THE February 2016 session of the ongoing trial of Prof Tim Noakes for his ‘unconventional’ views on butter, eggs, bacon and broccoli, was once again filled with twists, turns, drama and intrigue.
In the first of a two-part series, I look at why the Health Professions Council of SA hearing against has turned into an object lesson in unintended consequences for doctors and dietitians who don’t want Noakes giving dietary advice that differs from conventional ‘wisdom’.
By Marika Sboros
THE Health Professions Council of South Africa probably hoped its hearing against University of Cape Town emeritus professor Tim Noakes on a charge of unprofessional conduct would silence him. The very opposite has happened.
Noakes’ profile internationally is soaring. The hearing has given him a bigger global platform than before on which to disseminate and interrogate scientific evidence for and against low-carb, high-fat (LCHF, aka Banting).
LCHF is not yet mainstream. However, top specialists use it worldwide to enhance sports performance and treat obesity, diabetes, heart disease, cancer, even dementia, which some specialists are calling “type 3 diabetes” because of its link with diet. In medical jargon, these are called non-communicable diseases (NCDs), a clumsy term for chronic ailments known as lifestyle diseases.
Noakes told the hearing these are not diseases of lifestyle, but at heart are shown to be diseases of nutrition. In particular, he says NCDs are diseases of insulin resistance.
This strange saga had its genesis in February 2014 when then president of the Association for Dietetics in SA (ADSA) Claire Julsing Strydom reported Noakes to the HPCSA. That was for two tweets to a breastfeeding mother Pippa Leenstra. Noakes said that good first foods for infant weaning are LCHF – meat and veg. The biggest problem for the HPCSA from the outset is that ADSA, Strydom and paediatric dietitians and associations globally give the same advice.
The HPCSA went ahead anyway and charged Noakes with unprofessional conduct.
The HPCSA mustered a motley crew of “expert witnesses” to give evidence against Noakes at the November 2015 session of the hearing. These included NorthWest (formerly Potchefstroom) University nutrition professors Dr Este Vorster and Dr Salome Kruger, and a paediatrics professor Muhammed Ali Dhansay now with the Medical Research Council. Strydom gave factual evidence.
It’s an understatement to say Noakes’ advocates, Michael van der Nest SC and Dr Ravin “Rocky” Ramdass, a medical doctor with 24 years experience as a family physician, had a field day. They eviscerated the evidence of all the expert witnesses, eliciting concessions that left the HPCSA with gaping holes in its case.
Van der Nest did likewise with the HPCSA’s last hope at the February session: Stellenbosch University psychiatry professor Dr Willie Pienaar. Pienaar has a masters degree in medical bioethics and lectures part-time in the subject.
He told the hearing that Noakes acted unethically as he was in a doctor patient relationship with the breastfeeding mother on Twitter, and gave advice without knowing anything about the infant’s state of health. Van der Nest had no problem demolishing that argument. He pointed out if that were the case, Strydom was just as guilty, and so was another dietitian, Marlene Ellmer, who entered the fray on Twitter. Both should also have been charged.
Pienaar did not acquit himself well. He became flustered and fell back on lamentations about the possible threat to his profession if doctors were allowed to say anything at all on Twitter.
That is just one sign that the hearing has become an object lesson in unintended consequences on and off social media, and it isn’t only the HPCSA, ADSA and Strydom who are having to learn it. Top medical doctors, including the head of bioethics at Wits University, Prof Amaboo “Ames” Dhai, and academics at UCT and other universities are having to learn it as well.
The hearing has variously been called the “Banting for Babies Trial, even the “Nutrition Trial of the Century”. More recently, Noakes has been compared to a modern-day Gallileo, an analogy that is looking more and more apt. The hearing against Noakes is not a court of law, but might just as well be. It has been so adversarial, filled with twists, turns, drama and intrigue, it is now being likened to a scientific Spanish Inquisition rather than a simple inquiry.
The latest session that ran in Cape Town from February 8 to16 was true to character. It opened with evidence on the record by Van der Nest suggesting highly irregular conduct by the HPCSA Preliminary Committee of Inquiry that investigated Strydom’s complaint.
The committee, chaired by Dhai and whose members included UCT emeritus professor of surgery John Terblanche and retired UCT psychiatry professor Denise White, charged Noakes in September 2014.
