By Marika Sboros
There was more drama, intrigue and “silent dogs” on day one of the trial of South African scientist Prof Tim Noakes in Cape Town on October 17. Noakes resumed his evidence-in-chief and began to untangle what he believes the case against him is really about.
He also started to reveal just who he believes may be behind the Health Professions Council of SA (HPCSA) case against him. For “DNA” proof, Noakes pointed to “the dog did not bark”. He fingered some usual suspects and more:
The dog reference is Arthur Conan Doyle’s classic Sherlock Holmes story. (Click here to read Silver Blaze.) It is a metaphor for what Noakes says is the existence of “negative facts” – the “absence of expected facts”. These initially prevented him from seeing the “bigger picture” in the case against him and who is behind it. Until now.
Noakes led evidence that was highly entertaining to lay out his theory of what and who are behind this trial. Lest you think the strain of the hearing is showing, Noakes was relaxed, upbeat and making a compelling case.
The HPCSA has charged Noakes with “unprofessional conduct for giving unconventional advice to a breastfeeding mother on a social network (Twitter)”. That was for a single tweet in February 2014 saying good first foods for infant weaning are low-carb, high-fat (LCHF).
(For more background, click here to read: The real beef dietitians have with him.)
If you asked Noakes right now what he thinks is behind this case, he’d probably answer with a flourish worthy of Doyle’s fictional detective: “Elementary”.
First off, advocate Dr Ravin “Rocky” Ramdass asked Noakes if the HPCSA had ever given him guidelines on what health professionals conduct on social media. Noakes said no, “to my knowledge the HPCSA does not have any guidelines”.
Noakes then presented his first “negative fact”. The breastfeeding mother involved in the case against him, Pippa Leenstra, had not given evidence at the hearing.
Leenstra was “technically the wronged party”, Noakes said. If his words had harmed her or her infant, she should have laid the complaint with the HPCSA. The HPCSA’s own expert witness acknowledged there was no harm to Leenstra or her infant. Leenstra submitted an affidavit saying she had not followed his advice. She also described the case against him as “a circus”.
Had this hearing really been about his advice on Twitter, Noakes said he would have expected Leenstra to be “barking very loudly”. Instead, her silence is “a very telling negative fact”.
The second “negative fact” is that the HPCSA charged Noakes with “unconventional advice” on breastfeeding in the contested tweet.
“I did not give advice that was either conventional or unconventional about breastfeeding,” he said. “My tweet contained no information about breastfeeding other than that breast milk is full-fat and healthy.”
Thus Noakes said the HPCSA has charged him for something he didn’t do.
Click here to read: Could cardiologists be at the heart of HPCSA trial of Noakes?
It’s by now common cause that Johannesburg dietitian Claire Julsing Strydom complained to the HPCSA about Noakes. Strydom was then head of the Association for Dietetics in SA (ADSA). Noakes said he always wondered why Strydom and ADSA had become involved at all.
Their involvement becomes clearer, he said, after publication of a study by researchers at two of South Africa’s top universities, the University of Cape Town (UCT) and Stellenbosch University, in the PLoS (Public Library of Science) One journal in July 2014.
In effect, this paper is to the HPCSA hearing what the dog that did not bark was to Sherlock Holmes in solving the Silver Blaze case. Noakes said it is clear that the HPCSA has built its whole case around this study. It also happens to be “fundamentally flawed”.
His first expert witness, British obesity researcher, Dr Zoe Harcombe, will give all the details, but Noakes presented a slide showing some of the many errors.
The study is titled Low carbohydrate versus isoenergetic balanced diets for reducing weight and cardiovascular risk: a systematic review and meta-analysis. It is a review of 19 studies, including randomised controlled trials (RCTs).
It has become known as the “Naude Review”, after lead author Dr Celeste Naude of Stellenbosch University’s Centre for Evidence-based Health Care. However, is actually a Stellenbosch-UCT-Cochrane Collaboration review.
Co-authors include Dr Marjanne Senekal, associate professor of nutrition at the University of Cape Town, who is now a consultant for the HPCSA against Noakes. Senekal is also co-author of the “UCT academics letter” to the media in 2014. In it, she and colleagues attack Noakes for making “outrageous and dangerous” unscientific claims about diet. (Click here to read the academics letter and Noakes’ response.)
Noakes said it was only after he and Harcombe decided to submit Naude’s meta-analysis to a “very thorough review” that the truth “popped out”.
