Zoe Harcombe vs The Advertising Standards Authority: Candida (Part 3)

In this third post I want to look in detail at the responses that Zoe Harcombe provided to the Advertising Standards Authority (ASA) to support the claims that Candida causes food cravings and that the Harcombe Diet can treat Candida.

Firstly, to avoid any misunderstandings further along lets start by defining our terms clearly. When Zoe refers to “Candida” she is referring specifically to Candida albicans 1 a type of fungus commonly present in our mouth and gut flora, which typically co-exists without harmful effects.

It is true that Candida albicans can cause adverse health effects, from opportunistic local infections of mouth or vagina (thrush) to more serious systemic infections which can be life threatening to those who are immunocompromised. These conditions are distinguished by having objective criteria and laboratory tests which can be undertaken to give a diagnosis of cause. Generally effective treatments to prevent or cure infections are scarce and have been subjected to only limited  clinical trials 2.

What remains controversial however, is the idea that Candida overgrowth (alternatively referred to as chronic candidiasis, candidiasis hypersensitivity, yeast syndrome) occurs in otherwise healthy individuals who may not present verifiable diagnostic symptoms, and that Candida overgrowth is the cause of a wide variety of chronic, often unrelated health problems, including food cravings.

I challenged via the ASA complaint process 3 whether:-

…the claims in ads (a), (b) and (c) relating to Candida, hypoglycaemia and food intolerance misleadingly implied that they caused food cravings and could be treated by the Harcombe diet;

The response from Zoe Harcombe 3 was that:

…ads (a) and (b) did not mention food cravings. They said that ad (c) was a web page containing further background information on Candida and contained quotes from medical literature and peer reviewed references. They said it did not include claims or mention the Harcombe Diet, but factually reported work undertaken by Zoë Harcombe as a researcher.

The idea that no claims are being made is blatantly false and seems to be another attempt to avoid the burden of proof about her claims – that’s two now if we are counting – if you don’t believe me simply watch the video embedded on the same web page of the Harcombe Diet (from 4:03 onwards):

Phase I in the Harcombe Diet is a perfect diet to kill Candida…[…]…that is how Phase I came about, so you starve the Candida so it cannot proliferate any more and you actually get it back under control where it stops you craving all those bad foods…[…]…

It is also odd that Zoe asserts that she is not making any specific claims regarding food cravings, because this hypothesis is a central claim of her book 4 and during the previous investigation by the ASA 5 she gave the following response:-

ZH said the fact that there were three medical conditions that caused food cravings was ZH’s original discovery and the unique contribution of the Harcombe diet…[…]…ZH provided some brief extracts that referred to food cravings from a number of publications, which they listed…[…]…They said that the relationship between the conditions and cravings was now well known. They said that using an internet search engine returned a large number of results for links between the conditions and food cravings.

Ignoring the appeal to Google popularity –  from the above response we might have a reasonable expectation that there would be a strong body of supporting literature showing a direct casual relationship between Candida and food cravings. So lets look at the references currently on the Harcombe Diet page 6 references which I note only appeared after the ASA began investigating these claims back in September 2013 7.

Taking them in the order they appear on The Harcombe Diet website:

