The world is changing fast and to keep up you need local knowledge with global context.
In part one of a two-part review of the February hearing of the Health Professions Council of SA against world-renowned scientist and University of Cape Town emeritus professor Tim Noakes, I looked at why it has become a turf war – and a lesson in unintended consequences on social media. Noakes is charged with unprofessional conduct for telling a breastfeeding mother on Twitter that good first foods for infant weaning are low-carb, high-fat (LCHF), after Johannesburg dietitian Claire Julsing Strydom, then president of the Association for Dietetics in SA (ADSA), complained to the HPCSA. In part two, I look at why the HPCSA, ADSA and doctors and dietitians behind them may be so keen to silence him: they don’t like Noakes’s evidence-based theories on what’s really behind epidemics of serious diseases in SA and globally as well as what to do about them. These aim straight at the heart of conventional medical and dietary “wisdom” and the status quo. Here’s a peek into the future of food as medicine – and medicine as food. – Marika Sboros
By Marika Sboros
There’s more to the turf war that is the HPCSA hearing against Prof Tim Noakes than appears on the surface.
Noakes presented evidence in a global context, but with relevance to SA, suggesting that doctors and dietitians may just be foot soldiers – witting or unwitting proxies for powerful vested interests in the food and drug industries that oppose low-carb, high-fat (LCHF, also known as Banting).
These interests make billions from sales of high-carb, low-fat (HCLF) foods, as well as drugs to treat illnesses linked to diets based on these foods. Blockbuster cholesterol-lowering drugs known as statins are an egregious example.
Make ’em sick, then sell ’em drugs to treat the sickness appears to be the dynamic at play. It brings to mind a quote by US poet and environmentalist Wendell Berry: “People are fed by the food industry, which pays no attention to health, and are treated by the health industry, which pays no attention to food.”
Noakes spent much of his evidence on the “obesogenic” environment that has evolved and the influence of food and drinks companies in creating and sustaining it. He showed how these industries have bought the allegiance of top scientists, university academics and dietitians, and sponsored dietitians’ associations and heart foundations worldwide to put a spin on their products and “health wash” sugar and other carbohydrates. In this way, they influence public health messages about obesity. Coca Cola is just one egregious example.
“You have to ask the question, and it is important to this hearing,” Noakes said: “Why do dietitians continue to recommend carbs and sugar when neither is an essential nutrient?”
Why indeed, since humans are shown not to need a single gram of carbohydrate foods for survival. Noakes told the hearing the liver does a very good job of producing all the glucose needed, without dietary carbohydrates.
He said the evidence is clear: the diet-heart hypothesis (the one that first demonised saturated fat and glorified sugar and other carbohydrates) is unproven; taking people off a healthier diet and putting them on a diet with lots of carbohydrate and polyunsaturated fats has compounded it.
He focused on US Dietary Guidelines, the most influential nutrition policy in the world as they are followed by many, if not most, governments of English-speaking countries across the globe including South Africa. Countries that didn’t speak English “luckily” did not adopt the guidelines – their populations are healthier as a result, Noakes said.
He showed why dietary guidelines in SA and globally are short on science to back them up. He referred to the work of British obesity researcher Zoe Harcombe, and American science writers Gary Taubes (author of Why We Get Fat and Good Calories, Bad Calories), and Nina Teicholz (author of The Big Fat Surprise), and said their books should be required reading for all doctors, medical students and dietitians.
The US Congress has for the first time mandated an independent review of the dietary guidelines to find out what has gone so horribly wrong. Noakes said that was due largely to Teicholz’s groundbreaking work in exposing the weak science, the missing science, and conflicts of interest underpinning the guidelines. He hoped South Africa would follow suit.
Noakes was dismissive of doctors and dietitians who refused to read the vaulable science in these books because they are not peer-reviewed. In a devastating critique of peer-review, he said it had become “a way to maintain the status quo”.
“Journal editors determine what is the status quo by referring submitted manuscripts to reviewers who will either agree or disagree with the study’s findings,” Noakes said. “Since this is known beforehand, the review process is always biased.”
Doctors practise “medicine of failure”, Noakes said. They tell patients diabetes and obesity are complex diseases when they are not; they say diabetes is chronic, progressive and incurable when it doesn’t have to be. Industry says that too. That “absolves them of any need to address the real cause”: their products that cause obesity, diabetes and related health problems in the first place.
Noakes presented significant scientific evidence for issues central to this case, that aim straight at the heart of conventional medical and dietary “wisdom” and the status quo, and threaten careers, reputations, livelihoods and funding. (It is, after all, “difficult to get a man to understand something, when his salary depends on his not understanding it”, as US author Uptom Sinclair once said.)
These issues include:
- Evolution of diet
To understand obesity, diabetes, heart disease, cancer or other health problems in children or adults, we must consider where we came from, Noakes said. Official dietary guidelines don’t. “Understanding evolution is crucial to our understanding of genetics, and everything we teach in modern medicine.” Nutrition “seems to have forgotten” that we evolved for 3 million years eating different foods from those recommended today.
