They hope to be regulating a dozen different types of therapy, including reflexology, cranial therapy and homeopathy, by the end of the year—currently registration is only being invited from massage and nutritional therapists. During 2009 the CNHC hopes to register 10,000 out of their estimate of 150,000 alternative therapists currently in the UK. However less than a month after the launch a press release from the CNHC said that they had been “overwhelmed” with the response, resulting in “some unavoidable delay in processing applications”.
According to the CNHC’s new website http://www.cnhc.org.uk, the council was founded with the help of the Prince’s Foundation for Integrated Health, and of a range of complementary healthcare practitioners. For a practitioner to receive the quality mark, they must provide evidence that their training meets the National Occupational Standards for that discipline or achieved competency to the same level by means of relevant experience and assessment. However, evidence that the treatments actually work is not required. There is also to be in place a complaints handling process that is, says the website, “not intended to be punitive”.
HealthWatch is concerned that the CNHC mark will engender false confidence among patients. In fact practitioners carrying the CNHC mark may be in breach of the 2008 consumer protection laws which specifically forbid false claims that a product can cure a disease. We pointed this out to health minister Ben Bradshaw who replied, “The CNHC does not promote the efficacy of the therapies it represents—whether they work or not is for those who choose to use the therapies to decide. The main aim of the CNHC is protection of the public.” That it might be counter-productive to launch a body to protect the public by issuing licenses to businesses that break consumer protection laws, seems not to have been appreciated by the Department of Health.
Within days of the launch David Colquhoun, professor of pharmacology at University College London and now a member of the CNHC, was quoted in the Economist calling for the National Institute for Health and Clinical Excellence, which rules on the cost-effectiveness of medical treatments, to examine the evidence for complementary medicine [1]. “The whole problem of regulating alternative medicine will remain impossibly chaotic until the government grasps the nettle of deciding what works and what doesn’t,” he said in the report, which was sub-headed, “Britain simultaneously licenses alternative medicine and outlaws it”. Colquhoun again challenged the government to address the issue of efficacy in an open letter that he co-authored to The Times [2]. Whether his colleagues on the CNHC, who include some current or past practitioners of alternative therapies, will support his call remains to be seen.
Meanwhile Sean Ellis of Farnham, commenting online on the Times letter, was so incensed that the CNHC does not require even basic evidence of efficacy and safety that he set up a petition on the Number 10 website which hundreds have now signed. Sign by 22nd April at http://petitions.number10.gov.uk/CNHCsafety/
Mandy Payne
References
Duchy Herbals’ Detox Tincture, an artichoke and dandelion mix described as, “a food supplement to help eliminate toxins and aid digestion” costs £10 for a 50ml bottle. It is part of a range that was launched in January, when Duchy Originals’ herbalist Michael McIntyre said that each mix had been meticulously researched and was, “manufactured to the highest standards after exhaustive lab testing”. But Ernst said the suggestion that such products remove toxins from the body was, “implausible, unproven and dangerous”. The word “detox” undermined the treatment of people with drug addiction, he was quoted in the Scotsman as saying, adding, “If people are led to believe they can overindulge on food and drink and put that all right with a Duchy detox tincture, then that, to me, is endangering public health.”
In this issue of the HealthWatch Newsletter Edzard Ernst likens the NHS Alliance to a lobby group for complementary medicine (see below).
Mandy Payne
Further reading
US company NMT Medical contends that Wilmshurst, of the Royal Shrewsbury Hospital,
slandered and libelled it in an interview with the online publication Heartwire
(www.theheart.org), although they have not sued Heartwire. Wilmshurst had been
a lead researcher in the MIST trial, which aimed to discover a link between
patent foramen ovale (a congenital condition in which a heart valve does not
close properly) and migraine headaches. He reportedly speculated that the trial
may have failed because NMT’s Starflex device, which was used in the trial
to close the valves, did not work well. Wilmshurst was also quoted as saying
he believed the company had withheld trial data because it feared that it might
undercut sales of the device for other uses, like stroke treatment [2]. NMT
contend that his comments to the press breached a confidentiality agreement,
and that the comments made were defamatory and untrue. It alleges that the comments
were motivated by malice because the negative findings of the trial cast doubt
on Wilmshurst’s own personal theory on the link between PFO and migraine.
Journalist Jerome Burne has taken the story out of the medical press and into
the public domain with a feature in the Daily Mail [3] which reminds us that
around 25,000 people have had NMT Medical’s Starflex device inserted.