  • Hajjeh et al (2004) 8. While this paper supports the idea that Candida can have significant detrimental health effects, had Zoe not truncated its full title it would be clear that this paper is specifically about bloodstream infections of Candida in those admitted to hospital which were laboratory tested and verified by the Centre for Disease Control and Prevention (CDC). Candida albicans blood stream infections were identified in 12.6% of cases (45% of 28%) – is Zoe really asserting that the potential effects of Candida in the general population is in any way comparable to that of hospitalised patients, the majority of whom either had a central catheter or were recovering from surgery? This seems like scaremongering.
  • Achkar & Fries (2010) 9. This review paper deals with infections of the genitourinary tract and states that both men and women can be colonised by Candida albicans  without harmful effects, although it can lead to diseases which have clinical signs of inflammation. It also makes it clear that incidence numbers are the greatest in hospitalized patients. While this supports Zoe’s claim that Candida can have health consequences the distinction should be made that serious effects of Candida are not likely to the general population of dieters.
  • Calderone & Fonzi, (2001) 10. I couldn’t obtain a copy of this,  but it appears to be a paper about the technical details of just how Candida Albicans is able to successfully invade and sustain itself to cause localised or systemic infections in humans, not about symptoms. I may be wrong [Edit 05.01.2014, I now have the full paper, see the update underneath the post]
  • Trofa, et al (2008) 11 This paper is about Candida parapsilosis, not Candida albicans. Regardless, there is no mention of food cravings anyway.
  • Jobst & Kraft (2006) 12. I couldn’t obtain a copy of this paper but the part quoted is simply the introductory statement of the symptoms which are claimed to be associated with “Candida-Syndrome” not a conclusion. If I read this correctly 308 patients with unspecified symptoms filled in a questionnaire and provided a stool sample, of which about a third tested positive for Candida a “finding regarded as normal”. There were associations reported with candida-vaginitis and food allergies but “hints of a Candida-syndrome could not be found”. Even if the paper had found an association with food cravings, this is a cross sectional study so it wouldn’t be adequate to demonstrate causation anyway. [Edit 05.01.2014, I now have this paper, see the update underneath the post]
  • Nusbaum (1986) 13.  An opinion piece which suggests that Candida albicans perpetuates the problems of those with bulimia. The author clearly states that these are “theoretical explanations” for treatment of bulima and no direct studies showing causation are provided.
  •  Alcock et al. (2014) 14. This is an interesting paper which discusses potential mechanisms via which gut microbiota might manipulate host behaviour to bring about unhealthy eating behaviour such as increasing intake of foods which are high in sugar and fat. These are clearly  identified by the author as alternative explanations and tempered with caution. There are no specific references to Candida albicans in this paper, or good reason to extrapolate the findings.

Finally there are a variety of books referenced, two of which I have copies of:-

  • The Yeast Connection: A Medical Breakthrough by William G. Crook M.D 15. This is the book which really popularised the idea that Candida was a hidden health problem for the masses, containing a much copied self diagnosis checklist. Unfortunately by the authors own admission in the foreword “The book describes relationships which have been observed between the common yeast germ Candida albicans and human illness”. Yes – the whole book is basically a collection of uncontrolled, observational anecdotal case reports which do little to provide evidence of cause and effect.
  • Beat Candida Though Diet, by Gill Jacobs16. Again, this book is simply a collection of anecdotes in which Candida is implicated as the cause of a range of symptoms. No robust evidence is presented to show food cravings are caused by Candida, and the author seems happy to make even more outrageous unverifiable assertions about the effects on health: “Other conditions which are thought, or suspected to have a candida connection are as follows:…[…]…heart disease…[…]…AIDS…”. I mean really?

I would suggest that robust evidence that Candida Albicans *causes* food cravings is scant to non-existent. I could find nothing in the references listed on the Harcombe Diet website, and in the light of this the ASA’s adjudication 3 seemed reasonable, and inevitable:

We acknowledged that the claims were based on a view expressed in her books, but considered that they were presented as objective fact. We had not been provided with any evidence that Candida, hypoglycaemia or food intolerance were associated with being overweight or food cravings…

So what about claims that the Harcombe Diet can treat Candida?

Well, although the response in the ASA adjudication shows no evidence was provided on this point, it was specifically addressed in the draft ruling from the previous investigation 5. Its worth looking at this to see the merits of the evidence and arguments presented. Firstly Zoe claimed that:

…doctors writing about the three medical conditions documented their medical evidence, including when the conditions were dealt with the symptoms cleared up…

The fact that it was “doctors” like Dr William D. Crook MD writing about the conditions in books like The Yeast Connection is an irrelevant argument from authority, in the absence of randomised controlled trials, doctors relying on observation are subject to exactly the same biases and errors as the next person.

The bigger problem here is that there are no objective criteria to establish that Candida overgrowth was even a valid initial diagnosis in these accounts. The diagnostic symptoms in Crook’s checklist reproduced on the Harcombe Diet website are ubiquitous and not in any way specific to Candida. I would expect most people to test positive for some of them – headaches fatigues, particular as no time-scales are specified on the majority of them. If you claim someone has condition “X” but cannot show objectively how to diagnose and measure this, how could you subsequently verify the impact of any intervention?

Even if you grant the premise that Candida overgrowth was the problem in these cases, how do we know that the cases highlighted are ‘typical’ experiences which have not been subject to observer and confirmation bias? Should we not be wary of the post hoc ergo propter hoc fallacy, and how do we attribute cause and effect when such wide ranging, radical changes to diet and lifestyle have been simultaneously implemented.

It is also worthy of note that none of the previously cited papers 8, 9, 10, 11, 12, 13 about Candida infection cite any dietary intervention treatment as having demonstrable efficacy.

