Review: Real Food On Trial

It’s March, so I should probably make good on my New Year’s resolution to write a review of Real Food On Trial, the book about the persecution of Dr. Tim Noakes by the Health Professionals Council of South Africa (HPCSA). I read the book over the holidays, but as you know if you read my most recent post, I’ve been a bit distracted.

Most people in the low-carb/paleo/keto diet world probably know what happened to Dr. Noakes, at least in the general sense. It was, after all, big news on social media. I wrote about the trial, and I wrote about the appeal – the HPCSA’s second attempt to by gosh find Noakes guilty of something, despite being slapped down in their first attempt.

Real Food On Trial is the detailed, blow-by-blow version of the trials in all their ridiculous glory. Actually, Part Two of the book covers the trials. We’ll come back to that.

Part One, written by Noakes, is the story of how he evolved from promoting the standard hearthealthywholegrains! and arterycloggingsaturatedfat! advice to becoming an advocate for low-carb, real-food diets high in natural fats.

Dr. Noakes holds the highest rating South Africa can confer on a scientist. Science matters deeply to him. Science is what changed his mind. So early in the book, he takes the reader through both the science and his own experience – which included sending his type II diabetes into remission by changing his diet.

He knew the LCHF diet he now promoted was controversial, but much like the persecuted scientists whose stories Alice Dreger recounts in Galileo’s Middle Finger, he believed he was protected by the evidence itself. After all, scientists are supposed to be rational people only interested in finding their way to the truth. They welcome challenge and debate, right?

When I added these ideas in early 2012, I was certain that they were sufficiently correct for me to risk exposing them to a wider audience. I also assumed that because we live in a mature academic democracy in South Africa, these ideas would inspire a grown-up debate in the scientific community, especially among colleagues at my academic home, the Faculty of Health Sciences at the University of Cape Town (UCT).

Of course, the grown-up debate didn’t happen. Instead, several fellow academics at UCT blindsided Noakes with a media assault, accusing him (without citing evidence) of recommending a diet that would kill people. Despite his impeccable credentials as a scientist, they began publicly dismissing him as a “celebrity professor” promoting yet another “fat diet.” He began to realize that he’d committed the sin of challenging a dietary orthodoxy that had spawned billion-dollar industries – and as punishment, he’d been targeted for destruction.

Step one in the attempted destruction was a brand-spankin’-new meta-analysis of dietary studies known as the Naudé Review. Some of the UTC professors who had criticized Noakes were involved, and –- surprise, surprise! — the review concluded that LFHC diets are no better for health or weight loss than diets based on the conventional advice.

Noakes found both the timing of the review and its conclusions somewhat suspicious.

I was mildly surprised, as a meta-analysis of the effects of true LCHF diets had already been published the previous year. In the British Journal of Nutrition in May 2013, Nassib Bezerra Bueno and colleagues showed that people eating less than 50 grams of carbs per day (the diet I was promoting) lost more weight than those eating higher-carb diets. What is more, important health markers showed greater improvement in those eating the low-carb diet. I could not understand why we would need another meta-analysis of the same data. Unless, of course, the study was motivated by something other than the advancement of truth and science.

Say what? Scientists get together to produce a new study, and they’re not objectively seeking the truth?

The study was, of course, motivated by a desperate desire to discredit Noakes, as he learned later during the first trial. And as usually happens when scientists conduct a study to promote an agenda, there were problems with the study.

To make certain that the Banting/LCHF/‘Noakes’ diet had absolutely no hope of coming out on top, they did not even look at the diet that I advocate. Instead, they studied diets with an average carbohydrate content of 35%, knowing full well that the upper limit of the LCHF diet that I prescribe is between 5 and 10%, providing between 25 and 50 grams of carbohydrate per day.

We’ve seen that little trick in other studies. But when you’re attempting to bias a study, sometimes one trick isn’t enough. Zoe Harcombe conducted a deep-dive analysis of the Naudé Review and found it was full of errors, which she documented in a paper. If Noakes wasn’t suspicious before, he certainly was after Harcombe’s analysis.

Designing a study, the result of which is predictable before the study even begins, is not science. Rather, it is the scientific equivalent of match-fixing in sport. And, as in sport, if science is fixed, the question is, who is the ultimate beneficiary?

The answer: the dietitians who were already plotting to file charges against Noakes. They were just waiting for him to give them an excuse – which he did (although it was a flimsy excuse) with the infamous tweet.

