- Email: [email protected]
An interview with Kate Neil: Nutritional therapy explained
An interview with Kate Neil: Nutritional therapyexplained Kate Neil Kate Neil is a V|siting Lecturer at the University of Westminster for their BSc Health Sciences: Nutritional Therapy degree course. Kate was part of the team that established this course 2 years ago, which is the f|rst of its kind in this country and supervised their clinical training programme. Previously, Kate was the Director of Education Studies and Principal of the Institute for Optimum Nutrition in London. She directs her own company NS3UKwhich offers nutrition services to health care professionals (including a 3-year nutrition course in Dorking), industry and the public. Kate frequently contributes to professional and public journals and is Editor of the professional journal The Nutrition Practitioner. She is also author of Balancing Hormones Naturally. She practises from Harley Street and from NS3UK in Berkshire. She can be contacted at NS3UK. Tel.: 01344 360033; E-mail: [email protected] and www.ns3.co.uk. Kate is currently studying for an MSc in Nutritional Medicine at Surrey University. # 2000 Harcourt Publishers Ltd
It is the job of the nutritional therapist to ®nd out which type of diet will best suit an individual.
Kate Neil RN, RM, DipION Nutrition Services Supplies Support NS3UK, 51 Trevelyan, Bracknell, Berkshire RG12 8YD, UK.
INTRODUCTION BY KATE NEIL I think that few people would disagree that nutrition is essential for life. The fundamental reaction that goes on in every cell in our body between the food that we eat and the air that we breathe ensures our day-to-day survival. What is less commonly accepted is that the quality of the food that we eat will be a major determinant in our health outcomes. Some are born with abnormal genes and express certain conditions from early on in their lives. However, for many their genetic code is disrupted by both endogenous and exogenous noxious agents. Others might fall ill or fail to reach their health potential not as a result of genetic damage, but through an inability of their cells to cope with a toxic load. This relatively new way of looking at health and disease not only empowers practitioners to help their patients but also helps people to better understand how they might help themselves. As much as we inherit our genes, we frequently `inherit' diets and lifestyles from our parents too. The knowledge that diet and lifestyle can potentially alter gene expression and cellular function is a major motivator for change for many people. If sub-optimum diets and exposure to toxins can be inducers of the disease process then the converse could also be true, in that, optimum diets could maximize healthy gene expression and cellular function.
Denise Rankin-Box (DRB): What is nutritional therapy? Kate Neil (KN): Nutritional therapy is about working with patients to manipulate their diets and lifestyles in order to optimize cellular function. In addition, the nutritional therapist is uniquely trained to make interventions with nutritional supplements in both the prevention and management of health problems. It is in the preventative and therapeutic use of nutritional agents that nutritional therapy essentially deviates from the dietetic approach. A dietician concentrates on the patient's diet and tends to support the philosophy that a `well balanced' diet will provide all the nutrients needed for health. Dietitians concentrate on the scienti®c study and regulation of food intake and preparation.
DRB: What is the well-balanced diet? KN: This is hard to de®ne, as what is well balanced for one is not necessarily so for another. This could be described as `what is one man's meat is another man's poison'. For example, the metabolisms of some people are better suited to a higher protein to complex carbohydrate ratio in the diet while others ¯ourish on a high complex carbohydrate diet. It is the job of the nutritional therapist to ®nd out which type of diet will best suit an individual.
Complementary Therapies in Nursing & Midwifery (2000) 6, 124 ^129 # 2000 Harcourt Publishers Ltd
Nutritional therapy explained
This requires an understanding of why such dierent metabolic requirements occur. What can be quite con®dently said is that a well-balanced diet should be nutrient dense. Over the last few decades our calori®c intake has, in general, declined but still we are getting fatter. Levels of exercise have also declined and the intake of high calorie low nutrient dense diets have increased. These changes in lifestyles and dietary trends are likely to be major contributors to the increasing tendency towards obesity in the Western world. Research has shown that a major determinant of appetite is the presence of nutrients in the blood. High calorie, low nutrient dense diets satisfy the body's calori®c needs but can leave us feeling hungry as the body is still searching for the missing nutrients. The best way to achieve a nutrient dense diet is to choose a diverse range of foods. Most of our diets tend to be repetitive. For example, it is common in practice to ®nd people consuming a wheat-based cereal and milk for breakfast, a cheese sandwich for lunch and a pasta or pizza dish for their evening meal. Each of these meals are based on wheat and dairy produce which are the two major allergens in the British diet and are strongly linked to a variety of in¯ammatory disorders. Consuming foods repetitively exposes the body to the speci®c range of nutrients that food has to oer. Eating a range of grains, including wheat, rye, oats, barley, rice, corn, millet, and quinoa ensures a more diverse range of nutrients and lowers the allergic potential in the diet. Although dairy products form a major component of many people's diet, and is a major dietary allergen, the overall consumption of milk has declined over the past 25 years and is considered the major reason why the intake of vitamin A has declined. Recent ®ndings from the interpretation of surveys on the UK public by the Ministry of Agriculture Fisheries and Foods (MAFF) show levels of intake for vitamin A below recommended reference nutrient intakes in approximately one third of the UK adult population. More worryingly, 11% of adults, 8% of children under four, and 7% of children aged four years and over have intakes of vitamin A below the lower reference nutrient intake. Similar low dietary intakes have been highlighted for a broad spectrum of vitamins and minerals that are responsible for regulating our biochemistry. Eating a diverse, nutrient-dense diet has to be the number one priority for rectifying de®ciencies in dietary intake. Consuming nuts, seeds, dark green leafy vegetables and a variety of other colourful fruits and vegetables, alongside a range of grains, pulses and animal produce, is the best way to ensure a density of nutrients and phytoprotectants. If dairy produce needs avoiding because of an adverse reaction to it, then eating
125
an otherwise diverse diet should ensure adequate dietary intake of vitamin A and other nutrients that are required for the ecient metabolism of vitamin A in the body.
