Holford is quoted to

confirm that I have resigned my post as Visiting Professor at the School of Social Sciences and Law at the University of Teesside. I have made this decision because the main areas for which my involvement and input was requested, including setting up a Northern Brain Bio Centre working with the Cactus Clinic, which the University has now closed, are now not going ahead so I felt it was appropriate to resign the post. Food for the Brain is in discussion with other Universities to progress various research projects.

Teesside's spokesman echoes Holford's statement.

A couple of points to note about this article. Firstly, it sounds like Holford and Food for the Brain will be seeking to associate themselves with other Universities. We hope that anyone considering such a partnership will bear in mind events at Teesside when evaluating the pros and cons of such an arrangement.

Secondly, it is great to get a mention in CAM magazine - 'hard-core', indeed... - and all credit to them for running the article. However, we are not sure what is 'hard-core' about demanding things such as accurate CVs and reasonable quality research from Britain's professors. If the CAM industry and research establishment relies on 'hard-core' outsiders in order to hold researchers in the field to such basic standards, this raises significant concerns about the industry.

Finally, now that CAM Magazine have started to look at Holford's research, we would like to extend an offer to write a more detailed assessment of his work for the magazine. As a goodwill gesture, we will even donate any contributor's fees to an appropriate charity...

Holford and Teesside had a relationship that saw him enjoying the fruits of his professorship for far short of a 1000 days. But it was probably enough for both parties to have had a lasting impact on each other and to have parted with mutual regret.

No flowers by request. Champagne donations probably gratefully received by the noted scholars and researchers who were being linked to him by association.

One does wonder what will happen to the PhD student who was meant to be splitting her studies between Food for the Brain and the University of Teesside. And, just where are they going to find an MSc student to lumber with the wretched (some would say impossible) task of validating the lamentable questionnaire that they used in last year's FFTB 2007 Survey of Schoolchildren?

h/t to jdc for the introduction to the JKN gizmo. Sign up for JKN, it is excellent: unlike Furl, you can share it, and, as you can see, make handy annotations. Web 2.0, the party continues.

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In fact, another model does exist. There is a history of white protest against racism, a history of whites who have resisted the role of oppressor and who have been allies to people of color. Unfortunately these whites are often invisible to students; their names are unknown.

Think back to the beginning of this article. How many names of white antiracists were on the tip of your tongue? If students have studied the civil rights era (many of my students are poorly informed about this period of history), they may know about Viola Liuzzo and Michael Schwerner and other whites killed for their antiracist efforts. But who wants to be a martyr? Do they know about white allies who spoke up, who worked for social change, who resisted racism and lived to tell about it? How did these white allies break free from the confines of the racist socialization they surely experienced to redefine themselves in this way? These are the voices that many white students are hungry to hear.

This information needs to be provided in order to help white students construct a pro-active white identity. In my class I try to provide concrete examples of such people. White professors teaching about racism who see themselves as allies may be able to share examples from their own lives and in this way might be role models for their white students. As an African-American professor, I am limited in this regard.

My strategy has been to invite a well-known white antiracist activist, Andrea Ayvazian, to my class to speak about her own personal journey toward an awareness of racism and her development as a white ally.

Students typically ask questions that reflect their fears about social isolation at this phase of development. "Did you lose friends when you started to speak up?" "My boyfriend makes a lot of racist comments. What can I do?" "What do you say to your father at Thanksgiving when he tells those jokes?"<

White students, who often comment about how depressing it is to study about racism, typically say that the opportunity to talk with this ally gave them renewed hope.

Today's class began with a visit from . . . a white woman who has made dismantling white privilege a way of life. . . . Her personal story gave me a feeling of hope in the struggle against racism. [Terri, a white woman]

Now that we have learned about the severity of all of the horrible oppression in the world, it is comforting to know how I can become an ally. [Barbara, a white woman]

What a POWERFUL speaker! Andrea was so upbeat and energetic. I think that her talk really boosted the spirits in our class. I personally have become quite disillusioned with some of our small group discussions of late, and having her talk brought some deep reflection and positive insight on the future--especially ideas and revelations concerning my role as perhaps a white ally. . . . Her presentation was overall very well received, and I enjoyed it very much. There is hope! [Robin, a whim female]

One point that the speaker discussed at length was the idea that "allies need allies," others who will support their efforts to swim against the tide of cultural and institutional racism. This point was especially helpful for one young woman who had been struggling with the feelings of isolation often experienced by whites in the Disintegration stage. She wrote:

About being an ally, a positive role model:

. . . it enhanced my positive feelings about the difference each individual (me!) can make. I don't need to feel helpless when there is so much I can do. I still can see how easily things can back-up and start getting depressing, but I can also see how it is possible to keep going strong and powerful. One of the most important points she made was the necessity of a support group/system; people to remind me of what I have done, why I should keep going, of why I'm making a difference, why I shouldn't feel helpless. I think our class started to help me with those issues, as soon as I started to let it, and now I've found similar supports in friends and family. They're out there, its just finding and establishing them--it really is a necessity. Without support, it would be too easy to give up, burn out, become helpless again. In any endeavor support is important, but when the forces against you are so prevalent and deep-rooted as racism is in this society, it is the only way to keep moving forward. [Joanne, a white woman]

In my view, the restoration of hope is an essential part of the learning process. Otherwise, students, both white and of color, become immobilized by their own despair.

Though the focus of this article is clearly on the process of white racial identity development, it should be pointed out that students of color also need to know that whites can be allies. For some students of color, the idea that there are white people who have moved beyond guilt to a position of claiming responsibility for the dismantling of institutional racism is a novel one. They too find hope in the possibility. Writing in response to the activist's visit, Sonia, a Latina, commented:

I don't know when I have been more impressed by anyone. She filled me with hope for the future. She made me believe that there are good people in the world and that whites suffer too and want to change things.

In addition to inviting Andrea Ayvazian to my class, I try to provide written materials about white people who have been engaged in examining their own white identity and who have made a commitment to antiracist activity in their own lives. However, this information is not easily located. One of the consequences of racism in our society is that those who oppose it are often marginalized. As Colman McCarthy writes in the foreword to The Universe Bends toward Justice, "students know warmakers, not peacemakers."

As with other marginalized groups, the stories of peacemakers, of white allies, are not readily accessed. Yet having access to these stories makes a difference to students who are looking for ways to be agents of change. A resource list of materials I have been able to identify is included at the conclusion of this article.

Students, motivated by their own need for such information, can be quite resourceful in the generation of this knowledge. Recently, a white woman who had taken my Psychology of Racism course conducted an independent study project investigating the phenomenological experience of being a white ally on a college campus. Interviewing other white women, ranging in age from nineteen to forty-seven, she was able to generate valuable information about the daily implications of being an antiracist? It was apparent that her research was more than an academic exercise--indeed a way to strengthen her own commitment to antiracist action. More of this kind of research needs to be done so that the fourth model of whiteness, that of the white ally, becomes a more visible option for white students.

Though the focus here has been on the provision of white role models for students trying to construct a positive white racial identity, it is important to acknowledge that there is a parallel need for both white students and students of color to see and read about clear examples of empowered people of color. Teaching about racism should not be only a litany of the ways people of color have been victimized by oppression. It must also include examples of the resistance of people of color to victimization. Just as white students are not eager to see themselves as oppressors, students of color do not want to be characterized as victims.

In addition, white students should not be led to believe that the role of the ally is to "help" victims of racism. The role of the ally is to speak up against systems of oppression, and to challenge other whites to do the same. Teaching about racism needs to shift from an exploration of the experiences of victims and victimizers to that of empowered people of color and their white allies, creating the possibility of working together as partners in the establishment of a more just society.

Scholarly and judicial efforts to explain the constitutional significance of disproportionate impact and governmental motive in cases alleging racial discrimination treat these two categories as mutually exclusive. That is, while disproportionate impact may be evidence of racially discriminatory motive, whether impact or motive is the appropriate focus is normally posed in the alternative: Should racially disproportionate impact, standing alone, trigger a heightened level of judicial scrutiny? Or, should the judiciary apply a deferential standard to legislative and administrative decisions absent proof that the decisionmakers intended a racial consequence? Put another way, the Court thinks of facially neutral actions as either intentionally and unconstitutionally or unintentionally and constitutionally discriminatory.

I argue that this is a false dichotomy. Traditional notions of intent do not reflect the fact that decisions about racial matters are influenced in large part by factors that can be characterized as neither intentional -- in the sense that certain outcomes are self-consciously sought -- nor unintentional -- in the sense that the outcomes are random, fortuitous, and uninfluenced by the decisionmaker's beliefs, desires, and wishes.

Americans share a common historical and cultural heritage in which racism has played and still plays a dominant role. Because of this shared experience, we also inevitably share many ideas, attitudes, and beliefs that attach significance to an individual's race and induce negative feelings and opinions about nonwhites. To the extent that this cultural belief system has influenced all of us, we are all racists. At the same time, most of us are unaware of our racism. We do not recognize the ways in which our cultural experience has influenced our beliefs about race or the occasions on which those beliefs affect our actions. In other words, a large part of the behavior that produces racial discrimination is influenced by unconscious racial motivation.

There are two explanations for the unconscious nature of our racially discriminatory beliefs and ideas. First, Freudian theory states that the human mind defends itself against the discomfort of guilt by denying or refusing to recognize those ideas, wishes, and beliefs that conflict with what the individual has learned is good or right. While our historical experience has made racism an integral part of our culture, our society has more recently embraced an ideal that rejects racism as immoral. When an individual experiences conflict between racist ideas and the societal ethic that condemns those ideas, the mind excludes his racism from consciousness.