On 3 February 2014, Twitter user Pippa Leenstra tweeted the following to me and Sally-Ann Creed, my co-author on The Real Meal Revolution:

@ProfTimNoakes @SalCreed is LCHF eating ok for breastfeeding mums? Worried about all the dairy + cauliflower = wind for babies??

On 5 February, I tweeted my response:

@PippaLeenstra @SalCreed Baby doesn’t eat the dairy and cauliflower. Just very healthy high fat breast milk. Key is to ween [sic] baby onto LCHF.

Within a few minutes of posting my tweet, Leenstra received a response from Ellmer, who described herself as a ‘paeds dietitian’:

@PippaLeenstra Pippa, as a paeds dietitian I strongly advise against LCHF for breastfeeding mothers. #notokay

To which Leenstra responded:

@Mellmer80 thx, why do u say that?

Ellmer chose not to answer her question on Twitter. Rather she suggested they take the discussion offline:

@PippaLeenstra Why dont you email me on marlene.ellmer@gmail.com and I will explain. Ps food flavours are definately [sic] passed through BM

As you may recall, when the HPCSA filed charges against Noakes, they claimed his tweet constituted medical advice, and that he had established a doctor-patient relationship with Leenstra. When I first read the charge, I thought it was clearly ridiculous. A reply on Twitter establishes a doctor-patient relationship? Are you kidding me?

I didn’t realize until I read the book that the HPSCA’s charge wasn’t just silly; it was hypocritical in the extreme.

If this were the case – in other words, had I established such a doctor-patient relationship – then Ellmer’s latest tweet constituted supersession. By providing her contact details to Leenstra, Ellmer was seeking to make Leenstra her patient; in effect, she was stealing my patient. And stealing another medical professional’s patient is a breach of the HPCSA’s rules. If I were to be charged for breaching the rules, then the HPCSA would have had to act against Ellmer, too.

But of course, the real fun began when dietitian Claire Julsing Strydom joined the fray with her own tweets.

@ProfTimNoakes @PippaLeenstra @SalCreed I AM HORRIFIED!! HOW CAN YOU GIVE ADVICE LIKE THIS???? @ProfTimNoakes @PippaLeenstra @SalCreed YOU HAVE GONE TOO FAR, BE SURE THAT I WILL BE REPORTING THIS TO THE HEALTH PROFESSIONAL COUNCIL SA

@ProfTimNoakes @PippaLeenstra Pippa I am a breastfeeding mom of a 4 month old & a RD [registered dietitian] with a MSc in dietetics this info is shocking.

@ProfTimNoakes @PippaLeenstra Pippa please contact me on 011 023 8051 or Claire@nutritionalsolutions.co.za for evidence based advice

According to HPSCA rules, Strydom was now also attempting to steal a patient. But of course, she was never charged.

Leenstra, the supposed “patient” in the relationship, tweeted to everyone in the thread she had elected to follow the advice of the dietitians. As far as Noakes was concerned, that was the end of the matter.

As a result, I considered my job done and I disengaged. Leenstra had received the information she had sought. She had made her choice. That is why Twitter exists: to share knowledge and information that allows the interested participants to make their own informed decisions.

But of course, the dietitians now had the excuse for a prosecution they’d been planning all along.

True to her word, Strydom submitted a formal complaint to the HPCSA in the form of an email sent at 08h47 on Thursday 6 February 2014. It read:

To whom it may concern.

I would like to file a report against Prof Tim Noakes. He is giving incorrect medical (medical nutrition therapy) on twitter that is not evidence based. I have attached the tweet where Prof Noakes advices [sic] a breastfeeding mother to wean her baby onto a low carbohydrate high fat diet.

I urge the HPCSA to please take urgent action against this type of misconduct as Prof Noakes is a ‘celebrity’ in South Africa and the public does not have the knowledge to understand that the information he is advocating is not evidence based – it is especially dangerous to give this advice for infants and can potentially be life threatening. I await your response.

Kind regards,
Claire Julsing Strydom

Part Two of Real Food On Trial was written by journalist Marika Sboros, who attended and covered both trials. Reading the detailed account of the trials alternately infuriated and amused me. I was infuriated because the trial never should have happened. As Sboros explains:

From the outset, I found the charge of unprofessional conduct suspect. After all, the HPCSA reserves such a charge for practitioners who have committed really serious offences, such as sexual misconduct, theft, grievous harm or causing the premature death of patients. The HPCSA also does not have any ethical rules governing doctors’ conduct on social media.