Was any other evidence offered?

They said the research behind the Harcombe Diet analysed the dietary advise given by various doctors in relation the three medical conditions. They said the took the lowest common denominator of dietary advice for each condition to establish the core safe foods….

But the books cited don’t just offer dietary advice. The Yeast Connection for example makes it clear that the recommended treatment is dietary change accompanied by medication (the use of the anti-fungal Nystatin is mentioned frequently throughout the book) as well as cutting out alcohol, smoking and avoiding a number of supposed environmental triggers. You cannot rely upon someone else’s – rather poor – evidence for efficacy but cherry pick just the parts of the methodology related to diet. Incidentally the book also suggests hope and prayer* to treat Candida – why did these recommendations not make the cut for inclusion in the Harcombe Diet?

There was of course also a claim that:

…correspondence with people who had used the diet supported (sic) documented health improvements and they provided a selection of such correspondence.

*Sigh* We’ve been here before……

So in conclusion, we have seen that:-

  • Candida albicans is a type of fungus which is generally present without harmful effects in our bodies
  • Candida albicans commonly causes localised infections. Serious systemic infections are most likely in immunocompromised or hospitalised individuals.
  • The theory that a wide range of unbiqutous, unrelated symptoms  are due to candida overgrowth is unproven and accordingly there are no diagnostic criteria for this ‘condition’
  • The claims that food cravings are caused by Candida albicans are not supported by robust clinical trials
  • The claims that candida overgrowth can be effectively treated by dietary interventions such as The Harcombe Diet are not supported by robust evidence.

* Page 261 of the Yeast Connection says if your physician in unaware of the yeast connection you can take charge of your own health and suggests you:

Put your “emotional house” in order. Love, touch, faith, hope and prayer are all important in helping you get well and stay well”.


Update 05.01.2014

Big thanks to Rosie Norman (@GlutenFreeRosie) for providing me with full copies of the two papers I was missing. I can now give a more complete commentary.

Calderone & Fonzi, (2001) 10. As I suspected this is solely a technical paper. If you wish to understand what Candida is, how it can morph between unicellular yeast cells and filamentous growth it’s excellent. However citing this as evidence that Candida can “create havoc with our health and well-being” is borderline scaremongering because this paper is very clear that the clinical important of Candida is related to those with candidemia (i.e. an infection of the blood) patients with AIDs, or those suffering recurrent vaginitis. The former are serious health conditions, the latter has objective diagnostic criteria. How are these relevant to the general population of dieters looking to lose weight?

Jobst & Kraft (2006) 12. The paper does not support a link between Candida and food cravings, and if anything it simply demonstrates that the passage quoted on the Harcombe Diet page below is an example of egregious quote mining:

“Patients with unspecific symptoms were sometimes tested for Candida. In case of findings of this yeast-like fungus in their stools they often were labelled with the diagnosis of a ‘Candida-syndrome’. This comprises headache, weakness, flatulence, ravenous appetite for sweets, itching skin and several more unspecific symptoms.” [ii]

The emphasis on the above is not in the original paper and, as previously discussed this is a description of the symptoms ‘Candida-Syndrome’ is reported to be associated with i.e.. it is a description of the hypothesis they are investigating, not a conclusion of the paper. In fact it actually concludes that their study:

…indicates that Candida in stool is associated with smoking, Candida-vaginitis and allergies…[…]…these results are a statistical, not a causal finding.

There is nothing in this paper to support any link between Candida and food cravings. In fact the papers discussion section is quite dismissive of the whole idea of a “Candida-syndrome” as the following passages demonstrate:

Proponents of the so-called yeast-connection emphasise that consuming sweets are a major risk factor for the Candida-syndrome. This was not supported by our findings: distribution of positive and negative Candida tests were the same in patients who frequently were consuming sweets and patients who did not…[…]…Our results did not show headache/migraine, abdominal complaints, eczema/itching, tiredness/low general performances level, pollinosis, other skin diseases or the influence of intake of sweets to be associated to Candida occurrence in stools, each one considered as a part of the Candida-hypersensitivity-syndrome. Seen together with recent reviews [25, 26] our exploratory study leads far away from that idea.Candida in stool without evidence of a Candida-infection such as Candida-vaginitis is a normal finding. There is no need for further diagnostics towards a Candida-related disease or a therapeutic intervention than. Avoiding sweets because of Candida in stool does not appear to be useful.


