All RDs Are Nutritionists - But Not All Nutritionists Are RDs

Nutritionist. Food Coach. How Good Is Their Diet Advice?

Anyone can claim to be a "nutritionist" or "food coach."
So here's what you should look for

By Katherine Hobson
Posted on US News & World Report: February 5, 2010

If you feel the need for professional help with your eating habits or diet, you may assume a nutritionist is the person to talk to. As it turns out, that's not a particularly specific or useful term—a point driven home by recent advice published in a magazine from a "nutritionist" who claimed weight loss is aided by eating carbs and protein at separate meals, a notion not supported by science.

By no means is everyone calling herself a nutritionist (or a nutritional consultant, food coach, or weight-loss specialist) dispensing hogwash. But for consumers attempting to make an informed choice, the titles are meaningless; they don't capture the possessor's education, experience, or credentials. And those are all important when it comes to seeking eating advice, given the proliferation of fad diets and quick weight-loss schemes. “I can’t think of a field that has more quackery than nutrition,” says Lisa Sasson, a clinical associate professor of nutrition and food studies at New York University.

One specific title to look for: registered dietitian. In order to call himself an R.D., a person must have an undergraduate degree in nutrition or dietetics—or the equivalent in coursework—from an accredited institution, says Dee Sandquist, an R.D. and spokesperson for the American Dietetic Association, the professional organization that credentials R.D.'s (through the Commission on Dietetic Registration). On top of that, R.D.'s have to complete a yearlong, supervised internship and pass a national exam. And they must get credits in continuing education on an ongoing basis. Anyone calling herself simply a dietitian is also legally supposed to be an R.D.

The American College of Nutrition also issues C.N.S. (certified nutrition specialist) credentials for people with advanced degrees—master's, doctorate, M.D.—in nutrition or related areas. They, too, have to sit for an exam and also earn continuing education credits, says Madelyn Fernstrom, director of the nutrition and weight management program at the University of Pittsburgh Medical Center and author of The Real You Diet. Either an R.D. or C.N.S. designation means the holder has relevant education and experience, has passed an exam, and will make evidence-based recommendations, says Fernstrom.

I saw Fernstrom identified as a "board-certified nutritionist," referring to her C.N.S. certification. (She has a Ph.D. from MIT.) But the term "nutritionist" alone is meaningless. "It's not a bad thing," says Fernstrom. "But it's like saying you're a cook—you could be working in Denny's or at a five-star restaurant." So ask: What's the nutritionist's educational background? Does she have an R.D. or a C.N.S.? What experience does she have? Has she treated patients like you before? Is her practice grounded in scientific evidence? "You don't have to discount someone who has some other certification, but do your homework," Fernstrom says. "It's just like reading labels."

Making matters even more confusing is that most states have some kind of licensing, registration, or certification system in place but the systems vary in rigor. Some won't allow anyone to practice without meeting certain requirements, others allow qualified persons to use the titles "dietitian" or "nutritionist" but let others practice under different job titles, and others simply require people, regardless of credentials, to register with the state. (Here are the laws, state by state.) To be certain you're getting someone who has met national industry standards, look for an R.D. or C.N.S. credential.

If you have specific needs—say, you're an athlete who wants to know how to recover from races, are a newly diagnosed diabetic seeking help in planning meals, or are seeking help for your overweight child—be even more pointed in your questioning. Ask what specialized education or experience the person has. The ADA, for example, has additional credentials for R.D.'s who want to focus on kidney disease or cancer patients, children, the elderly, or athletes. The "Ask the Dietitian" website, run by Joanne Larsen, a registered dietitian, has some additional tips for vetting anyone offering nutrition advice. Among them: Question eating plans that require the purchase of certain supplements, avoid diets that eliminate entire food groups or prescribe "magic" foods that must be eaten daily, and ask for research—not testimonials—to substantiate claims.

