Pulling My Hair Out

or, The Role of Mineral Hair Analysis in the Sale of Food Supplements

initially posted on Holford Watch.

Patrick Holford has set up a charity. Not poorly, fluffy kittens or unwanted donkeys, but a charity dedicated to helping kids do better at schools with better ‘nutrition’. The charity is called Food for the Brain. Being against such a venture would appear to be like being against sunshine or trying to ban Christmas, but I have some genuine concerns about the nature of this charity and will be writing more soon, but for now, I would like to concentrate on one rather strange aspect of it.

The charity sets out to ‘promote awareness of the link between learning, behaviour, mental health and nutrition.’ Great. But this is no Jamie-Oliver-Throw-Out-The-Turkey-Twizzlers-And-Eat-Seared-Carpaccio-of-Beef style campaign. No, this looks like ION for kids – ideas from Patrick Holford’s Institute of Optimum Nutrition being sold to parents who quite rightly want to do the best for their children.

So, we see the usual ION themes – ‘optimum’ nutritional plans, ‘optimum’ health, food supplement regimes, questionable ‘allergy and intolerance’ testing and, what I want to cover today, hair mineral analysis.

The Food for the Brain web site discusses supplements for your kids in some detail and states that the charity uses hair mineral analysis as a diagnostic tool to see what supplements children may need in their school projects. For the schools, Patrick recommends Higher Nature’s Dinochews supplements, an organisation that Patrick Holford, funnily enough, formulates products for and lends his name to. There is also a link to a site called MineralCheck that appears to give independent advice about minerals and hair analysis. (More on this later!)

The idea that our diets may be deficient in minerals, even if we are eating a balanced diet, is popular in nutritionist circles. There are ideas out there in nutri-land that our soils may be depleted from nasty intensive farming and that we should be taking the right supplements to top up. However, scientific sources for this are hard to come by and invariably appear to originate from the suppliers of mineral supplements, as I have previously discussed.

Now, as an idea, diagnosing exposures to heavy metals and attempting to diagnose nutritional mineral deficiencies through analysing hair samples, has been around for some time. The only problem is that it looks like it does not work and has been shown to be flaky in a number of reviews.

Stephen Barrett, one of the first reviewers to look at the subject concludes,

Hair analysis is worthless for assessing the body’s nutritional status or serving as a basis for dietary or supplement recommendations. Should you encounter a practitioner who claims otherwise, run for the nearest exit!

Why would a charity, wanting to improve the nutritional status of kids, recommend to put them through doubtful diagnostic techniques? Before we come to any conclusions, let’s look at why hair mineral analysis probably does not work. It might involve a little science. Forgive me, I think it is worth it.

So, according to MineralCheck, Hair Mineral Analysis (HMA) claims to be able to determine if you have an ‘imbalance’ in minerals. You get a report back telling you about:

  • Your body’s level of nutrient minerals and toxic metals Mineral ratios
  • A list of recommended foods – and those to avoid
  • Food allergy indicators
  • Body chemistry balance analysis Suplement [sic] recommendations

Email the company and they tell you the following…

The cost of the test is £49 and the laboratory will test for 29 nutritional minerals including calcium, copper, zinc, sodium, potassium, magnesium etc) and 8 toxic minerals (including lead, aluminium, mercury and cadmium). The results are presented as a graph with a report attached explaining them and making diet and where appropriate supplement recommendations. Your sample can be sent by post and the report is returned by post.

All very impressive from a few strands of hair. The problem is that these sorts of analytical techniques are very hard. You are trying to find the levels of trace amounts of large numbers of metals in biological samples and then relate that analysis to an understanding of human physiological function and health. This is the stuff that a hundred PhDs are made off. Careers are devoted to such techniques. Let us walk through some of the questions that would have to be well answered by sound science if we are to get close to the MineralCheck promise…

