Ben Goldacre
Saturday July 1, 2006
The Guardian
Last year I noticed that lots of the lifestyle bunnies in the press and on the internet were suddenly showing off about being “RNutr” or “Registered Nutritionists”. Registered with whom? Imagine a two-headed monster called “The Nutrition Society”. On the one hand, they are a respectable and august research body, representing some of the sharpest academics in the country, doing research work on nutrition in both people and laboratories, publishing academic journals, and so on. That’s science. On the other hand, they “run” a “register” that I suspect consists mostly of those commercial “nutritionists” who make good money peddling lifestyle advice to the public. That’s inviting trouble. I am trouble.
I found a prominent nutritionist on their register who was doing exactly the kind of thing that nutritionists in mainstream media like to do – extrapolating rashly from research data – and I decided to complain, just to see whether the Nutrition Society’s register meant anything, really. Her name was Angela Dowden (RNutr), but it could have been anyone. She is “one of Britain’s most high-profile nutritional experts” according to the Daily Mail, and a “Registered Nutritionist” in her columns in the Mirror.
The first thing I found on Google for “Angela Dowden Nutritionist” – I wouldn’t want you to think I looked very hard – was this: www.healthspan.co.uk/articles/article.aspx?Id=112. It’s a pill-pushing online store with a slightly dubious “select your condition” way of selling tablets. Dowden wrote this for them: “Eye strain: Which fruit? Bilberries. How they help: These European cousins of American blueberries contain anthocyanin antioxidants which strengthen the blood vessels supplying the retina in the eye. Bilberry extracts have been shown to treat visual fatigue caused by prolonged reading and working in dim light.”
It sounds like fairly typical media nutritionist fayre – what you might read from any one of them – and it is horseshit, as media nutrititionist fayre often is. I looked, and there was nothing, in 84 “bilberry” references on Medline or Pubmed, to support it. Bilberry extracts had not “been shown to treat visual fatigue caused by prolonged reading and working in dim light”. Dowden admitted as much (but then subsequently complained to the Guardian about me). I read all 84 very boring abstracts to make sure. She was wrong.
So is the Nutrition Society’s “register” meaningfully regulated? Almost a year after my letter to them, they managed to convene what was their first ever “Fitness To Practic” panel. I’m not surprised it was their first ever panel because at the time, as I pointed out, and as they admitted, no information was available to the public, at least not through their website, on how to complain about people on this professional register. (They’ve fixed that since I wrote about it: well done!).
Now their findings on Dowden are in, and those of you who naively believe that regulation and registers are about accountability and transparency will be disappointed. I’d love to tell you what they told me about the hearing (they did not find her unfit to practice but they do go some small way to improving the register’s dismal reputation in my eyes): sadly, their letter is headed “STRICTLY PRIVATE AND CONFIDENTIAL” in bold capital letters, with the word “CONFIDENTIAL” one inch tall in grey watermark across the page. My lips are sealed. These are private hearings. Because the Nutrition Society have decided they should be. I look forward to a promised short report in their “Gazette” in December.
Compare other bodies. The GMC Professional Conduct Committee and Fitness To Practice Panels are fully open: they hold public hearings, and not only are the rulings publicly available (and searchable online) but the transcripts are too. People have predicted, recently, that lone MMR warrior Dr Andrew Wakefield will receive a repressive drubbing by the GMC: if you are one of these people, I heartily advise you to experience every single last gruelling colon of the hearing, and decide for yourself on their deliberations.
That’s accountability. That’s transparency. That’s regulation. The “register” arm of The Nutrition Society is something very different: that’s show business. They are currently angling to become an official register, like the Nursing and Midwifery Council, the General Medical Council, and the British Dietetic Association. I wish them the very best of luck.
AitchJay said,
July 1, 2006 at 1:05 am
I like their letters; RNutr.
And in the plural; Are Nutters.
Kimpatsu said,
July 1, 2006 at 5:37 am
Damn you, AJ; first you steal my initials, and now you steal my joke!
harry said,
July 1, 2006 at 8:32 am
The URL in the Guardian (unlike the one in the article above) does not work, because it includes the full stop.
Ben Goldacre said,
July 1, 2006 at 8:50 am
The URL in the Guardian (unlike the one in the article above) does not work, because it includes the full stop.
i guess that’s because they are an international media conglomerate whereas i am just some bloke.