DRB: Can all the nutrients required for health be obtained from a well-balanced diet? KN: Most nutritionists would like to believe that this is the case. However, the well-balanced diet is dicult to de®ne not only because what is wellbalanced for one is not necessarily so for another, but because there are many dierent views about this, even amongst the professionals. Nutritional therapists are generally of the view that the well-balanced diet is unlikely to provide all the nutrients necessary for health for many people. Since the Industrial Revolution the food chain has been manipulated in a way that frequently undermines the nutrient value of a food such as the re®ning of grains and the exploitation of the land by the use of arti®cial fertilizers which give rise to yields far greater per hectare than foods grown naturally. Over a similar period of time we have introduced thousands of synthetic chemicals to the food chain and our environment in general. The detoxi®cation pathways that predominate in the liver are induced when we encounter a toxic agent. The competence of these pathways are compromized when our exposure to toxins is in excess of our ability to detoxify them. The pathways of detoxi®cation are heavily nutrientdependent. The dual eects of denutrifying the food chain and being exposed to a vast coctail of synthetic agents places human beings in a potentially vulnerable position. This vulnerability is expressed dierently in people, which is a likely result of their diering genetic make-up. Nutritional therapists help each individual to maximize their nutrient intake from the diet, assess their likely potential for producing harmful substances within the body as a result of their diet and lifestyles, and assess their toxic load from the environment. They advise and encourage individuals to minimize their exposure to toxins through appropriate diets and lifestyles, but in principle are of the view that baseline supplementation of multi-nutrients is likely to prove valuable as an added protection against the consequences of our current environment.
DRB: How does a nutritional therapist view health? KN: This is an interesting question. Most nutritional therapists hold the view that health can be optimized. That is, that there is a potential for a state to exist within the body whereby cellular function is in peak condition.
126 Complementary Therapies in Nursing & Midwifery
This view is conceptual and is based on a premise that, conforming with natural laws combined with scienti®c understanding of how the body works, each individual can be helped towards achieving their maximum health potential. Sometimes this approach is called `Optimum Nutrition'. That potential is dierent for each of us as we will have inherited varying strengths and weaknesses. Therefore, it may not be possible for all of us to attain the same level of health, no matter how much eort we put in. Our genes we have inherited and it appears there is little that we can do to change that. Our environment, at least as adults, is more within our own individual control and ability to manipulate towards our advantage or disadvantage. As the body is in a constant dynamic state of ¯ux, haemodynamics, it is obviously nearly impossible, at least with our current technology, to capture the precise moment when the body is working in peak condition and what all the factors that brought that state into being were. The normal stresses and strains of living can alter the dynamics over any given period of time. Therefore, even if the technology was available, constant monitoring of cellular function over a dierent range of activities and stressors would be required. This is clearly impractical and not a reasonable way forward at this time in our history.
DRB: So what is a reasonable way forward? KN: For many years nutritional therapy was relegated to the realms of anecdotal data in that practitioners recommended various diet programmes for the management of dierent health problems including allergies, arthritis, migraines, PMS and for more serious conditions like diabetes, heart disease and cancer. The more `heroic' amongst the practitioners would also recommend speci®c nutritional supplements in the belief that they would bene®t their patients based on the dearth of scienti®c literature supporting such interventions. It is important to say here that nutritional therapists work from the standpoint of optimizing body function as opposed to treating speci®c diseases. This approach is now de®ned by some as `Functional Medicine'. If by optimizing body function disease states reduce, resolve or do not progress, then this is generally considered a successful nutritional intervention. Nowadays, functional and biochemical tests are available to most nutritional therapists. The strategic use of functional tests can aid the practitioner in understanding physiological and biochemical imbalances underlying complex symptom pro®les and disease processes. As a result the nutritional therapist is in a better position to recommend individualized diet
and supplement programmes that have an increased potential to bene®t their patients. The use of functional and biochemical tests has raised the professional pro®le of the nutritional therapist, as they can monitor through repeat testing the progress and ecacy of their patients following complicated diet and supplement programmes. This brings nutritional therapy into the realms of accepted scienti®c principles that rely heavily on measurable outcomes. The nutritional therapist, however, uses functional and biochemical tests as a tool to assist them in their practice, and steers away from only making nutritional interventions based on test results. Interpretation of test results is a major limiting factor. We have advanced technology in many areas of health care and medicine, but the skill of the `technician' in interpreting results from such technologies is in its infancy in some instances, and the experiences of the `technician' is variable. In addition, false negatives and false positives do occur in clinical tests. Besides, nutritional therapy is for many an unaordable luxury as it is currently mainly part of private health care. Most nutritional therapists would like to see this change. Gradually, nutritional therapists are beginning to work within GP practices.