  1. How does the mineral concentration in hair relate to whole body concentration?
    We are not actually interested in hair concentrations as such, but the levels in tissues that need the minerals, such as the blood and other organs. Does hair take up minerals in direct relation to body concentration? It need not. We need to know the answer to this question for each element being analysed.
  2. What individual variation is there in hair growth and mineral levels?
    How does age, ethnicity, sex, activity levels and health affect the result? Again, we need to understand this for each element being tested.
  3. What levels in hair are normal and what ranges are acceptable?
    And how does this vary across different geographies with different diets and lifestyles?
  4. How can we relate these levels to health issues?
    Even if a mineral level is outside the normal range, this does not mean that there is a problem. Mineral levels may be biologically unimportant within a wide range.
  5. How best should we collect samples?
    Does using steel scissors introduce contaminants? What about any sample packaging used? Is ‘home’ sampling OK, or do you need controlled lab conditions?
  6. How much hair do we need to get a reliable, repeatable result?
    One strand, a bunch, how long should the hair be?
  7. Do we need to prepare the sample to remove environmental contaminants?
    Shampoos, car fumes, cigarette smoke and general dirt will be on the hair. Can this be easily removed? Is it absorbed into the body of the hair? Do hair treatments, such as bleaching and colouring, affect the result and how?
  8. What analytical technique is best?
    Most techniques are poor at measuring wide ranges of elements, but are good at targeted elements. Do we need several techniques or the same technique optimised in many ways?
  9. How do we ensure the right levels of accuracy and precision at an affordable level to the testing laboratory and their customers?
    It is no good having a whizzy technique if it costs millions.
  10. How do we get good calibration samples?
    In order to get good results, you need good standard samples to compare against. How can a laboratory obtain known and certified reference materials for each mineral being tested at concentrations similar to that being tested? What analytical technique should be used to certify the references?
  11. How should Hair Mineral Analysis laboratories undertake external quality assurance?
    Good laboratories validate themselves against other independent laboratories to make sure they are not systematically getting this wrong. Who will do this?
  12. What do bald people do?

Now, the problem is that there are few answers to these questions and much work to be done. It could be one day that we answer these question in sufficient detail to have hair analysis as a useful diagnostic tool. But we are not there yet, and one of the reasons is that other more direct techniques, such as blood or urine analysis, are better tools to put our research energy into.

Given the poor state of the science of hair mineral analysis, one might expect that laboratories offering this service might lead to shabby, inconsistent and meaningless results. And that is what is found. Several studies have looked into the quality of results obtained from commercial laboratories. One 1985 study entitled, “Commercial hair analysis. Science or scam?” concluded,

The reported levels of most minerals varied considerably between identical samples sent to the same laboratory and from laboratory to laboratory. The laboratories also disagreed about what was “normal” or “usual” for many of the minerals. Most reports contained computerized interpretations that were voluminous, bizarre, and potentially frightening to patients.

Six laboratories recommended food supplements, but the types and amounts varied widely from report to report and from laboratory to laboratory. Literature from most of the laboratories suggested that their reports were useful in managing a wide variety of diseases and supposed nutrient imbalances. However, commercial use of hair analysis in this manner is unscientific, economically wasteful, and probably illegal.

As this was 20 years ago, we ought to be cautious, but luckily a similar study has been done more recently to see if things have improved. It concluded,

…Variations also were found in laboratory sample preparation methods and calibration standards. Laboratory designations of normal reference ranges varied greatly, resulting in conflicting classifications (high, normal, or low) of nearly all analyzed minerals. Laboratories also provided conflicting dietary and nutritional supplement recommendations based on their results.

CONCLUSIONS: Hair mineral analysis from these laboratories was unreliable, and we recommend that health care practitioners refrain from using such analyses to assess individual nutritional status or suspected environmental exposures. Problems with the regulation and certification of these laboratories also should be addressed.

It is no surprise then that QuackWatch calls this technique a ‘Cardinal Sign of Quackery’. Even worse, the American Medical Association issues a policy on the technique which states,

The AMA opposes chemical analysis of the hair as a determinant of the need for medical therapy and supports informing the American public and appropriate governmental agencies of this unproven practice and its potential for health care fraud.

So, why do people including MineralCheck continue to carry out such analyses? It is difficult to conclude anything other than it is very lucrative and a good way of pursuading people to buy supplements. Whilst blood analysis needs qualified practitioners to take and analyse the sample under medical conditions within a strict legal, ethical, and scientific framework, hair analysis requires none of this. Its much easier, and importantly, much cheaper; posting off a hair sample and getting a computer read-out back. Follow that up with recommendations to buy £50 worth of supplements per month, an order form, and a recommendation to repeat the test in a few months time and you are quids in.

