JDC reports that he “always thought that Dr John Briffa was like a more grown-up version of Patrick Holford” – and until recently I had rather agreed with him. However, Briffa has now taken up some worrying positions on vaccines and autism. Along with Dr Crippen, “I am worried about Dr John Briffa.”
I have just come across some of Briffa’s claims about food sensitivity testing – they are almost Holfordesque. Writing in the Guardian about Irritable Bowel syndrome, Briffa argues that:
Those with IBS can…benefit from identification of problem foods. Several methods of testing exist, such as kinesiology (muscle testing) and dowsing. I believe all such methods have some validity, though those who are more comfortable taking a more ‘scientific’ approach may have their blood tested for IgG antibodies to specific foods. One study published last year in the journal Gut found that elimination of foods identified by this form of testing was beneficial for IBS sufferers.
Now, Patrick Holford has written positively about health dowsing and Applied Kinesiology (AK), but this was quite a while ago. Briffa’s Guardian article was from 2005. As we’re going to find out below, Briffa gets things badly wrong on food sensitivity testing and on recommendations for dealing with (potential) sensitivities.
Applied Kinesiology
John Garrow has shown that AK is not an effective way to diagnose allergy. AK testing thus lacks a plausible mechanism of action, and – in a blinded trial – has failed to do better than one would expect if the practitioners were guessing. Professor Chris Corrigan was thus moved to describe AK – in his testimony to the House of Lords Science and Technology Committee – as
all completely bizarre and, I am afraid, utter nonsense. There is no scientific evidence or mechanistic base to suggest that these tests could be remotely effective.
Putting it politely, this is not a valid way to diagnose food sensitivities.
Dowsing
Quite simply, there is no plausible mechanism through which dowsing might work as a test for food sensitivity, and we have no good evidence that it does work. I cannot see any reason why a competent professional would recommend dowsing for anything other than entertainment.
IgG testing
When recommending IgG testing as a more ‘scientific’ approach to diagnosing food sensitivities, Briffa does point to an article in Gut. Unfortunately, its results indicate that an IgG-guided elimination diet is less effective than a ‘conventional’ elimination diet when you interpret the results using a straightforward Numbers Need to Treat analysis. This is not an effective way to diagnose allergy, intolerance or sensitivity. The House of Lords Science and Technology Committee’s 2007 Report on allergy [PDF, 8.40] have therefore cautioned against the recommendation of IgG testing:
We urge general practitioners, pharmacists and charities not to endorse the use of these products until conclusive proof of their efficacy has been established.
Unfortunate clinical recommendations
This dubious account of food sensitivity testing leads Briffa to make some unfortunate recommendations. Firstly, inaccurate food sensitivity testing can be harmful: both leading patients to avoid foods which they are quite able to eat (false positives) and failing to diagnose genuine allergies and intolerances (false negatives). Secondly, Briffa then suggests a rather haphazard approach to an elimination diet:
there is usually no reason why individuals should not make changes to their diet without testing. I advise trying a diet devoid of wheat (pasta, bread, biscuits, pastries, breakfast cereals) and cows’ milk (another common offender) for a week or two. Better tolerated grains include rice and oats (oat-based muesli, porridge, oatcakes), and rice and oat milks are good swaps for dairy milk, too.
While an elimination diet can be a useful way of diagnosing allergies and intolerances, one would be advised to take a more systematic approach (preferably under medical and/or dietetic supervision). As argued in Allergy: The Unmet Need [PDF, p 53) appropriate advice and supervision is important when a patient is cutting out certain food groups. It is also not entirely clear how Briffa has selected which foods are to be eliminated: for example, while lactose intolerance is relatively common, some milk products (such as some cheeses) contain negligible quantities of lactose.
We should also emphasise that cutting out whole foodgroups from your diet can be harmful, if you fail to adequately substitute alternatives. While eliminating these for 1-2 weeks – as Briffa suggests – is pretty safe in most circumstances, we would have more concerns in the longer term. It is unclear whether Briffa anticipates any kind of challenge protocol being used – for patients to test whether a food which they have eliminated causes problems when reintroduced – or simply expects IBS-sufferers to continue with the exclusion of wheat and cows milk if this exclusion coincides with an improvement in symptoms.