Second, the theory of cognitive psychology states that the culture -- including, for example, the media and an individual's parents, peers, and authority figures -- transmits certain beliefs and preferences. Because these beliefs are so much a part of the culture, they are not experienced as explicit lessons. Instead, they seem part of the individual's rational ordering of her perceptions of the world. The individual is unaware, for example, that the ubiquitous presence of a cultural stereotype has influenced her perception that blacks are lazy or unintelligent. Because racism is so deeply ingrained in our culture, it is likely to be transmitted by tacit understandings: Even if a child is not told that blacks are inferior, he learns that lesson by observing the behavior of others. These tacit understandings, because they have never been articulated, are less likely to be experienced at a conscious level.

In short, requiring proof of conscious or intentional motivation as a prerequisite to constitutional recognition that a decision is race-dependent ignores much of what we understand about how the human mind works. It also disregards both the irrationality of racism and the profound effect that the history of American race relations has had on the individual and collective unconscious.

It may often be appropriate for the legal system to disregard the influence of the unconscious on individual or collective behavior. But where the goal is the eradication of invidious racial discrimination, the law must recognize racism's primary source. The equal protection clause requires the elimination of governmental decisions that take race into account without good and important reasons. Therefore, equal protection doctrine must find a way to come to grips with unconscious racism.

Living in a White-supremacist culture, Black people receive the message daily, through both mass media and our interactions with an unenlightened White world, that to be Black is to be inferior and subordinate. Our Blackness is seen as a threat to be subdued or eliminated. Such a cultural context hardly prepares us to embrace healthy self-esteem.

In fact, Black people who do possess healthy self-esteem often find that we are more likely to face racist attacks, precisely because we do not fit the negative stereotypes of Black identity that many White people feel comfortable with. Black people with self-esteem are often told by unenlightened Whites--even some individuals who are liberal and friendly--that we are not "really Black." In telling us this, these Whites do not see themselves as expressing racism; they feel they are offering us a special place. Yet there is, in these words, an attempt to seduce us away from loving Blackness, to undermine the very self-esteem that, by its existence, eliminates White supremacist domination.

Let's face it: If all Black people were able to cultivate healthy self-esteem, institutionalized racism might continue to exist, but White supremacist domination would no longer have a place in our psyches or in our intimate lives. As Lerone Bennet, Jr., was fond of saying: "The last bastion of White supremacy is in the Black man's mind."

Internalized racism has been a feature of Black life in the United States from the very first moment Black people found that White people would reward them, be kinder to them, and like them better if they showed a higher regard for Whiteness than Blackness. There were no doubt many such moments during slavery, moments that became more pronounced as the rape of Black females by White males produced Black people who were fair-skinned and automatically deemed better in racist iconography.

When civil-rights advocates fought for racial desegregation, they did not produce documents addressing how the self-esteem of Black folks might be damaged by interactions with White folks who had not unlearned White supremacist thinking and action. In the late sixties and early seventies, it was often just assumed that White people who chose to hang out with Black people liked them, and that their friendly association with Blacks assured that these Whites were free of racist attitudes and behavior. It was a gesture of low self-esteem that some Black folks felt better about themselves when liked by a White person.

Racism is a systemic, societal, institutional, omnipresent, and epistemologically embedded phenomenon that pervades every vestige of our reality. For most whites, however, racism is like murder: the concept exists but someone has to commit it in order for it to happen. This limited view of such a multilayered syndrome cultivates the sinister nature of racism and, in fact, perpetuates racist phenomena rather than eradicates them. Further, this view of racism disguises its true essence, thus allowing its tenets to proliferate.

Racism conceived of in this way ignores the societal, systemic, institutional, and political institutions which both overtly and inherently ensure minority subjugation and protect white privilege. When racism is regarded in this way, it also helps white society to erect defense mechanisms to ignore its direct implication and involvement in the maintenance of white racism, white privilege, and the construction of "other." After all, if racism is conceived of as the conscious employment of certain acts, using certain taboo terms (i.e., nigger, spic) and one does not consciously perform "racist" acts or utter certain taboo terms, then one can reasonably assert that one is not a racist.

This notion suggests that racism is an abstract hypothetical that functions outside of our human and social systems and that without conscious human choice cannot occur. This notion of racism and American society is illustrated in Conceptual Model 1 (see below).

Another view of racism in America, however, is that it is a phenomenon constructed by Americans socially defined as "White," and that its primary role is to ensure that group's primacy to the exclusion of all others at whatever cost. This view of racism refutes the notion that racism is an abstract hypothetical that exists outside of the social milieu that requires conscious and deliberate acts to manifest. Further, this view asserts that racism is integrally and inextricably bound to all of our "human" and social processes and that, in fact, American society itself is a function of racism and lies imbedded in racist ideology. This notion of racism and American society is illustrated in a Conceptual Model 2 (see below).

Racism is thus perceived of as abstract hypothetical cause for the emergence of other fallacious syndromes. If racism is perceived as functioning outside of societal processes and as having to be consciously chosen and enacted to become concrete reality then racism in theory can be practiced by anyone. That is, "non-Whites," too, may engage in practicing racism and thus Whites themselves may be victims of racism.

Such a notion is exactly how racism is mostly perceived in American society, so that the possibility of deconstructing White supremacy, the progenitor and true underlying problem of racism and racist ideology, does not become the focus of racial investigation. That the entire infrastructure of American society is based upon and emanates from the Western canon; that European Americans raped the continent and decimated its indigenous peoples, instituted a system of society- and government-sanctioned chattel slavery for over three centuries; that the present population that is deemed "White" is still benefiting from these systems and institutions; these, it appears, are all points to be ignored.

By ignoring the historical specificity of the construction of race by "Whites," as a tool to ensure that group's supremacy and subsequent degradation of "others," and by promoting the concept of racism as abstract hypothetical, White society not only can ensure that the system of White supremacy remains intact but can, in fact, successfully create smoke screens that actually implicate "others" in the maintenance of such a system.

It's unfortunate that while some of the initial crop of endorsements are unexceptional, others have a little hint of controversy: e.g., Equazen and Cherry Active. Readers may recall that Equazen eye Q was recently reprimanded by the ASA for over-stating the demonstrable benefits of its products. We don't know what evidence Cherry Active submitted to FFTB as part of their accreditation but the nutritional information on their website is misleading- not that FFTB has any competence with number-handling - and they over-state the health benefits for their products and fail to provide appropriate references - the latter is something that FFTB has done itself. Even on the basis of its own criteria, the Cherry Active dried cherries fail 3/4 of the critieria and the evidence for the 5th is equivocal so the FFTB endorsement must be attributable to cherry-picking (you knew it was coming). So, birds of a feather, plus ca change and is there a problem?

We've just seen the outcome of a case where Alzheimer's Society joined forces with Eisai and Pfizer to compel disclosure of the NICE economic model for ajudicating prescription decisions. It will be interesting to see the eventual outcome of that.

Anthony Cox has a thoughtful piece on Abatacept and patient groups. He highlights a noticeable trend towards patient support groups being financed by manfacturers as a way of influencing campaigns such as the Informed Patient Initiative. Cox usefully quotes Herxheimer:

Most patients' organisations are poor and have little independent funding. Grants from and joint projects with pharmaceutical companies can help them grow and be more influential, but can also distort and misrepresent their agendas. Relationships must therefore be fully acknowledged and open, without public relations flummery.

There are charities that are partners in some very fine research programmes. They combine such work with vigorous advocacy for patients and their families. However, Holfordwatch wonders if there is an insidious shift in progress towards using charities to provide endorsements for commercial products and to give them cover for making claims that they might otherwise be restricted from making.

Sometimes, when there isn't a clear financial relationship, it looks like the charities are issuing as lukewarm an endorsement as they can get away with, or it is being uttered through gritted teeth because the charity is being pragmatic and they know that they have to say something because the product is in their bailiwick. E.g., Biocard reproduce what looks like an endorsement from Coeliac UK but the full statement, to which they link, is far more nuanced and cautious.

Other charities have no such inhibitions and openly celebrate their relationship with manufacturers. An obvious example is Heart Research UK and Pomegreat; they openly solicit other sponsorship opportunities.

Last year, the House of Lords recommended that Allergy UK should not endorse direct-to-consumer tests for allergies or food intolerance because there is an "absence of stringent scientific evidence" to support the tests. In January we noticed that AUK has created another division that is dedicated to food intolerance awareness. Part of YorkTest's credibility with the public is the often-repeated fact that it is recognised by AUK, although this is only a Consumer Award and based on anecdote rather than clinical evidence, and YorkTest pays an annual fee for it to be renewed.

FIA gives some decent advice about the elimination and challenge method for identifying food intolerances. They even discuss allergy tests that have no scientific support such as Vega and Applied Kinesiology. However, they don't mention the House of Lords' criticism of YorkTest's tests nor the plea that responsible professionals should not recommend those tests and that charities should not endorse them. And, it's unsettling that the FIA recommends that people should consult a (preferably BANT registered) nutritionist but neglect to mention Registered Dietitians. Particularly given that so many members of BANT are graduates of the Institute of Optimum Nutrition and IgG testing for food intolerance is a common thread in their practices; and, it is unlikely that Registered Dietitians are quite as supportive of non-conventional or evidence-light tests.

