By Marika Sboros
I’ve watched with growing fascination how the Health Professions Council of South Africa (HPCSA) is conducting its case against Prof Tim Noakes. It has charged him with unprofessional conduct. That’s a charge it usually reserves for doctors who have done something, really, really bad.
Its most recent, high-profile case was against the man dubbed “Dr Death'” – apartheid-era cardiologist Dr Wouter Basson. But could Noakes really be South Africa’s next Dr Death?
Basson is the apartheid-era cardiologist who ran the government’s chemical and biological warfare programme. His “duties”, according to allegations, included poisoning the ruling party’s opponents with lethal cocktails of muscle relaxants and other drugs. Some of those people died.
Basson got off all murder and attempted murder charges in South Africa, as many of the events took place in Namibia, formerly South West Africa. Therefore, that was outside the country’s jurisdiction.
The HPCSA found Basson guilty of unprofessional conduct in 2013 but has yet to decide on a suitable sanction. (UPDATE: The HPCSA is itself in complete disarray. A ministerial task team in 2015 found that it was riddled with incompetence and its top three executives were unfit to hold office.)
Johannesburg health writer Patricia Sidley has an MA in bioethics and health law from the University of the Witwatersrand. She is no fan of Noakes and finds it “strange” that the HPCSA has let the charge get this far. She describes the HPCSA’s action against him as “idiotic”, only in slightly more profane language.
But what exactly did Noakes do that makes the HPCSA put him in the same category as SA’s own “Dr Death”? It can seem anticlimax to say that he tweeted that good first foods are low-carb, high-fat (LCHF). In other words, meat, fish, chicken, eggs, full-fat dairy and veg.
And that the president of the Association for Dietetics in SA (ADSA) Claire Julsing Strydom tweeted in response that she was so “horrified” that she would report him. She did just that in February 2014, starting the HPCSA’s case against him.
It is becoming clear to some nutrition specialists that it was probably not so much what Noakes said that so “horrified” Strydom. It’s probably more about what he did not say.
Firstly, he did not advise baby cereal.
Focus on baby good
That’s important because Strydom and ADSA have vigorously promoted cereal for babies based on official dietary guidelines. Those are the same high-carb, low-fat, guidelines British obesity researcher Zoe Harcombe exposed in a meta-analysis in the BMJ Open Heart in February 2015.
Harcombe has shown how these guidelines had no scientific evidence backing them up when authorities imposed them on an unsuspecting public in 1977.
Research points to the same guidelines as contributing to epidemics of obesity, type 2 diabetes and heart disease. (UPDATE: The guidelines are under scrutiny in the US and UK.)
Secondly, ADSA and Big Food companies have variously called LCHF for infants, children, adults, or anyone at all “dangerous”, “deadly” and “unscientific”.
Interestingly, no paediatricians in SA reported Noakes for the tweet. And in 2014, the Canadian Paediatric Society, in a joint statement with Health Canada, Dietitians of Canada and the Breastfeeding Committee for Canada, issued the same advice as his tweet offered. However, the statement also offers the option of iron-fortified cereal.
LCHF is ‘no fad’
Via email, Pringle Bay registered dietitian and ADSA member Tamzyn Murphy Campbell told me that iron-fortified cereal was “suboptimal”. “It is highly-processed, high-glycaemic index, often sugar-packed and contains anti-nutrients that interfere with nutrient absorption.” she said.
Campbell is one of few registered dietitians in SA who has embraced LCHF for young children and babies. She doesn’t call LCHF a diet because “that makes it sound like a fad”. “It’s a lifestyle,” she said, “a way of eating healthily.”
So what’s really motivating Strydom and the HPCSA in this case? I would like to be able to give their sides side at length here but both aren’t talking. Strydom has repeatedly refused to answer questions – including on links with food companies.
She even stonewalled questions with no material relevance to her case against Noakes. Strydom also said that HPCSA had “advised” her not to talk to the media as the inquiry is “sub judice”.
I pointed out that sub judice does not apply, as anyone with even a rudimentary knowledge of the legal process in SA knows. The HPCSA is a statutory body, not a court of law. I also pointed out that the HPCSA had not given Noakes the same instruction. Its call centre told me that it does not instruct parties in dispute not to talk to the media.
Refuge in silence
Sidley says that sub judice is just a “refuge, a vague term that people throw around when they don’t want to talk to the press”. After all, even “lawyers are on the air all the time talking about their cases these days”.
A few days before I spoke to Strydom, she gave an hour-long TV interview, with top Johannesburg cardiologist Dr Anthony Dalby. Both described LCHF as “dangerous” and likely to cause premature death.
Dalby, at least, was prepared to have a phone chat with me, albeit brief. He said that LCHF was dangerous, not because of low-carb or weight-loss issues. It contravened “the best medical advice we have” on saturated fat recommendations, he said.
Patients develop very high, or moderately high cholesterol levels on high-fat diets, Dalby said. The results will play out in the long term, not the short term, he said. “You can feel great, lose weight, have less diabetes, but the long-term effects are unknown and appear to be adverse.”
Dalby dismissed research showing traditional societies, such as the Inuit, have eaten LCHF for centuries without a high incidence of heart disease as “not proof.” Japanese traditional diets have protein and carbohydrates but very little saturated fat. They also show little heart disease, he said.
