by Tim Noakes
In the summary of her evidence, Ellmer made the following points, all of which Noakes has easily dismissed:
Infants and young children are in the most nutritionally vulnerable stages of the life cycle. Noakes obviously agrees. It’s why he wrote Raising Superheroes. In the book, he explains why a high-fat diet is crucial during the first 1 000 days of an infant’s life.
Noakes’s advice to wean onto a LCHF diet is not ‘evidence based’ and is beyond his scope of practice and qualifications. For many reasons, this is not true: the information is evidence-based, and Noakes is qualified to give it.
Noakes’s information can also be potentially harmful to the infant because he does not define the exact composition of a LCHF diet. As a result, the advice is confusing and open to misinterpretation. That applies to any information. Twitter is restricted to 140 characters. Leenstra understood this when she posed her question. Had she sought a detailed response, she would have consulted her doctor or a dietitian.
Carbohydrates provide ‘readily available energy for growth and development as well as mental development’. It is not clear whether or not ‘the infant body can efficiently and timeously provide energy from protein and fat alone if carbohydrate is significantly reduced in the diet’. Carbohydrate is not an essential nutrient. The infant, like the adult, has no requirement for carbohydrate. Noakes points out that even the US National Academy of Medicine acknowledges this (see Chapter 7).
The weaning diet should include ‘meat and meat alternatives’, and ‘milk and milk products’. This is exactly what the LCHF diet provides.
Low-carbohydrate, ketogenic diets used in the treatment of drug-resistant epilepsy produce a wide range of complications. Ellmer does not understand that since it is not ethical to perform controlled clinical trials of the ketogenic diet (as the control group would continue to have multiple seizures), it can never be known if these are the complications of the underlying disease or of the diet. Conveniently, she assumes that the diet must be the cause. This is known as confirmation bias.
Although the diet is said to be low in protein, in fact, it will be high in protein if insufficient fat is eaten. High-protein diets can allegedly cause multiple complications in infants and children. Correct, which is why Noakes emphasises that LCHF is a high-fat, not high-protein, diet.
‘We currently have no evidence on the effect on growth, development and obesity risk of a high-protein or a high-fat complementary diet.’ Presumably, Ellmer is saying that we must therefore assume that these diets will be harmful. This is more confirmation bias.
Child health in South Africa is deteriorating. ‘Poor dietary intake, food insecurity and poor quality of basic services are important contributors to this problem.’ Noakes has often asked whether the current advice to wean South African children onto high-carbohydrate, cereal-based diets might be the cause.
Wisely, Ellmer chose not to put herself and her reputation through the mental anguish of going up against Van der Nest and Ramdass. They would have made short work of her ‘expert’ evidence.
It is significant that Ellmer referred to ketogenic diets in her summary. Ketosis and ketogenic diets would keep turning up like bad scientific pennies during the hearing. All of the HPCSA’s witnesses referred to ketogenic diets as if they were synonymous with danger and premature death. They all displayed surprising ignorance on the topic, conflating ketosis with ketoacidosis. The former is a natural, benign bodily state. The latter is potentially fatal, fortunately rare, and seen mostly in patients with uncontrolled type-1 diabetes.
To top it all, the HPCSA had not even charged Noakes with advising a ketogenic diet, dangerous or otherwise. His tweet said nothing at all about ketosis. Why the witnesses kept bringing up the subject would only be revealed towards the end of the hearing, when a series of emails came to light and was placed on record in February 2016.
Mapholisa opened his case by calling Strydom. As a factual witness, Strydom was required to restrict herself to the events leading up to her complaint against Noakes. Yet she frequently ventured expert opinion on the content of his tweet.
Van der Nest lodged the first of many objections on procedural grounds. Strydom could only be called as an expert witness if the HPCSA had notified the defence seven days before the hearing and had provided a summary of her evidence, he said. Mapholisa appeared oblivious of the requirements, arguing that Strydom could give both factual and expert testimony simply because she was a dietitian. ‘She is not just a layperson who, like myself, just reads about nutrition in a book or elsewhere,’ Mapholisa said. ‘She went to varsity, studied nutrition and I will submit that she can express an opinion in that regard as an expert as she is, in fact, qualified to do that.’