One title that's grown in popularity is "coach." People seeking guidance or help in their career, for example, may hire a business, life, or personal coach. There also are people who call themselves wellness, weight-loss, food, or health coaches. Rather than calculating how many grams of protein or carbohydrate someone should eat or tracking a client's weight, they're more likely to help a customer define his or her goals and needs and figure out how to meet them. Denise Holz, a weight-loss coach in Seattle, says she helps her clients—both in person and over the phone—to eat mindfully, teaching them to be present, slow down, and focus on taste while they eat. And she helps them figure out what's really causing the bad eating habits they want to change. Doing that, she says, helps them address the underlying issues and learn to eat in accordance with their true hunger and taste. "They approach food in a whole new way," Holz says. "They don't have to sneak, don't have to feel bad about themselves."

If coaching rather than (or in combination with) nutritional advice sounds like what you're after, be aware that, like "nutritionist," anyone can call himself a "coach," says Sasson. There are some certification bodies, including the International Coach Federation. And a company called Wellcoaches Corp., in partnership with the American College of Sports Medicine, now trains and certifies healthcare professionals in wellness coaching. Its training, says Margaret Moore, the company's founder, chairman, and CEO, is "based on theories that have evidence behind them" about things like how to motivate people. Until there's some kind of national credential (similar to an R.D.), ask prospective coaches about their education, training, and experience, says Moore. "They should have a background in what they're coaching and should be able to talk the language of what makes people change," she says. "Ask about their track record and talk to current or former clients. And find someone who fits with you—if your personalities don't jibe, it's not going to work." Sort of like finding the perfect diet.

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When I am asked "what is the difference between a Registered Dietitian and a Nutritionist", I always ask "Who makes the decisions about food & meals in your home?". That would be your personal nutritionist. As an RD I'm uniquely trained in medical nutrition therapy for a wide variety of health conditions. And have further specialized to deal with diabetes, pediatrics and many GI disorders. Another important skill is the ability to interpret and explain the research results and real meaning behind all the headlines announcing some nutrition or weight loss breakthrough.

I'm sorry there are NO magic bullets. There are NO "one diet fits all". There are NO shortcuts if you want good health. If it sounds too good to be true. If it makes amazing promises. If it claims to be a secret that the medical professionals don't want you to know. It's going to be a waste of your time & money (and possibly even dangerous). Please consult a licensed/certified health care professional. Ask to see his/her credentials & where they went to school/did their internship. Shop around to find someone who can help you succeed.

Are You a Couch Potato?

"Couch Potatoes Endanger Their Lives, Australian Study"

If you think vegging out in front of the tube after a stressful day is the best way to unwind, you may want to think again.

A study by the Australian Science Media Centre followed 8,800 adults over a six-year period and found that people who watched four hours or more television per day — as compared to less than two hours — had an 80 percent higher risk of death from cardiovascular disease. The findings were independent of traditional risk factors such as smoking or obesity.

The study says watching the television itself is not the problem, but rather sitting while you watch.

To combat these effects, researchers suggest not only regular exercise, but also to stand up and "get moving" during any prolonged period — be it in front of your television, computer, at work or during transport.
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The Q&A session with the researchers can be found HERE. The journal Circulation will have the published article up shortly.

What do you think of the study?

Again, There is NO Magic Bullet

Headline news in the diet field.

Setting the record straight on weight loss
It's time to set the record straight. The only reliable way to lose weight is to eat less or exercise more. Preferably both.

So why bother to state the obvious? Because a body of scientific literature has arisen over recent years, suggesting that fat oxidation – burning the fats we eat as opposed to the carbohydrates – is enough to promote fat loss. It isn't.

Sydney scientists have demonstrated that mice genetically altered to burn fats in preference to carbohydrates, will convert the unburned carbohydrates into stored fat anyway, and their ultimate weight and body composition will be the same as normal mice.