Both milk and wheat are significant sources of calories for many children and adults in the UK. Milk is a significant source of calcium, and some wheat-based products (such as certain fortified breakfast cereals) are a significant source of fibre for many people. Also, fortified wheat-based breakfast cereals and breads can be a useful source of a number of vitamins and minerals. One should therefore not exclude these food groups from the diet without finding suitable alternatives. There are particular concerns with children: Allergy observes [PDF, p11] that “it is harmful to put a child on an extensive exclusion diet that has no scientific basis, because of the risk of nutritional compromise and poor growth.”
This is all rather worrying. Briffa manages to recommend three inappropriate approaches to testing for food sensitivity, and then suggest an haphazard approach to an elimination diet. His clinical recommendations are also unfortunate – failing to take into account the potential harm caused by eliminating whole food groups if this course of action is continued for some time and without appropriate advice and supervision.
As Dr Crippen might put it, this is wibble – damaging wibble.
Holford Watch: Patrick Holford, nutritionism and bad science 
Can I just add what a brilliant piece Dr Crippen has written about Briffa.
Does anyone know anything about Dr Nigel Plummer on the ailment website?
Oddly enough, he’s not very keen to comment on the efficacy or otherwsie of AK:
http://www.drbriffa.com/blog/2008/06/06/health-professionals-ignore-their-patients-at-their-and-their-patients-peril/#comment-94321
(Comment 60)
Dr Nigel Plummer owns Cultech. He advises Biocare (pdf), like Former Visiting Professor Patrick Holford. Like the usual suspects, he lectures at CNELM (pdf), the ION, the Uni. of Westminster and similar.
Interestingly, on the Alimént website, you learn that supplementscompared.com praises their products. I reproduce a press release about supplementscompared.com.
Interesting overlap between some of the people who advise a company that distributes supplements (Aliment) and the advisory panel of a service that assesses the quality of supplements. However, it seems that all the proceeds go to charity so that must be OK.
“It’s an excellent way of sparking new interest in health supplements. …”
kerching!
And,regarding the point about DIY exclusion diets, I would echo your point about appropriate advice and supervision (and diagnosis!), especially in allergic children. There is a small possibility that reintroduction/accidental exposure to an excluded food might cause a significant reaction (I know personally a case where this happened). In this scenario, self-testing and self-treatment are not advised.
just spotted this – not an exclusion diet in the sense discussed here but a miserable outcome for this child:
http://www.dailyrecord.co.uk/news/scottish-news/2008/06/09/shock-as-vegan-diet-girl-12-diagnosed-with-rickets-86908-20600599/
Nice job on Dr Plummer.
I do find it hilarious that this same small group of ranking Nutritionistas fill all the “expert” slots, lecture on each others’ courses, puff one another’s books and columns, assess themselves etc etc.
The similarity with the “Look! a web of corrupt Pharma-Illuminati!” line that serial conspiracy loons like Martin J Walker and the JABS crew now gabble out endlessly re. the “Bad Science Lobby” is instructive.
Of course, winning a small Prize that is given by a charity but funded by the External Relations budget of a PharmaCo might seem rather different to being a direct and major financial beneficiary of a company or product that you are plugging. But not to the Alt.Reality loons.
If you will indulge us by reading one more remark from Holford’s account of why he did not participate in the Radio 4 programme:
We strongly suggest that Holford should have a chat with Jerome Burne, his co-author on Food Is Better Medicine Than Drugs. You see, one of those Science Writer awards, one of the ones that is “funded by the big pharmaceuticals”, it turns out that Burne wanted one. In 2005 (oddly, at the time when Burne was collaborating with Holford) both Burne and Goldacre were shortlisted for the award and Goldacre won.
—————
Above extract quoted from Ben Goldacre Usually Gets The Science Wrong: Patrick Holford Speaks From His Own Reality.
Was that the sort of Alt Reality (tm respected) that you had in mind?