Tony Hatfield said,
July 1, 2006 at 9:48 am
Harry,
“The URL in the Guardian (unlike the one in the article above) does not work, because it includes the full stop.”#
Mine worked fine. The full stop is outside the URL
BobP said,
July 1, 2006 at 4:39 pm
a) I didn’t get this one through email – did something go wrong?
b) I have watched – from a distance – the acupuncture profession prepare itself for statutory self-regulation in order to become a legal register (process currently stalled, apparently because of delays at the DoH). The changes needed were far-reaching and very necessary. These guys will hopefully need to make comparable changes in order to get anywhere.
There’s a general point here – the difference between a “trade association” (which exists to serve the interests of its members) and a “professional association” which hopefully has a broader public interest. I guess that it is possible for an organisation to progress from one to the other.
This is clearly a trade association – you only have to have a “genuine interest” in order to become a member, no qualification is necessary.
More on the members page of www.nutsoc.org.uk (!!).
Bob O'H said,
July 2, 2006 at 7:36 am
I don’t think that should stop an association from being a professional body. For example, the Royal Statistical Society (of which I’m a member) has the same rule for membership, but it is the body that represents professional statisticians and encourages good statistical practice (it has a code of conduct “… to define the behaviour expected of RSS Fellows practising in everyday professional life.”). They have a professional qualification (C.Stat.) as well, which acts as a register.
Bob
igb said,
July 2, 2006 at 10:21 am
It’s amusing that the referred nonsense is on Healthspan’s site. I’m incredibly cynical about vitamin supplements, but I keep a tub of chewable Vitamin C tablets on my desk as an alternative to eating sweets (oh, OK, as sweets to eat). A couple a day (~1g) aren’t going to crystalise out in my kidneys or whatever it is that excess Ascorbic Acid do, and who knows, they might even reduce the seriousness of colds. The neat placebo effect is that, together with a generic multivitamin, I seem better able to convince myself that colds are just colds, rather than take to my bed, although my diet certainly has plenty of Vitamin C in it. It’s almost certainly placebo effect, but if I can get my subconscious making me feel a bit better in the winter for a fiver a month, why get snitty about it?
But Healthspan are cheap, reliable and their tablets taste nice. I was referred to them by my mother who was recommended to them by her GP as a cheap source of Glucosamine: that the evidence is similarly thin to non-existant on _that_ supplement is another conversation. They also do a nice multivitamin jelly bear for kids which seems again something that’s unlikely to be harmful and might be possibly beneficial.
The upshot is that I get sent their catalogue. It’s, er, fascinating. Filled with pictures of glossy yummy mummies and glossy affluent retirees (with all the ethnic diversity you might expect from a Channel islands company), it gives the clear impression (but staying just this side of making unsupported claims) that with an appropriate handful (bucketful, more like) of supplements you can live to two hundred while running a marathon every weekend and winning Mastermind.
It’s a shame. Multivitamins probably aren’t necessary, but are highly unlikey to do harm and might do some good. Ditto Vitamin C. The evidence on Omega 3 is thin, but it’s cheap and no-one’s seriously suggested it has side-effects to worry about. A company which sells things like that cheaply, honestly and efficiently is no more dubious than a company which sells cycle helmets — the evidence of good is slim, but they’re hardly selling crack to children.
But once you get into the more far-reaching claims, you get a strong sense that weak people, possibly with existing health issues, are being led astray. My wife’s aunt spent a lot of money on selenium supplements when she was dying of cancer, and unless she had the urge to become a transistor it’s hard to see why.
ianh said,
July 3, 2006 at 10:44 am
I’m not a lawyer, but I don’t see why you should be held to a confidentiality notice they put in their letter unless you have signed something agreeing to such confidentiality (eg you are a member and that is a condition, or you have previously agreed to a confidentiality contract). Furthermore, surely there is a public interest issue here. Perhaps you feel it may damage your ability with this organisation to get additional information in the future, but dammit, the rest of us have a right to know!
Let’s expose these pseudo-science cranks which use their writing merely as a platform to peddle their ludicrous products!
nzchoufleur said,
July 3, 2006 at 5:37 pm
I find it intriguing that everyones favourite nutritionist (and we all know who I’m talking about) is not on the register. Did she get rejected? or did she not even bother to register with her own professional body.
By the way, you only need a genuine interest in nutrition to become a member of the society but to join the register you need some form of professional qualification and referrees etc. If I joined (which I could) would you be one of my referrees? (| have genuine actual qualifications which took me genuine actual years of genuine actual original research to get).
Alfster said,
July 3, 2006 at 7:04 pm
The confidentiality stuff is indeed rubbish.
They sent the document to Ben, he has not signed any confidentiality agreement hence he is free to do what he likes with the information.