Adams disagreed and sustained Van der Nest’s objections.
In giving testimony, Strydom added significant weight to my theory that the trial was partly a turf war. Dietitians don’t want Noakes taking business away from them. As ADSA president, Strydom had frequently made it clear that dietitians should have a virtual monopoly on giving dietary advice to the public. In her evidence, she said that Noakes erred in his tweet by not referring Pippa Leenstra to a ‘qualified’ professional. In addition, ADSA dietitians especially don’t like the fact that Noakes’s advice conflicts significantly with South Africa’s lucrative official dietary guidelines, which promote low fat and high carb. Not surprisingly, the guidelines became a main focus of the hearing.
Strydom also tried hard to distance herself as the complainant in the case. She claimed that she had lodged the complaint as ADSA president and not in her personal capacity. Yet her letter of complaint to the HPCSA and all the HPCSA’s correspondence with Noakes and his lawyers make it clear that she had complained personally. Back in 2015, I asked Strydom via email about her status. She replied that she would ‘prefer’ that I said she had complained from the outset as ADSA president. When I queried her use of the verb ‘prefer’, she went silent and stayed that way.
I also queried whether Strydom had a mandate from ADSA to lodge her complaint. In face-to-face discussions and emails, current ADSA president Maryke Gallagher was evasive. She and other ADSA executive members would only confirm that they had signed a letter more than a year after Strydom lodged the complaint. In it, they stated that, as president, Strydom had the authority to lodge complaints on ADSA’s behalf. Legal experts say that the letter was an attempt to alter facts after the event.
There were many other self-incriminating elements in Strydom’s testimony. One was a throwaway comment she made about the Naudé review, which would come back to haunt her, the HPCSA and ADSA. It was the first hint in evidence on the record of an organised campaign by prominent doctors and academics to nail Noakes. ‘Everybody was waiting for this publication,’ Strydom said, referring to the review, ‘because we could not simply go ahead and make [a] statement about Prof. Noakes’s hypothesis or diet without looking at the evidence. So, everybody, all these big organisations were waiting on the publication of this information before we could make any kind of media statement [emphasis mine].’
Under cross-examination, Van der Nest referred Strydom to statements issued by ADSA, the HPCSA and other organisations in July 2014, hailing the Naudé review as the death of Banting and proof that Noakes was on the wrong scientific track. Interestingly, the Naudé review does not mention Noakes, Banting or even LCHF.
‘It is not like the way you are saying it,’ Strydom protested. ‘It is not like everybody joined together to now make a statement against Prof. Noakes. We were all waiting for the evidence to be published.’ With those statements, Strydom teed up the Naudé review as the key piece of evidence against Noakes, a manoeuvre that she and the HPCSA would come to regret.
Van der Nest also raised the influence of ADSA’s sponsors – among them food and soft-drink companies such as Kellogg’s, Unilever, ProNutro, Huletts and Coca-Cola – on the case against Noakes. Mapholisa objected on the grounds of irrelevance, but Adams overruled him. Strydom, unsur
prisingly, denied any outside influence.
Strydom ventured into expert territory again by claiming that Noakes had entered into a doctor–patient relationship with the breastfeeding Leenstra on Twitter. She also claimed that Noakes’s tweet was medical ‘advice’, not information. By communicating on a social media platform as a medical doctor, ‘who is trusted and regarded as a celebrity in South Africa’, Noakes had given ‘advice’ that constituted a ‘public health message’. At this, Van der Nest sighed and objected again: ‘This is so over the line, it is just not true.’ Adams sustained the objection.