References

1 Why do you Overeat? When all you want is to be slim. The Harcombe Diet, 2013, Columbus Publishing, ISBN-978-1-907797-24-8, Page 92.

2 Clinical use of oral nystatin in the prevention of systemic candidosis in patients at particular risk, Mycoses. 1996 Sep-Oct;39(9-10):329-39.

3 http://www.asa.org.uk/Rulings/Adjudications/2014/12/Zo%C3%AB-Harcombe/SHP_ADJ_274813.aspx#.VIGOkNKsXHU

4 Why do you Overeat? When all you want is to be slim. The Harcombe Diet, 2013, Columbus Publishing, ISBN-978-1-907797-24-8, Page 130.

5 Draft Recommendation, Advertising Standards Authority, Case Number 13-242778, June 2014

6 http://theharcombediet.com/home/candida/

7 http://web.archive.org/web/20131209071702/http://theharcombediet.com/tools/candida/

8 Incidence of Bloodstream Infections Due to Candida Species and In Vitro Susceptibilities of Isolates Collected from 1998 to 2000 in a Population-Based Active Surveillance Programme, J Clin Microbiol. Apr 2004; 42(4): 1519–1527

9 Candida Infections of the Genitourinary Tract, Clin Microbiol Rev. Apr 2010; 23(2): 253–273

10 Virulence factors of Candida, Trends Microbiol. 2001 Jul;9(7):327-35

11 Candida parapsilosis, an Emerging Fungal Pathogen, Clin Microbiol Rev. Oct 2008; 21(4): 606–625

12 Candida species in stool, symptoms and complaints in general practice – a cross sectional study of 308 outpatients. Mycoses. 2006 Sep;49(5):415-20

13 Food for Thought: The Problem of Anorexia Nervosa and Bulimia. Journal of Orthomolecular Medicine

14  Is eating behavior manipulated by the gastrointestinal microbiota? Evolutionary pressures and potential mechanisms.” BioEssays. August 2014

15 The Yeast Connection: A Medical Breakthrough,  Third Edition, 1985, ISBN 0-933478-11-9

16 Beat Candida Through Diet, 1997, ISBN 978-0-09-181545-5.

Zoe Harcombe vs The Advertising Standards Authority: Weight Loss (Part 2)

In this second post I want to look in detail at the responses that Zoe Harcombe provided to the Advertising Standards Authority (ASA) to support the claim that the Harcombe Diet [1] leads to weight loss*.

But before I do that, I want to identify some fundamental principles of an evidence based approach which we might use to appraise claims.

  • The burden of proof rests squarely on the person making a claim. This is a basic principle of scientific and reasoned argument and not co-incidentally, is how the ASA investigation process works (They  expect an advertiser to hold robust evidence before making a claim).
  • Evidence to support any claim should be of a high quality. There are many aspects to this, but in its simplest form this means avoiding making claims based upon evidence which we know is likely to be subject to significant bias or errors.

Via the ASA complaint process I challenged [2] whether:

…the implication in the testimonials in ad (d) that the Harcombe diet led to weight loss could be substantiated

Here is advertisement (d) and the testimonials in question, as they looked in July 2014:

testimonials cropped

In response to this Zoe Harcombe [2]:

…said the testimonials were direct quotations from the book ‘Stop Counting Calories & Start Losing Weight’ and that they would amend the ad to make clear they were book extracts

Now there are two possibilities here: i) Zoe entirely missed the point that it is the use of testimonials to make objective adversing claims which is the problem rather than their source, or ii) she tried an unedifying manoeuvre in a bid to re-frame her advertising claims so as to put them outside the remit of the advertising regulator.

Lets look at both possibilities.

On the use of testimonials, I will spell it out: anecdotal evidence is one of the very weakest forms of evidence available to us, because by its nature it is uncontrolled and subject to a number of biases which mean it is not representative of the ‘typical’ experience. It is for these reasons that testimonials should not be used to support a generalised claim about the efficacy of a weight loss method.

Just to show I am not misrepresenting Zoes position, here is her response to the ASA from the previous investigation in June 2014 [3]:

 ZH said that the diet did work, and that they regularly receive feedback telling them that. They provided copies of some unsolicited feedback they had received…[…]…They said that the person who informed them of the “17lb in 5 days ” weight loss had done so so unsolicited.

