Tim Noakes: caught in a turf war over an inconvenient truth?

The Health Professions Council of SA hearing that resumes in October against Prof Tim Noakes for his ‘unconventional’ views on butter, eggs, bacon and broccoli, was once again filled with twists, turns, drama, intrigue and what may be ‘inconvenient truths’ for some doctors and dieticians. In the first of a two-part series, I review the hearing in February, and why it has become an object lesson in unintended consequences on social media, one that the HPCSA, the Association for Dietetics in SA, its former president Claire Julsing Strydom, and top medical doctors and professors at Wits, Cape Town, Stellenbosch and NorthWest universities are having to learn. In the second part, Noakes sees into the future of medicine as food – and food as medicine. – Marika Sboros

By Marika Sboros

Picture courtesy of the Noakes Foundation
Picture courtesy of the Noakes Foundation

If the HPCSA hoped its hearing against UCT emeritus professor Tim Noakes on a charge of unprofessional conduct would shut him up, the opposite has happened.

The hearing, which resumes in October, has given Noakes a powerful global platform to disseminate and interrogate the vast body of scientific evidence both for and against low-carb, high-fat (LCHF, aka Banting).

LCHF is not yet mainstream, but is used worldwide by top specialists to enhance sports performance and treat obesity, diabetes, heart disease, cancer, even dementia, which some specialists are calling “type 3 diabetes” because of its link with diet. In medical jargon, these are called non-communicable diseases (NCDs), a clumsy term for chronic ailments known as lifestyle diseases. Noakes told the hearing these are not diseases of lifestyle, but are shown to be diseases of nutrition.

It isn’t easy figuring out what’s really at the heart of this case against him. It’s a strange saga that began in February 2014 when then president of the Association for Dietetics in SA (ADSA) Claire Julsing Strydom reported Noakes to the HPCSA for two tweets to a breastfeeding mother Pippa Leenstra saying that good first foods for infant weaning are LCHF – meat and veg. That’s advice ADSA, Strydom and paediatric dietitians routinely give. 

Read also: Tim Noakes trial: the best to hope for – madness or miracle?

The HPCSA has charged Noakes with unprofessional conduct for giving “unconventional advice” that is not evidence-based to a breastfeeding mother on a social network. The hearing has become an object lesson in unintended consequences on social media, and it isn’t only the HPCSA, ADSA and Strydom who are learning it. Top medical doctors and professors at Wits, Cape Town, Stellenbosch and NorthWest universities, including the  head of bioethics at Wits, Prof Amaboo “Ames” Dhai, are learning  it as well.

The hearing has variously been called the “Banting for Babies Trial, even the “Nutrition Trial of the Century”. More recently, Noakes has been compared to a modern-day Gallileo, an analogy that is looking more and more apt. HPCSA hearings are supposed to be dispassionate, unbiased inquiries into the facts. The hearing against Noakes is not a court of law, but might just as well be. It has been so adversarial, filled with twists, turns, drama and intrigue, it looks more like a scientific Spanish Inquisition than a simple inquiry.

The latest session that ran in Cape Town from February 8 to16 was true to character. It opened with evidence on the record by Johannesburg advocate Michael van der Nest SC for Noakes showing irregular conduct by the HPCSA Preliminary Committee of Inquiry that investigated Strydom’s complaint.

The committee, chaired by Dhai and with members that included UCT emeritus professor of surgery John Terblanche and retired UCT psychiatry professor Denise White, charged Noakes in September 2014.

An emailed paper trail shows that Dhai and Terblanche in particular went far beyond their remit to ensure not just that Noakes was charged, but that the hearing against him succeeds. It suggests the HPCSA has been biased against Noakes from the start.

Van der Nest made another crucial point during cross examination of th HPCSA’s final expert witness, Stellenbosch University psychiatry professor Willie Pienaar, one on which this hearing hinges, saying: “South Africa has a  constitution that specifically guarantees scientists freedom of speech.

“This is important not only for our democracy, but for the development of humankind that scientists not be muzzled and that their freedom of speech is protected.”

