By Marika Sboros
Health Professions Council of SA (HPCSA) advocate Ajay Bhoopchand has spent two days cross-examining Prof Tim Noakes. He hasn’t got far in achieving any major concessions. He still has time but will he be the one to nail Noakes?
The HPCSA is clearly pinning all its hopes on him. The HPCSA brought him in as a part of team of outside lawyers once it became clear that its case against Noakes was failing.
Bhoopchand appears to be keeping for last his attempt to force concessions from Noakes on two studies. Both are key to the HPCSA’s case against him.
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. He tweeted that good first foods for infant weaning were LCHF.
In his cross-examination so far, Bhoopchand has challenged Noakes on his qualifications. He has also challenged Noakes’ expertise in nutrition in general and infant nutrition in particular. He said that Noakes was a medical doctor but not a paediatrician, neonatologist or dietitian. And that had not practised clinical medicine since 2000.
Noakes easily batted off those challenges. He told the hearing that currently he was one of few scientists with an A1 rating globally for both exercise science and nutrition. It wasn’t possible to be expert in sports nutrition without also having expertise in nutrition for all ages, he said.
Twitter and doctors under the spotlight
Bhoopchand appeared to have missed the point that clinical experience on its own is not always irrelevant. Noakes pointed out that clinicians relied heavily on research that academics generate to support and implement their practice.
Bhoopchand also spent an inordinately long time on the suitability of Twitter for health professionals. He conflated it with face-to-face interaction between doctor and patient. He also said Twitter was not suitable for doctor-patient consultations.
If his sub-text was a suggestion that Noakes really was in a doctor-patient relationship on Twitter, it withered under legal scrutiny.
As a result, Noakes had a field day with Bhoopchand’s views on Twitter. He pointed out that all HPCSA’s expert witnesses admitted that they knew little to nothing about Twitter. The same applied to members of the HPCSA’s Preliminary Inquiry Committee that first decided to charge him.
Click here to read: ‘Dog did not bark’ – proof of his innocence?
Anointed power wanes
Noakes said that Bhoopchand did not understand the “new world” of social media. It was the “future of medicine”, he said. It meant that the “power of the anointed” was giving way to the “wisdom of the crowd”.
Bhoopchand also tried butting heads with Noakes on the evidence for low-carb, high-fat (LCHF) foods. He suggested that a 1995 French study Noakes had presented showed that it was protein, not carbs, that made babies fat.
Noakes speedily despatched that. He gave Bhoopchand a mini-lecture on the difference between association and causation. He also covered at length the inbuilt limitations of associational research.
But it is Noakes’ evidence on two other studies that Bhoopchand will likely be keen to undermine.
One is a study by researchers at two of South Africa’s top universities – Cape Town and Stellenbosch. The HPCSA has based its whole case on that study. Noakes has said that the study was fatally flawed. If that is the case, then so was the HPCSA case against him.
The study is titled Low carbohydrate versus isoenergetic balanced diets for reducing weight and cardiovascular risk: a systematic review and meta-analysis. It has become known as the “Stellenbosch Review” and the ” Naudé Review”. That’s after lead author Dr Celeste Naudé of Stellenbosch University’s Centre for Evidence-based Health Care. However, it’s actually a Stellenbosch-UCT-Cochrane Collaboration review.
It is a review of 19 studies, including randomised controlled trials (RCTs). HPCSA expert witness Prof Este Vorster referred to it in her special report that the HPCSA Preliminary Inquiry Committee commissioned. The committee kept the report secret from Noakes and used it to charge him.
In his evidence in chief, Noakes told the hearing that “some important people in this trial are involved in that paper”.
Co-authors of the study include Dr Jimmy Volmink, a former colleague of Noakes’ at UCT. Volmink is now dean of Stellenbosch Faculty of Health Sciences. Another co-author is Dr Marjanne Senekal, associate professor of nutrition at the University of Cape Town.
Senekal is now a consultant for the HPCSA against Noakes. She is co-author of the “UCT academics letter” to the media in 2014. Her colleagues included former UCT dean of the Faculty of Health Sciences, Prof Wim de Villiers, now Stellenbosch vice-chancellor. Noakes’ lawyers consider the letter highly defamatory.
Click here to read the academics letter and his response.
Flaws and bias
Noakes told the HPCSA hearing that he and British obesity researcher Dr Zoe Harcombe had done their own analysis of Naude’s review. It has gone through the peer-review process and been accepted for publication by a medical journal. It showed that the review was flawed and biased from the outset against the low-carbohydrate diet.
Noakes also presented evidence that the researchers intended to publish their study in February 2013 but only did so in July 2014. He speculated that this may have been because results were “not what they really wanted”. They had to “ do something to make the results more acceptable”.
That’s a “big jump”, Noakes told the hearing, because “we all trust everyone and I am a scientist and I trust people to be honest”.
In it their analysis, Noakes and Harcombe question just how the authors of Naude’s review manage to make so many important errors and not spot them in time.
“Because remember,” said Noakes, “ when you sign your name on the paper you are accountable for the errors.”
Harcombe will be an expert witness for Noakes and will give detail on the errors.
Cochrane Institute going down the wrong path?
Noakes told the hearing that Naudé had recently been appointed to lead the Cochrane Nutrition with guidance from an international advisory board.
“This person, who may have made serious errors in this paper, is now being charged with the responsibility of running this Cochrane Institute,” he said.
She may have bias against low-carbohydrate diets, Noakes continued. It was, therefore, probable that she would reflect that bias in her position at the Cochrane Institute. Its vision, he said, was that Cochrane would be the “independent globally recognised go-to place for nutrition systematic reviews.
“Cochrane Nutrition will support and enable evidence-informed decision-making for nutrition policy in practice by advancing the production use of high-quality, globally-relevant, nutrition-loaded Cochrane reviews. Therefore, (Naude) will be deciding the future of nutrition in South Africa and this organisation will be determining it,” he said.
The second research in Bhoopchand’s sights is a joint Canadian-South African lifestyle intervention study. The lead author is South African-born Dr Stephan du Toit who now lives and works in British Columbia in Canada. Noakes is a co-author of the study and has identified implications for the HPCSA charge against him.
He pointed out that De Villiers, in the UCT academics letter, had said that LCHF would damage the health of adults who go on it.
First boost for LCHF
“We are the first people in South Africa to provide absolute evidence for a diet that works and that is the difference: (LCHF) is the diet that works.”
Data from the Canadian study showed that the high-carbohydrate diet people were eating was the more likely cause of their metabolic syndrome, he said. And that cutting carbs reversed it.
If the study had tested a drug “people would be signing up to give us a Nobel Prize because this effect is profound”, Noakes said. “We have affected every single risk factor of the heart disease on this diet and it is the diet that did it.”
Yet few experts have taken any notice of the diet. Noakes speculated that this was because “no-one is going to make money out of putting people on a high-fat diet”.
He referred to what Canadian media have reported as a “bombshell report” by a senate committee of Canadian senators calling for a total overall of Canada’s food system.
“These are totally independent senators who have no connections to other outside interests,” he said.
Noakes referred to the work of US expert Dr John Ioannidis, who he called “an absolute genius a professor of medicine at Stanford University”. Ioannidis has written eloquently on where evidence-based medicine has gone wrong. His implication was that “perhaps medicine is not as helpful to humans as it might be, Noakes said
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