I have heard of this before and even the BBC lawyers have said just having the words on there are not binding especially as the document was sent directly to him.
Robert Carnegie said,
July 4, 2006 at 10:29 pm
I suppose that previous correspondence may have indicated that confidentiality would be applied. It isn’t mentioned in the complaints PDF, except that it says “An anonymised summary of the case is published in the Society’s Gazette”. It does seem that they’re a bit too much of a Friendly Society.
But in any case, journalists have a convention of respecting claims of confidentiality unless it’s really good, and this probably isn’t really good. To scoop the Christmas edition of the Gazette of Nutrition (either their worst or best time of year, come to think) would not be a great coup.
If someone sends you a news release that says “Don’t tell anyone about this until next week!”, and you do, then they may not send you the next one, which you may want – and neither may anyone else.
raygirvan said,
July 4, 2006 at 11:06 pm
If someone sends you a news release
I don’t mind that. A time embargo, in good faith, is fine. The problem is when – pardon my French – someone lays some shit on you and claims you can’t tell anyone.
Ben Goldacre said,
July 4, 2006 at 11:59 pm
“An anonymised summary of the case is published in the Society’s Gazetteâ€
oh shit it’s anonymous, i guess i’ve really blown the gaff by mentioning dowden’s name then…
one thing i didnt have space to mention in the article, we are talking here about an organisation so obsessed with secrecy that when i contacted them, as a journalist, to ask them a few questions about the nutrition society, as a journalist, they replied to my journalistic questions with “CONFIDENTIAL…” etc etc etc across the top of the page. i pointed this out and they stopped, and sent me new replies… without the confidential secrecy stuff. i think secrecy and confidentiality might be a sort of deeply ingrained knee jerk routine with them? god knows why. what is the big secret in there? why does something that sets itself up as a regulatory body have to worry so much about hiding stuff? it really honestly does absolutely baffle me. and make me want to poke around more.
raygirvan said,
July 5, 2006 at 12:14 am
What do you make of the standard BBC e-mail outro?
“This e-mail (and any attachments) is confidential and may contain
personal views which are not the views of the BBC unless specifically
stated.
If you have received it in error, please delete it from your system.
Do not use, copy or disclose the information in any way nor act in
reliance on it and notify the sender immediately. Please note that the
BBC monitors e-mails sent or received.
Further communication will signify your consent to this.”
Is it frightfully confidential only if it goes to the wrong recipient? Or generally? If I e-mail back saying, “your response was so patronising and lame that it made me put my fist through the screen” does that bind me to secrecy?
Dr Aust said,
July 5, 2006 at 11:32 am
Leaving aside all this confidentiality…
Unless I’m wrong, we ALREADY have a recognised group of licenced professionals, with proper degrees, who give evidence-based dietary / nutritional advice. They are called Dietitians
Sadly, the NHS wait to see one is months, but having a bunch of self-promoting idiots giving poorly-founded /misleading “nutritional counselling” is hardly a solution.
Perhaps we should be training more dietitians who could set up in private practise and compete out the RNutr-oids? After all, if the wait list for NHS physiotherapy is too long, people can pay to see a properly trained physiotherapist privately, and therefore (hopefully) don’t go to untrained “physical therapy advisers”, or whatever.
More generally, I think PROPER regulation/registration is the only way forward for the Alt Health people to take the correspondence-degree charlatans out of the market . If they don’t want to do it voluntarily, then they should be MADE to by statute, as is the case in many continental countries.
In essence, if you are going to be a registered and licenced “Health Pracitioner”, you should have to have a recognised training from a serious recognised training institution. In Germany anyone WITHOUT a 4 yr degree and professional licencing who called themselves a “Medical Herbalist” would be promptly prosecuted.
techy said,
July 5, 2006 at 5:46 pm
This thread to me seems to boil down to two issues:-
1) What is a RNutr, especially when we have Dietitians ?
2) If the Nutrition Society is, as it claims, the best organisation to administer such a register then why are the top brass so instinctively secretive?
I have looked a little at these and it seems simple:
1) Dietitians versus RNutr:
Dietitians are primary focussed on giving one-to-one dietary advice (mainly NHS based). They are protected and need, like most nurses nowadays, need an appropriate specialist Degree and experience.
RNutr and PHNutr are primarily focussed upon research, health policy, communication etc., but NOT on one-to-one advice. They also need an appropriate specialist degree or PhD and experience to be registered, but are not protected in any way so the poo lady and others can use titles like “Nutritional Therapist” and nobody can do anything.