That raises the question: why would the HPCSA and ADSA dietitians want to deprive a world-renowned scientist of his right to freedom of expression? After all, Noakes, a medical doctor and an award-winning scientist, is one of few scientists in the world with an A1 rating by the National Research Foundation for expertise in both nutrition and exercise science.

There are few, if any medical scientists in SA who match him for qualifications (he has three doctorates, one on the heart and exercise and an honorary from the Vrye University, Amsterdam), achievements and research experience. He has been called a “national treasure”, and “a force in Nature”, by UCT deputy vice chanceller and law professor Danie Visser.

Moreover, it raises the question why ADSA and the HPCSA want to deprive South Africans of the scientific information that Noakes wants to impart.

In answering those questions, the hearing throws up more suspects (mostly usual) than a medico-scientific game of Cluedo. 

A week before the February hearing, the HPCSA said it would call Prof Jacques Rossouw as an expert witness. On opening day it announced it would not call him after all. That’s probably a wise move, since its legal team would have realised by now its case has gaping holes that need filling if they are not to prove terminal.

Noakes’ legal team, headed by Cape Town lawyer Adam Pike, of  Pike law, with Van der Nest and Durban advocate Dr Ravin “Rocky” Ramdass, a medical doctor with 24 years experience as a family physician, has so far under cross-examination effectively undermined the evidence of all the HPCSA’s five expert witnesses, and Strydom who was a factual witness.

Jacques Roussouw
Prof Jacques Roussouw

If the HPCSA intended Rossouw as a big-gun, pre-emptive strike against Noakes and the vast body of science he presented to the hearing – in more than 4000 pages and 900 slides with references from top scientists and institutions internationally, over nearly 40 hours – that was unlikely to happen (more on why in upcoming posts on the scientific debate). 

South African-born Rossouw, recently retired head of the US National Institutes of Health Women’s Health Institute (WHI) Branch in the Division of Cardiovascular Sciences at its National Heart, Lung, and Blood Institute,  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. (He isn’t saying, despite two emailed requests for comment.)

Noakes has said there is no one study that proves him or any diet conclusively right or wrong since it is impossible to undertake such a study. (You’d have to lock around 50,000 people up in a hospital jail for 40 years, which would be difficult and costly, if not ethically suspect and physically challenging.)

“You have to look at the totality of the evidence,” Noakes said in his own evidence.  “That’s what I am doing. I am a totalist. I have obsessive compulsive disorder with facts. That’s why I write like I do. If anyone tells me there’s no evidence to support low-carbohydrate diets, I tell them they haven’t read the literature.”

Read also: Tim Noakes and legal dream team helping him survive ‘trial by ambush’

Everyone is entitled to their own opinion, he said; no one is entitled to their own set of facts.

“I tell my students that when a single strand of evidence conflicts with their beliefs, they better start questioning their views.”

Noakes also said his views on LCHF are only unconventional to those who refuse to look at the evidence on which it is based.

ADSA’s complaint against Noakes rests squarely on the so-called diet-heart hypothesis – the one that says saturated fat causes heart disease (and obesity, diabetes and a whole lot else besides); the one that started lipophobia (fear of fat), the demonisation of fat and glorification of carbohydrates way back in the late 1970s; the one on which  South Africa’s paediatric and adult dietary guidelines (which ADSA members drew up) are  based.

Noakes presented evidence, including from Harvard  in the US, to show that saturated fat is not the issue and never was. He echoed experts internationally who say saturated fat may be the victim of possibly the “biggest scam in the history of modern medicine”.

“Carbs and insulin are driving obesity”, Noakes said, “not saturated fat.”

Read also: No bread, please, just pass the butter! Banting takes off globally

When  saturated fat was taken out of the diet, we had to replace it with something to make food more palatable, Noakes said. That something is sugar and carbohydrates that are shown to be highly addictive foods. The consequences for global public health have been nothing short of catastrophic: global NCD epidemics.