There is something remarkably déjà entendu et déjà compris about the site and, in a striking coincidence, it looks like Les Rowley of YorkTest set up a Food Intolerance Awareness Group last year. Now, although YorkTest is not explicitly mentioned on the FIA site as yet, it feels pervasive. You might feel that AUK trawled far and wide for many perspectives on food intolerance and it is no more than another unremarkable coincidence that all of the FIA panel of experts have YorkTest connections in one way or another and, specifically, to the test that was deprecated in the House of Lords' report.^[1]

If you are familiar with the YorkTest range of products, it is hard not to see the correspondences in the FIA page on Allergy or Intolerance? The section about the enzymes? In addition, YorkTest has recently announced a Gut Health Test. When you look up more information, it seems that the test will tell you about your candida status^[2] and let you know if you lack necessary digestive enzymes or are failing to produce sufficient hydrochloric acid. You may need to consult a nutritionist about this; and given the nature of the test, it is likely that a nutritional therapist rather than a Registered Dietitian will be familiar with such tests although it is Registered Dietitians such as Rhona Hobday who have recently assessed anti-Candida diets and found them to be unhelpful.^[3]

AUK benefits financially from endorsing YorkTest and YorkTest has a marketing advantage in being able to promote some of their products as 'endorsed by Allergy UK'; a fact that is mentioned prominently on their website and in their frequent press releases. It is a sensible, mutually beneficial arrangement. However, there is a niggling sense that this is not quite within the spirit of the House of Lords' recommendation. There is also a slight qualm that there is a potential for the public to believe (rightly or wrongly) that the fact something is endorsed by a charity means that any health benefits are medically-approved and evidence-based even when a particular product has been the subject of explicit criticism.

Which brings us to the latest, unbelievably well-thought-out marketing plan where FFTB is selling its endorsement of various products and supplements. We've mentioned Equazen and their recent brush with the ASA. FFTB has also endorsed the Cherry Active range.^[4] Cherry Active makes some vigorous and outlandish health claims for the benefits of its products;^[5] claims that they might not be able to make on their own behalf in the future, depending on the impact of the Office of Fair Trading Unfair Commercial Practices Directive (pdf) and the Nutrition and Health Claims regulations.^[6]

So, what is being said about these cherries? Cherry Active proudly states:

Food for the brain - leading nutritionist Patrick Holford recommends CherryActive Cherries as a snack for children to help boost concentration and energy levels

Well, yes, it is amazing what people will recommend when you pay them to endorse you. There is no distinctive evidence to support the cherry snack rather than an apple or orange or similar, but hey ho. Irritatingly, the nutritional information on Cherry Active's website is misleading. The claim that, "[t]hey also contain virtually no carbohydrate" looks like it is related to both the cherry concentrate drink and the capsules but it only relates to the capsules. It also fails to point out the one of the reasons that a capsule contains little carbohydrate (they refer to less than 0.5g) is because it contains 500mg of powder. Which is practically the entire weight, if the quoted details are correct.

The nutritional table reports that for the dried cherries 41/50g are carbohydrates which makes sense: there are 170 kcalories in 50g and the carbohydrates contribute around 160 of them (we've subtracted for the dietary fibre). However, there are some carbohydrates unaccounted for as the sugar grammes, as stated, are 15.3g fructose and 18.3g glucose or around 34g.

However, if we go by the information as given, then the glycaemic load of these cherries (one of the criteria for endorsement) is unimpressive. If you look at Patrick Holford's guide to glycemic load (GL), you will notice that the usual serving size for a dried fruit like raisins is 60g. The manufacturer sells 65g bags of dried cherries, so you might think that is a useful snack size. No, it seems that the recommended portion size is half a bag or 32.5g although not for any clearly-stated reason. If you calculate the GL^[6] for 65g of dried cherries, using the website information, then you would calculate (58 (estimated glycemic index from website) x 52 (number of carbohydrate grammes in a serving, we've subtracted the fibre)) and divide that by 100. Your result would be a GL of 30 which is "bad" according to Patrick Holford. 32.5g of dried cherries is 15 which is still "bad" but might be nudged into being OK-ish.^{[8, 9]}

Now, the stated criteria for an FFTB audit and endorsement are:

• Low GL
• High in essential fats (omega 3,6 and phospholipids)
• High in vitamins and minerals
• Free from harmful or unnecessary chemical additives or colourings
• Low in sugar

You might be able to finagle the calculation of the GL of the dried cherries a little but it is not possible to make them a low GL food even for as little as 32.5g. At 68g+ per 100g in named sugars, they are certainly not 'low in sugar' as a percentage of their overall calories; again, you can only artificially depress the absolute amount of sugar by stipulating a small serving size (the FSA states that anything with more than 15g of sugar per 100g is high which is a crude method but indicative here).

The dried cherries are neither "low GL" nor "low in sugar". Self-evidently, they are not high in essential fats. The website doesn't provide the full vitamin and mineral profile so we can't make a judgment as to that claim but we consider the claim equivocal. We have tracked down some sort of profile for what looks like a similar cherry product (pdf) and the values don't indicate that dried cherries are 'high in vitamins and minerals'. E.g., per 100g there is O.5mg of Vitamin C so it is safe to say that there is a negligible amount in the recommended serving size of 32.5g. At 3580mg of Vitamin A, that might be a reasonable source but not strikingly so for the portion size. So, unless FFTB received a very different profile, it is hard to see that this criterion is satisfied. And it is impossible to see how this even matches up to the website's claim:

a daily serving ensures your child’s intake of development promoting natural antioxidants and flavonoids.

We are using the usual understanding of 'antioxidants' here to refer to vitamins such as A, C and E^[10] and we are assuming their recommended serving size.

Which leaves the final criterion of "free from" etc. It is hard to see how that one criterion can be sufficient to base an endorsement on but it seems as if it is - which looks like egregious cherry-picking.^[11] Now, the FFTB endorsement isn't specified or quantified. It is reasonable to assume that if people are aware that it means that a product is 'low GL and low in sugar' then they might, mistakenly, think that this is true of the dried cherries. They might also think that the much-vaunted Scientific Advisory Board of the FFTB guarantees some form of respectability, by association, for the more remarkable medical and health claims. And similarly for the Food Advisory Committee and the nutritional claims.

Even consulting the FFTB Food Audit Model (pdf) does not clarify the issue of why the dried cherries qualified. The model exacerbates the confusion because it introduces a different criterion (low salt) and modifies others to be less rigorous. It looks like the advertising for the endorsements highlights criteria such as low sugar and high in vitamins and minerals but these are not insisted upon in the food audit and not essential for accreditation.^[12]

This FFTB endorsement may be useful not only in the UK but overseas. It seems that various cherry producers have attracted FDA attention and criticism and have resorted to sleight-of-website to off-load the responsibility for health claims. We mention this because both the US marketing website that is used as a proxy to make health claims for cherries and the Cherry Active site in the UK make similar claims, and they both provide the same Cherry Nutrition Report: Cherry Active (pdf) and Choose Cherries (pdf).

Interestingly, although a company may be constrained from making health or nutritional claims for its products, there may be comparatively few restrictions on such claims being made or implied by the endorsement of a charity. So, it might make good business sense for a food or supplement manufacturer to purchase a charity's endorsement because it may well permit it to make a string of health or medical claims, using the charity as its proxy. Charities have to obtain their funding from somewhere. But, if they can be used in this way, will charities further contaminate the public understanding of basic science? Is it acceptable to use them to promote outlandish concepts like this?^[4]

[H]idden hunger can not only damage and limit a child’s growth and intellect, but can also weaken their immune system

Is it acceptable for a charity to bestow the imprimatur of respectability of a product that has been deprecated by experts or for which the available evidence does not match the nutritional or health claims? It may benefit the charity but is it in line with its usual service remit? HolfordWatch wonders if it might be more appropriate to offer TRASH endorsements that are especially designed to meet the needs of Truthiness, Referenciness and Scienciness Hawkers.

Update June 26: I've just come across this explanation of how cherries are dried. Unless there is an independent analysis of a dried cherry product from a food laboratory, it seems unwise to extrapolate any nutritional information about cherries based on information about the fresh version. To me, this sounds very like the dried product has added sugar as well as its own sugars.

unlike grapes (dried into raisins) and plums (prunes), cherries have a low sugar content (the sugar acts as a natural preservative)...

"If you just dried the cherry, it would be tough and hard. To get it soft, you [have to] replace the water in the cells of the fruit with sugar solids," Nugent said.

He devised a method similar to pickling that uses sugar instead of salt; it preserves the cherries and removes the juice. Then the juice is concentrated and returned to the cherries in a process called "infusing." Then they're dried again for four to five hours.

Notes

[1] Dr Hilary Jones is a long-standing ambassador for YorkTest.
Liz Tucker is one of YorkTest's long-standing experts.
Angela Beescroft seems to work for YorkTest as one of their nutritionists.
Professor Peter Whorwell is one of the authors of the GUT paper that is endlessly cited by YorkTest in support of their products.
Dr Anton Emmanuel has also used YorkTest products in his research.
[2] Allergy UK on candida which is aka yeast overgrowth and said to be related to multiple chemical sensitivity. AUK argue that it should be considered for diverse symptoms.

In summary, yeast overgrowth should be considered in people who complain of bloating, wind, diarrhoea or diarrhoea/constipation, and who may also suffer lethargy, nasal symptoms, asthma, rashes / urticaria, and who have a history of repeated thrush of the mouth or vagina, lots of antibiotics, steroids or hormones.