Worryingly, there is a danger that, as the technique looks near useless as a diagnostic tool and the recommendations that come from it arbitrary, there is not only the risk that customers will waste their money, but that harm may come too from needless and drastic changes in diet and excessive supplements.

And, as promised, what do we know about the background of the web site MineralCheck? They don’t say much on their pages – no names, no company information, an anonymous email address, but they do give a telephone number. A quick Google reveals that this telephone number is also used by a Mrs Karen Watkins BA(Hons), Dip.I.O.N, MTTS. It turns out that as well as doing Hair Mineral Analysis, Karen is also Principle of Education at Patrick Holford’s Institute of Optimum Nutrition.

My advice for any school or parent involved with programmes to improve kids nutrition, and is using Food For the Brain for help, should be to question Patrick, the Charity Trustees and the Scientific Advisers to the Charity very hard about the value that Hair Mineral Analysis is bringing to the children. If you get evasive answers, particularly questioning the qualifications of those who doubt the advice from Food for the Brain, I suggest you follow Stephen Barret’s advice and ‘run for the nearest exit!’

On this theme…

26 Comments on Pulling My Hair Out

  1. Hair mineral “analysis”. The modern equivalent of the travelling snakeoil salesman’s prestidigitation. “Look, it’s science! It’s got numbers and a printout!”.

    PS: Do you have something against unwanted donkeys?

  2. i believe the hair is not analysed for its mineral content but is examined energetically using sophisticated computer software. I know of people at their wits end with severe health problems (e.g. uncontrollable epilepsy) who have had a diagnosis and successful treatment using this method. I trained as a scientist and have a healthy scepticism about any claims, including those with traditional research to back them, as we all should be aware that science can be abused and made to support almost any theory you care to name. I think people go for this because they run into brick walls with conventional methods and find a more helpful positive approach in the complementary/ alternative camp. However it works if it helps people improve their health whats the problem

  3. Alex – the problem is that we do not know that hair analysis works. You claim to be scientifically trained and yet you resort to anecdote. How do you know how many people this ‘works’ for? How many does it not ‘work’ for? You do not know.

    But the big give away is that you claim that hair is “examined energetically using sophisticated computer software”. This is pure pseudoscientific bullshit and makes me doubt you are scientifically trained and are just promoting this quackery.

  4. @ Alex's comment: "I trained as a scientist…" Brilliant, but rather vague…what sort of science Alex? Geo-, Environmental-, Molecular-? Or perhaps more likely, Computer Science…

  5. It’s amazing. A hair/mineral analysis test helped me a lot. You are such horrible horrible horrible people creating internet spin so you can get paid by pharmaceutical lobbyists who have devoted a fraction of their profits to eliminating the competition as they see it. But in doing so it’s peoples health that suffers. How absolutely disgusting is that. You are neither scientists nor healers of any kind. You profit on misery and sell ignorance. But people (like me) are waking up to your game, for what you do is simply not sustainable. You can have as many “watch” websites as you want but you only get the simple and narrow minded people’s interest.

    • As is typical of supporters of quackery, Ciaran, you attack me and not my arguments.

      Can you state any bit of this article that is ‘spin’ and not either fact or reasoned opinion?

      Can you produce any evidence that this blog is corrupted by ‘Big Pharma’ money?

      Can you show where I profit at all from this blog – especially in ‘misery and ignorance’?

      Shame on you.

      • I think there is quackery all around on both sides. That said I have had tests done for years on myself, not under insurance, and until last month they were only of the serum/rbc/whole blood type. I finally decided to give a hair mineral test a chance since it was relatively cheap compared to the blood tests. Surprise, they matched what my blood tests showed. It is very clear that the various companies can’t agree on what the ranges should be but that is also true of some blood tests as well, a glaring example of this is the LabCorp vs Mayo Clinic serum Selenium range. Using the results of a hair test to justify chelation therapy though is a step too far for me. If you are healthy your body will automatically detox anyway. My ‘toxin’ section came back as normal for everything except uranium, which could be due to my seafood consumption due to the recent meltdown in Japan.

      • To make clear, I use the hair tests as an adjunct to blood tests for verifying the dietary mineral levels. The fact that the tests also includes ‘toxin’ mineral levels is just a curio for me.

  6. I haven’t got time to pull out all the research, hair mineral analysis has SOME uses, it appears to be fairly accurate in the analysis of some metals, mercury being one of them. That being said, there are still many many issues with confounding variables.