Strydom appeared oblivious of the many deep legal and ethical holes she was digging for herself and Ellmer. If Noakes had established a professional relationship with Leenstra, then so had she and Ellmer. Both had tweeted far more extensively to Leenstra than Noakes. And if Noakes had given medical ‘advice’, then so had she and Ellmer. By Strydom’s own logic, she and Ellmer would also have been guilty of supersession. That’s the legal term for one health professional taking over the patient of another, without his or her knowledge or permission. Both Strydom and Ellmer told Leenstra to ignore Noakes and contact them instead. Strydom even tweeted her contact details to Leenstra. Under cross-examination, Strydom claimed not to know about supersession. Van der Nest said that as ADSA president she would have known about it. ‘You knew [on 5 and 6 February 2014] and you know today that it is not ethical for one health practitioner to take over the patient of another health professional,’ Van der Nest told her. Strydom had no choice but to concede, and Van der Nest pressed the point home: ‘You did not consider [Leenstra] to be the patient of either Prof. Noakes nor Ms Ellmer, because otherwise you would have been taking her over as a patient, and that was not what you were wanting to do, correct?’ Strydom agreed and eventually conceded that there was no doctor–patient relationship.
When Van der Nest raised Strydom’s ‘horrified’ reaction to Noakes’s tweet in front of 300 million Twitter users, she conceded that she may ‘have overreacted a little’. Van der Nest then asked Strydom to read out from the same booklet outlining the HPCSA’s ethical guidelines for health professionals to which she had referred in her testimony, specifically that ‘a practitioner shall not cast reflections on the probity, professional reputation or skill of another person registered under the Act or any Health Act’. Strydom was forced to concede that she had cast adverse reflections on Noakes’s reputation and skill in her own tweets to Leenstra.
To Strydom’s claim that Noakes’s tweet posed a danger to the infant because it was ‘unconventional’, Van der Nest posed the salient question: ‘Do you really believe that it is correct that someone who has an honestly held view, which you considered to be unconventional, should be struck off the roll of practitioners?’ (This was one of the possible consequences of a guilty verdict.) Strydom conceded that she did not believe that to be fair. She also conceded that no patient had alleged any harm from Noakes’s tweet. Even ADSA was not alleging any harm.
Hovering over all of this was a question that would crop up repeatedly during the hearing, one that the HPCSA resolutely refused to answer: If the HPCSA genuinely believed that Noakes had breached its rules, why had it not also charged Strydom and Ellmer? Crucially, under cross-examination Strydom conceded that Noakes had been debating the science of nutrition with her and many other dietitians on her business website, Nutritional Solutions. Van der Nest then made a significant point to which he would return later: ‘Because [Noakes] refuses to agree with you, you have him prosecuted?’ Strydom became flustered at this, and said that she was only concerned about Noakes giving ‘dangerous’ advice to the breastfeeding mother.
Van der Nest pointed out that the HPCSA had not charged Noakes with giving dangerous advice. In effect, Van der Nest told Strydom, she believed that she had a monopoly on free speech. She also believed that if she disagreed with Noakes, then the HPCSA had to prosecute him.
Hester Vorster was up next, and fared no better. Her evidence was based on a 20-page secret report, which the HPCSA’s Fourth Preliminary Committee of Inquiry had commissioned her to write. It later transpired that the committee had used Vorster’s report as the basis for its decision to charge Noakes, without showing it to him first. The defence team acquired the report by accident, shortly before the June 2015 hearing.
Vorster attempted to defend the contents of her report in her testimony. She also ventured into ethics territory by claiming that Noakes had established a doctor–patient relationship with Leenstra by giving ‘uncalled-for advice’ to wean a baby onto LCHF. This illustrated his ‘promotion of the LCHF diet at each opportunity’, she said. According to Vorster, health professionals are obliged to warn lactating mothers about the effects of LCHF, among them that the diet may not provide all the nutrients infants need and ‘that ketosis should be avoided’.
Noakes’s tweet was ‘irresponsible’, she said. It went against South Africa’s ‘up-to-date’ food-based dietary guidelines (which she wrote and updated in 2013), which, she said, included paediatric guidelines for babies and infants up to five years. These guidelines, Vorster told the hearing, are supported by the best available evidence, and are in line with the WHO, and the Australian, New Zealand and US guidelines.