- Cereals and grains aren’t health foods
These have only been in our diets for 12,000 years, compared to 3 million years for low-carb, high-fat (LCHF) foods. Noakes took great lengths to show that not one randomised controlled trial (RCT) shows any health benefits of eating cereals and grain. Instead, evidence links these foods to leaky gut syndrome and non-coeliac gluten sensitivity.
- Maize – a poor option for infant weaning
A complementary food for infant weaning is by definition not a substitute food, Noakes said. It should supply what breast-milk lacks – in this case zinc and iron. Maize does not have these nutrients in the concentrations of animal products. Like other grains and cereal, maize has “buckets of anti-nutrients which interfere with our gut function”. It makes sense to give infants foods containing iron and zinc in their natural packaging: animal products. Maize is touted as a staple food for rural and poor people, but was only introduced after the 1880s gold mining rush in South Africa, and was subsidised by the government of the day to support local farmers. “Just because maize became the staple food because of government interventions after the 1930s, doesn’t mean it’s the healthiest choice for our people,” he said.
- Insulin resistance (IR) – the basis for chronic diseases, including obesity, heart disease, diabetes, hypertension, gout
Modern medicine treats these conditions as if they are separate diseases. US endocrinologist Dr Gerald Reaven of Stanford University and others have shown they are all linked to a single underlying condition: insulin resistance. Noakes said: “Our patients don’t have high blood pressure or obesity, for example.” Rather the underlying condition is insulin resistance, and “if we don’t treat the underlying condition, we merely treat symptoms, not the disease”. He argued that insulin resistance is a benign condition that only becomes unhealthy and life-threatening in those who eat high-carbohydrate diets.
- Abnormal blood lipoproteins, not cholesterol, cause arterial (heart) disease
Arterial disease, particularly the development of arterial plaque, is not caused by “cholesterol” but by insulin, inflammation and abnormal lipoproteins, Noakes said. It is nonsense to talk of good or bad cholesterol, he said, because cholesterol is simply a chemical that cannot be both good and bad. Cholesterol (and triglycerides) are transported in the bloodstream in packages known as lipoproteins, and it is specifically abnormalities in these lipoproteins that cause arterial disease. The small LDL (low-density lipoprotein, aka “bad cholesterol”) particles are thought to be most damaging. They increase on a high-carb diet, and reduce on a low-carb diet. “This has been known for more than 20 years.”
- Diabetes – a disease of disseminated or generalised arterial obstruction
Conventional treatment aims to regulate the blood glucose concentrations of diabetics. This treats the symptom not the underlying cause – generalised arterial obstruction. New evidence suggests the best long-term treatment for diabetics is a low-carbohydrate diet to minimise the amount of insulin diabetics either secrete naturally or need to inject. Since insulin is ultimately the body chemical (hormone) that causes the most damage in these chronic diseases, reducing insulin requirements by limiting insulin use is the logical and proven “best therapy”, Noakes said. He said there have been many reported cases of diabetic patients able to come off all medication using dietary intervention alone.
- Appestat malfunction drives obesity
Just as the brain drives sports performance, it drives hunger and the development of obesity. “The key finding in the obese is that they are always hungry”, Noakes said. Excessive hunger is the result of appestat malfunction, the part of the brain that controls appetite and hence regulates the number of calories we ingest dail. “Obesity is ultimately a disease of the brain. The cause of appestat malfunction is the development of addictive, highly processed foods that have taken over the food environment.” Eating fat makes us thin because it takes away our hunger, he said. Carbohydrate make us fat because it stimulates hunger.
- Cancer may be a metabolic disease
Cancer may not be driven by genetic abnormalities or malfunctions. It appears to be linked to carbohydrate and glucose, probably also insulin. Evidence suggests a high-carbohydrate diet encourages growth of cancer cells. Obesity and diabetes are the most common risk factors for cancer and cancer rates have risen to match increasing rates of obesity.
Noakes has been honest in his evidence to say where and when he got things wrong. He admitted bias in favour of carbohydrates in his own early research: In the 1980s, his team was the first to show carbohydrate loading had no effect on sports performance. When he wrote up the study, he tried to account for it by explaining why the carbohydrate did not work.
“We were so convinced carbohydrates were going to help those people. We couldn’t get our minds around the idea that maybe something else was involved. I’m embarrassed when I read it now.”
Where does all this leave the HPCSA’s case against Noakes? With gaping holes. It hasn’t had much luck with witnesses, but may only have itself to blame for poor choices.
Its final expert witness was Stellenbosch University psychiatry professor Willie Pienaar, a surprise, last-minute choice. With only a masters degree in bioethics, Pienaar can be considered a lightweight. He earned his keep, though, by contending that Noakes had a doctor/patient relationship with Leenstra, and was unprofessional for giving advice without the infant’s health.