[3] The circle here is that many nutritional therapists receive training that endorses the use of IgG tests for determining food intolerance. They recommend these tests to their clients and may receive commission for them. When the test comes back with some +ve results, the nutritionist may have an opportunity to offer guidance on the restricted diet and to sell on any supplements that may now be necessary because of the dietary restrictions.
[4] The accreditation process is not arduous. At least 3 members of the FFTB Food Advisory Committee review the manufacturer's submission.
[5] There are remarkable claims for Cherry Active Kids:

Antioxidants play a vital role in the physical growth and mental development of children. A child’s full genetic potential for physical growth and mental development may be compromised due to subclinical deficiencies of micronutrients. This is commonly referred to as ‘hidden hunger’. This hidden hunger can not only damage and limit a child’s growth and intellect, but can also weaken their immune system leaving them vulnerable to develop frequent and more severe common day-to-day infections. CherryActive Concentrate (and Dried Cherries) is the perfect way to remove any hidden hunger, as a daily serving ensures your child’s intake of development promoting natural antioxidants and flavonoids. [Emphasis added.]

Ignoring the issue of 'hidden hunger', it does not seem as if this last claim can be true for the recommended 32.5g serving. There are no references to support the implication that otherwise well-nourished children in the UK are compromised by these "subclinical deficiencies of micronutrients". It is probably that none of these claims would survive the scrutiny of the ASA but are permissible on the company's website at present because websites fall under the remit of the Trading Standards departments.
[6] The Unfair Commercial Practices Directive (pdf) has some thought-provoking sections. E.g., Clause 17 of the 31 banned practices makes it illegal to make a false medical claim for a product or service which may curb the claims that manufacturers can make but it is unclear whether there is still a loophole that allows charities to say what they wish. However, where a charity is charging money for an endorsement, it is not established whether this changes the picture.
Clause 7.12 makes an offense of "misleading omissions". - e.g., a nutritional therapist who fails to mention that research has shown that there is no evidence-base for a particular blood test where the omitted information would result in the "average consumer" acting differently - i.e., not purchasing the test.
Clauses 14.35 to 14.37 apply to "vulnerable consumers", and places an obligation traders to take particular care with products aimed at this group. E.g., a nutritional therapist who claims that a food supplement might benefit people with mental health problems might find themselves crossing the boundary of the acceptable. This might be policed more rigorously for claims involving vulnerable child populations.
The Nutrition and Health Claims regulations substantially limit the claims that can be made without verification.
[7] Glycemic load is calculated by multiplying the glycaemic index of a food by the amount of carbohydrate per serving and dividing by 100.
[8] There may also be some controversy about the estimated glycemic index and load of the dried cherries: there is no indication that there has been a specific test to establish the GI and therefore GL of these dried cherries.
[9] We should mention that in vivo testing of GI sometimes yields a different result than one might expect from a calculation of the nutritional data. However, the website does not mention any in vivo testing which is why we performed a theoretical calculation.
[10] It is possible that they will deploy the non-conventional metric gambit of referring to ORAC units rather than what is commonly understood by antioxidants.
Professor UK Dietitian has kindly provided us with more information about the probably nutritional profile of these cherries. Vitamin A is only found in animal based products so the vitamin A as listed is more likely to be carotenes - alpha, beta and the like.
FSA database lists cherries as food 1096 in The Composition of Foods (spreadsheet). There is a group analysis of whole raw cherries that reports beta carotene as 25 mcg per 100g.
We should also point out that we are not being unduly picky about the nutritional profile. Post-menopausal women are advised that 1500mcg or higher consumption of retinol is not advisable.
[11] Oddly enough, the Health Products for Life portal still sports Patrick Holford's photograph and it markets the CherryActive range, including these dried cherries but although it makes its own odd claims, it doesn't make any claims about GL, low sugar or a fabulous vitamin and mineral profile. However, we are slightly at a loss to understand how the added apple juice concentrate doesn't count as a source of added sugar.

CherryActive Cherries are made from CherryActive's carefully selected Montmorency cherries infused with apple juice concentrate, a real pleasure for your taste buds and very healthy too! Cherry Active Cherries contain no added sugars, sweeteners...

[12] FFTB Food Audit Model (pdf) lists slightly different assessment criteria and loses some of the modifers.

1. Vitamins & Minerals
2. Essential fats
3. Low Glycemic load (GL)
4. Free from artificial colourings and flavourings
5. Low salt level

It states:

A product needs to fulfil at least criteria no. 4 and then two out of no.1, 2, 3 or 5 to gain approval

It is surprisingly easy for a dried fruit product to meet the low salt level requirement, particularly as the low sugar requirement has somehow disappeared, although heavily featured in the PR releases. However, we would still argue that even by the different criteria it is difficult to understand the accreditation of the dried cherries.

The Food for the Brain Child Survey 2007 (pdf) is irredeemable. There is nothing to be done to salvage the report because the data collection and analyses are seriously flawed. There are serious issues concerning the survey questions and this is yet another object lesson in why research must be conducted using standardised and validated questionnaires. The data were farcical even before the revelation that Professors Holford, Philip Cowen and David Smith (amongst others) want us to believe that something of statistical significance can emerge from a comparison of 2 outlier groups from an unrepresentative survey of 10,222 children. Outlier groups of 32 and 42 children which, when added together, make up 0.72% of the children (or 2.36% or so if you are just looking at the SAT group, but the point holds that these 74 children are the entire prop for the dietary recommendations).

Don't even trouble your head as to whether there has been a clustering technique to take account of any children from the same families. Every survey taker wants to highlight 0.72% of their total unrepresentative sample and pronounce on public and research policy on the back of that. However, more about this at another time and if you are interested, you might consult our multi-part review of the Food for the Brain Child Survey 2007 (references below).

So, we offer our comments as part of a commentary on how not to report research and the way in which proponents of nutritionism mislead the public; the kind view of this would be that it is episodic incompetence. However, you can decide for yourself whether there is an enduring trend by looking at the entire corpus of someone's work. We invite you to do that: we may even have some pointers available on our Holford Myths page.

We are astounded that Holford claims to be unaware of problems concerning the literature overview in the FFTB report. The literature overview is spectacularly disappointing: we offer our summary. What is especially depressing about this lamentable overview is that it looks to have been adapted from Chapter 16 of Food Is Better Medicine Than Drugs (FIBMTD) by somebody who had absolutely no degree of understanding for the comparative nuance that the author of that section used, nor for the ballpark relevance of the literature that is cited in the context of a discussion about children with ADHD rather than the general population of children (as per the FFTB Child Survey 2007). We disagree with FIBMTD's extravagant claims of "proof" and some of the nuance is wrong. But given the standards with which we are familiar, it is peculiarly gratifying to see that, at some point, somebody understood that distinctive groups of children who participated in the studies that they cite. We shall look at the FIBMTD version because it is instructive and gives a clue as to how some people fail to understand nuance. And fail to understand that some terms are not semantically equivalent and can't be used just because you consider them to sound more science-y - they do sound more science-y, and that's a problem if it really can't be justified.

If you want to see what the FFTB said, and our response, consult: our recent response or our original FFTB: Part 1. For this post, we are highlighting the difference between the original text written for FIBMTD and the text as it appeared in FFTB. Chapter 16 of Patrick Holford and Jerome Burne's Food Is Better Medicine Than Drugs (FIBMTD).

Now, thanks to the ground-breaking research of pioneer researchers...we have proof based on a series of double-blind trials of the benefit from supplying extra essential fats to children with learning and behaviour problems....[Text cites refs 2 and 3.] [Emphasis added.] [pg. 322]

Yes and no. We loathe the use of the word "proof" and would doubt that the authors of the papers under discussion would approve of it: "proof" is a substantial over-statement of the quantity and quality of the evidence (Equazen were reprimanded by the ASA and received a severe drubbing for submitting these papers as part of their argument for efficacy). These issues should have been self-evident to Holford, who frequently lauds his own scholarship (he used to have a band of respectable scholars who also endorsed his work but this is ever dwindling). However, unlike FFTB, we must highlight that FIBMTD does not indicate or imply that these findings can be generalised to the wider population of children who do not have developmental complications or issues. (For the full detail of our objections: FFTB Part 1.)

To date, 12 double-blind studies on vitamins and IQ have been carried out, and 10 out of 12 show a clear improvement...[Ref 1] [Emphasis added.] [pg. 322]

We have expressed our disagreement about the numbers and dispute that 10/12 showed a "clear improvement" but we celebrate the fact that FIBMTD did not make the FFTB mistake of reporting this as “significant improvement”. In the interest of fairness, we should also state that FIBMTD, like FFTB, also fails to comment on Benton’s caveats about generalising the results to the wider population of children. (For the full detail of our objections: FFTB Part 1.)

FFTB states that "a significant proportion of children with ADHD may have unidentified food and chemical sensitivities". One of the supporting references for that statement is also cited in FIBMTD.

[Carter et al] placed 78 hyperactive children on a "few foods diet", eliminating both chemical additives and common food allergens. During this open trial, the behaviour of 59 of the children (76 per cent) improved. The researchers then secretly reintroduced the foods and additives that had provoked reactions for 19 of the children. The children's behaviour rapidly became worse and so did their performance in psychological testing. [Ref 4][pg. 325]

Well, like the curate's egg, this summary is good in parts. However, like the FFTB, FIBMTD rather overlooks the fact that many of these children had neurological disabilities or associated allergic problems in addition to hyperkinesis (there were substantial co-morbidities). Plus, the children had already been referred to a specialist dietary clinic and their parents were interested in pursuing a dietary approach for the management of their children’s symptoms. Moreover, Carter et al state:

It is still not clear how generally applicable such a treatment might be within a general group of hyperactive children. [pg. 568] [Emphasis added.]

