THE February 2016 session of the ongoing trial of scientist Tim Noakes for his ‘unconventional’ views on nutrition was true to form. It was filled with twists, turns, drama and intrigue. In the first of a two-part series, I look at the consequences of the Health Professions Council of SA (HPCSA) hearing against Noakes so far. And the object lesson in unintended consequences on social media for doctors and dietitians who don’t want Noakes dishing out dietary advice.
By Marika Sboros
The public has called the HPCSA hearing the “Banting for Babies Trial” and the “Nutrition Trial of the Century”. If the HPCSA hoped it would silence Noakes, it has done the opposite.
As the latest February 2016 hearing has shown, it has given him a global platform to disseminate scientific evidence for low-carb, high-fat (LCHF, aka Banting).
LCHF is not yet mainstream. However, specialists use it worldwide to enhance sports performance and treat obesity, diabetes, heart disease, cancer and even dementia. Some doctors now call dementia “type 3 diabetes” because of the documented link with diet. In medical jargon, these are called non-communicable diseases (NCDs). That’s a mouhful for chronic ailments also known as lifestyle diseases.
Noakes told the hearing that NCDs are at heart diseases of nutrition. In particular, he said that NCDs are mostly diseases of insulin resistance.
The hearing began way back in February 2014. The president of the Association for Dietetics in SA (ADSA) Claire Julsing Strydom reported Noakes to the HPCSA for a single tweet to a breastfeeding mother. Noakes said that good first foods for infant weaning are LCHF. In other words, meat, fish, chicken, eggs, dairy and veg.
Problem of same advice
Click here to view: Noakes exposed: the real beef dietitians have with him!
The problem for the HPCSA from the outset has always been that ADSA and Strydom give the same advice to breastfeeding mothers. With one notable exception: they add breakfast cereals to the mix.
Despite that, the HPCSA went ahead anyway and charged Noakes with unprofessional conduct for giving “unconventional advice”. It mustered a motley crew of expert witnesses to give evidence against Noakes at the November 2015 session of the hearing. These included North-West (formerly Potchefstroom) University nutrition professors Este Vorster and Salome Kruger, and paediatrician Dr Muhammed Ali Dhansay.
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 in cross-examination. They easily eviscerated the evidence of all the expert witnesses, eliciting major concessions along the way.
Once it became clear that the HPCSA’s case was falling apart, it took a leaf out of Noakes’ legal team’s playbook. The HPCSA has brought in an expensive outside legal team with Johannesburg lawyer, Katlego Mmuoe, of KK Mmuoe attorneys, as instructing attorney. It has also acquired a doctor-turned- advocate Ajay Bhoopchand.
Bhoopchand could not stop Van der Nest from eliciting major concessions from Stellenbosch University psychiatry professor Willie Pienaar. The HPCSA brought Pienaar in as a last resort on medical bioethics around doctor-patient relationships. However, Pienaar is not a qualified medical bioethicist. He has only a masters degree in medical bioethics and lectures part-time in the subject.
He insisted that Noakes had a doctor-patient relationship with the breastfeeding mother (Pippa Leenstra) on Twitter. Pienaar also claimed that Noakes gave advice without knowing anything about the infant’s state of health.
Van der Nest said that if that were the case, then Strydom was just as guilty. So was another ADSA dietitian, Marlene Ellmer, who also tweeted information to Leenstra. The HPCSA should then have charged them both, said Van der Nest.
That pointed to an object lesson in unintended consequences for doctors and dietitians on and off social media. The February session opened with evidence of an email chain, the contents of which Van der Nest placed on the record. It suggested highly irregular conduct by the HPCSA’s own Preliminary Committee of Inquiry that it set up to investigate the charge against Noakes.
The chair of the committee was the head of bioethics at Wits University, Prof Amaboo “Ames” Dhai. Members included UCT emeritus professor of surgery John Terblanche and retired UCT psychiatry professor Denise White.
The email chain showed that Dhai and Terblanche went beyond their remit to ensure that the HPCSA charged Noakes. They also made comments suggesting hope that the charge against Noakes to succeed. Van der Nest said that this showed biased against him from the outset.
Van der Nest made another crucial point during cross-examination of Pienaar, one on which this hearing hinges. It is that South Africa has a constitution that specifically guarantees scientists’ freedom of speech. And that the HPCSA was seeking to limit’s Noakes’ freedom of speech.
That made the hearing important not only for South Africa’s young democracy, Van der Nest said. “It is important for the development of humankind that scientists not be muzzled and that their freedom of speech is protected.”
He pointed to Noakes’ qualifications. He is a medical doctor and one of few scientists in the world with an A1 rating by South Africa’s National Research Foundation. That is an international rating for both nutrition and sports science. Noakes also has three doctorates, in medicine, sports science and an honorary from the Vrye University, Amsterdam.
UCT deputy vice chancellor and law professor Danie Visser has called Noakes a “national treasure”, and “a force of nature”.
Yet, as Van der Nest pointed out, ADSA and the HPCSA seemed keen that South Africans should not hear scientific information from this “national treasure”. In answering why, the hearing has thrown up more usual suspects.
A week before the February hearing began, the HPCSA announced that it would call Prof Jacques Rossouw as an expert witness. On opening day, it announced it would not call him after all. Rossouw and the NIH have stayed mum on why, apart from saying that he did not get timely permission to attend.