Burne’s article reports that Professor Sir John Lilleyman, head of the
National Research Ethics service that oversaw the MIST trial, shares Wilmshurst’s
concern about the possibly conflicting results of echocardiogram reviews. He
also reportedly told Burne that he was worried that some patients in the trial
may believe their foramen ovale had been closed when in fact it hadn’t,
and is quoted as saying, “I believe we may have a duty of care to those
patients.”
Heartwire has now also published an interview with Lilleyman [4]. Journalist Shelley Wood reported that he believes the legal dispute between NMT and Wilmshurst may be deflecting attention away from unresolved issues with the trial. “Ignoring the spat between Peter Wilmshurst and NMT, basically what I’m concerned about is that we don’t know what the status of these patients is, and the only way to find out is to review their original scans with an independent, disinterested expert and possibly scan some of them again if the data are nonexistent or noninterpretable,” Lilleyman was quoted as saying.
Mandy Payne
References
Negative consequences of the NHS breast screening programme were highlighted in a letter to the Times in which 23 signatories, including HealthWatch members, called for more balanced patient information leaflets. Up to half of cancers detected by screening may not be harmful yet can trigger unnecessary traumatic treatment, and screening might save only one women in 2,000 over a ten-year period, with reported falls in breast cancer deaths being due to improved treatment, not screening. The letter ran with an article by the Times’ Health Editor.
The Times, 19 February 2009. See:http://www.timesonline.co.uk/tol/comment/letters/article5761650.ece and http://www.timesonline.co.uk/tol/life_and_style/health/article5762516.ece
Healthwatch’s Google group has taken off. There is a busy exchange of
information, and interesting press reports picked up can be quickly shared.
Access is restricted to HealthWatch members only, if you haven’t received
your invitation please e-mail david.bender@btinternet.com
Google’s advertising, however, needs more control, say Italian doctors
writing in bmj.com, to avoid linking to web pages that contain worrying medical
claims. Google AdWords places ads automatically on web pages carrying key words.
But Google’s filters still allow inappropriate advertisements that could
be harmful, say doctors at the University of Florence. HealthWatch flagged up
the problem three years ago after a Telegraph online article on autism carried
a Google Ad promoting homeopathic autism cures (HealthWatchNewsletter
issue 61, April 2006).
BMJ.com 20 March 2009. See: http://www.bmj.com/cgi/doi/10.1136/bmj.b1083
In debates about public health, are there things which really should be left
unsaid? Are there statements so damaging and unwelcome that the law should be
invoked to ban those statements from ever being published or communicated? And,
if so, should someone be able anyway to express serious concerns without any
fear of expensive and exhausting litigation?
Two recent legal cases have raised these fundamental questions. Both cases involve
high-profile science writers and, interestingly, both concern articles published
in The Guardian…
Jack of Kent
Jack of Kent is the pseudonym of an English solicitor who specialises in technology, media and telecommunications. His writing can be enjoyed on http://jackofkent.blogspot.com/
This
January, as is usual after the Christmas celebrations, the paperback best seller
list was packed with books on dieting, about which there is little new to be
said. Most of these are about how to lose the weight gained in the previous
month, and claim to reveal “secrets” hitherto unknown about diets
that will make you thinner and/or healthier. In truth there are very few secrets
still to be revealed.Since World War II we have learned a great deal about human nutritional requirements. There was an urgent need to know how to design rations for the civilian population, and to rehabilitate survivors from starvation in prison camps. Intravenous feeding saved the lives of severely wounded people who could not have been fed by mouth. A by-product of this was that we learnt far more precise information about the daily requirements of micronutrients than could be obtained by analysis of oral diets. In 1969 the Department of Health reported on daily requirements of 10 nutrients, by the time they reported in 1991 this had increased to 40 nutrients, but there has been little change since then.
If addition of a poison is excluded, the only way in which the diet of a normal adult could be altered so as to cause death in less than a week is to exclude all water. Someone deprived of any non-salty water because they are trapped under debris from an earthquake, or adrift in a lifeboat after a shipwreck, will soon die. How soon depends largely on the temperature and humidity, and hence the rate of evaporative loss of water.
Even if enough water is available total starvation will also inevitably cause death, but after a much longer period. The survival of victims of famine due to drought or warfare is usually threatened by disease as well as hunger, and they may be having small amounts of edible vegetation, so they do not provide reliable information about the lethal effects of starvation alone.