A rather important nuance that FIBMTD misses, along with FFTB, to be fair. Like with the Benton summary. Neither the Holford & Burne permutation nor the Holford & Fobbester one draw your attention to this: we mention this because Holford has a track record of accusing scientists and researchers of suppressing relevant nuances or information and cover-ups. And we emphasise it because the back-jacket of FIBMTD assures us that this is a "brilliantly researched, authoritative book, based on solid scientific trials". And because Holford claims that a cadre of professors reviewed and approved each section of FIBMTD.

Holford Watch could express itself at some length about the dubious claims, references and assertions in Chapter 16 of FIBMTD: Solving Attention and Learning Problems Ritalian vs making kids smarter. However, to do so would be off-topic for this post.

For now, we invite you to reflect upon the remarkable fact that it looks as if Holford & Fobbester drew upon FIBMTD for their literature overview for FFTB Child Survey. In doing so, not only did they fail to pick up on the errors in that work (which means that they can't have checked the primary sources), they failed to understand some of the nuance, and they produced a version that introduced more error. And Holford is not at all reluctant to accuse others of failing to check primary sources or misinterpreting information. You can read a fine example of Holford's adroitness with appropriate nuances and sources in his discussion of statins in FIBMTD.

And, just to be clear, Holford and Burne offer you an entire section in which they coach you to "encourage your doctor to practise food medicine". They anticipate the objections that you might meet. E.g., pg. 378:

Objection 2: There is no evidence these treatments work.
Response:...it is just not true. Any properly trained nutritional therapist will be just as keen on basing treatment on the evidence as a doctor. In fact, you might argue that the diet and exercise approach is more firmly based in the evidence.

...the evidence upon which the doctors have based their prescribing often turns out to be faulty. Of course, they are not going to take kindly to this kind of comment from you, but you could show them this book, including the list of references, or even offer to lend it to them...

Actually, judging by the content of The Rise of the Lifestyle Nutritionists: Part 1; it seems that properly credentialled nutrition scientists and doctors won't take those kinds of comments or references from their primary source - Holford. And, in the light of a remarkably extensive catalogue of errors, and frankly odd enthusiasms (e.g., Q-Link, dowsing for nutritional deficiencies), who can blame them?

References

[1] Benton D, Micro-nutrient supplementation and the intelligence of children. Neurosci Biobehav Rev. 2001 Jun;25(4):297-309.
[2] Richardson AJ, Puri, B. A randomized double-blind, placebo-controlled study of the effects of supplementation with highly unsaturated fatty acids on ADHD-related symptoms in children with specific learning difficulties. Prog Neuropsychopharmacol Biol Psychiatry. 2002 Feb;26(2):233-9.
[3] Richardson AJ, Montgomery P. The Oxford-Durham study: a randomized, controlled trial of dietary supplementation with fatty acids in children with developmental coordination disorder. Pediatrics. 2005 May;115(5):1360-6.
[4] Carter CM, Urbanowicz M, Hemsley R, Mantilla L, Strobel S, Graham PJ, Taylor E. Effects of a few food diet in attention deficit disorder. Arch Dis Child. 1993 Nov;69(5):564-8.

Notes

We used the paperback 2007 edition of FIBMTD in this post.

The FFTB Child Survey literature review was irrelevant and incompetent. But the number-crunching and display of summary data were breathtakingly, unbelievably bad. Office-neighbours-should-have-been-pounding-on-the-wall-and-calling-the-statistics-authorities-and-reporting-a-hazard-to-health bad. The-guilty-parties-should-be-having-their-keyboard-privileges-revoked bad. The authors didn't even have the courtesy to respect readers' time and energy by checking basic things like correctly labelled axes for the graphs or even correct titles for the graphs. However, that is nugatory in the overall scheme of the awfulness of the statistical analysis. We're conflicted. We don't want you to expose yourself to the full horror of that report yet it may be one of those things that you can't quite believe until you do look for yourself: we offer a brief summary.

But, what does Holford say about this?

A [Holford's response]. “The Food for the Brain Child survey is a simple survey of the diets, academic performance and behaviour of a group of over 10,000 children, a third of which also provided SAT scores. The survey simply reports which food group consumptions are associated with parental ratings of better or worse behaviour and academic performance, and SAT scores. The conclusions are based solely on this data, and make no reference to any other studies. The survey is available for all to see at our website www.foodforthebrain.org/childsurvey. There is a Q&A section for people to post critiques, and for our Scientific Advisory Board to respond. Professor Colquhoun’s critiques have been responded to. Professor Stein has not informed us of any. If there are errors we do our best to correct them.”

The numbers are irredeemable. There is nothing to be done to salvage them. There are serious issues concerning the survey questions and this is yet another object lesson in why research must be conducted using standardised and validated questionnaires. The data were farcical even before the revelation that Professors Holford, Philip Cowen and David Smith (amongst others) want us to believe that something of statistical significance can emerge from a comparison of 2 outlier groups from an unrepresentative survey of 10,222 children. Outlier groups of 32 and 42 children which, when added together, make up 0.72% of the children. Don't even trouble your head as to whether there has been a cluster analysis to take account of any children from the same families. Every survey taker wants to highlight 0.72% of their total unrepresentative sample and pronounce on public and research policy on the back of that. However, more about this at another time and if you are interested, you might consult our multi-part review of the Food for the Brain Child Survey 2007 (references below).

We are astounded that Holford claims to be unaware of problems concerning the literature overview in the FFTB report (we don't know what Professor Stein thinks but we would be surprised if we differ much on this point). The literature overview is spectacularly disappointing: we will repeat our summary here. What is especially depressing about this lamentable overview is that it looks to have been adapted from Chapter 16 of Food Is Better Medicine Than Drugs (FIBMTD) by somebody who had absolutely no degree of understanding for the comparative nuance that the author of that section used, nor for the ballpark relevance of the literature that is cited in the context of a discussion about children with ADHD rather than the general population of children (as per the FFTB Child Survey). We disagree with the extravagance of the claims of "proof" and some of the nuance is wrong but it is peculiarly gratifying to see that, at some point, somebody understood the the distinctive groups of children who participated in the studies. We shall look at the FIBMTD version in 2b because it is instructive and gives a clue as to how some people fail to understand nuance.

This is what Holford and Fobbester wrote in Food for the Brain Child Survey, September 2007 (pdf). Section 3.1 (pg 6):

A substantial and convincing body of scientific evidence, including many randomised-controlled trials, shows that a child's nutrition has a profound effect on their learning and behaviour:

• Ten out of twelve randomised controlled trials (RCTs) assessing the impact of vitamin and mineral supplementation have illustrated significant improvement in non verbal IQ and concentration^[1]
• A diet high in essential fats, especially omega 3 essential fats, as well as supplementation improves attention and reading, and reduces anxiety and aggression. Numerous studies have been conducted in this area^[2] including two recent randomised controlled trials^[3,4]
• A diet with a balanced glycemic load, incorporating more whole foods and slow-releasing sugars and less refined foods and fast-releasing sugars, eaten at regular intervals, may improve learning, attention and reduce anxiety and aggressive behaviour^{[5, 6, 7]}
• A significant proportion of children with ADHD may have unidentified food and chemical sensitivities^[8,9] Gluten sensitivity, for example, is far more common in children with behavioural problems than in those without^[10]

The evidence from what is now a large and growing body of broadly consistent research links sub-optimum nutrition with poor cognition and behaviour. While much is known about the kind of diet that provides Recommended Daily Allowances, little is known about the kind of diet that equates to optimal mental health, learning and behaviour. Since RDAs largely do not take into account recent research on nutrition and mental health there is no good reason to assume that these kinds of levels, if eaten, are optimal for mental health.

This is what we wrote as a summary of the problems with the literature overview, in January. If you want the gory detail, read the linked posts. But, to summarise:

• Benton's review^[1] has the potential to be a relevant reference but Holford and Fobbester mis-report the findings as indicative of "significant improvement" rather than "positive response" (it does matter) and they mis-report the number of RCTs. They also fail to notice Benton's caveats about generalising the results to the wider population of children.
• Holford and Fobbester's overview suggests that most of the trials to which they refer were conducted in a general population of children, however:
  • Richardson's review^[2] is about the role and putative benefits of fatty acids for children with developmental and psychiatric disorders and there is no evidence to suggest that her findings can be generalised to the wider population of children who do not have developmental complications
  • the fish oil trials^[3,4] in these references were similarly for a specialised population and not generalisable (as above).
• Holford and Fobbester supply 3 references for the putative value of a "diet with a balanced glycemic load" for children^{[5, 6, 7]} but none of the references address this:
  • Haapalahti et al^[5] discuss the dietary habits of children with functional gastro-intestinal disorders. These results are not representative of a wider population of children
  • Benton's review^[6] examines the importance of breakfast to later mood and performance. He makes some suggestions about the importance of meal scheduling on the cognitive performance of some of the population
  • Lien et al^[7] discuss the consumption of soft drinks and associations with the incidence of hyperactivity, mental distress and conduct problems in adolescents. They do not discuss 'glycemic load', whole foods or the importance of regular meals.
• both Egger et al^[9] and Carter et al^[8] discuss children with hyperkinesis symptoms who have food and chemical sensitivities. However, both of these studies concern children who have co-morbidities; ADHD and hyperkinesis are not necessarily equivalent; and all of the children had been referred to specialist clinics. These findings can not support the assertion about the wider population of children with complex behavioural difficulties, far less have any verifiable and substantial contribution to the study of nutrition among children who do not have these symptoms or disorders
• Holford and Fobbester's reference for gluten sensitivity and children with behavioural disorders^[10] does not exist.