Whether you call the HPCSA hearing an inquiry, trial or The Inquisition, it’s clear that Noakes isn’t its only target. The HPCSA and ADSA have LCHF squarely in their sights. To discredit the science behind it – and presumably Noakes along the way, the HPCSA has  taken a leaf straight out of the book of his dream legal team: it has outsourced its legal team to Johannesburg lawyer, Katlego Mmuoe, who also has an eponymous law firm (KK Mmuoe attorneys), and acquired its own doctor-turned- advocate Ajay Bhoopchand.

Bhoopchand tried hard to stem the flow of science Noakes presented, objecting that much of it, “while rather interesting”, was irrelevant. Pretoria advocate Joan Adams, chair of the HPCSA Professional Conduct Committee that is hearing the charge against him, disagreed and overruled him.

The charge against Noakes might seem simple but is complex, Adams said. It covers conventional versus unconventional advice and nutrition science; her committee unanimously decided there was no reason to limit Noakes’ right to defend himself fully and freely. 

I’d say Adams pressed the right legal button. It makes no sense for the HPCSA to charge Noakes with giving unconventional advice that is not evidence-based, then deny him the opportunity to present evidence showing it is in fact evidence-based.

The hearing has rapidly turned into a turf war: Noakes and LCHF on the one hand, and doctors, particularly cardiologists, ADSA dietitians, nutrition academics and HCLF on the other.

Doctors don’t want Noakes giving advice that differs from the conventional medical HCLF “wisdom” they regularly prescribe; ADSA dietitians see nutrition advice as their turf. They don’t want Noakes giving nutrition advice if it conflicts with official dietary guidelines and the HCLF advice they regularly dish out – notwithstanding that the guidelines contradict the scientific and factual findings upon which they are based.

That advice wouldn’t be such a problem were it not for well-documented effects on the health of people who followed it for decades: global epidemics of obesity, diabetes, heart disease, cancer, and dementia.

There’s another reason cardiologists may hate Noakes even more in future: he said heart disease in future would be treated by hepatologists (liver specialists), not by cardiologists.  Noakes presented compelling evidence in a study just two months old showing that the blood lipid (cholesterol) abnormalities that are linked to heart disease – so-called atherogenic dyslipidaemia – are caused by non-alcoholic fatty liver disease (NAFLD) in those who are also insulin resistant.

Read also: Noakes, low-carb, high-fat on trial: will the evidence ruin a good story?

“We now know (heart disease) begins when the liver is full of fat and that is called a fatty liver – that’s non-alcoholic fatty liver disease. The fatty liver is caused by carbohydrates and sugar, especially fructose, in the diet, not fat,” Noakes said.

Noakes also argued that diabetes is ultimately a disease of progressive, disseminated (widespread) arterial disease progressing over decades that leads ultimately to complete obstruction of blood flow to the eyes, kidneys and lower limb blood vessels, causing blindness, kidney failure and gangrene of the limbs, the latter requiring amputation. 

Although heart attacks and strokes occur also as a result of this same progressive arterial disease, they represent a “fundamentally different process”, he said, in which arteries that are incompletely obstructed suddenly develop an abrupt complete obstruction as a result of rupture of the arterial plaque causing the arterial disease. 

Noakes argued that while scientists such as Rossouw claim that the falling rates of heart attacks indicate that the low-fat diet is working to prevent all arterial disease, he offers a quite different explanation:  the reduction in smoking especially has reduced the number of patients experiencing the sudden plaque ruptures that cause heart attacks and strokes. 

With fewer people dying of heart attacks, but increasingly developing type 2 diabetes, the disease burden of arterial disease has simply shifted to the obstructive form found in diabetes, Noakes said. If the low-fat diet really preventED arterial disease as Rossouw and others claim, then he argued it would also have prevented the now much more prevalent obstructive form found in type 2 diabetics.

The reduction in smoking and the promotion of low-fat high-carbohydrate diets have simply “shifted the disease burden from heart attack to diabetic arterial obstructions”, he said.

“I find it baffling why so many have difficulty understanding this obvious truth. Perhaps it is inconvenient?” 

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