It all comes down to an enzyme known as ACC2 (acetyl-CoA carboxylase), which controls whether cells burn fats or carbohydrates. When it was shown that 'blocking' ACC2 will force cells to burn fats in preference to carbohydrates, many assumed that such 'fat burning' could make fat stores evaporate, and make people thin without changing food intake or energy expenditure.

Associate Professor Greg Cooney, from Sydney's Garvan Institute of Medical Research, discusses misconceptions surrounding ACC2 in findings that appear in the prestigious international journal, Cell Metabolism, article available online today.

"Our data urges a correction in people's concept of a magic bullet - something that will miraculously make them thin while they sit on the couch watching television," said Professor Cooney.

"While none of the large pharmaceutical companies have marketed ACC2 inhibitors, there are many kinds of so-called 'fat-burning pills' available in the health food, body building and alternative medicine markets, where limited clinical effectiveness data are required."

"Many such products can also contain potentially harmful stimulants or come with a recommendation to follow a calorie-controlled diet and do more exercise while taking them. If you follow those recommendations, then of course you'll lose weight - but you'd lose it anyway."

"The energy you use in your home can come from a coal-fired power station, hydroelectric power, or a wind turbine. You won't know which because the end result is electricity."

"The energy that fuels your body can come from fats, proteins or carbohydrates. You won't know which because the end result is ATP, or cellular energy."

"Your body will use the energy it needs and store the leftover fats, proteins or carbohydrates as fat. When you do the sums, it's ultimately a matter of calories in and calories out."

"It's important to stress that the focus of our study was limited to an analysis of the impact of fat oxidation on overall fatness. We didn't investigate all impacts of fat oxidation – and so we don't rule out benefits of burning off fats in specific tissues."

"For example, manipulating fat metabolism may - or may not - lead to better insulin action in muscles or in the liver. Should insulin action be improved, that would obviously benefit obese people with Type 2 diabetes. But we can't comment either way until we do the experiments."

And the take-home message? Follow a healthy, balanced diet and get plenty of exercise.


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ABOUT GARVAN

The Garvan Institute of Medical Research was founded in 1963. Initially a research department of St Vincent's Hospital in Sydney, it is now one of Australia's largest medical research institutions with nearly 500 scientists, students and support staff. Garvan's main research programs are: Cancer, Diabetes & Obesity, Immunology and Inflammation, Osteoporosis and Bone Biology, and Neuroscience. The Garvan's mission is to make significant contributions to medical science that will change the directions of science and medicine and have major impacts on human health. The outcome of Garvan's discoveries is the development of better methods of diagnosis, treatment, and ultimately, prevention of disease.

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Translation: Calories count! There is no magic bullet that will allow you to lose weight without controlling your energy balance. Eat less and exercise more.
There are some benefits to what foods/nutrients you eat and when you eat that can make you more successful in this endeavor, just as there are some more effective exercise/activity patterns that can influence how much weight is lost (but not *where* the fat comes off).

A Cure for Celiac???

New hope for celiac disease sufferers?
By Cathryn Delude, posted December 21, 2009

In a sense, the 2 million plus Americans with celiac disease are lucky. No other autoimmune disease has such a safe and effective treatment.

Purging the diet of gluten -- the protein in wheat, rye and barley that triggers an immune reaction in the gut -- can reverse the disease and reduce intestinal inflammation. That's important, because studies now show that the consequences of untreated celiac disease are graver than previously thought, causing anemia, arthritis, osteoporosis, hepatitis, neurological problems and even malignancies, as well as increased general mortality.

Still, it is very difficult to eliminate gluten entirely. It lurks in disparate sources such as vinegars, soy sauce, medications, lip balm and Play-Doh (which some children consider edible); and even gluten-free foods, which are expensive, may contain enough traces to cause symptoms. "When we study celiac patients who have been doing their best to follow a gluten-free diet, even after five years we see lots of damage in the small intestines in about half of them," said Dr. Robert Anderson, a gastroenterologist in Melbourne, Australia, who is working on a vaccine to prevent or switch off the reaction to gluten.

