A Tale of Two WorkForces in the Same Workplace: Different Rules for Dietitians and Nutritionists in the NHS?

Last week the newspapers covered the story of Katie Peck who is both a degree-credentialled nutritionist and a Registered Dietitian. What is particularly interesting about this story is not the nature of some of her advice but that had she been recruited to work as a nutritionist, rather than RD, in her role at an NHS Diabetes Clinic, then there would not have been a hearing involving the Health Professions Council (HPC) and it is plausible that there would be no mechanism to allow scrutiny of the evidence-base for her advice to patients (the hearing has been adjourned until December, Mrs Peck denies any wrong-doing).

So, if you were to dispense some advice that your colleagues claim to lack an appropriate evidence base as an RD, then you might be asked to account for your actions before the HPC. However, if you dispense the same advice as a nutritionist (and, let’s imagine a scenario where this is a BANT rather than Nutrition Therapy Council nutritionist), then the route for challenging the advice is unclear at best.

An NHS nutritionist told diabetic patients to eat a range of bizarre and trendy foods, including some that were ‘dangerous’, a disciplinary panel heard yesterday.

Katie Peck, 32, recommended dandelion tea, kelp granules, milk thistle, flax seed oil and chromium supplements – all apparently without any clinical reason.

She also allegedly recommended expensive vitamin supplements, including co-enzyme Q10, for which there is no evidence of any benefit.

A colleague at the Coxheath Centre Diabetes Clinic, near Maidstone in Kent, told a hearing most of the advice was baffling but harmless – but in the cases of two diabetic patients it was ‘dangerous’…

She banned mashed potato and alcohol and said red meat should not be eaten more than once a fortnight.

Her other directions included that water must be filtered, eggs must be free-range and the dried fruit on one patient’s daily porridge had to be organic, the panel heard.

Mrs Norris said there was no reason for that and it would cost the patients more.

She also said to have inappropriately recommended specific brands of products, including Rachel’s probiotic yoghurt, Tilda brown basmati rice and Alpro soya milk. [Daily Mail]

A nutritionist put her diabetic patients’ health at risk by recommending extraordinary but “dangerous” foods such as kelp seaweed granules and green bananas, a misconduct hearing was told yesterday…Katie Peck, 32, also proposed dandelion tea, milk thistle, flax seed oil and chromium supplements, none of which have any proven clinical benefits, it was alleged.

She banned a number of patients from eating grapes or drinking coffee and said one should eat cottage cheese – but never with pineapple, the Health Professions Council was told. [Daily Telegraph]

Some of this advice may be looking very familiar to regular readers of HolfordWatch, or indeed advice columns in newspapers from celebrity and media nutritionists or indeed the books by such nutritionists that are used as reference texts in some teaching programmes. The rationale for the advice to eat unripe bananas is usually based on unripe fruit having a lower glycaemic index and load than ripe fruit. Avoiding mashed potato is usually another piece of advice based on glycaemic numbers. Chromium supplements are regularly praised in newspapers and self-style nutrition bibles. Milk thistle supplementation (advice to take this is typically bolstered by some form of words that suggest, “It supports the liver“) is a mainstay of detox or ‘liver support’ advice. A certain genre of nutritionists regularly advises the use of filtered rather than tap water and advises that food should be organic. Celebrity nutritionists either have their own brands of foods and supplements or endorse products (look for the brand name Nairns; Patrick Holford brand at Biocare; Food Doctor; Gillian McKeith).

BANT does not have a readily accessible code of ethics nor a transparent complaints procedure. BANT is also sanguine about its members taking undeclared commission/discounts from the sales of supplements and various tests. Even if a nutritional therapist were reported to BANT for making claims for dietary advice or supplements that appear to be unevidenced then it is difficult to anticipate what the outcome might be. It isn’t implausible that many of those hearing any such case might share the practice of making unevidenced recommendations for diet, supplements and tests or might have qualified from courses that advocate their use.

Why does this matter?

BANT is encouraging its members to lobby GPs and PCTs to employ them as part of the NHS Vascular Checks Assessment programme. BANT newsletter, June 2009.

