The Pills ‘n’ Thrills & Bellyaches of Patrick Holford

Patrick Holford’s inadequate grasp of science and medicine has been pointed out many times before and he has even inspired a blog to correct his frequent and egregious errors and Clintonesque misstatements. Patrick was the subject of approximately 10 minutes of criticism by Ben Goldacre in his excellent Radio 4 series on lifestyle nutritionists past and present. Regrettably we didn’t get to hear Patrick’s dulcet tones, a voice that has pushed a million pills, as he felt that Radio 4 were:

quite aggressive and suggested a preconceived agenda to trash nutritional therapy with a highly-biased presenter, who has won numerous awards funded by the big pharmaceuticals.

Instead Holford has listed questions from the BBC and his responses on his website. Now Ben Goldacre may indeed be a Big Pharma shill, an anti-nutritionist bigot and the son of Satan but unless any evidence is forthcoming we should judge him on his words and on his deeds, as we should do with Patrick Holford. In fact Ben Goldacre, playing a synthesis of Copernicus and Galileo to Holford’s Pope Urban VIII, makes it clear that the world does not revolve around Patrick Holford:

As I believe the BBC explained repeatedly we were making a general programme about the misuse of science by nutritionists and the $56 billion food supplement industry in the Radio Science Unit, not a consumer programme about the various problems with Patrick Holford, and I personally am not very interested in a programme simply examining Patrick Holford….[]

Now it would be easy to mock Holford’s egotistical musings, after all even the most inflated ego can be let down by a small prick, but of more concern is Holford’s grasp of science and evidence in responding to the BBC’s questions. When examined superficially Holford’s responses seem reasonable and appear to cite evidence in favour of his argument, however, when a little bit of scrutiny is applied the evidence and arguments are revealed as little more than smoke and mirrors hiding a deep and dangerous ignorance.

Q. Chapter 24 of the latest edition of the ONB where he states that “AZT, the first prescribable anti-HIV drug ….is proving less effective than Vitamin C” (p.208). Could Mr Holford explain how he comes to make such a dramatic claim when the single study he references is in fact an in vitro test that does not once mention AZT?

A. You have an old edition of the book. The 2007 edition cites the studies that shows this to be true. The author of the study, Dr Raxit Jariwalla, states “Patrick Holford’s conclusion that ‘AZT, the first prescribable anti-HIV drug is proving less effective than vitamin C’, as interpreted from the results of our experiments, is correct. In two published studies in which we compared vitamin C to AZT in chronically and latently infected cells, our experiments consistently showed that AZT was less effective than vitamin C. I made this clear in my letter to the Guardian and am surprised that the Guardian journalist continues to wrongly accuse Mr Holford.’ There has been one human trial of high dose vitamin C and N-Acetyl Cysteine, the results of which are extremely encouraging. As I say in my book ‘It is a tragedy that this simple, non-toxic treatment hasn’t been further tested.’

Now it is pleasing that Holford has at last acknowledged errors in the older edition of ONB, especially as it was only last September that he was offering thinly veiled legal threats at Professor David Colquhoun for having the temerity to highlight inaccurate claims on vitamin C and AZT. It does appear though that Holford is perpetuating these inaccurate claims in his response above. I have nothing further to add to Prof Colquhoun’s criticisms of these papers and Holford’s interpretation, also Holford has not answered the question. He still refers to in vitro tests, which are cell culture experiments and cannot be extrapolated to whole organism physiology, and as Prof Colquhoun points out:

Holford also forgets to mention (or perhaps didn’t notice) that the concentrations of Vitamin C that are used in these in vitro studies are something like 10 times greater than can be achieved in man even with very high oral doses,

So even the corrected version of Holford’s book cannot justify his claims regarding vitamin C being better for treating AIDS than AZT. There is also no sign of the human trial on PubMed and Patrick has not provided a reference for it so he really has no basis to cite it in support of his arguments. Ironically there may be a role for vitamin C in conjunction with AZT, it appears that high doses of vitamin C may prevent some of the side affects of AZT in animal models. I wonder how long it will be before Patrick ignores his previous conclusions and peddles his vitamin C pills based on this research?

Q.That in the same book, Chapter 24, still on the subject of vitamin C, Mr Holford cherry picks studies in order to back up his claims about the role of vitamin C in the treatment or prevention of colds. What is Mr Holford’s reasoning for using a retrospective analysis of data from studies carried out before 1974 only and ignoring the many studies that have taken place since?