Aside from the bald assertion, it doesn’t appears to have dawned on Zoe that unsolicited letters from dieters are not only entirely uncontrolled accounts (we have no idea what other variables changed which may have contributed to that success), but are also a self selected sample which will probably more strongly favour those who were successful and thus felt motivated to share their experiences with her.

What about those who don’t write letters? Do dieters ever write to authors telling them it didn’t work? If so why does the marketing for the Harcombe Diet not include a representative proportion of these? This really is basic stuff and is exactly why the CAP Codes expressly point out that testimonials should not be used for to support objective claims.

If alternatively Zoes response was simply attempting to take the claims outside the ASA’s remit, then I have to conclude that would represent a cynical attempt to avoid the burden of proof. If the claims in her book are based on robust evidence and meet the standards of good science, then they should also stand up to the comparable (more on that later) scrutiny of an ASA investigation.

We should demand so much more of self appointed diet ‘experts’. Do we want to take advice from those who evade reasonable requests for evidence while applying that standard to others, or do we want those who recognise the burden of proof and invite scrutiny of the evidential basis of their own claims?

In the light of the above, it is unsurprising that the ASA adjudicated that [2]:

 Ad (d) included testimonials which referred to weight loss and we therefore considered that consumers would understand that undertaking the Harcombe diet would lead to weight loss. The CAP Code stated that any claim made for the effectiveness of a weight-reduction method must be backed, if applicable, by rigorous trials on people, and that testimonials were not sufficient to support such claims. We noted Zoë Harcombe said they would amend the claims to make clear they were book extracts, but were concerned that any such quotes were still likely to imply efficacy. We had not been provided with any evidence that the Harcombe diet, which we understood did not rely on calorie reduction, led to weight loss and therefore concluded that the testimonials breached the Code.

On this point ad (d) breached CAP Code (Edition 12) rules 3.1 (Misleading advertising), 3.7 (Substantiation) and 13.1 (Weight control and slimming).

Now in her defence Zoe has gone to great lengths to attempt to discredit the CAP Codes [4]. While I don’t think that the CAP Advertising Codes are perfect, I believe that in general they have some sensible principles which are important for consumer protection. It is therefore worth looking in detail at the breaches identified to see if she has a case.

Here are the first two Code requirements [5] which were breached:

3.1 Marketing communications must not materially mislead or be likely to do so.

Could anyone reasonably argue that marketing communications should not mislead?

3.7 Before distributing or submitting a marketing communication for publication, marketers must hold documentary evidence to prove claims that consumers are likely to regard as objective and that are capable of objective substantiation. The ASA may regard claims as misleading in the absence of adequate substantiation.

Are the claims in advertisement (d) not likely to be taken as an objective claims by consumers? You may disagree but I suspect how much will I lose? is probably the first and most important question people ask before embarking on any weight loss diet. The requirement for adequate substantiation (as noted below) in my opinion is simply a reasonable application of the burden of proof to an advertising claim and I fail to see how such fundamental principles can be wrong.

What about the more specific CAP rules on weight loss [6] which Zoe asserts [4] are invalid?:

13.1 A weight-reduction regime in which the intake of energy is lower than its output is the most common self-treatment for achieving weight reduction. Any claim made for the effectiveness or action of a weight-reduction method or product must be backed, if applicable, by rigorous trials on people; testimonials that are not supported by trials do not constitute substantiation

The first thing to note here is that compliance with this requirement is not contingent in any way on accepting what Zoe terms the ‘calorie theory’ (that a 3,500 kcal deficit in energy will lead to a 1 lb weight loss**), it simply infers that a calorie deficit is the most common approach which is likely to be used to achieve weight loss, but states that where applicable claims of efficacy for any method must be backed by human trial data.

Far from being against ‘non-conventional’ advice, what we have here is an entirely level playing field where any weight loss method which can be substantiated is not misleading. I suppose you could argue that a small diet business does not have the resources to conduct a suitably powered Randomised Controlled Trial (RCT) which might be capable of satisfying the ASA, but that I am afraid, appears to be the cost of making objective claims about weight loss. This certainly isn’t an argument for providing only the flimsiest of supporting evidence.

So in summary we have seen that:-

  • The claims that the Harcombe Diet leads to weight loss are by Zoes own admission based only on self selected anecdotal evidence, which may be biased and cannot be use to support generalised claims of efficacy.
  • Zoe Harcombe appears to have attempted to re-frame her claims to avoid scrutiny.
  • The CAP Codes require substantiation in line with a reasonable burden of proof
  • The CAP Codes require a high standard of evidence for objective weight loss claims, which the Harcombe Diet failed to meet.