An emailed paper trail shows that Dhai and Terblanche in particular went far beyond their remit to ensure not just that Noakes was charged, but that the hearing against him succeeds. It suggests the HPCSA has been biased against Noakes from the start.
Van der Nest made another crucial point during cross examination Pienaar, one on which this hearing hinges: “South Africa has a constitution that specifically guarantees scientists freedom of speech.
“This is important not only for our democracy, but for the development of humankind that scientists not be muzzled and that their freedom of speech is protected.”
Among many questions the hearing has raised is this one: why on earth would the HPCSA and ADSA dietitians want to deprive a world-renowned scientist of his right to freedom of expression? After all, Noakes, a medical doctor and an award-winning scientist, is one of few scientists in the world with an A1 rating by the National Research Foundation for expertise in both nutrition and exercise science.
There are few, if any medical scientists in SA who match him for his qualifications (he has three doctorates, one on medicine, one on sports science, and an honorary from the Vrye University, Amsterdam), achievements and research experience. Not all Noakes’ colleagues at UCT are ranged against him. UCT deputy vice chanceller and law professor Danie Visser is on record calling Noakes a “national treasure”, and “a force in Nature”.
Moreover, the hearing raises the question why ADSA and the HPCSA would want to deprive South Africans of the scientific information Noakes disseminates.
In answering those questions, the hearing throws up more suspects (mostly usual) than a medico-scientific game of Cluedo.
A week before the February hearing began, the HPCSA said it would call Prof Jacques Rossouw as an expert witness. On opening day it announced it would not call him after all.
If the HPCSA intended Rossouw as a big-gun, pre-emptive strike against Noakes and the vast body of science he presented to the hearing – in more than 4000 pages and 900 slides with references from top scientists and institutions internationally, over nearly 40 hours – that was unlikely to happen (more on why in upcoming posts on the scientific debate).
South African-born Rossouw, recently retired head of the US National Institutes of Health (NIH) Women’s Health Institute (WHI) Branch in the Division of Cardiovascular Sciences at its National Heart, Lung, and Blood Institute, is one of Noakes’ most implacable foes, and a staunch supporter of and researcher into high-carb, low-fat (HCLF) eating.
Presumably, Rossouw would have presented evidence from his WHI research and other research in support of HCLF.
Rossouw has since declined all requests for interviews on what his evidence would have been. He and the NIH are staying mum on the topic, apart from to say that Rossouw couldn’t get permission in time from the NIH to attend. That excuse doesn’t stand up to scrutiny given the amount of time he had to secure permission. However, given the ease with which Van der Nest and Ramdass have decimated all the other “expert” witnesses’ testimonies so far, I’d say it’s a smart move for Rossouw and the NIH.
Noakes has rightly pointed out that there is no one study that conclusively proves him or any diet right or wrong since it is impossible to undertake such a study. (You’d have to lock around 50,000 people up in a hospital jail for 40 years, which would be difficult and costly, if not ethically suspect and physically challenging.)
There is also compelling evidence that low-fat foods can over time cause heart disease:
Read also: NOAKES: LOW-FAT CAUSES HEART DISEASE! PART 1
“You have to look at the totality of the evidence,” Noakes said in giving his own evidence. “That’s what I am doing.”
Noeaks described himself as “a totalist”, who has”obsessive compulsive disorder with facts”.
That’s why he writes as he does: If anyone tells him there’s no evidence to support low-carbohydrate diets, he tells them: “They haven’t read the literature.”
Everyone is entitled to their own opinion, Noakes said; no one is entitled to their own set of facts. He said he tells his students that “when a single strand of evidence conflicts with their beliefs, they better start questioning their views”.
Noakes also said that LCHF is only unconventional to “those who refuse to look at the evidence on which it is based”.
ADSA’s complaint and the HPCSA case against Noakes rest squarely on the so-called diet-heart hypothesis – the one that says saturated fat causes heart disease (and obesity, diabetes and a whole lot else besides); the one that started “lipophobia” (fear of fat), the demonisation of fat and glorification of carbohydrates way back in the late 1970s; the one on which South Africa’s paediatric and adult dietary guidelines (which ADSA members drew up) are based.
Noakes presented evidence, including from Harvard in the US, to show that saturated fat is not the issue and never was. He echoed experts internationally who say saturated fat may be the victim of possibly the “biggest scam in the history of modern medicine”.
“Carbs and insulin are driving obesity”, Noakes said, “not saturated fat.”