DRB: What is the average cost for a patient seeking nutritional therapy? KN: This is almost impossible to answer as each individual case is so variable. However, consultations can cost as little as £10 for an hour in concessionery clinics. Students usually observe in concessionery clinics. Geographical location and the experience of the practitioner also aect costs. Patients can expect to be charged around £50 per hour in central London, and the same is true of experienced practitioners irrespective of location. The more variable costs to the patient relates to tests. Tests are, of course, optional. However, how far a practitioner can work with a patient in their pursuit of health can be inhibited by working on symptom and lifestyle factors alone. Similarly, nutritional supplements are recommended on an individual basis and eective treatment programmes can be expensive and therefore prohibitive for some patients.
DRB:This must raise ethical issues for nutritional therapists? KN: Yes it does. Many patients seeking private nutrition health care are in ordinary income brackets and sometimes on income support. This can place the nutritional therapist in a moral dilemma. On the one hand, the therapist knows when screening is important and at the same time is aware that should the test results prove positive
Nutritional therapy explained
then expensive foods and products are sometimes needed in order to actively manage an imbalance. Another aspect of the ethical issue is that nutritional therapists stand to gain ®nancially from tests and products that they recommend to patients. The Code of Ethics and Practice that most nutritional therapists follow now recommends tight guidelines about this ethical issue. However, I do not consider it ethical for the practitioner to make judgements about what is aordable for a patient. Some patients will be prepared to forego holidays and other pleasures in their pursuit of wellness. Others will be more reticent about such expenditure. It is not always those inhibited by ®nancial constraints that are the more reticent. I am frequently surprised at what investments and sacri®ces individuals will make to get well. My approach is to discuss with the patient my recommendations for screening and taking nutritional products alongside informing them of the advantages and limitations of such tests and products. This helps the patient to determine what is ®nancially realistic for them to consider. I think the biggest ethical issue confronting nutritional therapists is the ecacy of the tests and products that they recommend. It is easy for practitioners to climb on to the next bandwagon with a new test or a new product and lose sight of their role as educators about the importance of basic sound nutrition. I still ®nd that most health improvements are made by `cleaning-up' the diet, that is, removing highly processed, denutri®ed foods, the excessive use of stimulants like tea and coee, limiting alcohol and eating a diverse wholefood diet as close to nature as possible, plus eating ®ve or preferably ten 80 g pieces of mainly raw vegetables and fruits daily, alongside a litre of good quality still water. Organic produce is a high priority on my list of recommendations to patients as accumulating scienti®c data implicates pesticides in a diverse range of health issues that have the potential to play havoc with our hormones, the very substances that control procreation. Similarly, I advise patients to avoid genetically modi®ed food where they can, as it is clear to me that insucient trials have been implemented prior to their release on the human population, and that those in positions of power appear resistant to cautionary recommendations and public opinion. Unless clearly indicated from the outset, it is not always necessary to perform tests and implement complex expensive supplementary programmes. Giving time for a good diet and basic supplementation to work, and to monitor its eects through symptom relief and increasing experiences of wellbeing is very powerful therapy for both the patient and the practitioner. However, I think it is most pertinent to suggest that routine screening for micronutrient status
127
for instance could prove as valuable a health screen for the prevention and management of disease as cervical smears, breast checks and other routine health checks. Micronutrient de®ciency is common and relatively rarely screened for unless overt symptoms of de®ciency are present. Micronutrient de®ciency, or excess, has a role to play in almost all pathologies. Some patients in the pursuit of optimum health choose to use speci®c screens to keep a check on their potential health status and can adjust their programmes regularly.
DRB: Nutrition seems to be such a contentious subject. Why should this be so? KN: As I said at the beginning, we have to eat to live. Therefore, there are vested interests in food, particularly since we have mechanized most of our food production. Nutrition is a young science. In the early part of this century most vitamins had not been discovered. The understanding of biochemistry and metabolism was limited. In addition, nutrition was not generally considered to be related to disease, except overt conditions like scurvy, beri-beri, pellagra and kwashiorkor. Moreover, nutrition was always considered a `soft' science and related to women and what they did in the kitchen. Nutrititional science is now a rapidly developing ®eld of health care and only the medical ostrich can continue to perceive it as a `soft' science. In fact, many of the pioneers in the ®eld of nutrition see it as the medicine of the future. As nutritional science has gained ground and those pioneers in the ®eld have made successful clinical applications based on the research, it has created friction amongst those in positions of control in two of the most powerful industries, the food and pharmaceutical industries. Processed foods have a long shelf-life and contribute to the enormous pro®ts made by the industry. Vitamins and minerals and other naturally occurring substances found in many nutritional supplements cannot be patented. A synthetic chemical as used in drugs and agriculture can be patented for vast pro®ts. However, I was recently asked to give a short presentation to food product designers and marketeers for a major food company. I was delighted by their interest and awareness of the changing trends in consumer preferences and choices and their desire to capture the market. Separating, ®nancial gain from health care promotion is a political nightmare. For example, the MAFF is responsible to the industry and to the consumer. MAFF is frequently criticized for representing the interests of the food industry over those of the consumer. The government is paving the way to establish an independent Food
128
As the ®eld of nutritional medicine gains credibility, so it receives more and more attack. This is not uncommon when paradigm shifts are occurring.