In the next post Zoe Harcombe vs the Advertising Standards Authority: Candida (Part 3) I am going to look at claims about Candida overgrowth, food cravings and the dangers of encouraging self diagnosis.

* For clarity, I am not asserting that the diet cannot work, merely considering if the evidence put forward by Zoe Harcombe is robust and supports the claims about weight loss.

** The ‘Calorie Theory’ put forward by Zoe Harcombe is a strawman. ‘Conventional’ weight loss advice does not stand or fall solely on whether a rule of thumb used to estimate the calorie deficit required to lose a given quantity of weight gives a precise and accurate prediction each and every time. Additionally, anyone claiming that the validity of a weight loss model is dependant on its ability to make accurate predictions must, for consistency, also reject alternative theories such as the ‘insulin theory’ which fail this test.


References

[1] http://theharcombediet.com/

[2] http://www.asa.org.uk/Rulings/Adjudications/2014/12/Zo%C3%AB-Harcombe/SHP_ADJ_274813.aspx#.VIGOkNKsXHU

[3] Draft Recommendation, Advertising Standards Authority, Case Number A13-242778, June 2014

[4] http://www.zoeharcombe.com/2014/11/the-asa-trolls-working-together-to-censor-progressive-thinking/

[5] http://www.cap.org.uk/advertising-codes/non-broadcast/codeitem?cscid=%7B61a03caa-6750-498d-8732-68d55c0752fd%7D#.VIqv_dKsXHU

[6] http://www.cap.org.uk/advertising-codes/non-broadcast/codeitem?cscid={103cf916-ce1c-4224-b42c-49f4c4dc5203}#.VIqwuNKsXHU

Zoe Harcombe vs The Advertising Standards Authority: Introduction (Part 1)

I submitted two complaints to the Advertising Standards Authority (ASA) about Zoe Harcombe. The first was in September 2013 regarding claims made about her diet on her blog [1], the second in July 2014 about claims made on the Harcombe Diet Website [2] and the Harcombe Diet & Health Club Website [3].

I am writing this introductory post as there are likely to be a  number of subsequent posts over time, and I wanted to establish the full accurate chronology of events and my motivation for submitting these complaints before looking in more detail at the ASA investigation and the responses given to them.

The key dates in the complaints were as follows:-

  • September 2013: Complaint submitted about Zoe Harcombes Blog. Five claims investigated.
  • November 2013. Zoe Harcombe responds to the ASA and provides the evidence to support her claims.
  • June 2014: ASA produce draft recommendation for ASA council to consider, which suggested upholding four of the five complaints.
  • June 2014: Zoe Harcombe reaches an informal resolution with the ASA [4] and agrees in writing to amend the advertisments and to not make the claims again. As a consequence the draft recommendation was not published.
  • June 2014: ASA remind Zoe Harcombe that the commitments in the informal resolution apply equally to her other websites.
  • July 2014: Potentially misleading claims remain. Second complaint submitted about claims on the Harcombe Diet Website and the Harcombe Diet Club Website.
  • October 2014: Zoe Harcombe responds to the ASA and provides the evidence to support her claims.
  • December 2014: Final adjudication published upholding the complaints about five of the six claims [5]

The motivation for the complaints – contrary to the lurid, unsubstantiated ad hominem attacks which assert that I am in the pay of Big Flora, or a narcissistic psychopath [6] – was rather simple: I didn’t believe that the claims made were based upon high quality evidence, or that the arguments put forward were logical and coherent.

Additionally, with a significant twitter following, coverage in national press and a range of popular diet books, regardless of what any of us may think about the merits of her advice, Zoe is in a position where she directly influences peoples decisions about diet and health. This brings with it certain responsibilities which are above and beyond compliance with advertising codes, because bad advice can lead to harm.

The approach of challenging claims is one I would hope Zoe herself would agree with, her biography [7] states that her personal values are (my emphasis):

…health, relationships, personal development, mutuality and integrity

and she notes on her blog [8] that she likes to:

…expose non-evidence based nutritional messages

These are admirable values and demolishing dogmatic beliefs is a worthwhile endeavour. Zoe therefore should have had no problem with – and arguably should have actively embraced – a reasonable request from the ASA for the evidence which supported her ideas and claims.

In Zoe Harcombe vs The Advertising Standards Authority: Weight loss (Part 2) I will be looking at how the responses to the ASA stand up to the burden of proof, whether the evidence submitted was robust and how they relate to the CAP Advertising Codes.


