[2017] Lore of Nutrition: Challenging Conventional Dietary Beliefs

by Tim Noakes

  Therein lies one of the keys to why so many dietitians are so keen to silence Noakes: he and other LCHF experts do not advise cereals and grains, even in their unrefined state.

  Most entertaining in Noakes’s evidence was his list of all ‘the dogs that did not bark’ in the case against him. That was a reference to Sir Arthur Conan Doyle’s Sherlock Holmes story, The Adventure of Silver Blaze. Silver Blaze was a famous racehorse who went missing from his stable the night before a big race. The next day, the body of Silver Blaze’s trainer was found in the countryside not far from the stables, the apparent victim of a murder. Holmes solved the case on the basis of a negative fact: that a dog at the stables had not barked on the night that Silver Blaze disappeared. ‘That was the curious incident,’ said Holmes.

  Attorney Mike Skotnicki explains:

  The fact that the dog did not bark when you would expect it to do so while a horse was stolen led Holmes to the conclusion that the evildoer was not a stranger to the dog, but someone the dog recognized and thus would not cause him to bark. Holmes drew a conclusion from a fact (barking) that did not occur, which can be referred to as a ‘negative fact’, or for the purpose of this discussion, an expected fact absent from the record.16

  Noakes made the point that the HPCSA hearing included a number of such negative facts.

  The first negative fact was the absence of Pippa Leenstra. The person who had asked for the information on Twitter and who had the potential to suffer harm had not involved herself in any way with the prosecution. If Noakes’s Tweet had caused harm to either her or her infant, then she should have laid the complaint. But Leenstra had indicated on Twitter and in subsequent media interviews that she had not even followed Noakes’s advice.17 In his evidence, Noakes dismissed outright the charge of having had a doctor–patient relationship with Leenstra. He said that she was a stranger to him. When he tweeted his reply to her question, there was no point at which he considered her to be his patient. Crucially, Noakes said that he interpreted her question to mean that she was simply asking for nutrition information, not medical advice. He pointed out that he had been providing nutrition information on Twitter regularly for years, including on LCHF.

  Instead, Strydom had laid the complaint, allegedly on behalf of ADSA. Yet the Tweet could not have caused Strydom any direct harm. From this Noakes deduced that the complaint and subsequent hearing were clearly never about a single tweet. Had the hearing really been about the tweet, Leenstra would have been the key witness, barking very loudly. Instead, her silence was an obvious negative fact. The dogs that don’t bark are ‘the hardest to hear’, Noakes said.

  Reading the NSRD blogs on Strydom’s business website, Nutritional Solutions, and especially the sentiments expressed by Marlene Ellmer (see Chapter 8), it seemed to Noakes that the real reason for the complaint was the effect of the publication of The Real Meal Revolution just three months before the Twitter debacle. The Real Meal Revolution was causing huge swathes of the South African public to question the current dietary advice they were receiving and, ultimately, to lose faith in their dietitians. The latter were clearly disgruntled, he said. Strydom’s complaint to the HPCSA was therefore driven by a clear conflict of interest – a fact that should have been obvious to the members of the Fourth Preliminary Committee of Inquiry, who were responsible for deciding whether there were grounds to charge Noakes.

  The second negative fact was that he was charged with giving unconventional advice on breastfeeding on social media. As mentioned previously, he did not give any information about breastfeeding in his tweet. Rather, he provided an opinion on weaning.

  The third negative fact arose from the existence of Raising Superheroes, the follow-up book on infant and child nutrition written by Jonno Proudfoot, Bridget Surtees and Noakes. It had been published before the trial commenced in earnest in November 2015, and had even been reviewed by a committee of six ADSA dietitians, including Ellmer and current ADSA president Maryke Gallagher. In Raising Superheroes, Noakes wrote extensively on the science behind appropriate approaches to breastfeeding and infant weaning. If the hearing was really about his views on infant weaning, Noakes said, Strydom and the HPCSA should have presented evidence from the book that his advice was dangerous. But they did not, for the simple reason that there is no such evidence. The ADSA dietitians were unable to find fault with the weaning advice he provided in Raising Superheroes. The sole criticism they could muster in their book review was revealing:

  The authors clearly criticise the use of baby cereals or grains for children when complementary foods are introduced. It needs to be acknowledged that South Africa is a country with high levels of household food insecurity. Often, families cannot afford or access animal protein and vegetables or fruit daily. In such situations, grains such as oats and millet, appropriately fortified staples, such as maize and brown bread, and commercially produced enriched complementary foods, such as infant cereals, may provide cost-effective food options.18

  It seemed that Noakes was on trial for refusing to promote an inferior weaning diet to vulnerable South Africans, in particular those who believed they could not afford the ‘luxury’ of the best possible diet for the future health of their children.

  The fourth negative fact was that the most important body of scientific evidence used by Strydom and her team to bring their action against Noakes was not about breastfeeding, or weaning, or children, or even infants. It was the flawed Naudé review that deals exclusively with adult nutrition. That raised the question of what adult nutrition had to do with the initial charge laid against Noakes.