Complementary Therapies in Nursing & Midwifery
Standards Agency. However, the responsibility for pesticide safety will ultimately remain with MAFF. The top ten pesticide companies have not changed since 1996, and they account for 80% of total sales which is US$25,499. Novartis, Monsanto and Zeneca are the leading agrochemical companies. Monsanto was ®ned £17,000 earlier last year for failing to follow safety precautions in regard to genetically modi®ed food production. This ®ne equates with 1 minute of their annual turnover. It would appear that they can aord to break the rules. As the ®eld of nutritional medicine gains credibility, so it receives more and more attack. This is not uncommon when paradigm shifts are occurring. Resisting change seems to be the rule and ®ghts occur as power bases shift. Until now, nutritional supplements have been classi®ed as foods in the UK, and it has been the responsibility of the Medicines Control Agency (MCA), if it considers the product a medicine, to prove, in court if necessary, that the product is indeed medicinal. The MCA propose to amend the Medicines for Human Use Regulations by introducing a Statutory Instrument, called MLX 249, which would switch the burden of proof from the MCA onto the marketer of the product, such that in the future it is proposed that a company would have to prove that a product is a food. This will present massive problems, not just for high potency nutritional supplements but also for many herbal remedies. This change would restrict consumer choice and undermine the growing desire by consumers to take control of their own health. As there is currently no practical way to license many supplements, many safe, popular supplements will have no viable classi®cation and would be withdrawn from sale. The proposal allows the MCA to determine a substance as medicinal, and that would be sucient evidence in law that it is medicinal, i.e. the MCA's view is unchallengeable. This places the MCA in the position of policeman, judge, and jury. This may be a contravention on the European Convention on human rights, and it ¯ies in the face of 1000 years of English constitution. Most nutritional therapists would like to see improved legislation over the sale of nutritional supplements to improve the safety for public use. However, this sledgehammer approach would be devastating to the food supplement industry and ultimately to patient care.
DRB: Can you leave us with an example of how nutritional therapy has helped your patients? KN: Yes, I believe that I can leave you with a potent example. When I ®rst quali®ed as a
nutritional therapist, nearly 15 years ago, it was dicult to access tests and the range available was quite limited. It was commonplace to recommend dietary and supplement programmes based on symptoms, lifestyle factors and, where applicable, diagnosed disease states. Quite frequently patients improved, but sometimes they did not, and it was dicult to know why. I remember two women patients coming to see me about ten years ago. Both were in their 60s. One had been diagnosed with rheumatoid arthritis and had recently been bereaved. The other was a single lady that had a range of complex signs and symptoms that indicated glucose dysregulation. Both applied stringent dietary protocols and took what would be described as meganutrient programmes for around a year. Each of them expressed around a 50% improvement in their wellbeing as a result of keeping to their programmes. However, they were not as well as they had hoped. Around that time new tests became available that screened for the production of stomach acid, pancreatic enzymes and the porousness of the gut wall. I suggested to both women that they take these non-invasive tests to see if we could pick up a problem that might be inhibiting the release of nutrients from their food or an impaired ability to absorb nutrients. At the same time I recommended that they screened for their vitamin and mineral status using functional or cellular tests which are more signi®cant than measuring serum levels of nutrients. Problems with digestion and absorption were identi®ed in both women and their nutrient status was invariably below the laboratories reference ranges for acceptable levels. This was despite a good diet and meganutrient supplementation for a year. This was a steep learning curve for me. I recommended that they maintained their dietary programme, reduced their vitamin and mineral supplements to basics and implemented digestive aids and substances that assist the regeneration of the gut wall. Both women retested in six months. The patient with rheumatoid arthritis expressed normal nutrient levels and normal digestive and absorption pro®les. It took one year for the second patient to attain normal ®ndings in all parameters tested. Both women experienced a leap in their health as their nutrient levels returned to the reference ranges. Since then, hundreds of my patients have screened for eciency of their digestive processes and this has made a major dierence to the way that I practice. Good diets and meganutrient supplements do not necessarily bring about good functional levels of nutrients. Many factors can in¯uence this outcome. However, checking for digestive competence is crucial when improvements fail to occur within an acceptable period
Nutritional therapy explained
of time. As digestive symptoms are the most common that nutritional therapists encounter, I frequently recommend such tests at the outset in order to target problems as soon as possible.