Replying to someone who asks you a question on Twitter is hardly in the same category as sexual misconduct or causing grievous harm, wouldn’t you say? And who exactly was the victim here? Leenstra, the “patient,” elected to listen to the dietitians. She wasn’t harmed. Her infant wasn’t harmed (and wouldn’t have been harmed if Leenstra had listened to Noakes instead). So again, who was the victim?

The answer: the dietitians, of course.

When the first attempt of Health Professions Council of South Africa (HPCSA) to hold a hearing against Professor Tim Noakes rolled round in Cape Town in June 2015, it was easy to spot his supporters. They were dressed in bright-red T-shirts, the colour of the cover of Noakes’s book The Real Meal Revolution. It had sold more than 160 000 copies in its first six months, making it South Africa’s bestselling book ever. It quickly became the ‘bible’ of Banting, as the low-carbohydrate, high-fat (LCHF) lifestyle has become known in the country.

As the hearing progressed, it became clear that the book had played a crucial role. Its success had infuriated doctors, dietitians and academics alike. Among them was dietitian Claire Julsing Strydom, who had reported him to the HPCSA in February 2014 for what the public had dubbed the ‘Banting for babies’ tweet. As Noakes’s legal team would later note in their closing argument, these health professionals were furious with him not only because they disagreed with him on the science for optimum nutrition but also because the public appeared to be listening more to Noakes than they were to them. In other words, they were losing influence, and business, to Noakes. The Real Meal Revolution thus appeared to be one of the reasons that Noakes’s critics were so keen for the HPCSA to silence him.

The HPSCA couldn’t prove that Noakes had harmed anyone with his dietary advice – in fact, it’s clear that many, many people have been helped by following that advice. But he was sure as shootin’ harming the reputations of the dietitians. Emails discovered by his defense team (which the prosecution never intended the defense to see), revealed that the dietitians had been gunning for Noakes well before the infamous tweet. Here’s part of one sent to the HPSCA by Strydom:

Just would like to follow up on the Tim Noakes problem – the bashing of the profession continues and we need intervention from the HPCSA as a matter of urgency. As ASDA we do comment, but the HPCSA has a much bigger clout and we are desperate for an intervention.

In other words, We’re not big enough to really hurt the guy, so we want you to do it.

And so they tried. That’s where the whole, crazy affair becomes amusing. (Well, in retrospect. I’m sure Noakes wasn’t amused at the time, since HPSCA was trying to ruin him.) As Sboros recounts testimony and exchanges among attorneys, the prosecution team begins to look more and more like a courtroom version of the Keystone Cops.

For starters, their (ahem) “star” witnesses didn’t seem know what a ketogenic diet is.

All the HPCSA’s witnesses referred to ketogenic diets as if they were synonyms for danger and premature death. 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.

When Strydom took the stand, she promptly shot herself in the foot:

Strydom’s testimony was incriminating – of herself …. 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,’ she said.

Strydom appeared oblivious of the deep legal, ethical holes she was digging for herself and Ellmer. If Noakes had a professional relationship with Leenstra, then she and Ellmer also had one. Both had tweeted far more extensively to Leenstra than Noakes had done. 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.

Michael van der Nest, one of Noakes’ attorneys, pointed out the hypocrisy during cross-examination:

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 Professor 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 was forced to concede that there was no doctor-patient relationship.

No doctor-patient relationship. That’s one pillar of Strydom’s complaint effectively demolished. Not that she’d give up easily, of course.

Strydom became flustered 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.

As if they didn’t already look foolish enough, the prosecution team tried to prevent Noakes and his team from presenting scientific evidence that a LCHF diet is safe and often beneficial. Remember, in her letter encouraging the HPSCA to file charges, Strydom called his advice “dangerous.” By gosh, Noakes was giving medical advice that was going to kill babies! And yet at this point in the trial, the position taken by the Keystone Cops prosecution team could be summed up as:

Tim Noakes established a doctor-patient relationship on Twitter and gave dangerous advice. We’ve already admitted there was no doctor-patient relationship, and we don’t want to debate whether the advice is actually dangerous. Now can we please just conduct the Soviet-style trial we expected and find him guilty of something without all this bothersome evidence stuff?

You can imagine how that went over with Noakes’ attorneys.

Noakes had not asked to be prosecuted, Van der Nest said. Noakes had not asked to spend two years under a professional cloud, living with significant stress and having to spend a fortune on his own defence. ‘Dietitians brought the case against Noakes because he disagreed with them,’ Van der Nest said. ‘Because he had the temerity to hold a different view to them, they thought he must be prosecuted.’