A role for Nutritional Therapists in the NHS?
On the 1st April 2009, the vascular checks assessment (VRA) progamme was introduced in several test areas over the UK. This is an ambitious initiative which will offer preventative checks to all those aged 40 -74 to assess their risk of vascular disease (heart disease, stroke, diabetes and kidney disease) followed by appropriate management and interventions. The programme will be slowly implemented and introduced nationwide over the next 3 years.
The objective of this new policy is to promote the prevention or early identification of vascular disease by introducing a universal risk assessment and management programme. Those with high risk will get referred on for services (e.g. exercise or nutrition services). This may be an exciting opportunity as Nutritional Therapy could be included in this intervention in several ways e.g. weight management, lifestyle changes for impaired glucose tolerance, reducing blood pressure, cholesterol and triglycerides.
As well as the VRA, Polyclinics are opening all over the country and larger GP led practices in an attempt to integrate NHS services. The Department of Health says that one of the main challenges facing the NHS is that patients want greater control of their health care and the NHS wants to promote healthy lives. They want to concentrate on personal care for long term medical conditions. The emphasis is very much on quality. This is where Nutritional Therapists can really add value.
One of the problems that we may face is that each PCT interprets policy differently and many GPs are still not receptive to our services. When approaching GP practices we can help with them achieving their QOF targets (Quality and Outcomes Framework for GP practices – http://www.qof.ic.nhs.uk/) as well as giving added value to their practice, monetarily as well as qualitative.
For more information on the VRA go to http://www.improvement.nhs.uk/
vascularchecks

See NHS Health Check for more information about these programmes.

If BANT and their members succeed, unless PCTs and other bodies draw up stringent contracts and enforce strict monitoring, there may well be, de facto, different rules for RDs and some nutritionists when they work for the NHS.

RDs are not allowed to make recommendations for diet that are not based on good quality clinical evidence. RDs do not recommend particular brands of foods.

Nutritionists might be able to make recommendations with impunity and without due regard to the nature of the evidence that underpins their claims. What would happen in a ‘nutritional therapist’ advised a patient to ‘reduce inflammation’ by giving up gluten or all grains? Aside from the issue of expense (which might be considerable, particularly if the patient is unemployed or existing on a state pension), the patient might need considerable guidance on alternate sources for some vitamins and minerals (much of the bread and many breakfast cereals in the UK are fortified) as well as fibre. Nutritionists can and do make specific brand recommendations for food products (see above).

RDs recommend appropriate supplements to particular demographics and in response to particular health conditions or diagnostic tests and taking the patient’s diet and lifestyle into account.

Nutritionists might be able to recommend many supplements to many people without relying upon evidence relating to demographics etc. It is unclear what would happen if a nutritionist declared a suspicion that a patients had a leaky gut from food intolerances that was contributing to systemic inflammation and therefore vascular issues. Would a patient be encouraged to ask a GP for a food intolerance test or to purchase one privately? Would a nutritionist be able to ‘treat’ someone on the basis of the outcome of such a test? What about hair mineral analysis or health dowsing/kinesiology to diagnose nutritional deficiencies?

Patients might not always see a named diet adviser. What will happen if a nutritionist makes a number of recommendations that an RD disagrees with in a subsequent consultation or vice versa?

RDs are members of the Health Professions Council and have both a clear code of ethics and complaints procedure.

Nutritionists and nutritional therapists are not yet unified in regulation. There is no clear code of ethics or transparency for formal complaints.

If any part of the NHS were to employ a particular sort of nutritional therapist or nutritionist, then, very soon, there may be different rules governing individuals who are doing the same job, in the same workplace. As matters stand, it is only the RDs who might be formally challenged for any perceived errors of judgment. How is this not a recipe for confusing patients?

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16 Comments

Filed under patrick holford, supplements

16 responses to “A Tale of Two WorkForces in the Same Workplace: Different Rules for Dietitians and Nutritionists in the NHS?

  1. Along with these problems, would an NHS-employed BANT nutritional therapist be able to recommend products they have a financial interest in?

  2. patientia

    That’s a bit confusing. In my country there are no registered dietitians, nutritionists are scientists, and we don’t have a specific word for that type of charlatans.

    • This does get quite confusing.

      In the UK, Registered Dietitans are degree-qualified and have completed a compulsory 1 year stint in a clinical setting. RDs should be registered with the HPC if they are to work in the NHS and should have up to date registration (indicative of keeping up with continuing professional education etc.).

      There is no legal definition or protection for the term ‘nutritionist’ in the UK – anyone and everyone can call themselves a nutritionist. People are entitled to practise as a nutritionist with a degree, a mail-order diploma or no qualifications at all.

      You do need a diploma or such to register with BANT but then, they are not strikingly assiduous as regulators go.

  3. Don’t look for ethics. It’s gone. It’s been turned into fraud.

    Admin edit: Link removed and put into URL – see comments policy.