DRB: What is the biggest challenge to you as a practitioner of nutritional therapy? KN: The satisfaction of appropriately applying newly acquired scienti®c research into the clinical
129
setting and witnessing positive health outcomes from such interventions is what makes being a nutritional therapist worthwhile for me. I get frustrated about the limitations in my current knowledge about nutrition, and the inconsistencies in the ®eld in general. Conversely, the speed in which scienti®c data ¯ood the ®eld is daunting and con¯icting. Making sound clinical applications from the scienti®c data is my greatest dilemma. The art of practising nutrition in a world of scienti®c uncertainty is a regular challenge.
It is the job of the nutritional therapist to ®nd out which type of diet will best suit an individual.
Kate Neil RN, RM, DipION Nutrition Services Supplies Support NS3UK, 51 Trevelyan, Bracknell, Berkshire RG12 8YD, UK.
INTRODUCTION BY KATE NEIL I think that few people would disagree that nutrition is essential for life. The fundamental reaction that goes on in every cell in our body between the food that we eat and the air that we breathe ensures our day-to-day survival. What is less commonly accepted is that the quality of the food that we eat will be a major determinant in our health outcomes. Some are born with abnormal genes and express certain conditions from early on in their lives. However, for many their genetic code is disrupted by both endogenous and exogenous noxious agents. Others might fall ill or fail to reach their health potential not as a result of genetic damage, but through an inability of their cells to cope with a toxic load. This relatively new way of looking at health and disease not only empowers practitioners to help their patients but also helps people to better understand how they might help themselves. As much as we inherit our genes, we frequently `inherit' diets and lifestyles from our parents too. The knowledge that diet and lifestyle can potentially alter gene expression and cellular function is a major motivator for change for many people. If sub-optimum diets and exposure to toxins can be inducers of the disease process then the converse could also be true, in that, optimum diets could maximize healthy gene expression and cellular function.
Denise Rankin-Box (DRB): What is nutritional therapy? Kate Neil (KN): Nutritional therapy is about working with patients to manipulate their diets and lifestyles in order to optimize cellular function. In addition, the nutritional therapist is uniquely trained to make interventions with nutritional supplements in both the prevention and management of health problems. It is in the preventative and therapeutic use of nutritional agents that nutritional therapy essentially deviates from the dietetic approach. A dietician concentrates on the patient's diet and tends to support the philosophy that a `well balanced' diet will provide all the nutrients needed for health. Dietitians concentrate on the scienti®c study and regulation of food intake and preparation.
DRB: What is the well-balanced diet? KN: This is hard to de®ne, as what is well balanced for one is not necessarily so for another. This could be described as `what is one man's meat is another man's poison'. For example, the metabolisms of some people are better suited to a higher protein to complex carbohydrate ratio in the diet while others ¯ourish on a high complex carbohydrate diet. It is the job of the nutritional therapist to ®nd out which type of diet will best suit an individual.
Complementary Therapies in Nursing & Midwifery (2000) 6, 124 ^129 # 2000 Harcourt Publishers Ltd
Nutritional therapy explained
This requires an understanding of why such dierent metabolic requirements occur. What can be quite con®dently said is that a well-balanced diet should be nutrient dense. Over the last few decades our calori®c intake has, in general, declined but still we are getting fatter. Levels of exercise have also declined and the intake of high calorie low nutrient dense diets have increased. These changes in lifestyles and dietary trends are likely to be major contributors to the increasing tendency towards obesity in the Western world. Research has shown that a major determinant of appetite is the presence of nutrients in the blood. High calorie, low nutrient dense diets satisfy the body's calori®c needs but can leave us feeling hungry as the body is still searching for the missing nutrients. The best way to achieve a nutrient dense diet is to choose a diverse range of foods. Most of our diets tend to be repetitive. For example, it is common in practice to ®nd people consuming a wheat-based cereal and milk for breakfast, a cheese sandwich for lunch and a pasta or pizza dish for their evening meal. Each of these meals are based on wheat and dairy produce which are the two major allergens in the British diet and are strongly linked to a variety of in¯ammatory disorders. Consuming foods repetitively exposes the body to the speci®c range of nutrients that food has to oer. Eating a range of grains, including wheat, rye, oats, barley, rice, corn, millet, and quinoa ensures a more diverse range of nutrients and lowers the allergic potential in the diet. Although dairy products form a major component of many people's diet, and is a major dietary allergen, the overall consumption of milk has declined over the past 25 years and is considered the major reason why the intake of vitamin A has declined. Recent ®ndings from the interpretation of surveys on the UK public by the Ministry of Agriculture Fisheries and Foods (MAFF) show levels of intake for vitamin A below recommended reference nutrient intakes in approximately one third of the UK adult population. More worryingly, 11% of adults, 8% of children under four, and 7% of children aged four years and over have intakes of vitamin A below the lower reference nutrient intake. Similar low dietary intakes have been highlighted for a broad spectrum of vitamins and minerals that are responsible for regulating our biochemistry. Eating a diverse, nutrient-dense diet has to be the number one priority for rectifying de®ciencies in dietary intake. Consuming nuts, seeds, dark green leafy vegetables and a variety of other colourful fruits and vegetables, alongside a range of grains, pulses and animal produce, is the best way to ensure a density of nutrients and phytoprotectants. If dairy produce needs avoiding because of an adverse reaction to it, then eating
125
an otherwise diverse diet should ensure adequate dietary intake of vitamin A and other nutrients that are required for the ecient metabolism of vitamin A in the body.
