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The Difference between Nutritional Therapists and NHS Dietitians Part 3

This is the third in a series of briefing notes setting out the key differences between dietitians and nutritional therapists (NTs).

Nutritional therapy practice is often attacked for not being ‘evidence-based’ in contrast to dietetic practice. In fact leading expert dietitians readily admit the lack of evidence underpinning their current practice: the 2007 edition of the BDA Manual of Dietetic Practice, page 134, states:

“Section 1.16.8 Evidence based practice ..In order to be able to access and assess clinical evidence, dietitians must be able to search the literature and have skills in critical appraisal…. They also need to be aware of a major constraint in using an evidence-based approach in dietetics, i.e. the shortage of coherent, consistent scientific evidence for much of dietetic practice.

What dietitians do regard as ‘evidence-based’ are the national dietary guidelines based on 1991 Department of Health recommendations. However in November 2009 the UK Scientific Advisory Committee on Nutrition published new proposed calorie guidelines after admitting that the 1991 calculations were flawed and inaccurate. This may have huge implications for other recommendations across dietetic practice and food labelling.

In 2009 rapid advances have been made in nutrigenomics/nutrigenetics but as early as 2002 Artemis Simopoulos of the Centre for Genetics, Nutrition and Health in Washington DC said “there may be no such thing as a ‘normal’ population with respect to nutrient requirements, as was assumed when dietary reference values were established“, and “…populations should not copy each other’s dietary recommendations for the prevention of coronary artery disease, and cancer, or any other disease for that matter“. In 2006 the US Institute of Medicine President Fineberg spoke about the challenge facing the public health paradigm: “It is not just possible but likely that there are nutrients that affect some population groups differently than others, and public health guidelines will have to take such differences into account…A public health paradigm of universal education is going to have to be adapted to the scientific reality and scientific knowledge as it develops and unfolds“. And in 2007 experts from the European Food Safety Authority advised that food-based dietary guidelines could not be set at the European level, at most at the national level but even then special groups would have to be considered.

So the answer to the question “Why do nutritional therapists exist if dietetic practice is evidence-based and works?” is that NTs have long-recognised the extent of biochemical individuality and the potential flaws in transferring population guidelines to recommendations for optimising individual health. Public appreciation of NT as effective and meeting individual health goals grows year on year. Put simply, professional advice for optimal health has to take account of unique dietary and nutritional needs – and that is what NTs are trained to give.


Ames, B.N. 2003. The metabolic tune-up: metabolic harmony and disease prevention. Journal of Nutrition 133: 1544S-1548

S. Ames, B.N., Elson-Schwab, I. and Silver, E.A. 2002. High-dose vitamin therapy stimulates variant enzymes with decreased coenzyme binding affinity (increased K(m)): relevance to genetic disease and polymorphisms. American Journal of Clinical Nutrition 75: 616-658.

British Dietetic Association, 2007. Manual of Dietetic Practice

Dept. Health. Dietary reference Values for Food Energy and Nutrients for the United Kingdom (DH, 1991)

European Food Safety Authority. 2007. Food based dietary guidelines. Report of the 5th Scientific Colloquium. Available at: /EFSAScientificColloquiumReports/efsa_locale-1178620753812_FBDG.htm

Fenech, M. 2005. The Genome Health Clinic and Genome Health Nutrigenomics concepts: diagnosis and nutritional treatment of genome and epigenome damage on an individual basis. Mutagenesis 20: 255-269.

SACN, 2009. Draft Energy Requirements Report

Simopoulos, A.P. 2002. Genetic variation and dietary response: nutrigenetics/nutrigenomics. Asia Pacific Journal of Clinical Nutrition 11: 117-128.

Yaktine, A.L. and Pool, R. 2006. Nutrigenomics and beyond: informing the future. National Academies Press, Washington DC, USA.


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The Difference between Nutritional Therapists and NHS Dietitians Part 2

This is the second in a series of briefing notes setting out the key differences between dietitians and nutritional therapists.

For dietitians the idea of aiding detoxification through nutrition is “a load of nonsense”. In January 2009 the British Dietetic Association issued a press release stating that the body has a well-developed system of the skin, gut, liver and kidneys all responding to chemical signals to constantly eliminate toxins. Proper hydration, a sensible diet and regular physical activity “really are the only ways to properly protect your health for the year ahead”.

For nutritional therapists, detoxification, which is the biotransformation of harmful molecules, is a core determinant of physical and mental health and is dependent on nutritional status. Poor conjugation and poor excretion of exo- and endo-toxins, combined with elevated toxic load, results in insidious and cumulative damage to metabolic processes and increasing susceptibility to disorders such as inflammatory joint disease, neurological impairment, atherosclerosis, allergies, chronic fatigue, and cancer.

The primary mechanism of biotransformation involves activation of cytochrome P450 enzymes for Phase I oxidative metabolism followed by Phase II conjugation to facilitate excretion. Phase I metabolism can either directly neutralise some compounds or transform them to highly reactive metabolites ready for phase II conjugation. Balanced Phase I and Phase II activity is important to avoid increased production of intermediary metabolites which, without sufficient antioxidant protection, are damaging to DNA. Common variants (including deletions) in genes encoding for Phase I and II enzymes increase genome events which mediate aging (mitochondrial decay) and the disease process. Poor nutritional status leading to inefficient biotransformation contributes to long-term adverse health outcomes.