At the official levels the RNutr/PHNutr registers certainly seem to be recognised as being reliable. A couple of links to the Food Standards Agency and the British Nutrition Foundation are attached.
FSA – 3rd question on page: www.eatwell.gov.uk/asksam/healthydiet/healthyweightq/
BNF: www.nutrition.org.uk/home.asp?siteId=43§ionId=1164&parentSection=299&which=4
2) Are the Nutrition Society the “right” management?
The timidity with the press when questioned by a journalist is common in academic institutions and bodies so I can’t say I am shocked. This may not be the best approach but is hardly a sensation.
You point to the the transparency of complaints in the medical profession but my understanding is that GMC panels are reserved for only the most serious cases of gross and sustained misconduct/incompetence and are only reached after many earlier “private” stages of medical complaints processes through hospitals, trusts etc. If ALL complaints ever made against doctors, regardless of verdict, are published somewhere where they can be examined then I will happily stand corrected.
Openness versus Privacy is always a huge debate. Personally as a general principle I am in favour of privacy until verdict, and then release of details only if the verdict is guilty. Many Sun and Daily Mail readers may disagree.
Robert Carnegie said,
July 5, 2006 at 9:50 pm
Now I’m picturing a strangely unengaging gossip column. “Diary by ‘Circe’. Which registered member of the society, earlier this year, was picked out by a certain doctor writing a sceptical science column in a national newspaper? Well, to be frank, it was most of you, wasn’t it? ‘Confidentiality makes me want to poke around more,’ says Dr. B— G—, so Circe’s Christmas tip is that members who find that herbal viagra doesn’t hit the spot could do worse than try a bit of public exposure! Just don’t let the Doctor catch you anywhere near mistletoe!”
Richard said,
July 5, 2006 at 10:28 pm
I have a genuine interest in nutrition (in so far as I don’t want to get scurvy), perhaps I’ll join the society too.
But I can’t help thinking all these nutritionists and dietitians are taking the proverbial. Basically, eat a balanced diet with plenty of fruit and veg. What else is there to say about nutrition?
I can recommend bilberry pie though, it’s yummy.
kim said,
July 6, 2006 at 9:44 am
Richard, I suppose it depends what you mean by “balanced diet”. It’s not something I worry about (principally because I think my diet is pretty healthy) but I know a lot of people who do – they worry about eating too much cholesterol, or the wrong sort of fat or whether they’re getting enough of this or that vitamin or mineral. If you read people like John Briffa, they’re always telling you that you should eat x because it’s rich in “selenium” or y because it has plenty of zinc, which, you know, has health-giving properties. And potatoes are bad because they give you a carbohydrate rush (whatever that is) – and quite frankly you could spend all your time worrying about it while ignoring the fact that the modern diet is probably healthier than it’s ever been. 50 years ago nobody knew about zinc and nobody worried.
The people who really make me laugh are those who get obsessive about their diet while smoking 20 a day.
Sorry, a bit of a rant…
techy said,
July 6, 2006 at 10:14 am
Repost – this was after post 16 (Dr Aust) but for some reason was deleted.
No answers as to why some of us can investigate independently what a “balanced diet” is and others want to be told by an “expert”, let alone follow fads.
I do see a reason for experts and research though, as stagnation of knowledge leads stagnation all around. “Balanced diet” was different when I was a kid, but smoking was cool and associated with cowboys.
Anyway – deleted contribution below.
———————————–
This thread to me seems to boil down to two issues:-
1) What is a RNutr, especially when we have Dietitians ?
2) If the Nutrition Society is, as it claims, the best organisation to administer such a register then why are the top brass so instinctively secretive?
I have looked a little at these and it seems simple:
1) Dietitians versus RNutr:
Dietitians are primary focussed on giving one-to-one dietary advice (mainly NHS based). They are protected and need, like most nurses/midwives etc nowadays, an appropriate specialist Degree and experience.
RNutr and PHNutr are primarily focussed upon research, health policy, communication etc., but NOT primarily on one-to-one advice. They also need an appropriate specialist degree or PhD and experience to be registered, but are not protected in any way so others can use titles like “Nutritional Therapist” and nobody can do anything.
At the official levels the RNutr/PHNutr registers certainly seem to be recognised as being reliable. A couple of links to the Food Standards Agency and the British Nutrition Foundation are attached.
FSA – 3rd question on page: www.eatwell.gov.uk/asksam/healthydiet/healthyweightq/
BNF: www.nutrition.org.uk/home.asp?siteId=43§ionId=1164&parentSection=299&which=4
2) Are the Nutrition Society the “right” management?