Noakes believes that Rossouw did not want to debate the science with him on such a public platform.
South African-born Rossouw recently retired as 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. He 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. Noakes presented a vast body of science in his own defence against HCLF. That was in more than 4000 pages and 900 slides with references from top scientists and institutions internationally, over nearly 40 hours.
Noakes told the hearing that no study conclusively proved LCHF or any diet right or wrong. That’s because it is impossible to undertake such a study, he said. “You’d have to lock around 50,000 people up in a hospital jail for 40 years. That would be difficult, costly, ethically problematic and physically challenging.”
Low-fat causes heart disease?
He said that there was compelling evidence that low-fat foods could over time cause heart disease. “You have to look at the totality of the evidence,” Noakes said in his own evidence.
He told the hearing that LCHF was only unconventional to “those who refuse to look at the evidence”. He said that tells his students that “when a single strand of evidence conflicts with their beliefs, they better start questioning their views”.
Noakes spent much time in his evidence aiming at the diet-heart hypothesis that saturated fat causes heart disease. It’s the one that started “lipophobia” (fear of fat), the demonisation of fat and worship of carbohydrates way back in the late 1970s, he said. It’s also the one on which South Africa authorities have based their paediatric and adult dietary guidelines (that ADSA members drew up).
Noakes presented evidence to show that saturated fat does not cause heart disease. He said that saturated fat was the victim of possibly the “biggest scam in the history of modern medicine”.
“Carbs and insulin resistance, not saturated fat, are driving obesity,” he said.
When food makers took saturated fat out of the diet, they had to replace it with something to make food more palatable, Noakes said. That something was sugar and carbohydrates, which are highly addictive substances foods. The consequences for global public health have been “nothing short of catastrophic: global NCD epidemics”, he said.
Noakes took special aim in evidence at South Africa’s official dietary guidelines. These guidelines are modified for a South African context. However, they religiously follow the influential US dietary guidelines.
He said that South Africa’s official dietary guidelines were looking more like “misguidelines”. This was especially the case when it comes to guidelines on infant weaning, he said. That’s despite the fact that the guidelines do contain some good information.
Some of the information, however, was actively “bad for babies’ brains”, he said.
Noakes has also identified what he sees as the biggest and terminal problem with current dietary guidelines globally. “Science doesn’t lead them,” he says. Industry – food and drug companies – leads them and that’s a problem for public health.
At the February hearing, Bhoopchand objected frequently to Noakes’ evidence. He said that much of it, “while rather interesting”, was irrelevant.
Pretoria advocate Joan Adams, chair of the HPCSA Professional Conduct Committee hearing the charge against him, disagreed and regularly overruled him.
The charge against Noakes might seem simple but it was complex, Adams said. It covered conventional versus unconventional advice and nutrition science. Thus, her committee unanimously decided there was no reason to limit Noakes’ right to defend himself fully and freely.
It has become clear that the hearing against Noakes is a turf war. On the one side are Noakes and doctors and dietitians who support LCHF. On the other are doctors, particularly cardiologists, ADSA dietitians, nutrition academics who advocate for high-carb, low-fat diets
They appear not to want Noakes giving advice that differs from the conventional medical HCLF “wisdom”. ADSA dietitians, in particular, seem not to want Noakes giving dietary advice at all. They see that as dietitians’ turf.
But there’s another reason that some doctors, cardiologists, in particular, are so ill-disposed towards Noakes. He told the hearing that heart disease in future would be treated by hepatologists (liver specialists), not cardiologists.
Noakes also presented compelling evidence in a study just two months old about the effects of non-alcoholic fatty liver disease (NAFLD). The study shows that NAFLD causes blood lipid (cholesterol) abnormalities that are linked to heart disease – so-called atherogenic dyslipidaemia – in people who are insulin resistant.
“We now know (heart disease) begins when the liver is full of fat,” Noakes said. “That is called a fatty liver. That’s non-alcoholic fatty liver disease.” Carbohydrates and sugar, especially fructose, in the diet caused NAFLD, not fat, he said.
Noakes also presented the argument that diabetes was ultimately a disease of progressive, disseminated (widespread) arterial disease. He pointed out that diabetes progresses over decades. It leads ultimately to complete obstruction of blood flow to the eyes, kidneys and lower limb blood vessels. The consequences are most often severe. These include blindness, kidney failure and gangrene of the limbs, the latter requiring amputation.
Heart attacks and strokes also occur as a result of progressive arterial disease, he said. However, they represent a “fundamentally different process”. Arteries that are incompletely obstructed develop an abrupt, complete obstruction as a result of rupture of the arterial plaque causing arterial disease.
Falling heart attack rates
Scientists such as Rossouw have claimed that the falling rates of heart attacks indicated that the low-fat diet was working to prevent all arterial disease. Noakes offered a “quite different explanation”. The reduction in smoking especially had reduced the number of patients experiencing the sudden plaque ruptures that cause heart attacks and strokes.
Fewer people were dying of heart attacks but increasingly developing type 2 diabetes, he said. That meant that the disease burden of arterial disease had simply shifted to the obstructive form found in diabetes. If the low-fat diet really prevented arterial disease, it should also have prevented the now much-more-prevalent obstructive form found in type 2 diabetics.
“I find it baffling why so many have difficulty understanding this obvious truth. Perhaps because it is inconvenient?”