A healthy gut ecology is also important for optimal biotransformation and therefore hormonal balance and immunity. Biotransformed compounds can be deconjugated by enzymatic products of unfriendly gut flora and reabsorbed into hepatic circulation.

Functional testing is used by nutritional therapists to target individual advice.


2. Ames, BN, I Elson-Schwab,EA Silver: High-dose vitamin therapy stimulates variant enzymes with decreased coenzyme binding affinity (increased K(m)): relevance to genetic disease and polymorphisms. Am J Clin Nutr 75, 616-58 (2002).
3. Choi, W, SY Eum, YW Lee, B Hennig, LW Robertson,M Toborek: PCB 104-induced proinflammatory reactions in human vascular endothelial cells: relationship to cancer metastasis and atherogenesis. Toxicol Sci 75, 47-56 (2003).
4. Guengerich, FP: Influence of nutrients and other dietary materials on cytochrome P450 enzymes. Am J Clin Nutr 61, 651S-658S (1995)
5. Hennig, B, BD Hammock, R Slim, M Toborek, V Saraswathi,LW Robertson: PCB-induced oxidative stress in endothelial cells: modulation by nutrients. Int J Hyg Environ Health 205, 95-102 (2002)
6. Hennig, B, AS Ettinger, RJ Jandacek et al.: Using nutrition for intervention and prevention against environmental chemical toxicity and associated diseases. Environ
Health Perspect
115, 493-5 (2007).
7. Ito, S, C Chen, J Satoh, S Yim,FJ Gonzalez: Dietary phytochemicals regulate whole-body CYP1A1 expression through an arylhydrocarbon receptor nuclear translocator-dependent system in gut. J Clin Invest 117, 1940-50 (2007)
8. Loktionov, A: Common gene polymorphisms, cancer progression and prognosis. Cancer Lett 208, 1-33 (2004)
9. Ramadass, P, P Meerarani, M Toborek, LW Robertson,B Hennig: Dietary flavonoids modulate PCB-induced oxidative stress, CYP1A1 induction, and AhR-DNA binding activity in vascular endothelial cells. Toxicol Sci 76, 212-9 (2003)
10. Hattori M & Taylor TD: The Human Intestinal Microbiome: A New Frontier in Human Biology. DNA Res 16(1):1-12 (2009)
11. Round JL & Mazmanian SK: The gut microbiota shapes intestinal immune responses during health and disease. Nat Rev Immunol 9, 313-323 (2009)

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The Difference Between Nutritional Therapists and NHS Deititians Part 1

In September 2004 the Nutrition Society published a Department of Health funded report on “Understanding the differences between nutrition health professionals” 1 . The report revealed the extent to which consumers appear to be fascinated by the links between food and health but are confused by the different types of individuals who give nutrition advice and are thus prevented from making informed choices. This confusion is no more apparent than in relation to what ‘optimum nutrition’ means to dietitians, nutritionists and nutritional therapists. This briefing note aims to clarify the position so that consumers can be clear as to the differences.

(1) For dietitians and nutritionists (registered with the Nutrition Society) advising a client on optimum nutrition comprises 2,3

  • taking measurements appropriate to body mass
  • explaining the links between different foods (e.g. meats, vegetables, fruits, convenience foods, drinks) and nutrient composition using the ‘Balance of Good Health’ model (
  • reviewing and analysing the client’s food diary, nutritional plan and other lifestyle changes to promote health.

(2) Public health nutritionists, toxicologists and food scientists work together to provide policy managers and legislators with advice needed to promote health in the population at large. In particular with regard to micronutrients, they need to establish levels of benefit and of risk and look at ranges of intake values which need to be both nutritionally adequate and non-toxic for the whole population. In this instance optimum nutrition is defined as “the intake at which there are equivalent risks of both inadequacy and toxicity” providing that “data on both are of equal quality, are related to hazards of comparable severity and are equally well defined” 4.

(3) For nutritional therapists (who practise Complementary and Alternative Medicine) optimum nutrition encompasses individual prescriptions for diet and lifestyle in order to alleviate or prevent ailments and to promote optimal gene expression through all life stages. Recommendations may include guidance on natural detoxification, procedures to promote colon health, methods to support digestion and absorption, the avoidance of toxins or allergens and the appropriate use of supplementary nutrients, including phytonutrients. Nutritional therapists advise on each person’s unique dietary and nutritional needs for metabolic and hormonal homeostasis, using a variety of biochemical and functional tests to inform recommended protocols and programmes.


1. Nutrition Society (2004) Understanding the differences between nutrition health professionals
2. Skills for Health Allied Health Professionals’ Competences 13 and 14.
3. The British Dietetic Association and the Nutrition Society (2002) Joint Professional Development Guidance on the Employment of Nutritionists in NHS Nutrition and Dietetic Departments.
4. Renwick, AG et al (2004) Risk-benefit analysis of micronutrients. Food Chem. Toxicol. 42 (1902-1922).

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