The timidity with the press when questioned by a journalist is common in academic institutions and bodies so I can’t say I am shocked. This may not be the best approach but is hardly a sensation.
You point to the the transparency of complaints in the medical profession but my understanding is that GMC panels are reserved for only the most serious cases of gross and sustained misconduct/incompetence and are only reached after many earlier “private” stages of medical complaints processes through hospitals, trusts etc. If ALL complaints ever made against doctors, regardless of verdict, are published somewhere where they can be examined then I will happily stand corrected.
Openness versus Privacy is always a huge debate. Personally as a general principle I am in favour of privacy until verdict, and then release of details only if the verdict is guilty. Many Sun and Daily Mail readers may disagree.
sciencefan said,
July 6, 2006 at 3:41 pm
Kim, you wrote “you could spend all your time worrying about it while ignoring the fact that the modern diet is probably healthier than it’s ever been. 50 years ago nobody knew about zinc and nobody worried.”
I admire your confidence in the face of the overwhelming evidence to the contrary! Sure, if you choose the right foods you can eat as healthily today as 50 years ago (and not worry too much about supplementation), but the reality is that the vast majority of people just don’t or won’t do it – hence e.g. the worrying increase in the numbers of overweight and obese adults and children, the concomitant increase in the incidence of ‘adult-onset’ lifestyle diseases and conditions in ever-younger children etc. The link between diet and disease has been shown time and again to exist (not least by Doll and Peto’s work on the factors leading to cancer; if I remember correctly, nutrition was approx. as significant a factor as smoking).
There is an urgent need for good nutrition advice to families – just telling them to eat a balanced diet is not enough. But who is to provide sensible advice? The RNutrs? The dieticians? GPs?
IMHO anyone recommending multivitamins has automatically disqualified him/herself. Look for the evidence of the efficacy of such supplements: it is thin on the ground, I fear, while the evidence of their harmful effects is documented in several large-scale studies.
raygirvan said,
July 6, 2006 at 4:18 pm
50 years ago
I wouldn’t know about 50 years ago, but my chief recollection of food from the early 1960s was that it was bloody horrible. In particular it was in the tail-end of an era of ludicrously long cooking times for vegetables (I have a cookbook here recommending cooking carrots for 45-50 minutes) which I don’t suppose left much in the way of vitamins.
kim said,
July 6, 2006 at 4:44 pm
sciencefan – I don’t completely disagree with you. Yes, probably a lot of people do eat a very unhealthy diet, ie they live on burgers, chips, fizzy drinks etc. But I think there is certainly the opportunity to eat more healthily now – a much wider range of fruit and veg is available than when I was a child. In the 1960s ingredients such as pasta and rice were still regarded as exotic, and I must have been well into my 20s before I tasted an avocado, for example. (And I agree with raygirvan about the veg: even now I know older people who just boil vegetables to death, and it makes you wonder if they have any nutritional value at all.)
Even junk foods aren’t all bad, because some of them do have vitamins etc. added to them.
About the link between diet and cancer: yes, I accept there may well be a link, but I’m sceptical about whether we know enough about it to say precisely that certain foods cause certain kinds of cancer. Ben posted a link a while back to an epidemiological site that said the evidence about smoking and cancer was overwhelming, while the evidence relating to nutrition and cancer was much more patchy and debatable. (This is from memory; I hope I’m not misrepresenting here.)
Richard said,
July 6, 2006 at 4:49 pm
“There is an urgent need for good nutrition advice to families”
I appreciate that many people are eating poor diets. But I don’t think they need specialist nutrition advice, as it is extremely simple to eat a good diet. Prepare and cook your meals yourself, rather than eat ready meals. And eat a varied diet including plenty of fruit and veg. It’s really easy to eat a balanced diet. You don’t have to think about it. Just get a nice thick recipe book and work through the various different recipes in it. It’s easy and fun!
sciencefan said,
July 7, 2006 at 1:38 pm
Richard: ‘good advice’ doesn’t equate to ‘specialist advice’. I think that people like Jamie Oliver can do a lot more that the average RNutr to show that a good diet isn’t hard to achieve. It still remains a challenge for your average working mum with 1,5 children.
When you consider that the number of nutrients identified in e.g. an apple or broccoli runs into the tens of thousands (and the total number present is estimated to be an order of magnitude greater) AND that no one component works in isolation but in synergy with others, the idea that we can create a supplement with some 20 or 30 (usually synthetic) vitamins and expect it to have the same effect as eating even ‘five a day’ is laughable.