  The fifth and final negative fact was that Strydom laid the complaint in February 2014 on the grounds that the LCHF diet was dangerous, especially for infants. But in her testimony in November 2015, Strydom said that ‘everybody was waiting for this publication [the Naudé review] because we could not simply go ahead and make [a] statement about Prof. Noakes’s hypothesis or diet without looking at the evidence’.

  She essentially acknowledged that on 6 February 2014, when she laid the complaint, she had no evidence on which to base her claim that the LCHF diet was dangerous. When the Naudé review was finally published in June 2014, it failed to show that the LCHF diet was either more or less dangerous than the ‘isoenergetic balanced diet’. Yet the HPCSA concluded that a negative study in adults provided definitive evidence that the LCHF diet must be harmful to infants.

  Noakes’s evidence took up the remainder of the February session. Adams adjourned the hearing to Monday 17 October 2016. Noakes concluded his presentation on the first day of the October session, and then spent four days under relentless cross-examination.

  Bhoopchand was faced with several dilemmas when he eventually stood up to cross-examine Noakes. One was that he had to undermine the HPCSA’s own witnesses’ contention that LCHF did not actually conflict with official paediatric dietary guidelines. To do so, he frequently had to defend the indefensible. One was the cost of LCHF foods.

  In his evidence, Noakes said that cereals and grains are a major contributor to the obesity epidemic and rising levels of T2DM in children as young as three. He referred witheringly to Vorster’s stated rationale for including starchy foods in the dietary guidelines. ‘We have to be realists and we have to realise that the poorer communities are eating maize,’ she had said. Noakes and other public health experts found that advice shocking. ‘These foods are bad for babies’ brains,’ he said. ‘They have no place in diets for infant weaning.’

  The Eat Better South Africa campaign has dispelled any notion that LCHF foods are expensive and beyond the reach of the poor, Noakes said. The campaign is an arm of The Noakes Foundation, which he established to do nutrition research independent of strangling vested interests.

  When Bhoopchand challenged Noakes’s evidence on the affordability of LCHF foods, suggesting that the alternative was far cheaper, Noakes told him: ‘Unfortunately, sir, you are forgetting that if you raise people on maize, there are costs to us, as taxp
ayers, because what you are producing is a population that is unhealthy. The rates of obesity and diabetes, cancer, hypertension, dementia are rising exponentially and we are paying those costs. Those costs are not included in what we provide to our poor people. If you were to do an analysis of what is the real cost of providing and weaning onto maize, you would discover, sir, that [the conventional LFHC diet] is an incredibly expensive diet.’

  Noakes later suggested to me that the ADSA dietitians should perhaps review the ethics of their position. ‘Surely our goal should be to ensure that the poor are provided with the best foods to allow their children to escape the poverty trap, and not just accept that it is good enough to provide high-carbohydrate foods to the children of the poor during the first two years of their lives when their greatest need is for a diet providing an abundance of fatty foods with sufficient protein?’

  Bhoopchand tried and failed to get Noakes to concede that there was little or no research to show the safety of LCHF diets for infants. He painted himself into a scientific corner, because the same holds true for the safety of conventional LFHC diets. By calling into question the evidence for LCHF for infants, Bhoopchand put the spotlight back on LFHC and opened the door for Noakes to present significant evidence of the ill effects of the LFHC guidelines for infants.

  Bhoopchand again tripped himself up trying to force Noakes to concede that he had contravened the HPCSA’s rules on ethical conduct for medical professionals on Twitter. The HPCSA does not have rules for medical professionals on Twitter or any other social media platform. Bhoopchand even admitted to this, thereby undermining his own argument. He seemed oblivious to the obvious implication that Noakes was being charged with breaching rules that do not exist.

  Bhoopchand read at length from the HPCSA’s regulations relating to the practise of the health professions, in particular the norms and standards for medical practice. He read from Regulation 237, which contains the regulations defining the scope of the profession of medicine in terms of Section 33(1) of the Health Professions Act. The regulation deems an act pertaining to the medical profession to be ‘on the basis of information provided by any person or obtained from him or her in any manner whatsoever, advising such person on his or her physical health status’. Bhoopchand suggested that ‘any manner whatsoever’ covered what was said on social media.

  Noakes vigorously disputed this suggestion. He said that it would have serious implications for doctors and dietitians if everything they said on social media was deemed to be medical advice. It would change the nature of the way they communicated with the public, and would have implications for doctors not just on social media, but also when writing books and giving lectures.

  To Bhoopchand’s suggestion that he had no ‘ethical restraint’ in his tweeted communications, Noakes replied: ‘Sir, I am a very ethical person and ethics drives what I do. I will follow the ethics that I believe are relevant. The reality is if you act unethically it does not matter if there are any rules, you broke them. Ethics is a way you live, it is a way you practise. You cannot make people ethical [just] by writing rules.’

  He continued: ‘I have lived my life as a highly ethical person in my medical career, in my scientific career. I have always been ethical and I will continue to be utterly ethical in whatever I do – including my interactions on Twitter. I would be absolutely disgusted with myself if I were to do anything unethical, and that includes anything that were to break the [HPCSA’s] rules, whether or not I am practising as a medical doctor.’