Naude and co-authors concluded that:
- Trials show weight loss in the short-term irrespective of whether the diet is low (carbohydrate) or balanced.
- There is probably little or no difference in weight loss and changes in cardiovascular risk factors on either diet.
In so doing, the researchers appeared to have succeeded spectacularly where top scientists internationally failed for decades.
Noakes presented evidence on instant media responses to the study from ADSA, the Heart and Stroke Foundation of SA (HSFSA), even the HPCSA’s own dietetics board and Stellenbosch university journalists. All quickly hailed Naude’s review as proof of the dangers of “Banting”, as LCHF is known in South Africa.
The HPCSA’s own witnesses, including Strydom, have said they waited for the study to be published before charging him. It bears mentioning that Strydom laid her complaint before the study was published.
Noakes quoted from Strydom’s evidence in which she refers to “big organisations” and “big associations” that were “waiting for this study”.
He asked rhetorically: “Who are these big organisations and associations and why were they waiting for this study?”
Other academics were clearly also waiting – and for what can seem like an inordinately long time – before going after Noakes. Noakes pointed to an article in the SAMJ (South African Medical Journal) by journalist Chris Bateman. That was on UCT’s Great Centenary Debate between Noakes and Prof Jacques Rossouw of the National Institute of Health (NIH) Women’s Health Initiative (WHI).
Rossouw is a particularly vociferous opponent of LCHF – and Noakes. He also has what some scientists say is the dubious distinction of spending more than $700 million funding trying and failing to prove that low-fat diets reduce the risk of heart disease in post-menopausal women. Consequently, he is clearly not an objective voice in this debate.
The HPCSA tried to call Rossouw as an expert witness against Noakes at its February 2016 hearing session. Rossouw initially agreed but failed to turn up on the day, citing difficulties getting permission from the NIH. Both the NIH and Rossouw have consistently declined to comment.
Noakes pointed to evidence showing that other UCT professors, Krisela Steyn and Naomi (Dinky) Levitt, both ardent critics of Noakes and LCHF, were waiting for the Naude Review.
That raises the question, he said, just why it took so long for the researchers to publish their. He suggested it was because their data did not show what they wanted it to show.
But the really big question around the study, Noakes said, is why the HPCSA used the Stellenbosch review at all, since it identifies a third “negative effect”. The most important body of scientific evidence Strydom, and the HPCSA have used to prosecute him is not about breastfeeding, weaning, children, or infants. It is and always has been about low-carb, high-fat (LCHF) for adults.
Noakes presented a meta-analysis of the evidence published in the British Journal of Clinical Nutrition in 2013, that conflicts with Naude’s review. He presented more current research, a joint Canadian-South African study published in the South African Medical Journal (SAMJ) in September 2016. Click here to read the full text of: A successful lifestyle intervention model replicated in diverse clinical settings.
Lead author is South African Dr Stefan Du Toit who now works in remote rural areas of Canada. Noakes is third co-author. Du Toit’s research did not start out as a study on LCHF but morphed into one over time.
On the motivation behind the study and its conclusions, Du Toit has said:
“As a physician, you give prescriptions every month for chronic conditions and you don’t see any improvements in health. Actually, things tend to get worse over time.
“So we started to question: as physicians practising recommended guidelines, why aren’t we seeing the desired improvements in health? Why is evidence-based medicine not working?
“We started these group-based lifestyle interventions with obese, pre-diabetic and diabetic patients. We tracked patient outcomes with the electronic medical record data -practice based evidence. What we found was participants’ health improved; they reduced their need for medication and their control improved. Then things took off from there.”
Noakes said Du Toit’s data show positive outcomes that are “very different from those that conventional medical management using standard pharmacotherapy achieves in diabetic and weight loss patients”.
This clearly is an important study even as critics were quick to knock it. It goes straight to the heart of what’s wrong with “evidence-based medicine”, Noakes said. Or as Du Toit and his researchers put it, medicine that “no longer cures”.
They say the staunch faith most doctors still have in classic RCTs is “misplaced”. “Evidence-based medicine” that doctors are supposed to rely on simply “isn’t working” to treat or beat the diabesity pandemics.
Therefore, a question all doctors should ask is: Why isn’t it working and what can we do better?”
They should also keep an ear out for scientific “dogs that don’t bark”.
The hearing continues in Cape Town until October 26.