This looks like a list of assertions for which the authors feel the truthiness, and attempt to create the necessary scienciness through referenciness. It is clear to even the casual reader that Holford was making assertions about the RDAs based upon his interpretation of the literature; a literature that he appears not to cite accurately nor to interpret appropriately.

Holford and Fobbester refer to the truism that a child's nutrition affects their learning and behaviour. They cite studies to argue that children with "sub-optimum nutrition" (an undefined term) have poor cognition and behaviour. The studies that the authors cite indicate that multi-supplements may be of benefit to a small sub-group of children. However, several reviewers have remarked that these are most effective for children who might have deficiencies that approach clinical levels; even appropriate supplementation is unlikely to promote a substantial difference in the absence of other supportive factors such as a stable homelife or stimulating education.

There is a buzz of excitement about the claimed benefits of Omega 3 supplements. However, it is unfortunate that the evidence in this area is currently of such poor quality that it weakens its probative value. The FFTB authors draw our attention to studies that involve children with clinical disorders; results of such studies may not be generalisable to a wider population.

It is premature, at best, to attempt to use the results of this FFTB report or its literature overview to argue that there is a robust scientific case for a change in public policy or dietary recommendations that affects the general population of children. The results are not even sufficient to sustain the authors' animadversions about the current recommended RDAs. Ironically, when so few children in this survey of children (albeit, it is not a representative sample) adhere to the dietary recommendations that already exist (see, e.g., the publications of the Caroline Walker Trust), it would seem that this sample can not be used to comment on the adequacy or otherwise of RDAs.

It is disingenuous of Holford to start making modest claims for the influence or meaning of the Food for the Brain Child Survey 2007 when the media promotion and Dame Tutt's foreword to the report are a marked contrast to such modesty or fine restraint in publicising the findings (findings that are overwhelmingly flawed, in their current forms).

This is the scholar who has a visiting professorship at the University of Teesside. An institution where, one hopes, they teach young scientists to cite research accurately, to interpret it appropriately. Nonetheless, a place where Professor Holford shall be supervising students and applying for research support.

And Holfordwatch has a special appreciation for the disingenuous claim that FFTB now offers a Q&A for posting critiques. We wrote to Professor Holford on January 11 and did not receive any response. Our criticisms of the report have been detailed and thorough, and available since January: our criticisms were known to both Holford and other members of the FFTB Scientific Advisory Board. We are still waiting for answers.

References

[1] Benton D, Micro-nutrient supplementation and the intelligence of children. Neurosci Biobehav Rev. 2001 Jun;25(4):297-309.
[2] Richardson AJ, Long-chain polyunsaturated fatty acids in childhood developmental and psychiatric disorders. Lipids. 2004 Dec;39(12):1215-22.
[3] Richardson AJ, Montgomery P. The Oxford-Durham study: a randomized, controlled trial of dietary supplementation with fatty acids in children with developmental coordination disorder. Pediatrics. 2005 May;115(5):1360-6. [The authors misquote the name in the FFTB Survey.]
[4] Sinn N, Bryan J. Effect of supplementation with polyunsaturated fatty acids and micronutrients on learning and behavior problems associated with child ADHD. J Dev Behav Pediatr. 2007 Apr;28(2):82-91.
[5] Haapalahti M, Mykkänen H, Tikkanen S, Kokkonen J. Food habits in 10-11-year-old children with functional gastrointestinal disorders. Eur J Clin Nutr. 2004 Jul;58(7):1016-21.
[6] Benton D. The impact of the supply of glucose to the brain on mood and memory. Nutr Rev. 2001 Jan;59(1 Pt 2):S20-1
[7] Lien L, Lien N, Heyerdahl S, Thoresen M, Bjertness E. Consumption of soft drinks and hyperactivity, mental distress, and conduct problems among adolescents in Oslo, Norway. Am J Public Health. 2006 Oct;96(10):1815-20.
[8] Carter CM, Urbanowicz M, Hemsley R, Mantilla L, Strobel S, Graham PJ, Taylor E. Effects of a few food diet in attention deficit disorder. Arch Dis Child. 1993 Nov;69(5):564-8.
[9] Egger J, Carter CM, Graham PJ, Gumley D, Soothill JF. Controlled trial of oligoantigenic treatment in the hyperkinetic syndrome. Lancet. 1985 Mar 9;1(8428):540-5.
[10] The FFTB Child Survey cites: Gerarduzzi T et al. Celiac disease in USA among risk groups and general population in USA. Journal of Pediatric Gastroenterology and Nutrition. Vol 31 (suppl) 2000: pp S29, Abst 104. [Having searched Jnl of Ped Gastro and Nutr, this paper doesn't seem to exist as per this reference. It appears in Google Scholar as a citation only which might indicate an error.] Holford Watch has previously mentioned our difficulty with this reference: Running out of tolerance.

Further Reading

Food for the Brain Child Survey 2007: The Promotion
Holford Watch looks at the literature review:
Food for the Brain Child Survey 2007: Review Part 1
Food for the Brain Child Survey 2007: Review Part 2
Food for the Brain Child Survey 2007: Review Part 3
Food for the Brain Child Survey 2007: Review Part 4
Food for the Brain Child Survey 2007: Review Part 5

Holford Watch appeals for help to Professor Holford and two members of the Scientific Advisory Board who approved this report and then looks at the data and analyses:
Food for the Brain Child Survey 2007: Review Part 7
Food for the Brain Child Survey 2007: Review Part 8
Why Don't Food for the Brain Report Their Survey Results on Supplement Pills Survey: Review Part 9
Food for the Brain Child Survey 2007: Review Part 10

We still do not have a direct response but they have just posted some Q&A about this report.

Disappointingly, in their response to some simple questions, FFTB has already erred in simple arithmetic, reporting only 3130 children in the SAT group rather than the 3139 mentioned in the report (pg. 6). The report states that 1% of the children eat nuts and seeds once a day or more but when asked for the raw number, they quote 92; this is not 1% of either the full sample of 10,222 (which should be 102) nor the SAT group of 3139 children (it matters because of their claims). And the claims for statistical significance go awry but more at another time.

We are going to accept the FFTB invitation to pose questions about the report. You may recall that we wrote more than 10 posts, discussing problems with the literature overview and the data analyses. We shall distill those down into more questions. For now, we shall just resubmit most of the ones that we asked in January. We have produced them below. If FFTB has answered some form of the question in their current Q&A then we comment on what they provided by way of a response (it would be wholly inappropriate to style some of them as answers - you will understand why). We have put the FFTB responses in green/bold (it might depend on your browser).

Email sent from Holford Watch to Patrick Holford January 11 2008

We're also in the process of analysing the science of the September 2007 Food for the Brain Child Survey, and it would be very helpful if you could answer a couple of questions and respond to a couple of criticisms. If FFTB is looking to publish this as a journal article, I suspect that these points will be among those raised by reviewers anyway - so hopefully shouldn't create too much additional work:

In most of the report, it's not clear whether the nutritional data are drawn from the data collected on all 10,222 children or just those for whom their SAT scores are known (the 3,139). 3.5 states that the data for assessing food/food group associations were generated from the 10,222 respondents. However, it is unclear whether this data were comparable to those of the sub-group of the 3,139 for whom there were SAT scores or not; it is this latter group that is represented in later analyses. Could you clarify this?

HW: We could comment further about this but any pretensions of relevance for these data are completely undercut by the later admissions that their recommendations for an ideal diet for UK children rests upon a comparison involving the outliers of their survey who make up 0.72% of the whole.

The graph 4.2.1 is represented as showing a "direct and consistent increase in SAT scores with improving diet", yet it doesn't. The improved diet is based on a score that is derived from the survey results of these children with a substantially below average SAT score. It is difficult to tell from the data but it seems as if the no. of children in the 'very good diet' category may be as low as 120 or so - is this the case?
FFTB responds: The difference between the the SAT scores of those with the very poor diets and those with the very good diet was 11% (p<0.05).This data suggests a trend towards increasing SAT scores with improving diet, not a direct and consistence [sic] increase. We accept this criticism.

Holfordwatch put up an explanation of what is wrong about this graph and FFTB's claims. FFTB's response is inadequate. They have provided SDs but no confidence intervals. There is a startling revelation that the FFTB dietary recommendations are grounded in a comparison of two outlier groups, as represents the very good and very poor diets, with sample sizes of 42 and 32 respectively. They really don't seem to notice that this adds up to a grand total of 0.72% of the whole survey sample or 2.36% of the SATs sub-group. At these levels, and with an acknowledged unrepresentative sample, and no awareness that some of those children in those groups may be from the same families, and might need further adjustment for clustering, you are more likely to be discussing statistical noise with those outlier groups. Plus, you really don't claim "statistical significance" as FFTB does when mentioning these figures in response to a later question - certainly not without divulging your confidence intervals. We should also add, that somewhere, they have lost 9 children; the numbers that they give add up to 3130 rather than 3139 (FFTB report, Very Good 42; Good 868; Neutral 1706; Poor 482; Very Poor 32). Normally, we wouldn't draw much attention to this but, unfortunately, given the small numbers in the outlier groups, these missing children might be disproportionately important.