When saturated fat was taken out of the diet, we had to replace it with something to make food more palatable, Noakes said. That something is sugar and carbohydrates that are shown to be highly addictive foods. The consequences for global public health have been nothing short of catastrophic: global NCD epidemics.
Whether you call the HPCSA hearing an inquiry, trial or a Spanish Inquisition, it’s clear that Noakes isn’t its only target. The HPCSA and ADSA have LCHF squarely in their sights.
To discredit the science behind it – and presumably Noakes along the way, the HPCSA has tried taking a leaf out of the book of Noakes’ dream legal team, headed by Cape Town attorney Adam Pike, of Pike Law. It has now outsourced its legal team to Johannesburg lawyer, Katlego Mmuoe, who also has an eponymous law firm (KK Mmuoe attorneys), and acquired its own doctor-turned- advocate Ajay Bhoopchand.
At the February hearing, Bhoopchand tried hard to stem the flow of science Noakes presented, objecting that much of it, “while rather interesting”, was irrelevant.
Pretoria advocate Joan Adams, chair of the HPCSA Professional Conduct Committee that is hearing the charge against him, disagreed and overruled him.
The charge against Noakes might seem simple but is complex, Adams said. It covers conventional versus unconventional advice and nutrition science; her committee unanimously decided there was no reason to limit Noakes’ right to defend himself fully and freely.
I’d say Adams pressed the right legal button there. It makes no sense for the HPCSA to charge Noakes with giving unconventional advice that is not evidence-based, then deny him the opportunity to present evidence showing it is evidence-based.
The hearing has rapidly turned into a turf war: Noakes and LCHF on the one hand, and doctors, particularly cardiologists, ADSA dietitians, nutrition academics and HCLF on the other.
Doctors don’t want Noakes giving advice that differs from the conventional medical HCLF “wisdom” they regularly prescribe; ADSA dietitians don’t want him giving dietary advice at all. They see that as their turf. They definitely don’t want Noakes giving advice that conflicts with official dietary guidelines and the HCLF advice they regularly dish out.
That wouldn’t be such a problem were it not for well-documented effects on the health of people who followed official dietary guidelines for decades: global epidemics of obesity, diabetes, heart disease, cancer, and dementia.
But there’s another reason that some doctors, cardiologists in particular, may hate Noakes even more in future: he said heart disease in future would be treated by hepatologists (liver specialists), not by cardiologists.
Noakes presented compelling evidence in a study just two months old showing that the blood lipid (cholesterol) abnormalities that are linked to heart disease – so-called atherogenic dyslipidaemia – are caused by non-alcoholic fatty liver disease (NAFLD) in those who are also insulin resistant.
“We now know (heart disease) begins when the liver is full of fat and that is called a fatty liver – that’s non-alcoholic fatty liver disease. The fatty liver is caused by carbohydrates and sugar, especially fructose, in the diet, not fat,” Noakes said.
Noakes also presented the arguement that diabetes is ultimately a disease of progressive, disseminated (widespread) arterial disease progressing over decades that leads ultimately to complete obstruction of blood flow to the eyes, kidneys and lower limb blood vessels, causing blindness, kidney failure and gangrene of the limbs, the latter requiring amputation.
Although heart attacks and strokes occur also as a result of this same progressive arterial disease, they represent a “fundamentally different process”, he said. In that case, arteries that are incompletely obstructed suddenly develop an abrupt complete obstruction as a result of rupture of the arterial plaque causing the arterial disease.
Noakes argued that while scientists such as Rossouw claim that the falling rates of heart attacks indicate that the low-fat diet is working to prevent all arterial disease, he offers a quite different explanation: the reduction in smoking especially has reduced the number of patients experiencing the sudden plaque ruptures that cause heart attacks and strokes.
With fewer people dying of heart attacks, but increasingly developing type 2 diabetes, the disease burden of arterial disease has simply shifted to the obstructive form found in diabetes, Noakes said. If the low-fat diet really preventED arterial disease as Rossouw and others claim, then he argued it would also have prevented the now much more prevalent obstructive form found in type 2 diabetics.
The reduction in smoking and the promotion of low-fat high-carbohydrate diets have simply “shifted the disease burden from heart attack to diabetic arterial obstructions”, he said.
“I find it baffling why so many have difficulty understanding this obvious truth. Perhaps it is inconvenient?”