DRB: Can all the nutrients required for health be obtained from a well-balanced diet? KN: Most nutritionists would like to believe that this is the case. However, the well-balanced diet is dicult to de®ne not only because what is wellbalanced for one is not necessarily so for another, but because there are many dierent views about this, even amongst the professionals. Nutritional therapists are generally of the view that the well-balanced diet is unlikely to provide all the nutrients necessary for health for many people. Since the Industrial Revolution the food chain has been manipulated in a way that frequently undermines the nutrient value of a food such as the re®ning of grains and the exploitation of the land by the use of arti®cial fertilizers which give rise to yields far greater per hectare than foods grown naturally. Over a similar period of time we have introduced thousands of synthetic chemicals to the food chain and our environment in general. The detoxi®cation pathways that predominate in the liver are induced when we encounter a toxic agent. The competence of these pathways are compromized when our exposure to toxins is in excess of our ability to detoxify them. The pathways of detoxi®cation are heavily nutrientdependent. The dual eects of denutrifying the food chain and being exposed to a vast coctail of synthetic agents places human beings in a potentially vulnerable position. This vulnerability is expressed dierently in people, which is a likely result of their diering genetic make-up. Nutritional therapists help each individual to maximize their nutrient intake from the diet, assess their likely potential for producing harmful substances within the body as a result of their diet and lifestyles, and assess their toxic load from the environment. They advise and encourage individuals to minimize their exposure to toxins through appropriate diets and lifestyles, but in principle are of the view that baseline supplementation of multi-nutrients is likely to prove valuable as an added protection against the consequences of our current environment.
DRB: How does a nutritional therapist view health? KN: This is an interesting question. Most nutritional therapists hold the view that health can be optimized. That is, that there is a potential for a state to exist within the body whereby cellular function is in peak condition.
126 Complementary Therapies in Nursing & Midwifery
This view is conceptual and is based on a premise that, conforming with natural laws combined with scienti®c understanding of how the body works, each individual can be helped towards achieving their maximum health potential. Sometimes this approach is called `Optimum Nutrition'. That potential is dierent for each of us as we will have inherited varying strengths and weaknesses. Therefore, it may not be possible for all of us to attain the same level of health, no matter how much eort we put in. Our genes we have inherited and it appears there is little that we can do to change that. Our environment, at least as adults, is more within our own individual control and ability to manipulate towards our advantage or disadvantage. As the body is in a constant dynamic state of ¯ux, haemodynamics, it is obviously nearly impossible, at least with our current technology, to capture the precise moment when the body is working in peak condition and what all the factors that brought that state into being were. The normal stresses and strains of living can alter the dynamics over any given period of time. Therefore, even if the technology was available, constant monitoring of cellular function over a dierent range of activities and stressors would be required. This is clearly impractical and not a reasonable way forward at this time in our history.
DRB: So what is a reasonable way forward? KN: For many years nutritional therapy was relegated to the realms of anecdotal data in that practitioners recommended various diet programmes for the management of dierent health problems including allergies, arthritis, migraines, PMS and for more serious conditions like diabetes, heart disease and cancer. The more `heroic' amongst the practitioners would also recommend speci®c nutritional supplements in the belief that they would bene®t their patients based on the dearth of scienti®c literature supporting such interventions. It is important to say here that nutritional therapists work from the standpoint of optimizing body function as opposed to treating speci®c diseases. This approach is now de®ned by some as `Functional Medicine'. If by optimizing body function disease states reduce, resolve or do not progress, then this is generally considered a successful nutritional intervention. Nowadays, functional and biochemical tests are available to most nutritional therapists. The strategic use of functional tests can aid the practitioner in understanding physiological and biochemical imbalances underlying complex symptom pro®les and disease processes. As a result the nutritional therapist is in a better position to recommend individualized diet
and supplement programmes that have an increased potential to bene®t their patients. The use of functional and biochemical tests has raised the professional pro®le of the nutritional therapist, as they can monitor through repeat testing the progress and ecacy of their patients following complicated diet and supplement programmes. This brings nutritional therapy into the realms of accepted scienti®c principles that rely heavily on measurable outcomes. The nutritional therapist, however, uses functional and biochemical tests as a tool to assist them in their practice, and steers away from only making nutritional interventions based on test results. Interpretation of test results is a major limiting factor. We have advanced technology in many areas of health care and medicine, but the skill of the `technician' in interpreting results from such technologies is in its infancy in some instances, and the experiences of the `technician' is variable. In addition, false negatives and false positives do occur in clinical tests. Besides, nutritional therapy is for many an unaordable luxury as it is currently mainly part of private health care. Most nutritional therapists would like to see this change. Gradually, nutritional therapists are beginning to work within GP practices.