  4. Wulfstan

    Quackometer suggests that some occupations might re-think their desire for statutory regulation if they absorb the lessons from the GCC experience.

    All this sounds as ridiculous as the ASA being able to consider a claim as untruthful if it appears on a bill-board but not if it appears on a website (unless it is advertising on someone else’s website).

    The greatest victim here will be patients’ understanding of nutrition and the way in which their bodies work. Possibly also biology if we have more of that ‘each seed is a nutrient powerhouse that contains enough to grow a tree‘ nonsense.

    • It is confusing and inconsistent. This is something that NHS procurement needs to work out before BANT or individuals manage to sell their services to PCTs or GPs.

  5. uk dietitian

    Excellent article. Neatly sums up the additional health risks to patients given dodgy nutritional advice to help manage an original health complaint.

    If Peck is found guilty of the alleged comments and struck off the HPC register, at least she has the fallback position of becoming an ‘MBANT’. Indeed, with those alleged statements, she’s 3/4 way into the usual alt.nutritionista dogma, anyway.

  6. If the nutritionists want a slice of the NHS cake then that ought to come at cost. This ought to be used as leverage on the industry so they are forced to unify, to adopt an evidence-based approach and a proper regulatory framework. I suspect there are a minority of nutritionists out there who would honestly be fine with it, but the majority will know it’s not what they signed up for. That said they’ll just rename themselves as foodologists and things will get even more confusing.

    • Yes, and the nutritionists should have both an accredited degree and mandatory clinical internship (like RDs).

      As for ‘foodologists’ :) Dara Ó Briain sums up the difference between dietitians and nutritionists: ‘dietitian’ is a protected title, they need to be educated to a high level, etc., while anyone can call themselves a ‘nutritionist’. Dara draws a comparison with dentists: you have to meet certain, fairly stringent, criteria to call yourself a dentist or dietitian; anyone, though, can call themselves a toothiologist or nutritionist.

  7. We should re-emphasise that Mrs Peck has not yet put her defence to either the charges relating to paperwork and record-keeping or her rationale for advising the diet and supplements that she did. It may yet prove that she is exonerated on some or all of these issues.

    However, if should she lose her HPC registration, it is interesting that she has the fallback of adopting either MBANT or NTC coverage for her professional work. Under such circumstances, it is feasible that she would be able to apply for other NHS positions?

    I would like to know if the BDA is taking action to alert GP Practices and PCTs to BANT’s wish to place its nutritional therapists into the NHS as part of the Vascular Checks and other lifestyle/risk assessment programmes. The BDA needs to defend its turf if it is to ensure that patients receive evidence-based advice on nutrition from within the NHS.

  8. uk dietitian

    “I would like to know if the BDA is taking action to alert GP Practices and PCTs to BANT’s wish to place its nutritional therapists into the NHS as part of the Vascular Checks and other lifestyle/risk assessment programmes.”

    I very much doubt it.
    Just where is the public evidence that the BDA has ever appeared to defend its RD members and promoting their credentials above those of the NutritIONista?

  9. Just where is the public evidence that the BDA has ever appeared to defend its RD members and promoting their credentials above those of the NutritIONista?

    How very odd. Now, there are some charities that claim to campaign for their own obsolescence (Child Poverty Action Group comes to mind) but how unusual for a professional organisation to fail to defend its own turf against encroachment by lesser-qualified competitors.

    As far as I can tell, BDA is increasingly being marginalised to the role of rubber-stamping decisions taken by government and other ‘stakeholders’. One example of this is the lamentable Change4Life – it seems that some horrible decisions were taken, and then relevant parties were consulted at a point where they could do little to undo those decisions. I have in mind Diabetes UK’s clean-up operation when stories came to light of children with Type 1 Diabetes being bullied as ‘fat and lazy’ because that was the advertising thrust of Change4Life (a propos a distorted view of middle age, obesity and Type II Diabetes).

    If the BDA isn’t going to run a campaign to alert PCTs and GP practices to these attempts at entryism by lesser-qualified ‘diet and lifestyle’ consultants, then who will?

    It’s very troubling.

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  12. Avoiding high GI foods is essential for people with diabetes, prolonged hyperglycaemia itself is not very pleasant, being hyperglycaemic and having low insulin levels can lead to diabetic ketoacidosis which, left untreated, can lead to death. So there are some nuggets of common sense in her approach.

    The remainder of her advice appears to be faddish. What is worse, other papers have reported that it she even recommended the kelp to patients with kidney disease which, apparently, would have exacerbated the kidney problems and therefore she was treating a condition and not the patient (there is a difference, believe me).

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