Looking directly at [prosecutor] Bhoopchand, a steely Van der Nest said: ‘Do not get upset when you prosecute someone and he puts up a fight. That is the consequence of prosecuting someone for a tweet that was ignored by the so-called patient, Ms Pippa Leenstra. That is why we are here. [Noakes] is the defendant. He is entitled to defend himself to the fullest and he will.’

Fortunately, the committee chair, Joan Adams, agreed.

After an adjournment, Adams ruled that while the charge against Noakes might seem simple, it was complex. It made no sense, she said, for the HPCSA to charge Noakes with giving ‘unconventional advice’ only to deny him the opportunity to give evidence showing that his advice was not unconventional. The committee unanimously agreed, she said, that there was no reason to limit Noakes’s constitutional right to defend himself fully.

To defend himself fully, Noakes called upon three women Sboros dubbed Tim’s Angels:

They weren’t really celestial beings, but there was something scientifically angelic about the three experts 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.

Believe it or not, the prosecution team tried again to prevent them from testifying. Once again, the objections were slapped down by the committee hearing the case.

It’s easy to understand why the prosecution didn’t want these women anywhere near the courtroom: as Sboros recalls in the book, their testimony on the science was so solid, the prosecution barely bothered with cross-examinations.

You know the outcome: the committee found Noakes not guilty on all charges.

With that, the room erupted. Supporters rose to their feet, cheering, applauding and hugging. Noakes remained seated. He dropped his head into his hands but only for a moment. He later told me that he thought he would cry. Instead, he lifted his head, raised both arms and punched the air with clenched fists in victory, shouting, ‘Yes!’ His lawyers were equally jubilant, reaching over and embracing him and one another, their relief etched on their faces.

That’s when a sane person would decide it’s time to give up the persecution. But as we know, the dietitians didn’t believe they’d shot themselves in foot quite enough yet. They apparently told themselves this dangerous, horrible man who had to replied to a question on Twitter by offering dangerous, horrible advice simply had to be found guilty of something.

Immediately after the ruling, ADSA president Maryke Gallagher gave a TV interview and said that ADSA would not change its advice to the public. She repeated the claim that ADSA gives evidence-based dietary advice. Therefore, Gallagher signalled that while Noakes had won a significant battle, ADSA’s war with him continued.

When the HPSCA decided to appeal and drag Noakes through another trial, I wrote a post titled Dear Dietitians of South Africa: You Look Like @$$holes Right Now. See, that’s the reason @$$holes act like @$$holes: they lack the gene that tells a normal person, Gee, I really look like an @$$hole right now. I’d better stop what I’m doing.

Here’s how you can tell you’re being an @$$hole, even if you lack that gene: people who agree with your advice beg you to stop what you’re doing.

Two days before the appeal hearing, a group of doctors launched an online petition that the influential, US-based Nutrition Coalition immediately supported. The petition called on the HPCSA to ‘stop prosecuting’ Noakes. Before the week was up, more than 31,000 of doctors, scientists, dietitians and assorted others from across the globe had signed … Among the signatories was Harvard physician and nutrition professor Walter Willett. Willett promotes plant-based diets as the healthiest option. He is, therefore, on the opposite end, ideologically, from classic, animal-based low-carb, high-fat (LCHF) diets. Willet confirmed to me that he signed to signal his support for the right of scientists to express opinions even when they differed significantly from his.

But of course, the dietitians don’t believe in the right to express opinions that differ from theirs. So the persecution continued into a second trial – and the dietitians lost again. As Sboros put it:

The mere fact that the HPCSA was prepared to fork out millions in the prosecution, in a weak case with facts that never merited a second glance, and then fork out a couple of million more on appeal, doesn’t just speak volumes. It shouts volumes about the lengths to which powerful vested interests in food and drug industries and conflicted, captured doctors, dietitians and academics will go to suppress dissent.

That’s what Real Food On Trial is about: powerful interests ganging up to ruin a lone scientist because he dared to tell them (and the public) that their advice is wrong.

But in the end, they did us a favor. When Tim Noakes elected to stand up to these bullies instead of quietly riding off into the sunset, he didn’t just fight for himself. He fought for all of us. He fought for the right of scientists to challenge the consensus, to disagree, to speak their minds. And glory, glory hallelujah, he won. Nothing makes a bully think twice before bullying again quite like being on the short end of a good old-fashioned ass-kicking.

There’s much, much more to the book than I can effectively summarize here, so please, get your own copy.  If you’re like me, you’ll laugh, you’ll gnash your teeth, and you’ll utter words not considered polite.  But you’ll be glad you finally read the full story.