  Bhoopchand also tried and failed to get Noakes to concede that his tweet to Leenstra was medical advice, not information. Noakes dismissed the idea, saying that doctors and dietitians regularly give out information on and off social media. He argued that the real danger was a lack of information, not access to information. He said Twitter’s ‘natural democracy’ meant that ‘what works percolates to the top, what does not work falls to the bottom’.

  The problem for Bhoopchand was that, like most of the HPCSA’s expert witnesses, he is at best a ‘Twitter virgin’, at worst a ‘Twitterphobe’. It didn’t help that Noakes clearly has no fear of the medium. In his evidence, he described Twitter as a ‘communication vehicle’ that he uses specifically to learn information. For those who are clever about Twitter, it can be ‘one of the most powerful ways’ to get new scientific information, Noakes said. It is not possible for scientists to stay as up to date on the research as he is without being on Twitter. The future of medicine ‘lies on the internet and on social media’, he said. It is why the ‘power of the anointed’ is rapidly giving way to the ‘wisdom of the crowds’. If he gave out any wrong or harmful information, social media would expose it within weeks, or even days. Crucially, Noakes said, social media is turning conventional advice into unconventional, incorrect advice. ‘That’s the key,’ he said. The ultimate measure is not whether information is conventional or unconventional: ‘It is whether it is right or wrong and the quality of the evidence that supports it.’

  Bhoopchand tried changing tack, saying that Noakes, ‘as a responsible human being’, should have amplified the information he gave Leenstra. In other words, now he was suggesting that Noakes should have tweeted more, not less, information.

  Noakes responded with barely disguised irritation: ‘Sir, I am a very responsible human being. I am a teacher. I have spent my life, 40 years of it, educating people at my cost – answering emails, answering letters, writing articles, writing books. I have made essentially nothing out of it. I am here to help the public. That is my mission. I have dedicated my life to that. For you to say I am … being unethical, badly behaved, breaking the ethics of medicine because I do not respond more to one question from this lady, I find that not very helpful, sir.’

  Noakes threw the gauntlet back at the establishment: ‘There are thousands of doctors and scientists around the world who believe exactly as I do, but that information is hidden and suppressed. The question is why that should be.’

  He pointed out that he had been sharing his knowledge in lectures to the public and answering questions from interested people since 1972, without anyone claiming any harm or trying to silence him. ‘I don’t tell people what to do. I don’t prescribe a diet for pregnant mothers or their babies. I simply talk about the biology of obesity, of insulin resistance, carbohydrate ingestion. I explain why a low-carbohydrate diet is the biologically proven diet to eat if one meets any of those other conditions.’

  Bhoopchand then suggested that Noakes had brought the hearing on himself by not paying sufficient attention to his reply to Strydom’s initial letter of complaint. He also suggested that Noakes wanted to be ‘treated differently’ because he considered himself to be ‘special’.

  Gone completely was the smile that usually played around Noakes’s lips. ‘That is just laughable,’ he told Bhoopchand. He quoted from an email from Professor Amaboo Dhai, chair of the Fourth Preliminary Committee of Inquiry, to members of her committee, in which she called the hearing against Noakes a ‘high-profile, celebrity case’ and said that it should be expedited. The email had been in the file that the defence had obtained in November. It was clear that certain people in positions of power considered Noakes a ‘celebrity’ and demanded that he be prosecuted for it.

  ‘It is the exact opposite of your suggestion,’ Noakes told Bhoopchand.

  Bhoopchand then asked Noakes if he was seeing conspiracy where none existed. Noakes said that he believed in truth, not conspiracy theories. Dhai spoke the truth in her email, he said. She used the word ‘celebrity’. He asked why Dhai had not called him in to discuss Strydom’s complaint. ‘Is it a conspiracy? I do not know. I do not care. You used the word. So, I would just put the question back [to you], and say: Is it because I am a celebrity that I am here? That’s the exact opposite of your question.’

  Bhoopchand sensibly did not press the point any further.

  Noakes was upbeat at the end of the cross-examination. Bhoopchand had not extracted a single major conce
ssion. Noakes, on the other hand, had presented robust evidence in his own defence. He had knocked down all the pillars of the HPCSA’s case and highlighted instances of endemic bias and unfairness in its prosecution of him.

  Noakes emphasised the implications of his case for scientists. He called for scientists to be protected, not prosecuted, for their opinions and research. He described himself lyrically 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, he said, is simply ‘to get the people to see billions of bits of information out there and make their own decisions’.

  13

  The Angels

  ‘Angels can fly directly into the heart of the matter.’

  – Author unknown

  The public had dubbed them ‘Tim’s Angels’. Although they weren’t really celestial beings, there was something scientifically angelic about the three expert witnesses who flew into Cape Town from three different continents to defend Professor Tim Noakes in October 2016. British obesity researcher and public health nutrition specialist Dr Zoë Harcombe, US science journalist Nina Teicholz, and New Zealand–based nutrition academic Dr Caryn Zinn arrived in South Africa amid a hearing that was growing more Kafkaesque with each session.