His is one of many efforts underway to develop new, non-dietary treatments for celiac disease. Ultimately, celiac patients may be able to take a pill before a meal so they could, for example, have stuffing with their holiday turkey. Or, as is Anderson's goal, they could go for a series of treatments similar to allergy shots that would teach their immune systems to tolerate gluten.

"It's very exciting that the pathophysiology of celiac disease is understood to such a degree that we can design potential therapies," said Dr. Peter Green, director of the Celiac Disease Center at Columbia University College of Physicians and Surgeons in New York.

There are two categories of treatments being developed. One would supplement a gluten-free diet and protect patients from occasional gluten exposure; the other would train the immune system to tolerate gluten and allow patients to eat a regular diet.

Enzyme therapy

Within the first category, one approach uses oral enzymes that target gluten. We cannot completely digest gluten because humans lack digestive enzymes that can break it down, but researchers at Stanford University combined enzymes from bacteria and barley that finish what our own digestive juices cannot. They showed in rats that when gluten is broken down into smaller fragments, it no longer causes inflammation in the intestines. Alvine Pharmaceuticals, based in San Carlos, Calif., has developed this "glutenase" therapy and is now recruiting patients for a Phase II clinical trial.

In this trial, as with the others, participants have had a diagnosis of celiac disease confirmed by a biopsy but have had it under control on a gluten-free diet. They are given either a drug or placebo, along with a gluten challenge, often the equivalent of one or two slices of bread.

"From the early data it looks like the oral enzymes break down enough gluten to be useful," said Dr. Daniel Leffler, director of clinical research for the Celiac Center at Beth Israel Deaconess Medical Center in Boston. Leffler was not involved in the enzyme trial but is an investigator in a nearly completed Phase II trial testing a different drug, larazotide, developed by Alba Therapeutics in Maryland.

The larazotide approach leaves the gluten peptides, or small fragments of proteins,intact but aims to prevent them from penetrating beneath the lining of the gut into the mucous layer where the immune reaction occurs. In celiac disease, as in many autoimmune diseases, including Type 1 diabetes, this intestinal barrier is "leaky" or permeable.

Larazotide is a bioengineered drug designed to close those leaks to keep out gluten and prevent or reverse the disease. In preliminary results from about 300 patients in Phase I and II trials, the drug did seem to benefit patients, who had fewer adverse symptoms after eating gluten. It also reduced the levels of the antibody that serves as a blood marker for the immune response to gluten. But interestingly, the drug did not seem to reduce intestinal permeability.

"So the drug works, but maybe through a different mechanism that we don't understand yet," said Green, who is on the clinical advisory board for both Alba and Alvine. He predicts that, if ultimately found effective, the oral enzymes and larazotide would be marketed as supplements to a gluten-free diet but that many patients would want them to actually replace the restrictive diet. It's unclear not only whether such a use would be possible but also whether it would be a daily regimen or followed only when dining out or traveling, for instance.

Immunotherapy

The second category of treatment, known as immunotherapy, is more investigational but also more exciting, Leffler said. It would allow patients to eat a regular diet by quelling immune response in the gut. This response is driven by immune cells known as T cells, which react when other immune cells display gluten fragments on their surface.

In Australia, a company founded by Anderson, called Nexpep, is packaging the gluten peptides that trigger this immune response into a vaccine that will desensitize the immune reaction. The theory, which he says works in animals, is that by introducing these peptides through injections under the skin rather than through the gut, the immune cells learn to tolerate them and no longer display them to the T cells. That can theoretically prevent or turn off the reaction that damages the intestines

Anderson expects Phase I safety trials of this vaccine, Nexvax2, to be completed in mid-2010. He anticipates that patients would receive a series of injections of the vaccine, followed by occasional maintenance doses.

"If we can figure out how to give the drug, how frequently and when we need maintenance therapy," he added, "then we can use the same principle to explore treatments for other autoimmune diseases." Several other groups are also developing vaccines for celiac disease, but this one is furthest along.