DRB: What is the average cost for a patient seeking nutritional therapy? KN: This is almost impossible to answer as each individual case is so variable. However, consultations can cost as little as £10 for an hour in concessionery clinics. Students usually observe in concessionery clinics. Geographical location and the experience of the practitioner also aect costs. Patients can expect to be charged around £50 per hour in central London, and the same is true of experienced practitioners irrespective of location. The more variable costs to the patient relates to tests. Tests are, of course, optional. However, how far a practitioner can work with a patient in their pursuit of health can be inhibited by working on symptom and lifestyle factors alone. Similarly, nutritional supplements are recommended on an individual basis and eective treatment programmes can be expensive and therefore prohibitive for some patients.
DRB:This must raise ethical issues for nutritional therapists? KN: Yes it does. Many patients seeking private nutrition health care are in ordinary income brackets and sometimes on income support. This can place the nutritional therapist in a moral dilemma. On the one hand, the therapist knows when screening is important and at the same time is aware that should the test results prove positive
Nutritional therapy explained
then expensive foods and products are sometimes needed in order to actively manage an imbalance. Another aspect of the ethical issue is that nutritional therapists stand to gain ®nancially from tests and products that they recommend to patients. The Code of Ethics and Practice that most nutritional therapists follow now recommends tight guidelines about this ethical issue. However, I do not consider it ethical for the practitioner to make judgements about what is aordable for a patient. Some patients will be prepared to forego holidays and other pleasures in their pursuit of wellness. Others will be more reticent about such expenditure. It is not always those inhibited by ®nancial constraints that are the more reticent. I am frequently surprised at what investments and sacri®ces individuals will make to get well. My approach is to discuss with the patient my recommendations for screening and taking nutritional products alongside informing them of the advantages and limitations of such tests and products. This helps the patient to determine what is ®nancially realistic for them to consider. I think the biggest ethical issue confronting nutritional therapists is the ecacy of the tests and products that they recommend. It is easy for practitioners to climb on to the next bandwagon with a new test or a new product and lose sight of their role as educators about the importance of basic sound nutrition. I still ®nd that most health improvements are made by `cleaning-up' the diet, that is, removing highly processed, denutri®ed foods, the excessive use of stimulants like tea and coee, limiting alcohol and eating a diverse wholefood diet as close to nature as possible, plus eating ®ve or preferably ten 80 g pieces of mainly raw vegetables and fruits daily, alongside a litre of good quality still water. Organic produce is a high priority on my list of recommendations to patients as accumulating scienti®c data implicates pesticides in a diverse range of health issues that have the potential to play havoc with our hormones, the very substances that control procreation. Similarly, I advise patients to avoid genetically modi®ed food where they can, as it is clear to me that insucient trials have been implemented prior to their release on the human population, and that those in positions of power appear resistant to cautionary recommendations and public opinion. Unless clearly indicated from the outset, it is not always necessary to perform tests and implement complex expensive supplementary programmes. Giving time for a good diet and basic supplementation to work, and to monitor its eects through symptom relief and increasing experiences of wellbeing is very powerful therapy for both the patient and the practitioner. However, I think it is most pertinent to suggest that routine screening for micronutrient status
127
for instance could prove as valuable a health screen for the prevention and management of disease as cervical smears, breast checks and other routine health checks. Micronutrient de®ciency is common and relatively rarely screened for unless overt symptoms of de®ciency are present. Micronutrient de®ciency, or excess, has a role to play in almost all pathologies. Some patients in the pursuit of optimum health choose to use speci®c screens to keep a check on their potential health status and can adjust their programmes regularly.
DRB: Nutrition seems to be such a contentious subject. Why should this be so? KN: As I said at the beginning, we have to eat to live. Therefore, there are vested interests in food, particularly since we have mechanized most of our food production. Nutrition is a young science. In the early part of this century most vitamins had not been discovered. The understanding of biochemistry and metabolism was limited. In addition, nutrition was not generally considered to be related to disease, except overt conditions like scurvy, beri-beri, pellagra and kwashiorkor. Moreover, nutrition was always considered a `soft' science and related to women and what they did in the kitchen. Nutrititional science is now a rapidly developing ®eld of health care and only the medical ostrich can continue to perceive it as a `soft' science. In fact, many of the pioneers in the ®eld of nutrition see it as the medicine of the future. As nutritional science has gained ground and those pioneers in the ®eld have made successful clinical applications based on the research, it has created friction amongst those in positions of control in two of the most powerful industries, the food and pharmaceutical industries. Processed foods have a long shelf-life and contribute to the enormous pro®ts made by the industry. Vitamins and minerals and other naturally occurring substances found in many nutritional supplements cannot be patented. A synthetic chemical as used in drugs and agriculture can be patented for vast pro®ts. However, I was recently asked to give a short presentation to food product designers and marketeers for a major food company. I was delighted by their interest and awareness of the changing trends in consumer preferences and choices and their desire to capture the market. Separating, ®nancial gain from health care promotion is a political nightmare. For example, the MAFF is responsible to the industry and to the consumer. MAFF is frequently criticized for representing the interests of the food industry over those of the consumer. The government is paving the way to establish an independent Food
128
As the ®eld of nutritional medicine gains credibility, so it receives more and more attack. This is not uncommon when paradigm shifts are occurring.