References

[1]http://web.archive.org/web/20130910075438/http://www.zoeharcombe.com/

[2] http://web.archive.org/web/20140805170422/http://theharcombediet.com/

[3] http://web.archive.org/web/20140709084502/http://www.theharcombedietclub.com/30dayblitz/

[4] http://www.asa.org.uk/Rulings/Adjudications.aspx?SearchTerms=zoe%20harcombe#2

[5] http://www.asa.org.uk/Rulings/Adjudications/2014/12/Zo%C3%AB-Harcombe/SHP_ADJ_274813.aspx#.VIGOkNKsXHU

[6] http://www.zoeharcombe.com/2014/11/the-asa-trolls-working-together-to-censor-progressive-thinking/

[7] http://www.amazon.co.uk/Zoe-Harcombe/e/B003ANDBNM

[8] http://www.zoeharcombe.com/

Nina Teicholz, Health Ministers and the Swedish “Government” Low-Carb Diet Guidelines

I’ve not yet got round to reading The Big Fat Surprise by investigative reporter Nina Teicholz, but her recent tweets in support of her thesis (the claim that the science says that a healthy diet includes large amount of fats from butter, meat and cheese) have become increasingly bizarre.

Here is an example:

Now, lets stop for a moment and think really hard about what she might be implying here.

Could it be that Teicholz knows in detail about the particular diets of these individuals (Maggie De Block, Belgium; Gabriel Wikström, Sweden and Gaetan Barrette, Quebec) and is implying that by observation alone we can see that one particular diet is the best for weight?

Even if that were true – and I can find no evidence to support the idea that Gabriel Wikström achieved or maintains his weight using LCHF – how does an uncontrolled observation based on three individuals with a multitude of other differences tell us anything about diet?

It also raises the ugly spectre of cherry picking – why were these particular members used as examples and not say the UK’s Jeremy Hunt, another country which hasn’t adopted low-carb dietary guidelines?

jeremy-hunt-wild-things

For the avoidance of confusion, Jeremy Hunt is the svelte chap on the left. No, the use of Health Ministers implies something else…….

Could it be then, that Teicholz is implying that you cannot be a health minister on merit, if your BMI isn’t acceptable?

Hmm, while there may be an element of offensive fat shaming involved, I think her further tweet eludes to her real meaning:

Teicholz seems to be implying that the health ministers are in some way the physical manifestation of the success of the dietary policies of the nations or province.

Aside from the fundamental daftness of this idea, and the fact that the Swedish Council on Health Technology Assessment was only written just over a year ago (thus having limited time to effect the health of an entire nation), she gets fundamental facts about it totally and utterly wrong.

It is not a Government Report or set of consumer guidelines, it is a Swedish Council on Health Technology Assessment.  This report has been misrepresented so much that Swedish National Food Agency even took the step of clarifying this matter:

Sweden does not have any guidelines on low-carb-high-fat diets. The information that Sweden has guidelines on low-carb-high-fat diets is based on incorrect information circulating on the Internet.

Has this investigative reporter heard of Google? Did she not think it weird that no-one has actually produced this set of paradigm shifting guidelines?

Also I cannot see how the report itself can be interpreted by Teicholz, or anyone to mean the Swedish Government is the first to:

…formally ditch the low-fat diet.”

I mean even with just the press release in English it seems pretty clear to me that the report states that Low Carb is the best for short term weight loss (<6 months), but is one of a number of comparable options for longer term weight loss which includes low fat and Mediterranean diets:-

In the short term (six months), advice on strict or moderate low carbohydrate diets is a more effective means of achieving weight loss than advice on low fat diets. In the long term, there are no differences in the effect on weight loss between advice on strict and moderate low carbohydrate diets, low fat diets, high protein diets, Mediterranean diets, diets aimed at achieving a low glycaemic load or diets containing a high percentage of monounsaturated fats.

Further the only diet for weight maintenance with sufficient evidence is low fat, in preference to either LC or Mediterranean:

Maintaining reduced weight. When obese individuals have lost weight, they can maintain their weight more effectively with advice on low fat diets with a low glycaemic index and/or high protein content rather than low fat diets with a high glycaemic index and/or low protein content. There is no data available to assess whether advice on low carbohydrate diets and Mediterranean diets, for example, is effective to prevent weight increase after weight loss.

