The consumer magazine's web-site ran the headline 'Nutritional therapists: gambling with your health?', and called on the UK government to introduce regulations "to stop nutritional therapists putting people's lives at risk". Furthermore, "Which? advises anyone worried about their health to visit their GP, who can refer them to a specialist where necessary."
The report, published in the February edition of Which?, is welcomed by the British Dietetic Association (motto: Trust a dieti-tian to know about nutrition), which is openly opposed to its nutritional rival-and supplied one of its members to sit on the Which? expert panel. "Dietitians interpret the science of nutrition into practical evidence-based advice for people while nutrition therapists do not use evidence in a robust fashion and their advice is often based on personal opinion," says BDA vice-chairman Sian Burton.
The BDA has produced a leaflet that draws a line between a dietitian and a nutritionist. Essentially, nutritionists follow "unproven" approaches such as highdose vitamins, detox and food avoidance, according to the leaflet. They also believe-wrongly, according to the BDA-that poor health, including mental-health problems, can be
the result of nutritional and bio-chemical imbalances.
The Which? investigation involved five undercover researchers, two of whom claimed to have been diagnosed with DCIS (ductal carcinoma in situ), a benign and localized type of cancer, two pretended to have serious fatigue and one said that she had been unable to conceive for a year. Each researcher visited three nutritional therapists chosen from Google searches.
The headline-grabbing visit came from one researcher, 'Sarah', whose role was to be someone recently diagnosed with DCIS.
She was told by one nutritional therapist to delay for between three to six months the lumpec-tomy and radiotherapy recommended by her oncologist while changing to a sugar-free diet, which the therapist said might help to starve the cancer.
All three experts on the panel-registered dietitian Catherine Col-lins, GP Dr Margaret McCartney and David Colquhoun, professor of pharmacology at University College London-agreed that the advice was dangerous, and that the sugar-free diet was not proven. Dr McCartney described the advice as "highly irresponsible", and continued: "If cancer treatment were as simplistic as cutting out sugar, surely we would have discovered a cure."
Against the code
However, there is some doubt that any of the therapists surveyed actually said it. Thirteen of the 15 therapists visited are members of the British Association for Applied Nutrition & Nutritional Therapy (BANT), and the organization was sent transcripts of the interviews.
A BANT spokesperson said: "We have found no evidence in the transcripts that the practitioner directly made the recommendation . . . the practitioner made it quite clear that the client's oncologist must be involved and that the client should refer the suggestions to them to seek their opinion and agreement."
The Which? investigators have also said they didn't want their GPs or specialists contacted-not surprisingly, as the cases were all fictitious. The subterfuge made it impossible for the therapists to liaise with the doctors.
Also, the BANT spokesperson pointed out that all of its members are aware of its code of practice, which forbids any practitioner from encouraging the delay of any cancer therapy in favour of a nutritional approach. A genuine breach would result in an enquiry.
Even if the advice had been given, it is not as dangerous and unproven as the expert panel suggests. The sugar theory was first mooted by two-time Nobel-Prize-winning biochemist Otto Warburg in 1924. It suggests that cancer cells get their energy from 'fermentation', known today as 'glycolysis', by extracting it from glucose without using oxygen, as normal, healthy cells do, and it was only in 2002 that researchers in Spain found the biological mechanism to suggest that Warburg may have been right (Cancer Res, 2002; 62: 6674-81).
In addition, two radiologists at the University of Arizona realized that medicine has been unwitting-ly working with the 'Warburg effect' for years, as body-scanning machines look for glycolysis in cancer cells to measure progression of the disease (Nat Rev Cancer, 2004; 4: 891-9). Researchers from Harvard and MIT have also confirmed the theory (Proc Natl Acad Sci USA, 2005; 102: 5992-7).
Although a therapy based on Warburg's theory has not yet been developed, nutritionists who recommend an alkaline diet are help-ing prevent the spread of cancer.
The other supposed suggestion-of 'watchful waiting' after a DCIS diagnosis-is also in line with the current medical thinking. DCIS is a very low-risk form of cancer that is rarely malignant; in fact, fewer than five per cent of cases ever become invasive and, yet, the diagnosis has traditionally triggered a lumpectomy or even a full mastectomy (JAMA, 2009; 302: 1685-92). Because of this, doctors are beginning to adopt a watchful-waiting approach to see if the DCIS develops into an aggressive cancer.
Furthermore, researchers at the University of California at San Francisco (UCSF) are investigating non-surgical ways to treat DCIS, including hormone therapy. In a study of 40 women diagnosed with DCIS, 23 had a positive response to the therapy, as revealed by shrinking of their tumours (BMC Cancer, 2009; 9: 285).
The Which? expert panel says that, instead of getting irresponsible and dangerous guidance from a nutritional therapist, people should see their family doctor first, who could then refer them on to a specialist, such as a dietitian, if necessary. But is the family doctor a qualified gatekeeper?
According to recent research among medical students, he isn't. A survey of 127 medical schools in the US discovered that someone who has read even one book on nutrition would be better qualified to give such guidance. Overall, medical students had 19.6 hours of nutrition instruction during their five-year courses, researchers at the University of North Carolina at Chapel Hill discovered.
More than half of the graduating med students felt they had not received adequate training to advise patients on nutrition, a view shared by practising physicians. Not that the bar is set very high: the US National Academy of Scien-ces' "ground-breaking" report on nutritional training at medical schools called for a minimum of 25 hours of tuition (Acad Med, 2010; 85: 1537-42).
By comparison, a small handful of universities offer three-year BSc courses in nutritional therapy; more institutions did so several years ago, but they faced a relentless attack from Colquhoun and his 'quackbusting' friends, and so dropped the courses.
Which? prides itself on its unbiased reporting and recommendations, but has it fallen short on this occasion? BANT certainly thinks so, and has pointed out that no nutritionist was invited to sit on the expert panel.
BANT also points out that dietetics and nutritional therapy are based on different views of health and wellness. Dietetics is based firmly in the conventional medicine camp, and believes that diet and nutrition do not directly cause any disease. An example is the eating guide given to cancer patients at the Royal Marsden Hospital. The guide, prepared by a dietitian, encourages patients to eat cakes and biscuits and other sweet things to boost energy during a course of chemotherapy, while increasing the amount of fried foods "if you can manage them".
These ideas are contrary to those of nutritional therapy, which has grown out of a new style of ther-apy called 'functional medicine', which seeks to treat the whole person. Functional medicine, in turn, has been built on the work of early medical pioneers such as Max Gerson and Linus Pauling.
Yet, instead of including a nutritional therapist-or, indeed, a functional medicine practitioner-Which? chose two people, the dietitian and Professor Colquhon, who are hostile to nutritional therapy. Colquhoun is one of the UK's leading 'quackbusters' and, in his Web blog, has described nutritional therapists as fantasists, and nutritional therapy as "magic medicine". He has also suggested that vitamins can kill people.
Critics such as the Alliance for Natural Health, which campaigns against the natural-health restrictions imposed by the EU, argue that the Which? survey was set up to fail. From the small surveyed sample to the way the sample was chosen, to the approach of the investigators and the creation of a biased expert panel, it appears that Which? already had the answer before it asked the question.
It has created a great deal of smoke and some heat-but no light-on an important topic.
WDDTY Vol. 22, 12. March 2012