A low-tech immunotherapy approach might require just one inoculation -- of hookworm. It is known that a non-pathogenic hookworm introduced to the gut can relieve asthma symptoms. Researchers suspect that it is because we evolved with intestinal parasites that trained our immune system to tolerate environmental irritants, but our hygienic modern living has deprived us of this beneficial symbiosis.

Researchers at the Brisbane Princess Alexandra Hospital in Queensland, Australia, tested the effects of hookworm inoculation on 20 patients with celiac disease to see if it would blunt the immune response to gluten. In addition to hoping to provide relief for celiac patients, the researchers want to learn if this could be an effective therapy for inflammatory bowel disease and Crohn's disease.

The results have not been published, but when the Phase II trial was over and the patients were offered a medication that would kill the parasites, they all opted to keep their hookworms.

health@latimes.com
Copyright © 2009, The Los Angeles Times
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Extending the Honeymoon in Type 1 Diabetes - New Use for an Old Drug

FDA-approved drug may slow beta cell destruction in type 1 diabetes patients

DALLAS — Dec. 4, 2009 — New findings by UT Southwestern researchers suggest that a drug already used to treat autoimmune disorders might also help slow the destruction of insulin-producing cells in patients recently diagnosed with insulin-dependent (type 1) diabetes.

In type 1 diabetes, formerly known as juvenile diabetes, cells in the pancreas called beta cells, which produce insulin, are destroyed by an autoimmune process.

Researchers at UT Southwestern and 14 other centers worldwide found that injections of the drug rituximab slowed beta cell destruction in the pancreas of those newly diagnosed with type 1 diabetes for at least a year, suggesting a potential treatment option that might improve management and reduce long-term complications of the disease.

“Our findings in no way suggest that rituximab should be used as a treatment or that it will eliminate the need for daily insulin injections,” said Dr. Raskin, principal investigator of the trial’s local effort. “This is not a cure for type 1 diabetes.

“The results do, however, provide evidence that B cells play a significant role in type 1 diabetes and that selective suppression of these B cells may deter the destruction of the body’s beta cells.”

Prior research has shown that two types of immune cells — B cells and T cells — help trigger type 1 diabetes. T cells attack and destroy the insulin-producing beta cells. The B cells, however, don’t directly attack insulin-producing cells, but researchers have speculated that they trigger the T cells to attack. Rituximab directly attacks and destroys the beta cells.

For the current study, researchers conducted a randomized, double-blind study in which 81 participants received infusions of either rituximab or a placebo once a week for four weeks. The participants, who ranged in age from 8 to 40 years and had been diagnosed with type 1 diabetes within 100 days of enrollment in the study, returned approximately every three months for two years to undergo blood tests and meet with a physician. Two-thirds of the 81 participants received the drug.

The scientists found that after one year, the participants who received rituximab needed lower doses of insulin and were able to produce more of their own insulin than those who received the placebo. They also had better control of their blood sugar.

Dr. Raskin said researchers do not think rituximab could ever be used to completely reverse type 1 diabetes because the pancreas typically is too damaged by the time diabetes is diagnosed.

He also said that while the exact mechanism of how rituximab affects type 1 diabetes remains unclear, the study clearly shows that a therapy that targets B cells may improve beta-cell function in early type 1 diabetes.

The next step, Dr. Raskin said, is to evaluate the potential effects of rituximab in diabetes.

Other UT Southwestern researchers involved in the study include Dr. Perrin White, professor of pediatrics; Dr. Bryan Dickson, associate professor of pediatrics; Dr. Soumya Adhikari, assistant professor of pediatrics; Dr. Mark Siegelman, associate professor of pathology; Marilyn Alford, senior advanced practice nurse in internal medicine; Tauri Harden, a former advanced practice nurse in internal medicine; Erica Cordova, registered nurse at Parkland Memorial Hospital; and Nenita Torres and Maria Lourdes Pruneda, senior research nurses in internal medicine.