Our problem with table 4.3 is that we don't understand if the data in the first 3 columns are drawn from the analysis of the 10,000+ or just the 3,000+ that are represented in the SAT scores of column 4. Beyond that, we don't understand what is meant by the effect size mentioned in the notes. The report does not mention how FFTB calculated the effect size or any useful information such as SDs. We have never seen an equivalence drawn between a % and the effect size: an effect size of 8% is said to indicate that a high consumer of a food has an 8% higher score than a low/non consumer. It also seems quite novel to calculate an effect size for an observational survey without any intervention?

The wholly inadequate response to a simpler form of this question is as follows, however, it can be summed up as, "We didn't mean effect size, qua effect size, or any of the normal formula that involve knowing SDs etc.".

FFTB: The ‘effect sizes’ were calculated by looking at the prevalence of respondents in each (high or low) consumption band giving a ‘very good’ rating. The increase or decrease in prevalence between the two represents the ‘effect size’. This represents the increase (or decrease) in likelihood of a very good rating. The comparisons were only made where the variances in prevalence were statistically significant (shown by the colour bandings). We have not calculated standard deviations for these values. We accept that this grid may be trying to ‘do too much’ and we may have compromised on clarity by perhaps trying to be too concise. We are looking at a simpler mechanism that will more clearly show the dramatic difference between consumption groups and the apparent effect of increasing consumption of different foods on stated overall health, stated academic behaviour, SAT scores and a series of everyday symptoms.
HW current response: We think your data are irredeemable. Trying to be concise was not your over-riding problem: we have commented on this in several places, notably in Food for the Brain: Child Survey: Review Part 10. The way in which the authors calculate the impact of foodstuffs on behaviour and academic performance is beyond the normal understanding of "That's wrong".

4.4 has ideal diet recommendations for children. The recommendations are a little tricky to interpret; do the 5+ fruit and 5+ vegetables include the portion of nuts and seeds and the dark green veg or are these last two in addition?

We don't have any helpful gender breakdowns. Given the better academic performance reports for girls than boys (6.3), it is a little odd that we don't see analysis of different SAT scores, particularly the higher ones that are drawn from comparatively small numbers that may be disproportionately female?
FFTB respond to a simpler form of this question: There were no statistically significant gender variances in the SAT score data. The data in 6.3 represents parental subjective view of academic performance and this may (or may not) include other subjective views of academic performance aside from SAT scores - (see para 3.5 in the report that confirms this and explains use of total sample for this high level report).

HW current response: This really isn't good enough. It is clear that girls have better reports than boys; given the tiny numbers in the outlying groups it is feasible that there are gender differences. FFTB should release the raw numbers. The reference to the report really doesn't explain anything. FFTB report says:

girls are more likely than boys to perform well academically (Girls 26% very good versus 16% of boys). [HW has not evaluated this claim: section 6.3, pg. 17]

Those completing the FFTB questionnaire were asked whether the children used essential fat and multivitamin supplements, but the results of this are not included in the report. Was there a particular reason for this omission, and are these results available?

HW comments more fully on the issue of these missing data about supplements.

7.3 reports improved academic performance of children who eat a portion of nuts/seeds per day. However, in the table for 8 we discover that 1% of the sample achieved this. Is this 1% derived from the 10,000+ sample or the 3000+ set.
FFTB respond to a different form of this question: 92 children reported eating nuts and seeds every day. The ‘3-5’ and ‘at least once a day’consumption groups did not show a statistically significant effect on SAT scores in this case. The only statistically significant finding was reported, stating “regular consumption of fresh, raw nuts and seeds is associated with a statistically significant (p<0.001) 7% increase in mean SAT scores at a consumption level of 2-3 times per week.” This trend is consistent with those found in relation to parents rating of behaviour and academic performance.

HW responds: We have many problems with this that we shall elaborate on at another time. For now, ask yourself whether it is accurate for 92 children to be 1% of either 10,222 (the total sample) or 3139 (the SAT sub-group) children; small numbers can mean a lot here. Further, if you consult 9:16 on pg 30, you will see that there is a SAT score difference of the size that FFTB otherwise rhapsodises about. A score of 3.14 at a consumption frequency of 2-3 per week but 2.98 at once or more a day (2.96 for 3-5 time a week and 3.03 for rarely). FFTB bruits about there there is a significant 7% increase in the mean SAT scores. Actually it is 6.8%; we don't mention this to be persnickety, but because you can obtain a 6% difference between the mean SAT score of the 2-3 per week and the 3-5 per week, a score that falls with increasing consumption.

There is something badly amiss with these data and their analysis. Of course, if there are errors in the size of the groups, there is no possibility of these data being correct. We were going to digress on to more reasons why these data can not be correct but it would really take far too long here.

For the whole of 9, we are not clear whether the data are from the 10,000+ sample or just the 3000+ SAT set - perhaps you could clarify. It also seems a little odd to put the 2 lowest groups together as one class and contrast them with a small group of the comparatively well-behaved or high academic performers: what was the rationale for this?

Re: nuts/seeds, how does 9:16 relate to the recommendation for a daily serving?

As above, but the drop in SAT scores would seem to mitigate the usefulness of this recommendation. If you accept these data (which we don't) your SAT scores fall as you increase your consumption; however, this looks like statistical noise to us.

10.1 is interesting because it would have been helpful if they had indicated how many children fell into each group so that we might have some idea of the samples. It seems as if the 'very good diet' group would have to be part of the subset of children who are in the 6% who eat oily fish 3+ times per week, 2% who frequently eat dark green veg, and the report refers to 1% who eat nuts/seeds daily: is this correct? What is n for this group - it looks like it might be very small?
The sample sizes are as follows. [FFTB report, Very Good 42; Good 868; Neutral 1706; Poor 482; Very Poor 32].
While these are small sample sizes the difference was statistically significant.

You will notice that somehow they have lost 9 of the 3139 children. Unfortunately, given the small numbers in the outlier groups, these missing children might be disproportionately important. You will notice that they are relying upon a tiny number of children to estimate their ideal diet recommendations for children throughout the UK. It is hard to understand why they think these outliers offer "statistically significant" results.

We asked the above questions before we fully understood just how flawed the FFTB Child Survey 2007 is. We will provide further questions to the FFTB and their SAB and post them here and notify you of any responses.

Further Reading

Food for the Brain Child Survey 2007: The Promotion
Holford Watch looks at the literature review:
Food for the Brain Child Survey 2007: Review Part 1
Food for the Brain Child Survey 2007: Review Part 2
Food for the Brain Child Survey 2007: Review Part 3
Food for the Brain Child Survey 2007: Review Part 4
Food for the Brain Child Survey 2007: Review Part 5

Holford Watch appeals for help to Professor Holford and two members of the Scientific Advisory Board who approved this report and then looks at the data and analyses:
Food for the Brain Child Survey 2007: Review Part 7
Food for the Brain Child Survey 2007: Review Part 8
Why Don't Food for the Brain Report Their Survey Results on Supplement Pills Survey: Review Part 9
Food for the Brain Child Survey 2007: Review Part 10

The second part of the BBC Radio 4 show The Rise of the Lifestyle Nutritionists (listen again here, later tonight) starts by noting that "Everybody wants to be healthy, but how do you know who to trust?" Ben Goldacre then spends a considerable amount of time speaking to a number of eminent professors, in order to demonstrate that one cannot trust Holford's science: Holford's science fails in numerous ways.

The interviewees are extremely critical about the quality of Holford's work, and Holford has predictably claimed that the programme was unfair. However, this programme is actually an accurate and balanced assessment of Holford's work. If Holford finds such assessments harsh, we would argue that he should look to improve the quality of his own work and offer a meaningful response to some of the criticisms raised, along with correcting his numerous errors. His current (non)responses to the serious questions raised are woefully inadequate.

Holford is arguably the most influential nutritional therapist in the UK:Goldacre analyses Holford's New Optimum Nutrition Bible (NONB) as an example of influential writing in the field of nutritional therapy. Initially, Prof David Colquhoun discusses Holford's claims about vitamin C - both as an AIDS treatment and as a prophylactic against colds. In both cases, he concludes that Holford misrepresents the evidence. Colquhoun is shocked that Holford refers to an in vitro test to justify his claims about vitamin C and AIDS: as Colquhoun argues, such studies are of little value to clinicians making treatment decisions. Colquhoun also finds that cherry-picking of studies is a frequent problem in Holford's work. For example, Colquhoun finds that Holford's focus on a study offering the 'right' results on vitamin C and the common cold is an astonishing example of cherry-picking data (the first Cochrane Review of the topic was available in 1998 and updated ones were also available by the time of Holford's revision to NONB). Did we mention that Holford is Visiting Professor at Teesside University, and there are plans for him to head the University's CACTUS clinic - I'm sure that Teesside will be pleased to know that their new professor is leading the field in something. And I do like cherries...

Prof Tom Sanders then discusses Holford's response to a meta-analysis of Randomised Controlled Trials (RCTs) of antioxidant pills which showed that these pills don't improve survival, and that some may even increase mortality. As reported on this blog, Holford complained that two association studies - not RCTs - had not been included in the meta-analysis of RCTs: this strikes Sanders as a misrepresentation of the scientific literature, and gives him the impression that Holford does not understand the difference between association studies and RCTs. But, then again, Holford's only being lined up to lead some of the research at Teesside from his new professorial position - one mustn't be too harsh on him. And - while Holford is Head of Science and Education at Biocare - a little confusion between associations studies and RCTs isn't much of a problem. Right?