Vorster also alleged that Noakes had breached the HPCSA’s code of conduct by criticising dietetic training in South Africa. ‘Maintaining an opposite viewpoint in public could also be seen as unprofessional,’ Vorster stated, before recommending that the HPCSA ‘take the matter up’ with Noakes.
Vorster supported Strydom’s view of dietitians as best placed to give dietary advice. Despite his A1 rating, she said that Noakes was someone ‘who has not been trained sufficiently in nutrition and would not qualify for registration as a dietician or nutritionist to provide dietary advice on an individual level’. He should not have given advice that differed from ‘what the dietetic profession and registered dieticians accept as correct’. The ‘correct conduct’ would have been for Noakes to refer Leenstra to a dietitian.
Vorster also criticised Noakes for his ‘inappropriate’ use of Twitter as a communication medium, yet she admitted that she knew little about the popular social network. That was an understatement. Vorster said that she had ‘just sort of looked in Wikipedia’ to find out about it. Twitter’s ‘inherent nature’ and ‘short sound-byte messages’ made it an ‘unsuitable medium’ for health professionals to give dietary advice to the public, she said.
Advocate Rocky Ramdass did a thorough demolition job on Vorster’s evidence in cross-examination. Ramdass is also a medical doctor, with more than 23 years’ experience as a family physician. He referred to Vorster’s qualifications, which included an undergraduate degree in home economics and a doctorate in physiology. She confirmed that she had no qualifications or training in dietetics, had never practised as a dietitian or seen patients, had not done any research into LCHF diets and was not an expert in medical bioethics.
Ramdass noted Vorster’s lack of knowledge of what constituted a low-carbohydrate diet. Vorster suggested it was one in which 45 per cent of energy was derived from carbohydrate foods. He also noted that she showed little understanding of the role of IR in chronic diseases other than diabetes. Ramdass asked Vorster why she would not acknowledge that a high-carb diet could be the cause of chronic disease, and why she insisted that dietary fat was the culprit. He pressed her for the evidence behind her recommendation in the South African Food-based Dietary Guidelines for adults and children ‘to make starches the basis of most meals’.
‘The point I am making,’ Ramdass told Vorster, ‘is that industry has a huge role to play in the provision of carbohydrates for an unsuspecting community.’
Vorster disagreed. She referred to research, including the Transition and Health during Urbanisation of South Africans (THUSA) study in which she was involved.1 She conceded that the sugar industry was one of the study’s sponsors, but denied that it had any influence. ‘We are actually against sugar intake,’ Vorster
said. ‘In addition to developing this guideline, we published against an increase in sugar intake, advising a low-sugar intake in South Africa very recently.’ Taking a sideswipe at Noakes, she said, ‘He also had money from the Sugar Association in his earlier days of research.’ Noakes has always been open about this fact.
Ramdass questioned Vorster’s support for wholegrains in the diet despite solid evidence implicating grains in dental disease, obesity, heart disease and more. He also questioned her wholehearted support for mieliepap – a cheap, staple food for South Africa’s rural poor. Vorster said that nutrition guidelines had to consider what rural populations were eating and what they could afford. Her comment could be considered shocking. Mieliepap is dirt cheap, but it is also heavily fortified and very high-carb. Many nutrition experts, Noakes included, argue that nutrition guidelines should be based on a food’s nutrient density, not on cost. They also say that ‘real’ food, by definition, needs no fortification to make it nutritious.
Ramdass pointed to another anomaly in Vorster’s evidence: official guidelines for infant weaning don’t stipulate that starch should be the basis of most meals. He read out the guidelines:
Continue breastfeeding to two years and beyond. Gradually increase the amount of food, number of feedings and variety as your child gets older. Give your child meat, chicken, fish or egg every day or as often as possible. Give your child dark green leafy vegetables and orange coloured vegetables and fruit every day. Avoid giving tea, coffee and sugary drinks, high-sugar, high-fat, salty snacks to your child.
He pointed out that these recommendations are no different from what Noakes said in his tweet. The implication was not lost on either side.