The study is supported by the Juvenile Diabetes Research Foundation International, the American Diabetes Association and the Type 1 Diabetes TrialNet Study Group, a clinical trials network funded by the National Institutes of Health.

Visit www.utsouthwestern.org/endocrinology to learn more about UT Southwestern’s clinical services in endocrinology, including diabetes.

BUZZ: Movie Popcorn is Bad For You (Duh!)

I love reading headlines related to food and nutrition. This is what showed up on my Yahoo BUZZ today:

Horror at the Movies: Popcorn
by Claudine Zap (posted 21 Nov 2009)

We would want to be the last ones to ruin movie night, but this just in from Center for Science in the Public Interest: Chowing down on a medium popcorn and soda is the calorie equivalent to three McDonald's quarter-pounders and 12 — yes 12 — pats of butter. And it gets worse: About 90% of this 1,600 calorie bomb comes from fat.

‘Two Thumbs Down’ for Movie Theater Popcorn
(posted 18 Nov 2009)

New Lab Tests of Movie Theater Popcorn Show It’s Still the Godzilla of Snacks

WASHINGTON—It's hard to picture someone mindlessly ingesting three McDonald's Quarter Pounders with 12 pats of butter while watching a movie. But according to new laboratory analyses commissioned by the nonprofit Center for Science in the Public Interest, that food is nutritionally comparable to what you’d find in a medium popcorn and soda combo at Regal, the country’s biggest movie theater chain: 1,610 calories and three days’ worth—60 grams—of saturated fat. (Nutrition aside, that combo costs $12—for raw ingredients that must cost Regal pennies.)

The study, published as the cover story in the December issue of Nutrition Action Healthletter, updates a famous exposé the group conducted 15 years ago. For Regal and AMC, CSPI tested samples from theaters in the Washington, D.C., area. For Cinemark, samples came from Texas, Illinois, and Maryland.

The oversized boxes and bags (four to five ounces) of candy sold at movie chains are universally high in calories. A 5-ounce bag of Twizzlers has 460 calories and 15 teaspoons of sugar. A 7-ounce box of Nerds has 790 calories and 46 teaspoons of sugar. Chocolate candies like Butterfinger Minis, Raisinets, Sno-Caps, or M&M's have between 400 and 500 calories and at least a half day’s worth of saturated fat. An 8-ounce bag of Reese's Pieces is just a cup of candy. But with 1,160 calories and 35 grams of saturated fat, it's like eating a 16-ounce T-bone steak plus a buttered baked potato.
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Another interesting thing about popcorn, is that eating it while watching a movie leads us into mindless eating. Tons of it. For some real interesting insights into portion size influencing our eating habits, take a read of this:

Big portions influence overeating as much as taste, even when the food tastes lousy, Cornell study finds
By Susan S. Lang (posted 5 Nov 2005)

Large portions push people to overeat -- even to overeat foods they don't like.

According to a new Cornell University study, when moviegoers were served stale popcorn in big buckets, they ate 34 percent more than those given the same stale popcorn in medium-sized containers. Tasty food created even larger appetites: Fresh popcorn in large tubs resulted in people eating 45 percent more than those given fresh popcorn in medium-sized containers.

"We're finding that portion size can influence intake as much as taste," said Brian Wansink, the John S. Dyson Professor of Marketing and of Applied Economics at Cornell. "Large packages and containers can lead to overeating foods we do not even find appealing."

Wansink and Junong Kim, assistant professor of marketing at the University of Central Florida, gave 158 moviegoers either medium (4.2 oz) or large (8.4 oz) tubs of free popcorn that was either fresh or 14 days old. The researchers asked the moviegoers to describe the popcorn after the movie, and they weighed how much popcorn was left in the containers. As expected, the 14-day-old popcorn was described with such remarks as "stale" and "it was terrible."