A healthy adult of normal build who takes no nutrients apart from water—such as a hunger striker—will probably die in about 10 weeks. Between 1964 and 1970 there were several reports of severely obese patients who were treated by total starvation for long periods. The longest period recorded is 249 days starvation, during which she lost 64.9 kg. However some people on starvation diets unexpectedly died and at autopsy were found to have severe damage to their heart muscle, so this treatment was abandoned.
The largest reported weight loss (227 kg) was on a low calorie diet (800 kcal/day) and took 2 years as a hospital inpatient [1]. The patient was admitted weighing 310 kg, but an unknown proportion of that was water, since he was initially massively oedematous. Since 1970 it has been accepted that prolonged total starvation is too dangerous, but 800 kcal/day will keep the patient alive and losing weight quite quickly. There is still controversy about how much lower than 800 kcal it is safe to go, since a few patients have died while using very low calorie diets, although there has been insufficient evidence to implicate the diet itself as a cause in these cases. Our research indicates that it is not the prescribed energy intake, but the actual rate of weight loss, that determined the danger. A desirable rate of weight loss in obese patients is 0.5 to 1.0 kg per week. [2]
The dangers of too great a reduction in total energy intake have been considered above, but many commercial diets emphasise alterations in the balance of protein, carbohydrate and fat, from which dietary energy comes. (Alcohol is also a source of dietary energy, but it will not be considered here since the dangers of a high intake of alcohol are well known).
Human beings tolerate very large differences in macronutrient balance. For example vegetarians have a much lower intake of protein and fat than omnivores, but the amount of protein in vegetables is enough to maintain health in adults if total energy intake is adequate. However small children have a higher requirement of protein in relation to body weight because they need extra protein to support growth, and they cannot eat such large quantities of the bulky carbohydrate diet as adults. Hence in chronically undernourished populations the deficiencies show up first in stunted growth of children. Protein supplements are not very effective in improving the health of children who also have an inadequate energy intake: both deficiencies need to be remedied.
The other two macronutrients, carbohydrate and fat, are the main sources of energy. High fat diets (of which the popular “Atkins” plan is an example) have been advocated for weight loss, because if carbohydrate is restricted total energy is almost bound to be restricted also. Very severe reduction of carbohydrate causes ketosis (signalled by an unpleasant smell on the breath), since some carbohydrate is needed for the normal metabolism of fat. There is good evidence that a high fat diet causes a high concentration of lipids in the blood, so if a high-fat diet is used repeatedly or adopted as a long term strategy there is an increased danger of cardiovascular disease and coronary thrombosis.
On the other hand, extreme restriction of fat such as in the most stringent versions of the low-fat diets popular in the 1990’s causes reduction in the intake of fat-soluble vitamins A and D and possible deficiencies in these nutrients.
In affluent countries deficiency of vitamins or minerals is very rarely found among people who are having an adequate energy intake from a variety of foods. I have worked in some countries where dietary deficiency of vitamin A, iron, or iodine cause serious illnesses, but I have never seen such cases in the UK. The problems usually arise in adults who are deliberately restricting energy intake in order to lose weight, and are taking inappropriate supplements in order to correct the resulting deficiency of micronutrients. The exceptions to this general statement are old people who are not exposed to sunshine; pregnant women; and adults or children who have metabolic diseases or dietary intolerances.
There is a huge industry that promotes micronutrient supplements on the false premise that if a deficiency of Vitamin X causes ill health then a massive intake must bring extra good health. The reverse is nearer the truth. Especially when the supplement contains a dose of a single micronutrient that could never be encountered in a diet of normal food. For example health food shops offer capsules containing single amino-acids which can never be helpful except in rare metabolic diseases. Aminoacids are the building blocks from which protein is synthesised. A single amino-acid such as leucine or lysine are “essential” amino-acids, so without them protein cannot be synthesised. But a supplement of one of these does more harm than good, because an excess of one amino-acid cannot make protein unless the others are present in the appropriate proportions. The extra aminoacid therefore has to be used to make urea and excreted, resulting in a net loss of protein to the body.