Van der Nest tied Pienaar up in knots under cross-examination, undermining his evidence with concessions, among others that there had been no agreement to treat or be treated, and if Leenstra were Noakes’ patient, she would also have been Claire Julsing Strydom’s patient, (ADSA’s then president who lodged the complaint against Noakes) and ADSA paediatric dietitian Marlene Ellmer’s patient as well.
Ellmer and Strydom tweeted to Leenstra to ignore Noakes’ advice and consult them instead. Both would have been guilty of “supersession” – the legal term for taking a patient away from a health professional without permission – a breach of HPCSA rules.
Both Strydom and Ellmer should also have been charged, Van der Nest said.
Pienaar repeatedly said Noakes had “made a mistake” and he feared for “my profession” if doctors were allowed to give advice freely on Twitter. “Patients will no longer trust us,” he said, and lives would be at risk.
Van der Nest said while he didn’t mean to be insulting, Pienaar was “a dinosaur” about Twitter. And when Pienaar made a throwaway comment that Leenstra was “wise” to ignore Noakes’ advice, an increasingly exasperated Van der Nest said: “You have demonstrated your bias. Your petticoat is showing, professor, and you are making it worse.”
Van der Nest wasn’t the only to pick up on inconsistencies in Pienaar’s testimony:
Dr Janet Giddy, a member of the Professional Conduct Committee chaired by Pretoria advocate Joan Adams, that is hearing the charge against Noakes, asked Pienaar if there were “different rules for different people” and as a bioethicist, he felt it was right that Noakes alone was charged, despite other health professionals also giving medical advice on social media, as “that’s what’s happening here”.
Pienaar, rather unwisely I thought, said Noakes should be made into a “test” or “moral” case. That idea didn’t seem to go down well with Giddy. It’s anyone’s guess how well it will go down with rest of the committee. My guess is: not very well.
Noakes was articulate and at times emotional in his defence, explaining what drives him: “I was influenced by Prof Christiaan Barnard,” he said. “I wanted to make a difference and try to be world-class – as a doctor or a scientist, it didn’t matter. As I went through my education I realised my interest was in discovering and providing new information, educating and helping people to become healthy.”
His own father’s death from the complications of type 2 diabetes was also a major influence. Noakes himself was diagnosed with the condition after eating a high-carb, low-fat diet for 33 years, which motivated him to make changes. He controls his diabetes through diet and low-dose medication (metformin). He has gone off the drug at times, but is back on it as he has said he wants “perfect blood glucose control”. He hopes in time to be able to go off the drug completely.
Noakes is often criticised for promoting LCHF as a one-size-fits-all diet, but told the hearing that ironically the SA dietary guidelines are the one-size-fits-all diet: “We are saying: actually, hold on, there may be other sizes to fit people. Humans are very different; we have to look at the individual response. “
He said Raising Super Heroes, which he co-authored, is “ one of the best books ever written on nutrition for infants and for children”. Noakes contributed the chapter on the science, and said it’s the fruits of at least a year plus 40 years of his research before that, and his understanding of biochemistry and physiology.
“I do not prescribe a diet for pregnant mothers or their babies, I simply talk about the biology of obesity, of insulin resistance, carbohydrate ingestion and explain why a low-carbohydrate diet is the biologically proven diet to eat if one meets any of those conditions.”
Noakes said evidence now suggests that on an LCHF regimen, people eat between 25g to 200g a day of carbohydrate, depending on their level of insulin resistance.
Medicine must move away from the paternalistic model and the “power of the anointed” to the “wisdom of the crowd”, Noakes said.
“That’s critical because in my view, the future of medicine lies on the internet and social media, because that’s where people are going to get their information. If I tell people to eat a high-fat diet and it does not work, it will be exposed within weeks on internet, on the social media.”
Ultimately, Noakes’ vision harks back to the Hippocratic injunction to physicians to “let food be your medicine and medicine be your food.”
Of course this is all from Noakes’ perspective. I’d have preferred to have been able to give you both sides (more likely all sides) of this peculiar battle. But from the outset, the HPCSA and ADSA stonewalled all material questions. After Last year’s hearing, HPCSA CEO Dr TKS Letlape said it would be “inappropriate” to comment, as “whatever the outcome, either party could appeal”.
HPCSA COO advocate Tshepo Boikanyo had no such inhibitions. Boikanyo was interviewed by John Robbie on Radio 702 last year. His comments made it clear he thinks Noakes is guilty.
Boikanyo is one of three executives considered to be “unfit to hold office” in a report by the ministerial task team mandated by Health Minister Aaron Motsoaledi to investigate the HPCSA in 2015, and told to step down. The team found the HPCSA to be in a “state of multi-system organisational dysfunction”. All three executives declined to step down and the HPCSA announced it would conduct its own in-house investigations.
Noakes, after prescribing a high-carb diets for 33 years and harming people, including himself, said he has “learned to be a little more humble”. He described himself as just “one tiny ray of knowledge in a galaxy of billions of other humans who have their own experiences and their own knowledge”.
His focus is “simply to present the evidence as I see it and get the people to see billions of bits of information out there and make their own decisions.”
The hearing continues in October.