When the moviegoers were asked if they thought they ate more because of the size of the container, 77 percent of those given the large tubs said they would have eaten the same amount if given a medium container. "This means that the moviegoers were unaware that the exceptional amount they ate was due to the size of the container," said Wansink, who also is the author of the new book, "Marketing Nutrition: Soy, Functional Foods, Biotechnology, and Obesity," and director of the Cornell Food and Brand Lab, made up of a group of interdisciplinary researchers who have conducted more than 200 studies on the psychology behind what people eat and how often they eat it.

Several of Wansink's previous studies show that larger portions prompt people to eat more not because of a clean-your-plate mentality, but because large packages and portions suggest larger consumption norms. "They implicitly suggest what might be construed as a 'normal' or 'appropriate' amount to consume," said Wansink, who tested this concept in 1996 with volunteers given different-sized bags of M&Ms that were too large to be finished while watching a videotape; those given larger bags ate twice as much as those with smaller bags.
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For some interesting reading, I highly recommend his book Mindless Eating – Why We Eat More Than We Think, by Brian Wansink. Published by Bantam-Dell (2006).

So what do I eat at the movies? Sometimes I brought in my own snacks (grapes or raisins; one evening I even packed an entire dinner in to-go containers and used a big purse). But lately I just don't get anything to eat or drink. It's not like we're going to starve during the 2 hr show. It's one way to break that behavior change of tv & movies connected to food & eating. And think of all the money you save by skipping the snack bar.

Positive Placebo Power

Experts: Placebo power behind many natural cures
By MARILYNN MARCHIONE, AP Medical Writer Marilynn Marchione, Ap Medical Writer – Tue Nov 10, 3:16 pm ET

EDITOR'S NOTE: Ten years and $2.5 billion in research have found no cures from alternative medicine. Yet these mostly unproven treatments are now mainstream and used by more than a third of all Americans. This is one in an occasional Associated Press series on their use and potential risks.

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People looking for natural cures will be happy to know there is one. Two words explain how it works: "I believe."

It's the placebo effect — the ability of a dummy pill or a faked treatment to make people feel better, just because they expect that it will. It's the mind's ability to alter physical symptoms, such as pain, anxiety and fatigue.

In just the past few weeks, the placebo effect has demonstrated its healing powers. In tests of a new drug to relieve lupus symptoms, about a third of patients felt better when they got dummy pills instead of the drug.

The placebo effect looms large in alternative medicine, which has many therapies and herbal remedies based on beliefs versus science. Often the problems they seek to relieve, such as pain, are subjective.

"It has a pejorative implication — that it's not real, that it has no medicinal value," said Dr. Robert Ader, a psychologist at the University of Rochester in New York who has researched the phenomenon.

But placebos can have real and beneficial effects, he said.

"Much of the results of certain alternative procedures are largely placebo effects, unless you believe there are people who exert magical powers so they can hold their hands over your body and cure you of disease," Ader said. "Make you feel better? That's entirely possible, especially if you believe it."

The placebo effect accounts for about a third of the benefits of any treatment — even carefully tested medicines, scientists say. This dates to a landmark report in 1955 called The Powerful Placebo. Viewed as groundbreaking, the analysis of dozens of studies by H.K. Beecher found that 32 percent of patients responded to a placebo.

Later studies found that dummy pills could raise pulse rates, blood pressure and reaction speed when people were told they had taken a stimulant; the opposite occurred when people were told that a drug would make them drowsy.

How does it work? Scientists do not always know, but there are many possible ways. Brain imaging shows that beliefs ("I know these pills will help") can cause biological changes and affect levels of chemical messengers and stress hormones that signal pain or pleasure.

Emotions, too, can trigger physical changes. Take the case of a child with croup. Crying tightens the airways and makes it tougher to breathe. Many people believe that cool mist is helpful, but when it has been tested in hospital studies with croup tents, it has not been found to help, said Dr. Owen Hendley, a pediatrician at the University of Virginia.