Trace elements such as zinc and copper are required in very small quantities. Transport mechanisms in the gut wall normally absorb the right quantities, but a large supplement of one (for example zinc) may overload the transport system and block the absorption of copper. This can create clinical problems that are very difficult to diagnose. If you do not know about the zinc supplements you have to be quite astute to recognise copper deficiency in a patient who has a normal amount of copper in his diet, but an inadequate absorption of copper caused by an excess intake of zinc.
This brief review has implied that so long as you eat a reasonable amount
of ordinary food you will avoid major problems. However this depends on having
kidneys working well so that if you take an excessive amount of fluid, or water-soluble
vitamins, the kidneys will excrete the excess in urine. The situation is very
different in people with impaired kidney function.
The commonest supplement-related life-threatening situation is when someone
with damaged kidneys and legs swollen with fluid is advised to take supplements
containing potassium. The concentration of potassium in the blood may then rise
to a level at which regulation of the heartbeat is disturbed, and this may cause
death.
Attempts to achieve rapid and marked weight loss, or consume inappropriate amounts of dietary supplements, should be discouraged. A safer and more useful approach would be to aim for a smaller but sustained rate of weight loss, and to modify eating habits so as to maintain the desired level of weight achieved.
Position paper prepared by John Garrow and approved by the HealthWatch committee in January 2009
References
The
website of the NHS Alliance informs us that this body, apparently one of the
largest GP organisations in the UK, has a “plays a major part in supporting
and developing Primary Care Trusts and similar primary care organisations and
in providing opportunities for them (and the individuals within them) to network
and exchange best practice” [1]. There is no clear mission statement and
the site might easily give one the impression that the NHS Alliance is a lobby
group for “alternative” medicine…
Edzard Ernst
Professor of Complementary Medicine
Peninsula Medical School, Exeter
Reference
Adapted from an article first published in Pulse 24 Feb 2009, with the author’s kind permission. See http://www.pulsetoday.co.uk
Little progress seems to have been made since the description of the placebo effect at the end of the 18th century, when Benjamin Franklin and Antoine Lavoisier investigated Franz Mesmer’s magnetic healing techniques. Recently, Tilburt and his colleagues showed that most specialists in the US are still prescribing placebos [1].
In fact many, respecting at least the informed consent principle, fall from
magic into insanity—by prescribing a placebo and saying so…
Alain Braillon, M.D, Ph. D.
Hôpital Nord, Amiens, France
braillon.alain@chu-amiens.fr
Reference
Dr Braillon is indebted to Sylviane Dubois-Lombard for her assistance with this article.
Published by Routledge, 20 October 2008. Paperback, 184 pages £19.99 ISBN-10: 0415449812 ISBN-13: 978-0415449816
Autism is a form of mental handicap. Some children with learning difficulties can be recognised at birth as they look abnormal, but autistic children look like any other children, and their handicap doesn’t start to show until after the first year of life, and not long after children have had their routine vaccinations.
Few people had heard of it twenty years ago. Now, thanks to the pressure of outraged, vaccine-refusenik parents, everyone has. The condition was depicted by Dustin Hoffman in the film The Rain Man, and the writer Mark Haddon gets wonderfully inside an autistic boy’s mind in his book The Curious Incident of the Dog in the Night-time…
Caroline Richmond
Medical Journalist
Published by Oneworld Publications, paperback edition available 240 pages
out 1st April 2009, £9.99.
ISBN-10: 1851686231 ISBN-13: 978-1851686230
The first shock comes on page eight when we learn that, in law, we cannot own our own bodies or body parts. Once that bombshell has exploded, the stage is set for the issue which is the focus of Donna Dickenson’s book. If we don’t own our own organs, cells, genes, can anyone else? The answer, of course, is yes…
Mandy Payne
In response to John Garrow’s challenge in the October 2008 newsletter, I offer a brief account of my own salutory and frustrating experience of attempting to change my clinical practice in the light of evidence from clinical trials.
Throughout my career I had a major interest in radiotherapy of head and neck cancer. It has long been known that hypoxic cells are more resistant to killing by ionising radiation than are well-oxygenated cells, and that squamous carcinomas contain viable but hypoxic cells whose presence militates against cure by radiotherapy. From the 1950’s onwards attempts were made to overcome the problem of hypoxic radioresistance. One approach was to irradiate patients in a hyperbaric chamber: a definite effect was seen, confirming that hypoxia really was contributing to radiotherapy failure, but the method proved too hazardous and cumbersome for routine use…
Michael Henk
Consultant clinical oncologist (retired)