But scientists are not blameless here – as soon as a fruit / vegetable / herb / seed / fungus etc is discovered to have a particular health benefit, what happens? Immediately the search starts to identify and isolate the ‘active component’ (note the singular form) with the objective of synthesing it to produce a new drug. OK, this is how e.g. antibiotics were developed and it can be a valid approach for the treatment of disease, but we tend to lose sight of the bigger picture: good nutition offers the opportunity for real prevention, which is not in the interests of the pharmaceutical industry but which would save the NHS billions and improve the quality of life of the whole population. How the pension system would cope is another matter!
A study published in Nature showed that one 100g apple contains more cancer-fighting antioxidant capacity than a 1,500-milligram dose of vitamin C. (Nature, 2000, 405: 903-904). Some may argue that the jury is still out on whether antioxidants are significant, but it isn’t just epidemiological studies that suggest that is far better to eat an apple than to take a vitamin C supplement ; this is (presumably) because of the complex synergy at work between the myriad nutrients available in the apple.
No wonder that a nuclear physicist friend recently stated that nutrition is far more complex than his subject!
Dr Aust said,
July 7, 2006 at 9:21 pm
Richard
The evidence from studies suggests a lot of people who DON’T eat healthy diets (often the urban poor) have surprisingly good awareness of what should be in a healthy diet. They don’t because of what the social scientists call “structural and access constraints” – e.g. problems of time (working/childcare) lack of money (junk food superficially seem cheap – £ 2.00 a Happy Meal or whatever), lack of access to good raw ingredients (shop on estate sells only processed garbage, no car to get to Sainsburys) etc.etc.
Education is also important -but at home as well as in school. See Jamie Oliver’s show where many kids couldn’t even RECOGNISE common vegetables.
Robert Carnegie said,
July 8, 2006 at 12:25 pm
I think there are good ready meals. In fact I’m depending on it. Look for low salt, low calories, higher vegetable content, smaller portions, no GM or hydrogenated fat or oil if you worry about those. In fact I often buy child ready meals; normally the people who buy them don’t taste them as a rule, so leaving out the salt doesn’t mean that people say “This tastes blah” and they don’t buy it again. And it works for me too.
I’m not a good cook, but why shouldn’t I eat nice food? And life’s too short anyway.
A reasonable basis for scientific investigation of active chemicals in natural sources is that in nature they’re mixed up with all the other chemicals in the same product – suppose it’s something poisonous, like cyanide precursor in apple seeds – and you don’t necessarily get a regular dose from different varieties of the same plant, or from plants grown under different conditions – this is mentioned in connection with St John’s wort, and of course cannabis.
Dr Aust said,
July 9, 2006 at 5:58 pm
Re. sciencefan’s post 21, the current obesity epidemic is not just down to “bad diet”. It is also a question of SOCIAL CHANGE.
Leaving aside the Qs about precisely WHAT we eat, the total CALORIES that we eat have NOT gone up in the last 30 yrs, contrary to what many people believe. It is more that the energy we “burn off” has gone DOWN. This is due to a whole range of things: less people working in jobs involving physical activity, less people walking or bicycling to work or to do the shopping, less kids walking to school, loss of school playing fields and parks, people go everywhere in cars, one-stop supermarket shopping instead of walking along a local high street, more cars are on the streets so kids don’t play outside, the rise of recreational activities based on sitting around (TV, computers), etc.etc.
Anyway, overall we don’t eat more than 30 yrs ago – we just have a major problem with eating more than we need to eat. To lose weight you can eat less OR do more. Hence all the medical advice about regular physical activity.
sciencefan said,
July 11, 2006 at 5:28 pm
Dr Aust,
I take your point about the balance between energy intake and expenditure and the general reduction in physical activity.
But hasn’t there also been a dramatic shift from the intake of complex to simple carbohydrates, influencing the satiety response,and thus leading to overeating. Or is this merely anecdotal?
Dr Aust said,
July 11, 2006 at 7:43 pm
Satiety is a tricky one, as the signals for satiety are still poorly understood. There are undoubtedly multiple signal pathways, sensing multiple things (distension/fullness e.g. in the stomach, presence of things in the duodenum – fats is a relatively well-described example, but protein is probably sensed too – plus hormonal changes evoked by arrival of nutrients via the blood etc etc. Still being worked out. And the “sensing” pathways also interact. Even simple scientific reviews of this are hellishly complicated: e.g.
www.physoc.org/publications/pn/subjectcollections/pncollectionspdfs/Integrative/2005/Bloom.PDF
(and that one doesn’t even mention insulin, I thnk….!)