    The point being, it may be useful as a guide to an individual who has exhausted all routes of conventional medicine and for £50. It might give you a clue to potential toxicity levels or insuffiency of certain minerals. If you were seriously ill, had exhausted all areas of treatment and there was a test with conflicting scientific evidence that may guide you in potential treatment, would you do it? I guess you will say no because you aren’t one of those individuals, and until you are, then i guess you cant have an opinion. Not everything can be solved by a positive P value unfortunatley, thats the problem with you wannabe ‘new scientist’ brigade.

    My main issue would be with the Labs, you could have one man and his dog ‘analysing’ these samples. This isn’t to say there are reputable labs out there who do use the science behind this technique. Do a pub med search, the science base is there.Quack off and do your research.

    I suggest you chaps use a little more evidence base in your articles, your science doesnt seem to be very scientific. Very misleading title, simply ALL hair mineral analysis as quakery. Quacks claiming quakery.

  7. I’m afraid Mark, that a poorly characterised analytics technique remains just that even if you have “exhausted all routes of conventional medicine”. Wishing that it can give you reliable results, just because you feel desperate, does not make it so.

  8. Stop just disregarding information! rarely do tests have 100% specificity and/or sensitivity. Usually a combination of signs, symptoms, histological findings, medical history etc are needed to even get close to diagnosis of complex chronic disease.

    It’s not ‘wishing’ anything. It’s taking an evidence base and using it. it may have less chance of finding accurate information, but only as much as many medical tests for many diseases. It’s about piecing the complete case together, not wishing. An indication is better than no indication. Even so, it IS accurate for the measurement of some not all minerals.

    “poorly characterised analytics technique”, do a pubmed search and stop being so anecdotal! Where is your evidence that it’s a poorly characterised technique!!!! Ridiculous. As i said, do a pubmed search and you’ll find out how accurate it can be, and an extremely valuable inexpensive analytical tool for some diseases.

    Why is everything so black and white with some people. Jesus, open your mind a little and just do a little critical thinking of your own.

    http://www.ncbi.nlm.nih.gov/pubmed/20155631 – a very quick search on pubmed. Now wake up and stop disregarding valid techniques. Bad labs=bad results. Unfortunately as the article states, regulation is non-existant. Fortunately new laws will soon be in place.

    I don’t know why i bother commenting, it just enrages me how you ‘quackometer’ guys think you are so enlightened, yet can’t even formulate the simplest piece of critical evaluation, using ALL the evidence, it’s called cherry picking your evidence! The very arguement you so often use as your trump card.

  9. Ironically, I see you cherry pick a study on hair analysis that does not show that the test is giving reliable results but instead shows that it is being used to sell supplements to people with cancer. The study you cite is typical of nutritional quackery – no controls, small and failing to show that the intervention actually did any good.

    By making the straw man of my argument that I am demanding “100% specificity and/or sensitivity”, you clearly do not understand analytical techniques – I guess you are in the business of selling vitamin pills? No?

  10. I didn’t cherry pick, i explained exactly what i did; a very quick pubmed search on the topic area, i unfortunately didn’t have to time to fully critically analyse the full text. How is it quakery?! The study doesn’t in anyway claim that they have looked at supplementing zinc and selenium in cnacer patients. Just that zinc and selenium status is low, which is also reflected by serum levels, and the old chestnut that it requires further research. Fair enough.

    “By making the straw man of my argument that I am demanding “100% specificity and/or sensitivity”, you clearly do not understand analytical techniques – I guess you are in the business of selling vitamin pills? No?”

    How so my friend? what a terribly weak response, throwing a wild accusation and then the assumption that i know nothing of analytical techniques. I admit it isn’t my specialist field of interest, but i know enough to understand the pro’s and con’s of many types of lab diagnostic methods. It seems…. you don’t.

    I am in no such business, i have vey mixed opinions on vitamins and other food supplements, but thats another story that i couldn’t even scratch the surface of on an internet blog. Actually i’m currently just writing my Msc disseration, hopefully to be published in Gut (i’ll let you know when it is, then you can try critically evaluating some diagnostic methods for coeliac disease and how even established analytical techniques can be very unreliable, especially in complex chronic disease).

