesting that having a lovely personality helps you to make the grade. In fact, as the most recent post on my own blog make clear my personal experience is many alternative practioners don’t have lovely personalities. What I am wondering is what to do with these people now that we have them. What worries me is that plans I have seen for regulation just risk giving legitimacy to nonsense.
@Mary Parsons – if you are go on to the ION website you will see in the top left-hand corner they are trying to recruit new tutors. I think they have clinical practice in the third and possibly second years of the diploma. Earlier this year “Optimum Nutrition” magazine was advertising for volunteers for free nutrition consultations – presumably for student clinical practice? I did think about volunteering, but was afraid I would get in to an argument with the “clinician” and never be seen again! One thing I did notice when looking at Dip ION website is that several students “graduated” to being tutors or clinicians after finishing their courses.
Has anyone seen the ION curriculum? The only thing I have able to find is a pamphlet about the course on the website.
iirc, Ben Goldacre asked to see the course notes, lecture materials or exam papers etc. and was told that he could not as there are copyright restrictions.
ION provided Goldacre with a list of tutors and 7/24 list the DipION as their sole qualification another 1 also lists that she is part-way through a Dip Natur. so – at that time, 8/24 had no graduate background.
Somewhere on the Bad Science Forum is a 2007 list of ION lecturers and the module that they teach. However, the search function is broken so we can’t link to it.
The curriculum outline is sketchy but probably light to reflect that this is a part-time course with occasional w/end lectures. In Year 3:
Given the standard of Holford’s own literature reviews and the fact that he thanked a couple of IONistas in his recent mailout for the research that they had contributed, it would probably be interesting to see some of those reviews.
Thanks DVN, that’s brilliant and just what I need – not sure how I missed it on my travels around planet ION! Half of the eight modules are – in my subjective opinion – rather woolly and don’t seem to involve learning anything.
Something I have discovered is that there seems to be a relationship between Dip IONs without other science qualifications and an interest in alternative therapies.
Here is my favourite one:
http://www.focusnutrition.com/www.focusnutrition.coms/info.php?p=13&pno=0
An individual who has knowledge of metabolic typing, kinesiology, iridology and phytobiophysics but nonetheless “believes in the evidence-based approach to health where possible.”
Better stop this in case anyone thinks my interest in Dip IONs has become a certifiable obsession ….
PS Does anyone know what phytobiophysics is?
Surely phytobiophysics is some quantum vibration thingummyjib of plants with a healthy dose of flapdoodle? Maybe you should write and ask Ann Walker, she is bound to know.
Hmm… one might cynically suspect that the IoN students’ “dissertations” could well provide some of the laughable “research” that ends up on the IoN website.
Of course, as H’watch has already pointed out, having Patrick’s IoN-trained proteges as the students’ tutors pretty much ensures that a lack of understanding of what it really takes to assess biomedical literature properly, and an uncritical acceptance of unproven nutri-nonsense, is being passed on as mother’s milk, as it were.
Although you can learn to spot SOME classic failings of bad science easily (like no blinding, or no proper control group) it takes a lot of know-how and experience to be good enough at literature interpretation to (say) run a meta-analysis, or referee papers for journals. Speaking as a career scientist, I would say that you really only start learning the very basics of interpreting and grading scientific literature as an undergraduate student, and that’s if you do a real B.Sc. degree taught by proper scientists, not a bunch of re-badged bollocks delivered by smiley IoN nitwits.
You get a lot better at scientific literature interpretation by the time you finish a Ph.D., but really it takes that AND typically three-plus years as a postdoc fellow before you have anything like the expertise necessary to referee a paper for a proper journal properly. It is being asked to referee papers and grant proposals that tells you when you are at the point where your peers regard you as “fully fledged”.
Of course, Patrick and his IoN friends no doubt think they have reached that point as they doubtless get asked to “referee” papers for Cargo Cult journals like the “Journal” of Orthomolecular Medicine“. Any real scientist who has ever glanced at the hobbyist nonsense that fills various Journals of Alt.Reality will know different.
Talk about the blind leading the blind…
@Lee T
In second link you provide, to the Nutrition and Allergy Clinic, there is some indication that they subscribe to Clinical Ecology/Idiopathic Environmental Intolerance/Multiple Chemical Sensitivities theories. I’m not qualified to comment on the validity of these, but would just note that these theories are controversial in medical allergy and bodies like the AAAAI are cautious.
Admin edit for spelling as per later comment.
P.S. many thanks to the Blue Writing Genie (Dr Aust)!
Mary is spot on about the use of “phytobiophysics” being flapdoodle.
The word itself COULD exist. “Phyto-” just means “plant-derived”, which biophysics is… [while], biophysics, the application of the concepts and methods of physics to biology. You can of course apply biophysical methods or ideas to plant-derived whatever just as well as to anything else. For instance, if I tried to use a fancy microscope to work out the deformability of lignin derived from a plant, that would be a piece of “phytobiophysics”.
In contrast, it is pretty clear that it is being used in the example above in the Prince Charles sense of “ummm umm, plants, umm quantum thingy, sort of mysterious healing, y’know”.
Admin edit: [while] as per later comment.
@Claire – unfortunately, I am not qualified to comment on the claims made on the website. She did look more impressive than anyone else ….!
Perhaps Dr Aust would be willing to peer review her research papers which are also detailed on the website….?
you know, the level of banter on this site is such fun. Unlike the Dr Briffa site which is full of tedious point scoring.
LeeT, Claire, Mary,Wulfstan, jdc, et al – great to blog-comment with y’all
:)
Sorry, mean “while” at the end of the first line there. Blame lousy typing.
Correction to spellings my last post – it is of course ‘idiopathic environmental intolerance’ and ‘sensitivities’.
On this topic, Dr Adrian Morris (pdf warning) has written an analysis, which leans towards the conclusion the psychological factors are playing a major role
Lee – re your last comment.. what research papers? …couldn’t find any listed (and her name doesn’t give any “hits” on PubMed).
Presumably I’m being dense and her complete lack of any papers is the point.
Must say I am still tickled by the random use of the term “phytobiophysics”. I must start a collection somewhere of these sort of “ten dollar words” (as the Americans say) which have actual real meanings, but are used by Woos to lay claim to a kind of spurious “science-y-ness”. Anything with “Quantum” in presumably qualifies.
PS What with inflation, nowadays they are probably “fifty dollar” or “twenty pound” words. So it goes.
Admin edit: Dr Aust, we think the reference is to these papers by Margaret Moss.