A. “The referenced study used in the Optimum Nutrition Bible in relation to colds and vitamin C, was the most up-to-date systematic review of studies on vitamin C, published in 2000. The most recent systematic review of studies on vitamin C, published last year reaches more or less the same conclusions that Vitamin C supplementation reduces the duration of symptoms, reduces the severity of symptoms, but there is no convincing evidence on reducing incidence ie the number of colds. It reports that the strongest effect is for immediate high doses on the onset of a cold, for example if 8 grams is taken 46% of subjects have a cold for no more than a day. That is the equivalent of 176 oranges, hence the recommendation in the Optimum Nutrition Bible to supplement vitamin C in high doses when you have a cold. When the book is next updated I will cite this more recent review.

The most recent review of vitamin C and the common cold is this one from the Cochrane Library. The plain language summary is below:

Plain language summary
Vitamin C for preventing and treating the common cold

The term ‘the common cold’ does not denote a precisely defined disease, yet the characteristics of this illness are familiar to most people. It is a major cause of visits to a doctor in Western countries and of absenteeism from work and school. It is usually caused by respiratory viruses for which antibiotics are useless. Other potential treatment options are of substantial public health interest.

Since vitamin C was isolated in the 1930s it has been proposed for respiratory infections, and became particularly popular in the 1970s for the common cold when (Nobel Prize winner) Linus Pauling drew conclusions from earlier placebo-controlled trials of large dose vitamin C on the incidence of colds. New trials were undertaken.

This review is restricted to placebo-controlled trials testing at least 0.2 g per day of vitamin C. Thirty trials involving 11,350 participants suggest that regular ingestion of vitamin C has no effect on common cold incidence in the ordinary population. It reduced the duration and severity of common cold symptoms slightly, although the magnitude of the effect was so small its clinical usefulness is doubtful. Nevertheless, in six trials with participants exposed to short periods of extreme physical or cold stress or both (including marathon runners and skiers) vitamin C reduced the common cold risk by half.

Trials of high doses of vitamin C administered therapeutically (starting after the onset of symptoms), showed no consistent effect on either duration or severity of symptoms. However, there were only a few therapeutic trials and their quality was variable. One large trial reported equivocal benefit from an 8 g therapeutic dose at the onset of symptoms, and two trials using five-day supplementation reported benefit. More therapeutic trials are necessary to settle the question, especially in children who have not entered these trials.

This review certainly does not recommend the therapeutic use of vitamin C and is clear that the research is uncertain and more trials are needed. With specific regard to Patrick Holford’s claim that the review states that 8 g of vitamin C causes 46% of recipients to have a cold for no more than a day the review actually states:

The statistically significant Anderson 1974e entry combined two different dosage arms. Anderson 1974e administered 4 g/day, and Anderson 1974f administered 8 g/day on the first day of illness only. The mean duration of illness episodes for those in the 4 g/day arm was 3.17 days, while that for 8 g/day arm was 2.86 days compared with the duration in the placebo group #4 of 3.52 days. This 1974 trial was bedeviled, however, by the fact that the investigators originally intended to compare results with two separate placebo groups. One of the placebo groups (#6) had substantial baseline differences when compared with the six vitamin C groups. The comparisons presented here are with the placebo group #4 that was much closer to the vitamin C groups with respect to baseline data (seeHemilä 2006a). If comparisons had been made with the placebo group #6 or a combination of the two placebo groups as the investigators had originally intended, the benefits would have been minimised as the mean episode duration for the placebo group #4 was 3.52, and for placebo group #6 was 2.83. Nevertheless, notwithstanding the placebo group problem, the proportion of ’short colds’, that lasted for only one day was larger in the 8 g/day group (46%; 222 out of 483) compared with the 4 g/day group (39%; 164 out of 417) (P = 0.046), consistent with the possibility of therapeutic benefit at the higher dosage (see p. 42 in Hemilä 2006a).

This is rather at odds with Mr Holford’s analysis of the 8 g claims and alongside his inaccurate claim that the review endorses therapeutic dosage with vitamin C suggests that Mr Holford has problems with comprehension.

Q. In Mr Holford’s article “Anti-Oxidant Review is a Stitch Up” he makes the mistake of confusing randomised controlled trials with observational (correlational) studies by suggesting that the meta-analysis on anti-oxidants (which reviewed only RCTs) left out two studies but in fact they were not RCTs and would not have been included. Does Mr Holford accept that his criticisms were wrong? And will he correct this article and others which make the same mistakes?