To make it worse, the whole question of how much you are “programmed” to eat is not wholly a biological one – there is plenty of evidence that early life learning of eating habits also plays a role. “Finish up everything on your plate!” Or ask the Q: why do some people keep eating when they are full while others stop? Probably behavioural psychology rather than “genetic programming”.
So it is probably a good idea NOT to force your kids to eat everything, rather contrary to how I was brought up.
On the specific subject of carbohydrates, the theory I think you are alluding to is the idea that simple carbohydrates cause a more rapid rise in blood glucose than complex ones, and hence also a faster/larger increase in insulin. But if anything, insulin is a satiety signal (swirches off eating). Of course, a lot of insulin secretion will in turn cause hypoglycaemia, which promotes eating. So as you can see, it is hard to be definite (!).
The best way to put as far as I can see is probably that the nutrient uptake / satiety system is finely balanced normally, and just tweaks itself up a bit when you add food. Complex carbohydrates need to be broken down in your gut for absorption, so will arrive in the blood at a nice manageable rate, requiring minor tweaks to get the body to “store the energy away”. Huge doses of refined carbohydrates require bigger “excursions” of the control system, which in general “push” the system more and are best avoided. Sorry, bit waffly, and haven’t really answered the Q, but hard to be definite. Perhaps a proper nutrition scientist (!) can give you a better answer.
Dr Aust said,
July 12, 2006 at 8:53 am
PS Another useful property of “complex” carbs is that they contain a lot of fibre. Since this remains in the gut, and retains water there, it helps “bulk out” the gut contents and this could also help you feel full (satiety) due to the “distension effect” mentioned above.
It also stops you getting constipated…
Good grief… I’m turrning into “Doctor” McKeith….
…can I have my RNutr now, please?
JQH said,
July 12, 2006 at 10:51 am
Dr Aust, in our house the command “finish what’s on your plate” is to ensure Little H actually eats her veg rather than to push her into eating more than is necessary for her.
Dr Aust said,
July 12, 2006 at 11:10 am
Hi JQH
With you 100%…. of course, this is what makes it all such a pain in the a@!e… One reason why we are trying to grow veg in the garden to make the stuff personal / interesting for Junior Aust.
I was thinking more of my own 40-something generation being made to eat lukewarm leather-tough Sunday lamb and soggy spuds “flavoured” with chemical mint. My father used to tell us that during the war his mother would encourage him to “eat up” with the words “You have to eat that, it’s got SAILOR’S BLOOD on it”. Now that’s what I call positive reinforcement.
Talking of “child taming”, think the child psychology-based shows (e.g. Houseof Tiny Terrors) progs are FAR more useful in terms of inculcating sensible “life habits” (in all spheres) than the nutri-bollocks. Of course, the child psychologist is also a trained professional, probably significant (compare the average TV “nutritionist”).
Leading nutritionist said,
July 12, 2006 at 6:49 pm
As a nutritional scientist, albeit not an exalted RNutr, who has a research interest in obesity, I will concur with Dr Aust that satiety is a tricky one! A simplistic model of eating behavior starts with neuropeptides in the hypothalamus that stimulate or suppress eating (these include neuropeptide Y, agouti related protein, proopiomelanocortin and cocaine-amphetamine regulated transcript). NPY and AgRP stimulate feeding while POMC and CART suppress it. The balance of these peptides (and consequently eating behavior) is influenced by projections from other areas of the brain (that provide information on the ‘rewarding’ aspect of the food) and from signals arising from the ‘body’. These signals from the body include stomach distention, hormones released in the digestive tract and metabolites in the blood. All these are short-term signals of energy availability. The ability of these short-term signals can be further influenced by signals of long-term energy availability (adipose tissue) which include insulin and leptin (high levels of insulin and leptin should reduce sensations of hunger).
Of course learning or prior experience has an impact on food preference and selection. How these factors interact with the physiological appetite system to determine body-weight is currently anybody’s guess. The impact of physical activity on body-weight is also debatable. Many believe the appetite system attempts to match energy intake to energy expenditure – therefore, even if energy expenditure has fallen, why hasn’t food intake fallen in concert? There are other ideas regarding the purpose of the appetite system, but the idea of body-weight homeostasis remains probably the most prevalent. Also, the data suggesting that energy intake has not changed over the past few decades is pretty suspect. Changes in methodology and substantial under-reporting demand cautious interpretation. I am not saying it is wrong, I just wouldn’t put my house on it.