And I like the summary of who owns what and advises where in a comment on Dr Crippen’s post.
Anjana Ahuga was writing about autism quackery but the figures of speech seem on the money:
Dowsing? DOWSING!?
Good grief.
Grief, indeed.
Thank you for the info on Nigel Plummer.
The reason i asked was because as i looked at the ailment website, i noticed that i had seen this guy lecture a couple of years ago in the U.S
He was talking about IL1 IL6 TNF and their relationship with atherosclorosis. He seem to make alot of sense and did not once mention any supplement companies.
In your opinion, do you beleive Dr Plummer should not be lecturing on such a subject? I am genuinly interested in what you think.
Dr Plummer has a lot of relevant industrial experience with formulating products. He is obviously successful with his OmegaWise range of products and I gather that he has a range of nutraceuticals that he supplies to health practitioners in the US .
In general, people with a lot of industrial experience are exposed to a broad range of research interests and can speak well and informatively on a number of topics. The need for specialisation will vary with a particular audience. E.g., is it a one-off education lecture, at a fairly basic level for a general audience or a very technical, specialist event/seminar for a very specific, very knowledgeable audience.
You’re the one who attended his lecture (was it a postgrad event for nutritionists or people involved in the clinical management of atherosclerosis?), so you’re in a much better position to have an opinion about the coverage of the topic, meeting the audience’s needs etc. Was it an educational event or a conference?
According to this bio, he is a world expert in:
*The role of fatty acids in infant cognitive development, inflammatory disease, depression, psychiatric disorders, and age-related mental processes
*The influence of the human gastrointestinal and genitourinary tract microflora on disease and health, including antibiotic-associated effects, IBS, IBD, allergy and autoimmune disease (Dr. Plummer developed and manufactured the very first human-use commercial probiotic derived from indigenous lactic acid bacteria)
*The evaluation and potential for plant-derived antimicrobials .
Ultimately, if you came away from his lecture with good resources, insights, fresh understanding and information that you didn’t have before about that topic, and you have been able to apply what you learned – then, IMO, that is a good lecture.
it was for people who are involved in clinical management of atherosclerosis although the lecture was based on nutritional practices.
His theory was suggesting that the atheroslerotic process is an inflammatory one created by increased levels of plasma lipoproteins building up and eventually being oxidised in the intima. The unrecognised LDL particles activate macrophages to produce the cytokines plus stimulate endothelium cells to do the same.
The cytokines stimulate the endothiluim cells to produce adhesion molecules which trap more LDL molecules, which leads to further build up and further oxidation.
The monocytes that drop from circulation and become macrophages, engulf the oxidised LDL and become foam cells.
I am noticing in practice that patients that develop atherosclorosis usually have long term inflammatory conditions all involving these cytokines, be it asthma, fibromyalgia, RA, IBS, IBD etc.
It is now strange to see this guy only out for profit, he really didnt come across that way.
I am interested in what might be characterised (crudely) as systemic inflammation and its association with several chronic illnesses that are themselves associated with co-moribidities that have an inflammatory component.
It has also been fascinating to watch the conventional wisdom change. It certainly used to be a widely-held truism that, e.g., people with asthma rarely developed rheumatoid arthritis and were supposed not to develop various other illnesses. However, in the last few years, as asthma diagnosis has detected more cases and more people are being managed for asthma (prompting the call for the abolition of asthma as a single disease entity and discussed here) it seems as if asthma is typically associated with co-morbidities once people hit their 40s and 50s. The usual confounding variables here are whether people tend to be overweight through lack of exercise which they haven’t engaged in because of their asthma. And, there is the speculation about adipose tissue effectively operating as another endocrine system and manufacturing its own pro-inflammatory substances. However, the argument holds that some researchers are looking at chronic diseases as manifestations of underlying systemic inflammation.
As a matter of interest, were there recommendations other than the standard (where applicable): smoking cessation; watch your weight; be active; monitor blood pressure; monitor blood sugar for signs of IGT or diabetes; monitor for dysregulated lipids; monitor for elevated inflammatory markers? Did you receive some useful resource pointers for further information? Or was it part of a lecture (series) asking you to monitor particular risk factors as part of a data-gathering exercise or awareness programme? (Ignore if this is too intrusive.)