Complementary Therapies in Nursing & Midwifery
Standards Agency. However, the responsibility for pesticide safety will ultimately remain with MAFF. The top ten pesticide companies have not changed since 1996, and they account for 80% of total sales which is US$25,499. Novartis, Monsanto and Zeneca are the leading agrochemical companies. Monsanto was ®ned £17,000 earlier last year for failing to follow safety precautions in regard to genetically modi®ed food production. This ®ne equates with 1 minute of their annual turnover. It would appear that they can aord to break the rules. As the ®eld of nutritional medicine gains credibility, so it receives more and more attack. This is not uncommon when paradigm shifts are occurring. Resisting change seems to be the rule and ®ghts occur as power bases shift. Until now, nutritional supplements have been classi®ed as foods in the UK, and it has been the responsibility of the Medicines Control Agency (MCA), if it considers the product a medicine, to prove, in court if necessary, that the product is indeed medicinal. The MCA propose to amend the Medicines for Human Use Regulations by introducing a Statutory Instrument, called MLX 249, which would switch the burden of proof from the MCA onto the marketer of the product, such that in the future it is proposed that a company would have to prove that a product is a food. This will present massive problems, not just for high potency nutritional supplements but also for many herbal remedies. This change would restrict consumer choice and undermine the growing desire by consumers to take control of their own health. As there is currently no practical way to license many supplements, many safe, popular supplements will have no viable classi®cation and would be withdrawn from sale. The proposal allows the MCA to determine a substance as medicinal, and that would be sucient evidence in law that it is medicinal, i.e. the MCA's view is unchallengeable. This places the MCA in the position of policeman, judge, and jury. This may be a contravention on the European Convention on human rights, and it ¯ies in the face of 1000 years of English constitution. Most nutritional therapists would like to see improved legislation over the sale of nutritional supplements to improve the safety for public use. However, this sledgehammer approach would be devastating to the food supplement industry and ultimately to patient care.
DRB: Can you leave us with an example of how nutritional therapy has helped your patients? KN: Yes, I believe that I can leave you with a potent example. When I ®rst quali®ed as a
nutritional therapist, nearly 15 years ago, it was dicult to access tests and the range available was quite limited. It was commonplace to recommend dietary and supplement programmes based on symptoms, lifestyle factors and, where applicable, diagnosed disease states. Quite frequently patients improved, but sometimes they did not, and it was dicult to know why. I remember two women patients coming to see me about ten years ago. Both were in their 60s. One had been diagnosed with rheumatoid arthritis and had recently been bereaved. The other was a single lady that had a range of complex signs and symptoms that indicated glucose dysregulation. Both applied stringent dietary protocols and took what would be described as meganutrient programmes for around a year. Each of them expressed around a 50% improvement in their wellbeing as a result of keeping to their programmes. However, they were not as well as they had hoped. Around that time new tests became available that screened for the production of stomach acid, pancreatic enzymes and the porousness of the gut wall. I suggested to both women that they take these non-invasive tests to see if we could pick up a problem that might be inhibiting the release of nutrients from their food or an impaired ability to absorb nutrients. At the same time I recommended that they screened for their vitamin and mineral status using functional or cellular tests which are more signi®cant than measuring serum levels of nutrients. Problems with digestion and absorption were identi®ed in both women and their nutrient status was invariably below the laboratories reference ranges for acceptable levels. This was despite a good diet and meganutrient supplementation for a year. This was a steep learning curve for me. I recommended that they maintained their dietary programme, reduced their vitamin and mineral supplements to basics and implemented digestive aids and substances that assist the regeneration of the gut wall. Both women retested in six months. The patient with rheumatoid arthritis expressed normal nutrient levels and normal digestive and absorption pro®les. It took one year for the second patient to attain normal ®ndings in all parameters tested. Both women experienced a leap in their health as their nutrient levels returned to the reference ranges. Since then, hundreds of my patients have screened for eciency of their digestive processes and this has made a major dierence to the way that I practice. Good diets and meganutrient supplements do not necessarily bring about good functional levels of nutrients. Many factors can in¯uence this outcome. However, checking for digestive competence is crucial when improvements fail to occur within an acceptable period
Nutritional therapy explained
of time. As digestive symptoms are the most common that nutritional therapists encounter, I frequently recommend such tests at the outset in order to target problems as soon as possible.
DRB: What is the biggest challenge to you as a practitioner of nutritional therapy? KN: The satisfaction of appropriately applying newly acquired scienti®c research into the clinical
129
setting and witnessing positive health outcomes from such interventions is what makes being a nutritional therapist worthwhile for me. I get frustrated about the limitations in my current knowledge about nutrition, and the inconsistencies in the ®eld in general. Conversely, the speed in which scienti®c data ¯ood the ®eld is daunting and con¯icting. Making sound clinical applications from the scienti®c data is my greatest dilemma. The art of practising nutrition in a world of scienti®c uncertainty is a regular challenge.