Fat in the spotlight
“We need a lot more evidence in every respect than these off-the-wall diets that we see.”
Saturated fat is simply “not great to recommend”, Dalby said. The “best advice” is that saturated fat should be no more than 10% of the diet.
He would not comment on some experts’ claims that there is no proof that saturated fat causes heart disease. “If you believe that, I leave it to you,” Dalby said and abruptly ended the call.
Strydom and ADSA have mostly stayed resolutely behind the HPCSA’s sub judice curtain. That’s except for the odd public statement about the HPCSA case really being “all about Twitter”. Strydom replied through Twitter in 2015, directing me to ADSA’s Guidelines on Infant Nutrition posted on April 27.
These guidelines mostly support Noakes’ advice, and no longer routinely advise cereal as a first food for infants. One theory on social media is that the HPCSA and ADSA’s motivation in going after Noakes is because LCHF is bad for business.
That prompted me to look into ADSA’s sponsors. Consumer group Grass Action’s recent investigation shows cereal maker Kellogg’s to be a major sponsor of ADSA. Other sponsors include Nestle, Woolworths, Unilever, the sugar industry – via Equisweet, a sweetener product made by Hulett’s. Coca Cola is there too for nutrition education events – which can sound like an oxymoron.
Big Food at work
Kellogg’s doesn’t just sponsor ADSA. It has ADSA’s executive committees members on its staff and as consultants.
Strydom is a Kellogg’s consultant. On her business website, Nutritional Solutions, she says she has presented “nutrition intervention programs and nutrition presentations for various organisations including Kellogg’s”. She is quoted in a press release promoting a Kellogg’s cereal product.
ADSA’s new president, Maryke van Zyl, is a consultant to and worked full-time for Woolworths in 2009. ADSA executive Linda Drummond is Kellogg’s nutrition and public affairs manager; Cheryl Meyer is Kellogg’s nutrition assistant.
Of course, the close ties of ADSA executives with food companies are not an exclusively South African phenomenon. And Strydom is on record saying that sponsorship does not equal endorsement of products. However, research uncovers a different global picture.
Just as with the drug industry, studies that the food industry funds tend to produce results that please the industry. The same applies to dietitians in bed with food companies.
British investigative health writer and author Jerome Burne has written of “cuddly dietitians in the cosy embrace of industry fatcats”.
Dishing up the conflicts of interest
“Declarations of interest by individual researchers are obviously important but they are peripheral,” Burne writes. “However, once you get on some board or committee you probably shouldn’t have any commercial links at all.”
Burne’s post follows an extensive forensic analysis in February 2015 in the BMJ (British Medical Journal), by British writer, freelance journalist Jonathan Gornall. Titled Sugar: spinning a web of influence, it reveals the “true nature of the relationship between industry and (UK) nutritional experts”.
Gornall’s analysis is UK-focused but globally relevant. The findings implicate international food and drinks manufacturers and the dietitians in their pay or thrall.
Gornall says that his investigation gives “a clue to why so many global companies with nutritionally contentious products feel the need to fund research”. And why they invite public health experts onto their advisory boards and into their boardrooms as consultants.
Stifling scientific debate
It also looks at why they have engaged in the UK with the government’s “responsibility deal”. That’s in two of the most recent annual submissions to the Securities and Exchange Commission in the US, Gornall writes.
But back to the HPSCA hearing against Noakes. Sidley says that it will likely “stifle scientific debate and narrow the space within which scientific argument can occur”. If the HPCSA does Strydom’s bidding, it will go down “a very dangerous road, and set a very dangerous precedent”.
Sidley thinks that the case itself “holds out dangers for the public in the use of new technology”.
Noakes is characteristically bullish. In an interview with EWN’s Stephen Grootes, he said that Strydom’s action was“possibly the best thing that’s ever happened to medicine in the past 10 or 20 years”.
He says that the HPCSA will have to investigate not just him, but “what dietitians are teaching the South African public about nutrition”. And the scientific basis dietitians’ education– or lack thereof.
It will also have to rule on the science around porridge as a first food for infants. That’s if it manages to prove that suggesting meat and veg for infants constitutes “unconventional advice” and “unprofessional conduct”.
South African-born US paediatric, adolescent and adult bariatric and transplant surgeon Dr Robert Cywes is an LCHF specialist who has treated carbohydrate addiction for over 15 years. He has operated on about 6000 people. In patients before and after surgery, he has had more than 800 000 encounters with fat people.
Learning from the past
“You’d be an idiot if you don’t learn from that,” Cywes says.
In an email, Cywes says that the HPCSA faces “an opportunity for scientific truth rather than a challenge to Noakes’ integrity. He has the humility and the science to be very persuasive.”
In the end, Sidley says that Strydom’s action presents the HPCSA with an unenviable task. It will have to navigate a “whole new world of medicine, including diagnosis, intervention and delivery of information that is changing electronically”.
Doctors already charge for telephone consultations with patients, and increasingly use digital media.
There is an “enormous amount of activity going on electronically on Twitter and other social networks”, she says. Doctors, dietitians, nutrition specialists and therapists continually give opinion, information and advice. Quite when that free flow of information becomes “consultation”, diagnosis and treatment between doctor and patient and enters dangerous ethical waters is not clear.
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