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

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

It seems strange that Mr Holford should accept the criticism of his criticisms then go on to reiterate his criticisms in a further attempt to avoid criticism. Anyway, as Holford has forgotten to provide references here is a link to the review. Now I cannot find the statement in the review suggesting that the Correa reference skews the results towards the negative. In fact if you look at this table it seems the Correa reference is just one of many showing that mortality in controls was lower than in the anti-oxidant group, certainly the conclusions of the review do not hinge on the Correa paper. Also, while the intention of the paper was not to study mortality it does have data that can be used in later analyses in conjunction with data from other studies to address questions of mortality. The Correa paper certainly does suggest there are benefits in supplementing with anti-oxidants in terms of gastric dysplasia but it does not look at potential side effects such as increased mortality. Given Holford’s previous problems with accurately quoting people may I suggest that Dr Correa’s remarks may have been taken out of context or misquoted.

The second paragraph above contains a number of phrases in quotation marks that are different from the actual phrases used in the paper. The following passage from the results section is the one referred to above:

Vitamin A given singly or in combination with the other supplements did not significantly affect mortality. After exclusion of high-bias risk and selenium trials, vitamin A singly or combined significantly increased mortality (Table 5).

Vitamin E given singly or in combination with the other supplements did not significantly affect mortality (Table 5). Vitamin E given singly in high (1000 IU) or low dose (<1000 IU) did not significantly affect mortality (RR, 1.07; 95% CI, 0.91-1.25; I² = 0% and RR, 1.00; 95% CI, 0.94-1.07; I² = 13.0%, respectively). After exclusion of high-bias risk and selenium trials, vitamin E given singly or combined significantly increased mortality (Table 5).

Vitamin C given singly or in combination with the other supplements was without significant influence on mortality, even after the exclusion of high-bias risk trials and selenium trials (Table 5).

Selenium given singly or in combination with other antioxidant supplements had no significant influence on mortality when analyzed separately (Table 5). Selenium given singly or combined significantly decreased mortality when analyzed together. After exclusion of high-bias risk trials, selenium given singly or with other antioxidants had no significant influence on mortality (Table 5).

Holford it seems has cherry picked and altered quotes so that it appears the results do not match the conclusions. However, even the most cursory of readings shows that the reviewers eliminate trials with high-risk of bias from their conclusions. It seems that Holford, for all his talk of pharmaceutical bias, is quite happy to ignore bias when it suits his prejudices. It is not the reviewers who are cherry-picking, it is Patrick.

Q. In the Food for the Brian Child Survey, we asked Professor John Stein to look at the literature review which underpins the very conclusions of this report – a report which was heavily promoted in media and which may possibly go on to have some influence on government policy. His view was that most if not all of the references were systematically misrepresented, or perhaps misunderstood by the authors of the report. As the Food for the Brain project is on-going does Mr Holford agree with these criticisms and will he use his influence to ensure that future reports or statements about Food for the Brain projects accurately reflect the nature of the evidence and do not overstate it in order to promote their cause?

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

The best thing to do here is refer readers to Holfordwatch’s thorough dissection of the errors in this report. Needless to say the errors have not been corrected.

Q. Finally, will Mr Holford make clear any commercial relationship to any company past or present that promotes and manufacturers vitamin and mineral supplement pills, food intolerance tests or similar related products?

A. “If it’s got my name on it, be a book or a supplement, I earn a royalty. I do formulate my own supplements with the scientific experts at Biocare, whom I believe to be one of the best supplement companies in the UK, and for which I do receive royalties, however I do not simply direct people to take my supplements. I explain, in my books, articles and on my website, what to look out for in supplements, how to make sure you are getting the right levels of the nutrients that the scientific evidence supports as beneficial. I categorically am not in the business of simply persuading people to take supplements so that I can make money out of them, but advise supplements for many reasons which are apparent from articles on my website and in my books.”

This is a load of waffle where a simple list would do but it is a revealing insight into the hypocritical nature of the Holford mindset. While stating he is not in the business of pushing supplements to make money out of people he runs a website that charges fees so that:

As a member of the 100%health Club I’ll use all my expertise, contacts and research to bring you clear, unbiased advice on how to stay healthy. That’s what you’ll receive as a 100%health member

Effectively Patrick is acting as a paid consultant making money out of people by advising them on how to stay healthy, usually by taking supplements. It is a shame that, as this very brief look at his responses shows, he distorts evidence, misrepresents and misspeaks making him thoroughly unqualified to offer dietary advice. When you couple this with his clear business interests in profiting from supplements it beggars belief that this man has become an authority in the eyes of the media.