With regards to carbohydrates, I believe Sciencefan is referring to the concept of glycemic index (or the revolutionary new science of glycemix index – first mooted in 1981). GI relates to the ability of a food to raise blood glucose levels (high GI = rapid rise, low GI = slow prolonged rise). Foods with a high GI tend to contain a greater proportion of simple sugars whereas low GI foods consist of complex carbohydrates. Some evidence suggests that low GI foods are associated with increased satiety and lower food and high GI with reduced satiety and increased food intake. This is debatable. Moreover, the GI of a food (never mind a diet) is not completely predictable (a foods GI changes with cooking, processing and ripening) which makes following a low GI diet difficult. In answer to Sciencefan’s point, and to cut a long one short, there have been so many changes in dietary habits over the past few decades that to blame one in isolation is unwise.
To join in on the Nutrition Society debate, I have to disagree with Ben’s assertion that since Boyd Orr things have gone downhill! There are currently some top class members of the Nutrition Society and the current President (Dr Ann Prentice) is an excellent scientist. However, some of the individuals on the register…
Also, the media nutritionists trivialize the subject and are a constant source of annoyance to the nutritional scientists I know (myself included). When I read their interpretation of nutritional science, I tend to cringe with embarrassment rather than feel flattered.
Ben Goldacre said,
July 12, 2006 at 11:52 pm
Yes, Ann Prentice is clearly very sound, apart from anything else she runs the truly excellent MRC HNR department at Cambridge. But they must surely be wondering now about the wisdom of giving their authority to commercial lifestyle advisers? My take on this from chatting to lots of nutrition academics is that people working in the field were initially rather flattered that their research backwater had become the “bollocks du jour” and was receiving so much lavish attention, but now they’re beginning to realise that it’s slightly undermining in the long run…
Leading nutritionist said,
July 13, 2006 at 1:59 pm
I fear the RNutr register is a good idea that has not (yet) worked out as intended. In the past (as now), there were lots of people offering nutrition advice – some of it was good, some was crazy, but harmless, some was downright dangerous (i.e., your cancer will disappear if you stop the conventional medical treatment and just avoid dairy foods). But it was difficult for the public to determine whether they were getting advice from a properly trained professional or a self taught (or even worse, someone with a correspondence PhD) charlatan (although, if scientific literacy was higher it would be obvious). By making a register of qualified individuals (you require at least a BSc, a number of years experience, and three references from members of the NutSoc) you should at least offer the public some protection against the more dangerous ‘nutritionists’. Bilberry Dowden has a degree in Food Science from a very reputable University and qualifies. Is her advice sound? Well, she certainly provides a different interpretation of the literature than I, or I suspect most others, would. Is she providing dangerous advice? I don’t think so. Should people who give crazy but harmless advice be on the nutrition register? In the interests of standards and the society putting forward a professional face, probably not, but I think the register should be aimed at people like her. I am an academic who provides no advice to the public – what is the point of the register being full of people like me? It protects no one. However, I do think that the register should promote professional development and higher standards across nutritionists who provide advice to the public (I think that this is the eventual aim). At the minute, standards are patchy at best.
Flattery, I understand what you are saying and maybe I entered the field of nutrition when people had become more cynical about the lifestyle nutritionists. I am sure people who were initially flattered by the interest didn’t predict that this potentially symbiotic relationship would end up with diet manuals by Carol Vorderman and Anthony Worrell Thompson or TV shows by a fake PhD nutritionist (The worlds leading nutritionist apparently, I cannot remember voting for her) who sniffs turd. I guess it is too late to put the genie back in the bottle.
drewprice said,
July 14, 2006 at 1:28 pm
The point is; you can get a respectable degree and gain access to the register but that does not stop you giving unsound advice.
In the more recent article (The Red Baron) mention is made of a couple of RNutr and they are attacked for their practices, one of them however would seem to be in training to become a Dietician.
So, once Mr Abu-Jabir registered as a Dietician does that suddenly make his advice more sound?
On going use of titles and registers means little unless they are supported by CPD and monitoring to ensure not just that you have a qualification that means something but that you are delivering quality care, most nutritionists (myself included) would welcome this.
Drew
CYvonne said,
July 21, 2006 at 12:22 pm
Mr Abu-Jabir isn’t registered with the Health Professions Council so I assume he either never finished his dietetic training or is still a student. If he does register as a dietitian he will have to abide by the HPC’s code of conduct and CPD requirements which might make bioenergetic medicine a bit harder to practice.
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