By Marika Sboros
Health Professions Council of SA (HPCSA) advocate Ajay Bhoopchand has spent nearly two days cross-examining Prof Tim Noakes. He hasn’t got far in achieving any major concessions. He still has time, but will he really be the one to nail Noakes?
Bhoopchand is clearly keeping for last his attempt to force concessions from Noakes on two major studies on which the HPCSA has hinged its case against him. There are some big scientific hoops he’ll have to go through before then.
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, in which he said that which he told a breastfeeding mother that good first foods for infant weaning are LCHF.
In his cross-examination so far, Bhoopchand has challenged Noakes on his qualifications. And his expertise in nutrition in general and infant nutrition in particular. He said that Noakes is a medical doctor but not a paediatrician, neonatologist or dietitian and has not practised clinical medicine since 2000.
Noakes easily batted off those challenges. He is one of few scientists in the world with an A1 rating for both exercise science and nutrition. He said it isn’t possible to be an expert in sports nutrition without also having expertise in nutrition for all ages.
Bhoopchand appeared to have missed the point that clinical experience on its own is irrelevant. Noakes pointed out that Clinicians rely on research which 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 quite rightly said Twitter was not suitable for doctor-patient consultations. If his sub-text was a prelude to suggesting that Noakes was in a doctor-patient relationship, that wouldn’t stand up to scrutiny.
Noakes had a field day with Bhoopchand’s views on Twitter. He pointed out that none of the HPCSA’s expert witnesses knew anything about Twitter, nor did the members of its Preliminary Inquiry Committee that first decided to charge him.
Click here to read: ‘Dog did not bark’ – proof of his innocence?
Noakes said Bhoopchand does not understand the “new world” of social media. It is the “future of medicine”, Noakes said. It means that the “power of the anointed” is giving way to the “wisdom of the crowd”.
Bhoopchand has also tried to go head-to-head with him on the science on which low-carb, high-fat (LCHF) is based. He suggested that a 1995 French study Noakes presented in his own evidence shows that it is protein, not carbs, that make makes babies fat.
Noakes quickly despatched that, inter alia with a mini lecture to Bhoopchand on the limitations of associational studies and the difference between association and causation. And anyway, that study was just one cog in the wheel of all the available research Noakes has been turning in support of LCHF therapies.
But it is Noakes’ evidence on two other studies that Bhoopchand will likely be most keen to discredit.
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 says the study is fatally flawed. If that’s the case, then so is the HPCSA case against Noakes.
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). HPCSA expert witness Prof Este Vorster referred to it in her sepcial report which the HPCSA Preliminary Inquiry Committee used to charge him, without letting him see it beforehand.
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.
In his evidence in chief, Noakes told the hearing that “some important people in this trial are involved in that paper”.
Co-authors 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. In it, she and colleagues, including former UCT dean of the Faculty of Health Sciences, Prof Wim de Villiers, now Stellenbosch vice-chancellor. They make statements against Noakes that could be defamatory.
They accuse him of making “outrageous and dangerous” unscientific claims about diet. They say has gone against the university’s “commitment to academic freedom as the prerequisite to fostering responsible and respectful intellectual debate and free enquiry”.
(Click here to read the academics letter and his response.)
Noakes told the HPCSA hearing an analysis of Naudé’s study, which he and British obesity researcher Dr Zoe Harcombe had done, shows that it was biased from the outset to favour the high-carbohydrate diet and to minimise any benefit of the low-carbohydrate diet.
Harcombe will be an expert witness for Noakes and will give detail on the errors showing bias.
Noakes has 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”.
He and Harcombe have done their own thorough review of the submitted their findings on Naude’s review in a paper to a journal. It has gone through the peer-review process and been accepted for publication.
In it, 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.”
For starters, Noakes said the Naude review doesn’t actually study low-carb diets. These were high-carbohydrate diets, he said. The carbohydrate content was 35% carbohydrate. He has defined low-carbohydrate as between 5% to 10%.”
Noakes has questioned why the researchers called their diet a low-carb trial when it was not.
It turns out, said Noakes, that 14 papers were considered for inclusion in the meta-analysis but one did not have data that could be included. Yet “somehow it got in”.
Noakes and Harcombe have taken that paper out and analysed the 13 remaining papers where they corrected a long list of data errors they found. Their analysis shows that Naudé’s study actually favours low-carb.
Noakes told the hearing that Naudé has recently been appointed 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 and it is therefore probable that she will reflect that bias in her position at the Cochrane Institute. Its vision, as Noakes pointed out, is that Cochrane will 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 practise by advancing the production use of high-quality, globally-relevant, nutrition-loaded Cochrane reviews. So, (Naude) will be deciding the future of nutrition in South Africa and this organisation will be determining it. That is very important information,” he said.
On the second research, a joint Canadian-South African lifestyle intervention study, Noakes was even more forthright about its implications for the HPCSA charge against him.
He pointed out that De Villiers, in the UCT academics letter, said that LCHF would damage the health of adults who go on it.
“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 proves, Noakes said, that the high-carbohydrate diet people were eating caused their metabolic syndrome and cutting out 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 did it.”
Yet there was little notice taken of the diet because “no-one is going to make money out of putting people on a high-fat diet”, Noakes said.
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,” Noakes said.
Noakes referred to the work of US expert Dr John Ioannidis, who he calls “an absolute genius a professor of medicine at Stanford University”. Ioannidis has written eloquently on where evidence-based medicine has gone wrong.
His implication is that “perhaps medicine is not as helpful to humans as it might be.
He quotes Ioannidis saying: “I am still fantasising of some place where the practice of medicine can still be undeniably helpful to human beings and society at large.
“Does it have to be in a very remote place in Northern Canada close to the Arctic? Just maybe.”
Noakes told the hearing: “That is exactly where (Du Toit’s Canadian study) took place and he wrote that article about two years before we did.”