As Goldacre summarises matters, the BBC's investigation found a fairly enduring pattern of poor scholarship in Holford's work. When appointing Holford as a Visiting Professor at Teesside, or as Head of Science and Education at Biocare, one does wonder whether those appointing him also took the opportunity to review his work - and whether they picked up on the very basic errors therein.

A number of people have chosen to associate themselves with Holford's work, and to act as if it is scientifically credible. This is not a trivial matter: Holford offers (often erroneous) advice on treatments for a number of serious conditions, and is seeking to influence public policy and academic research agenda. We would therefore suggest that Biocare and Teesside University might like to reconsider their positions. We would also suggest that the academics on the Food for the Brain Scientific Advisory board reconsider whether they want their names associated with such poor quality work, and also look to produce a full list of errata to supplement the error-ridden Food for the Brain child survey report. Finally, we would ask that Holford's publishers work with Holford - or independently - to produce suitable lists of errata to accompany his work, and that those mainstream media outlets that promoted his work look to correct their previous errors and run a compensatory more accurate assessment.

Having just posted about Professor Patrick Holford of Teesside University's curious relationship with the mainstream media, we were fascinated to see Patrick Holford responding to the Radio 4 programme: The Rise of the Lifestyle Nutritionists. From what he writes, it sounds like he does feature in Part 2 of the series. I haven't heard Part 2 yet - it's scheduled to be broadcast on March 31 at 8pm - but it's already clear that Holford fails to offer an adequate response to the questions raised. His responses range from dodging the questions asked, to answering while giving a clearly incorrect answer, and so gobsmackingly wrong that they even fail to qualify as wrong. Now I'm really looking forward to the radio programme: Holford digs himself in deep enough without having heard the programme, but I'm sure that the BBC's research skills will allow them to provide a JCB or two to join Holford in his hole.

Holford complains that:

Two weeks ago I was approached by Radio 4 saying they were doing a programme, presented by Ben Goldacre, on nutritional therapy and wanted to do a pre-recorded interview, that would be edited.

I declined the interview for the reasons given below but I provided Radio Four with comments in answer to their questions to be read out verbatim on the programme. They would not agree to reading these out unedited however and so did not use them

So, maybe Holford has extrapolated from his own editing and treatment of Dr John Marks' remarks. Mean old BBC, right? Except Holford's "short and concise" response to the BBC runs to over 1000 words; there is considerably more on the Food for the Brain site. Keep in mind that the radio programme has about a 27min slot, and it would take over 10mins to read out Holford's response - and the questions he's responding to - at any vaguely sensible speed. And it is unlikely that the programme is all about him.

Anyway, given the quality of these responses, I'm sure that the BBC would have loved to have been able to quote from them. I can't cover them all here, so I will just pick out a few choice examples. What I find especially interesting is that - not only is this an epic failure on Holford's part - but he seems entirely unaware of this fact, even claiming victory at the same time as he digs himself in deeper.

Holford's unique approach to research is especially clear in Food for the Brain's attempts to defend their widely reported Child Survey. The one that we explored and discussed in detail that has been described as 'mercilessly thorough'. FFTB acknowledge a number of problems with the research:

• While the survey is touted as including 10,222 children, Holford admits that he ended up comparing two of the groups of children analysed; these groups contained just 32 and 42 members respectively. Most researchers would see this as a problem: for example, a handful of extended families could constitute all of one or both of these groups and thus completely skew the results. However, Food for the Brain are still proudly insisting that - for comparisons between these two tiny groups - p<0.05. Do you think it is appropriate to pronounce on the optimal diet for UK children based on 74 children from a unrepresentative sample of 10,222? Some of us would call those groups outliers.
• In the survey, "The ‘effect sizes’ were calculated by looking at the prevalence of respondents in each (high or low) consumption band giving a ‘very good’ rating." This is a very non-standard - to the best of my knowledge, it's completely unique - way to calculate effect size. While one may need to introduce novel approaches to statistics from time to time, these need to be argued for: for Holford to blithely use and calculate 'effect size' in such a unique way, without mentioning this in the survey, is simply wrong. And wrong at a very basic level.

One more thing to note about the survey - again, using technical language in a very unique and unclear way, without explaining why - is a simple Q&A that will stand by itself:

Q. The word "variance" seems to be used throughout not in the usual statistical sense of the word. Am I right in supposing that it is being used here as a synonym for 'difference'?
A.Yes.

In Holford's 'full response' on his own site he - entertainingly - continues in his habit of confusing food allergies and intolerances. To quote from (just one) part of the response where he does this:

While the conventional view is that IgE antibodies are responsible for most immediate onset allergies, there is growing evidence that IgG antiobidy [sic] mediated reactions, may indeed be responsible for more ‘hidden’ allergies.

The type of IgG mediated intolerances that Holford refers to are quite different from IgE mediated allergies: while food intolerances are inconvenient and may be unpleasant, allergies can kill (for example, can cause anaphylactic shock). And - as we've shown - the type of IgG blood tests recommended by Holford are not an effective way to diagnose food allergies or intolerances. (I would also be wary of taking advice on allergies from someone who can't spell 'antiobidy'.)

Holford was also asked "His views on a famous, some might say, infamous, paper by Bjelakovic et al. [PDF] which describes the possible risks of taking certain antioxidants. Mr Holford's article was called "Antioxidant Review is a Stitch Up"."

Given his own rather classic series of blunders in both the literature review and statistical analysis of the FFTB Child Survey 2007, it is with breath-taking and rather touching bravado that Holford offers criticism of the Bjelakovic et al meta-analysis:

[my] two main criticisms of this paper were that the one study, by a Dr Correa from the pathology department at the Louisiana State University Health Sciences Centre, that apparently skewed results for antioxidants overall towards a negative, showed a clear protective effect of antioxidant supplements against gastrointestinal cancer. I decided to contact Dr Correa and he was ‘amazed’, he said, because his research, ‘far from being negative, had shown clear benefit from taking vitamins.’ Correa told us, there was no way the study could show anything about mortality. ‘Our study was designed for evaluation of the progress of precancerous lesions,’ he said. ‘It did not intend, and did not have the power, to study mortality and has no value to examine mortality of cancer.’

Also, the summary of this study states ‘treatment with beta carotene, vitamin A, and vitamin E may increase mortality’ creating the impression these antioxidants are no good. What it failed to say in the summary, all of which are clearly stated in the results, is that ‘vitamin C given singly, or in combination with other antioxidants did not affect mortality, and selenium given singly or in combination with other antioxidant supplements may reduce mortality’. It also fails to say that ‘beta-carotene or vitamin A did not show increase in mortality if given in combination with other antioxidants’, or that ‘vitamin E given singly or combined with 4 other antioxidants did not significantly influence mortality’.

Now that is interesting: we addressed this paper in HolfordWatch's first ever post. Aw, I'm all misty-eyed with nostalgia... Firstly, one might note that Holford's 'Antioxidant Review is a Stitch Up' piece complained bitterly - and rather strangely - about quite a range of things. For example, Holford objects that:

The next way to investigate whether an analysis is a stitch up is to see if all trials are included, how trials are excluded, and what the trials actually say. Two classic primary prevention studies, where vitamin E is given to healthy people, are those of Stampfer et al, published in the New England Journal of Medicine, the first of which gave 87,200 nurses were given 67mg of vitamin E daily for more than two years. A 40 per cent drop in fatal and non-fatal heart attacks was reported compared to those not taking vitamin E supplements (1). In another study, 39,000 male health professionals were given 67mg of vitamin E for the same length of time and achieved a 39 per cent reduction in heart attacks (2). Guess what? They are not included.

However, as noted in the original post, these two studies aren't included in the Bjelakovic et al. meta-analysis of RCTs on antioxidants because, um, they're not RCTs. Holford's complaint about this suggests some confusion as to what an RCT is. This is rather odd in someone that Teesside University has raised to professorial status. Happily, Holford now acknowledges that arguing for these studies to be included was incorrect (though it would have been nice if he had let us know about this, and thanked us for pointing this out, when we posted on the topic about a year ago). As will be shown below, though, it is unfortunate that Holford failed to take on board our other criticisms.

In answer to the criticisms of the Bjelakovic et al. article that Holford does cleave to in his response to the BBC, though, I will quote from this blog's first post: they were all addressed in there.

The abstract of the JAMA article says that “The potential roles of vitamin C and selenium on mortality need further study.” It therefore does say that there’s a need for further study on the role of vitamin C and selenium supplementation, and that they may have reduce (or increase) mortality...The meta-analysis doesn’t explicitly say that different combinations of antioxidants may have different effects (or, for example, that antioxidant may have different effects if you exercise regularly, smoke 30 a day, etc.) It didn’t seek to analyse every possible combination of factors, and it wouldn’t have been feasible to do this...

I’m not sure how Holford concludes that the JAMA meta-analysis assumes that Correa et al’s paper is negative: the results would have been included in the meta-analysis as would the results of all the other trials with low bias risk. Others may have misread Corea et al’s article as showing that taking vitamin E could have been damaging, but I can’t see any evidence that the JAMA meta-analysis has done the same thing.

Right, after that blast from the past I'll allow myself to look at one more point from Holford's response to Radio 4: the rest can wait till another day. Holford also claims that:

My views on the benefits of fish oils are shared by many doctors and scientists. The recent Associate Parliamentary Food and health [sic] Forum ‘The Links Between Diet and Behaviour’, makes this clear.

No