  11. I would like to draw readers to the statement made by the US Environmental Protection Agency (E.P.A) in 1979

    “The consensus of most workers in the field is that if hair samples are collected properly, cleaned and prepared for analysis correctly and analyzed by the best analytical methods, using standards and blanks as required, in a clean and reliable laboratory, by experienced personnel, the data are reliable.”

    Toxic Trace Metals in Mammalian Hair and Nails. United States Environmental Protection Agency Publication 1979; EPA-600/4: 79: 049

    Their conclusion is further supported by the recent finding of substantial inter-laboratory variability in reported results by Seider et al.

    The literature is replete with examples of the value of hair mineral analysis in assessing toxic exposure. I have come across papers supporting the validity of hair mineral analysis in assessing nutritive status but am less familiar with its clinical and diagnostic value.

    Here is a link to a collection of excerpts relating to hair mineral analysis.

    http://drlwilson.com/HAIR%20ANALYSIS/HA%20Prof.%20Statements.htm

    I appreciate that these are highly selective and the author appears to offer detoxification therapies but I consider (I have also read several of these papers in entirety) that there is sufficient indication of efficacy and assuming there has been no attempt to misrepresent the findings, that the lay or educated reader could not defensibly conclude that this technique is no value.

    The JAMA paper by Seider et al has been quoted followed by a remark by the author “It is no surprise then that QuackWatch calls this technique a Cardinal Sign of Quackery.’ At the very least I would offer that Dr. Stephen Barret is ill informed.

    The quote from Seider et al was also selectively highlighted, appreciably to draw attention, however it is important to note the inclusion of the phrase “Hair mineral analysis from these laboratories was unreliable.” This would permit one to infer that hair mineral analysis from ‘other’ laboratories could conceivably be reliable adopting appropriate technical procedures – in line with the E.P.A statement.

    I am loath to paste this link from wikipedia but it’s late and i’m tired 🙁

    http://en.wikipedia.org/wiki/Hair_analysis

    Hair analysis is widely used in forensic toxicology (note this link does not discuss mineral analysis)

    http://www1.imperial.ac.uk/medicine/research/researchthemes/cancer/research_cancer/meta/toxicology/hair/

    Whilst I was going to make this post substantially longer, I am sleepy so I will end on several sloppy points

    – I have mentioned the literature is replete with examples supporting the value of hair mineral analysis

    > I have provided no references so I could be confabulating

    – People appear to have difficulty fathoming how one may garner useful information from hair analysis

    > That’s your problem, go formulate a hypothesis and attempt to rigorously falsify it. As a side note physicians still, astonishly, conclude that a patient has normal magnesium levels from a serum test when no accurate determination can be made about tissue levels – Oh no!

    – I have no love for people that misrepresent my love which is toxicology either denigrating it or stratospherically inflating it.
    I impress upon myself the need for tentative knowledge, how do you know that they’re aren’t little fairies inside Quark particles telling them what to do? To my knowledge no-one has disproven this theory.

    > A stupidly vivid point of the need for tentative knowledge and to abhor absolution – one i have been told off for using. Be warned i may be a fairy.

    And whats wrong with vitamin pills? They are physiological substances of which deficiencies or insufficiencies can lead to metabolic deficits. A simplistic example may be the chronically tired patient with demonstrable insufficiences in several of the B-vitamins which are cofactors in the TCA cycle (wikipedia it if you must). Impaired ATP production is a valid cause of premature fatigue. Sometimes I do wonder when I hear ‘some’ doctors saying you only need to eat a balanced diet. When questioned as to what this entails they tell me to go clerk a patient 🙁 I know where i want to stick that bow tie. I also wonder when i hear ‘some’ nutritionists say vitamins are soaked up by the brain – i missed the detailed workings of the vitamin sponge in biochemistry. To put it simply nutrient levels are function of metabolic demand and supply. (Saying that statistically defined nutrient sufficiency may not be equivocal to metabolically defined nutrient sufficiency due to enzyme polymorphisms!) Science is like Alice’s rabbit hole except a lot of the rabbits have their heads inside their bums and think thats all there is too see. Now thats gross. Returning to the notion of metabolic demand, find out what Michael Phelps eats on a day to day a basis then chastise him and his dietary advisers for failing to following a ‘balance diet.’ (Not directed at anyone. I believe many would readily consider macronutrient requirement i.e. protein, carbohydrates, fat on a day to day basis but fail to appreciate the importance of micronutrient requirement which has equal importance.) I feel it most unfortunate the potential for modification of biological systems with dietary constituents has been maligned but the fact that it is ‘food’ appears to colour its value and besides no-one likes food that is good for them!