For someone who is an investigative reporter there is a staggering amount of poor reasoning and a lack of fact checking here.

Its time for the zombie fact about the Swedish Low-Carb guidelines to be put back in its grave for good, and Nina can start that process with a retraction of what is clearly misinformation.

Updated 31/10/2014

In response to comments from Jacques Rousseau on twitter (do read his excellent blog post here) Nina Teicholz’s claims:

Firstly on the issue of policy, Health Technology assessments are authored by the independent Swedish SBU and the reports produced:

…could, for example, be an important source of information for other decision-making authorities, such as the National Board of Health and Welfare, the Medical Products Agency and the Dental and Pharmaceutical Benefits Agency. Professional associations of health care personnel, such as doctors, nurses and dentists, can use SBU reports as a basis in preparing their own guidelines. An SBU report can also be used at an individual health centre or clinic to provide guidance on the possible benefits for patients of introducing, prioritising or, in some cases, excluding methods.

Note the use of the words could, and can. The purpose of a HTA is to act as an independent guide to decision making. Yes the recommendations can be adopted within separate guidelines (or used to devolve decision making all the way down to individual doctors and nurses) but it is not and never will be a Government Policy. If Sweden had translated the HTA into guidelines rejecting the LF diet, where are they?

This are, of course moot points, because Nina Teicholz totally misrepresents the content of the report.

The idea that the authors were biased to keep in line with established wisdom is laughable – I mean just read the report itself, each decision was graded based upon specific evidence presented by the SBU and the evidence for LCHF was simply lacking, or absent in many area. If you don’t believe me feel free to read a translated summary here.

Faced with this refusal to amend her false claim I issued a simple challenge which would take no more than 10 minutes on google:

..and further offered to set the record straight if I am wrong:

After a number of requests Nina Teicholz simply blocked me on twitter.

 

Action on Sugar, Salt, Saturated Fat, Advertising and Supermarket Layout

“Campaign group” Action on Sugar yesterday launched their Childhood Obesity Action Plan, as requested by Jeremy Hunt MP and having read it I am again confused, baffled and befuddled, in fact nearly as much it seems, as they are.

I highlighted the many obvious problems with the Action on Sugar campaign previously noting their narrow focus and failure to acknowledge obesity as a multifaceted issue. I also more recently pointed out that their campaign had singled out sugar as uniquely damaging while espousing the virtues of fat and that this was a bad idea.

It doesn’t take a genius to work out that an obsessive focus on a single macronutrient (fat) is one of the reasons that we are where we are today, and that claims that reducing added sugar alone in processed food would solve the obesity crisis are ridiculous.

It seems however that something, somewhere has changed.

The Childhood Obesity Action Plan produced by Action on Sugar finally acknowledges that there are wider issues than just sugar reduction and that a range of measures will be required. Its not exactly a step change, the suggested measures are impractical and they still seems determined to blame the food industry for everything, but its an improvement of sorts.

However if you read the detail of the action plan you might raise an eyebrow – as unfeasibly high as Roger Moore during the 1980’s – at some of the contents.

Take Action 4 for example

Fat is a major source of calorie intake; we propose an incremental fat reduction programme similar to the salt and sugar reduction programme, to reduce fat by 15% by 2020 in all products.

Hallelujah!

Its taken them nearly six months to realise that calorie dense foods containing fat – which has about twice the calories of sugar – also need to be considered if you are to offer a joined up solution to obesity. Yes the suggest reduction constitutes only roughly 30kcal/day for 11-18 year olds but why did no one realise this for so long?

Even more surprising however is the rationale for targeting reductions in saturated fat

This should particularly focus on saturated fat, as this is the major factor controlling cholesterol levels (which is the third cause of death globally, through the vascular disease it causes, which leads to both strokes and heart attacks and peripheral vascular disease

Surprising because Action on Sugars Science Director Aseem Malhotra is the very person who wrote an article in the BMJ expressly refuting each and every statement in this rationale.

Does the Science Director not set the campaigns approach based upon the consensus view of the evidence? Has he had an epiphany since last year? How are decisions taken at Action on Sugar: A coin toss? The direction of the wind? A spur of the moment decision by the author of the press release?

Does anyone really think that Action on Sugar – now seemingly Action on Sugar, Salt, Saturated Fat, Advertising and Supermarket Layout – can come up with a coherent joined up solution to obesity when their very name shows how little they understand the issues, and they have a science director who doesn’t even subscribe to the views they promote?