I really have no idea at all as to Dr Plummer’s motivations etc. However, I am interested in the inter-connections of who supports which supplements, sits on advisory panels for independent review bodies, set up by someone who manufactures and distributes supplements etc. Partially for the reasons given in Nick Gene’s stories that we cite in Grand Rounds. And partly because, in the UK, if you mention that you don’t think that there is an evidence base to support the use of some supplements, then as night follows day, you tend to be called a Pharma Shill and accused of some very odd conflicts of interest.
Popey
I wonder if you can provide any references to support this contention. I recognise you are repeating the opinions of a third party but hope that party provided scientific evidence.
LDLs are recognised by LDL receptors and not adhesion molecules. Now there is some evidence that LDL levels can affect levels of adhesion molecule expression in some cell types but there is no evidence for a direct physical interaction between LDL and adhesion molecules. Rather it is likely to be a signalling event mediated by the binding of LDL to the LDL receptor. LDL receptors have been described as the swiss army knife of the cell as they can bind to a staggeringly large range of molecules and thus function in a bewildering array of signalling pathways. Teasing apart these interactions is a very difficult job and while there are legions of biochemists and molecular biologists doing just that it is far from clear how LDL levels affect atherosclerosis. I wonder if Dr Plummer is guilty of simplistic explanations for complex events to boost the commercial profile of his company?
His protocols were generally based on down regulating the three main cytokines in all tissues along with NFkappa B and peroxinitrite. He also discussed antioxiandant/oxidant equlibrium, so possibly a sales pitch for his antioxidant supplements.
At the time i remember thinking how well referenced his lecture was, but will have to dig out my notes if i can find them and have a second look.
popey could you clarify what you mean by “the three main cytokines”, also are you sure you mean down regulating these in all tissues. It seems to me that this would severely impair the inflammatory response after tissue damage or infection that could have detrimental effects on health. Likewise NFkappaB which, as I’m sure you know, is a transcription factor that affects gene expression in many different tissues and in many different processes. Isn’t this an unrefined sledgehammer approach where you hammer down gene expression in all tissues rather than specific targeting of a specific pathway in a specific cell type?
I’m sure if his lectures were so well referenced you will have no problem in supplying supporting detail.
NFkappaB and peroxynitrite definitely sounds like an antioxidant pitch.
The problem is the following “antioxidant paradox”:
– lots of lines of evidence implicate oxidative mechanisms in bad things all over the body, in multiple systems.
BUT:
– supplementation with “anti-oxidants” pills has NEVER been shown to have clear-cut benefits. No matter what antioxidant has been tried, and no matter for what problem.
This is true even in the “best-case” scenarios where the role of “oxidative stress” in the underlying pathophysiology is surest.
The good news, though, is that there are things people can do to damp “oxidant stress” or if they are worried about “generalised subclinical inflammatory this and that”.
These are: eat more fruit and veg, don’t over-eat , take regular exercise, lose some weight, start a hobby, don’t get wound up…
…sounds rather familiar, what?
Not keying obsessively on one’s lack of antioxidants, or pro-inflammatory cytokines, is probably a good idea too. Although if everyone did this, the supplement sellers’ profits would start looking less healthy.
Without knowing any of the details, and this may not apply to Plummer, one of the major issues with Patrick Holford is that people are readily impressed by the number of references he supplies.
Again, this may not apply to Plummer in any way, but when you start checking Holford’s references, the story falls apart. The references are either remarkably obscure (a no longer available cassette of a lecture delivered in the 80s, or a report written by a Catering Organisation in the 80s or books that even the British Library doesn’t have) or, when you look at them, they don’t support the claims being made. Or, too frequently, although Holford describes the work in such a way as to imply that the research was conducted with humans, the research has been done with animals or cell lines.
If you can find your notes, it would be very helpful to know more about Plummer’s references and recommendations (e.g., the protocols).