Try it at home, though, and you may get a different result.

"The child sits in the lap of the mother and the mother holds the mist maker close to the child. The child settles down, the mother settles down. The setting, and the mother feeling that it is helping, makes everybody calmer," and the child actually is able to breathe better, Hendley explained.

If it were not for the placebo effect, "physicians would not be nearly as successful as we are," said Dr. Thomas Schnitzer, a Northwestern University arthritis specialist. He helped lead a big study that found glucosamine and chondroitin supplements were no better than dummy pills for arthritic knee pain.

Doctors sometimes exploit the placebo effect to help patients. One survey found that many doctors admitted sometimes giving patients sugar pills or drugs or vitamins that would not really help their condition, in an effort to trigger a placebo effect.

In Baltimore, the University of Maryland Medical Center's shock trauma center is offering some patients Reiki therapy, which claims to heal through invisible energy fields manipulated by a special "master." The hospital's anesthesia chief, Dr. Richard Dutton, says it is self-hypnosis and compares it to Lamaze classes that teach pregnant women breathing exercises to take their minds off the pain of labor.

Roy A. Armstrong's family agreed to it after he was injured in a motorcycle crash last year. The 39-year-old suffered cardiac arrest and had many broken bones. As he lay tethered to a breathing machine, nurse Donna Audia and a partner circled his bed, waving their arms through the air and touching his head while humming and making tunes by rubbing a crystal bowl with a wand.

Armstrong was too sedated to remember anything, but "I think in some way it helped him to get better," his wife said. He is still recovering through physical therapy.

Dutton said: "You can call it a placebo effect, you can call it a chicken soup effect. It's all about creating the right mental state in the person. The patients tell us they seem to like it. And in pain management, that's the whole goal. If 30 percent of your patients get better on placebo, why not give it to them?"

Swear-by-it stories and anecdotal reports of benefit are one thing. Proving a treatment helps is quite another. Many alternative medicine studies have not included a placebo group — people who unknowingly get a dummy treatment so its effect can be compared.

Acupuncture is especially hard to research. Positive studies tend to lack comparison groups that have been given a sham treatment. Or they are often done in China, where the treatment is an established part of health care.

One U.S. study found that true acupuncture relieved knee arthritis pain better than fake acupuncture, in which guide tubes were placed but no needles were inserted. But a European study involving twice as many patients and using a more realistic sham procedure found the fake treatment to be just as good. The conclusion: Pain relief was due to the placebo effect.

Advertisements and testimonials from product users can encourage a placebo effect. The Federal Trade Commission last summer reached a settlement over advertising claims for Airborne, a product "invented by a teacher" that was supposed to ward off germs spread through the air.

"Products like Airborne are what we call `credence products.' That's a fancy word for saying it's difficult or impossible for consumers to determine if the product has done anything for them," said commission lawyer Rich Cleland. "Part of that is because of the placebo effect. Part of that is because people don't want to believe they've been ripped off."

Barbara Domen, a former kindergarten teacher in Caswell Beach, N.C., said she was prone to colds and used Airborne six or seven times a year when she flew on planes.

"It worked for me," although it could be because since she retired, "I'm away from all the germs," she said. She skipped it on one flight and caught a terrible cold.

"Maybe it's psychological, but I think I'll continue to use it," she said.

Some placebo effects are due to conditioning, or ascribing benefits to something you did that may in fact have played no role in your improvement. Insomnia is an example, said Michael Perlis, a psychologist and neuroscientist at the University of Pennsylvania.

If you have trouble sleeping one night, your body's need for sleep makes it very likely you'll sleep well the next night. If you take a sleeping pill, you think you slept well because of the pill, he said.

Do any herbal remedies work for insomnia? "Not that I know of," Perlis said. "But all of them have potential to be useful with time. It has nothing to do with them — it has everything to do with conditioning."

FDA article on placebos (2000)
American Cancer Society article on placebos (2009)