    Ps. I am a medical student and because I’m still a baby I feel the need having read more of Stephen Barrets writings – which contain some gross inaccuracies to say i’m not his friend and that he has cooties. Ewwwwww

    Hal

    • Hal

      You are discussing using HMA for the detection of exposures to toxic trace elements such as Hg or U. It may well be then possible to see gross and large changes in the concentrations of these elements and then indeed you may wish to see a toxicologist.

      But this post is about going to see a nutritionist to look at nutritional levels of important trace elements. There, it would appear, the role of HMA is just as a quack’s sales tool.

      Look at how you link to the Dr Wilson site. He offers nutritional analysis by HMA – but the papers he uses to justify this are selective and mainly based on toxic exposure levels. Classic misdirection.

  12. Good response Hal.Have you read the book ‘biochemical individuality’?

    Le Canard, I definately agree that it is a toxicologist that should analyse these results. I doubt many people would actually get to see a toxicologist (apart from in an acute setting) but we can dream.

    Oh…. one point that made me smile…….

    I had a quick browse on your profile and found this!

    “If I had a pound for every quack who has accused me of being in the pay of ‘Big Pharma’ I would be richer than if I was really in their pay.
    It looks like accusing someone of just being a shill for evil medical interests is a standard way that quacks avoid answering the criticisms made against them. Its very shallow.”

    Le canard, i completely agree, how very shallow, shame on them.

    Let me take you back a couple of paragraphs:

    “you clearly do not understand analytical techniques – I guess you are in the business of selling vitamin pills? No?”

    Hoisted by your own petard!Resorted to throwing out pathetic accusations. Boosh, got ya!

    What a load of drivel anyway! Of course you should look for conflict of interest first! Just as if a probiotic was being clinically trialled, and it happened to be one of the big supermarket probiotic yoghurt brand carrying out the research, do you not think this may add an immeridate bias?!!!It immediately questions the integrity of the research. MONEY! It’s all business at the end of the day. Why do think conflicts of interest have to be stated!

  13. Hey Mark,

    Yes I have read biochemical individuality – pity the author’s dead I would have loved to have met him!

    It should be on the syllabus for undergraduate medics/scientists impresses on need to appreciate the variability of biology and unwittingly takes to task the token nod to ‘heterogeneity’ in academic and clinical medicine.

  14. I hope to return to this website later and read this debate properly, in order to make my response worthy. In the meantime, I would like to state that I have witnessed over one hundred people of all different ages, races, backgrounds, health problems etc. on a nutritional balancing program, specifically designed through interpretation of hair mineral analysis. Every single one has experienced health improvements. That’s sufficient proof for me.

    • How did you rule out regression to the mean in your interpretation of what you observe? In other words, how did you control for the biases that invariably make direct interpretation of such observations so difficult, such as expectation effects, the natural course of illness, regression to mean etc?

      Given that there the whole premise of nutritional medicine so shaky and that hair mineral analysis is completely unstandardised, isn’t it more likely you are just seeing normal health improvements?

  15. hey, i was wondering what you think of this article from a top hair mineral analysis “expect”. http://www.drlwilson.com/articles/hair_analysis_controversy.htm

    i don’t advocate hair analysis and am personally trying to find out if it’s of any use. i know there’s quackery in alternative medicine but i also know that the fda is bullshit when they say MSG is a generally safe ingredient when i see my dad have horrible reactions (sick for days, throwing up) whenever he eats something with MSG. anyway, any help you can offer would be great.

  16. Did the person who wrote this article actually try hair mineral analysis before writing it? Everything I’ve researched about it makes absolute scientific sense and the nutritionist I spoke with was incredibly kind and forthright. I am going to try it as all other medications I have taken have not worked. Pharmecutical companies are a multi billion dollar industry. Why wouldn’t they discourage against it?

    • I have heard that most pharmaceutical companies only test their products against a placebo. Can you shed some light on this?

  17. Family experience (not mine) of hair analysis for mental health reasons. Results prompted much needed dietary improvements. Yet in my view, little clear evidence either way. On balance, this proved a helpful stepping-stone towards recovery.

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