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26 April 2016

Professor Noakes' ridiculous Banting trial – Part II

CyberShrink investigates and demolishes the arguments the Health Professions Council brought against Prof Tim Noakes and concludes that they owe him an apology.

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I tried to find out more about the hitherto little-known Claire Julsing-Strydom. Not quite a household name, so gathered what information I could about this keen defender of the public digestion.

Powerful lobbies and companies

I tried to trace and read all of Ms Julsing-Strydom’s books and articles in major world scientific journals, but found very little to work on, apart from some minor pieces in minor magazines. Though she claimed to have been so profoundly shocked by the horror of Noakes’ weaning advice that she immediately complained to the Council, I haven’t yet found evidence of any comparable shock about any other dietary issues.

Nothing, for instance, about the lack of good scientific evidence for promoting cereals to children, the excessive amounts of sugar in heavily promoted foods, or the spurious benefits of “sports drinks” and “energy drinks”. Or indeed about anything backed by any commercially powerful lobby or company.  

She tried to give opinions to the Committee and was rightly reminded that she is not an expert witness, but the complainant. Her side called an odd and profoundly unimpressive bunch of “expert witnesses”. Noakes’ expert legal team was able to show that these actually recommended much the same infant diets as he does (meat, fish, chicken and eggs daily) and the importance of enough fat.

Read: Baby foods to avoid

Although the HPCSA has no guidelines on doctors’ activities on social media, it did not stop them from pursuing Noakes for flouting these non-existent guidelines. The Council has irresponsibly and ignorantly tried to discourage the development of telemedicine and similar initiatives, which could bring valuable help to rural and under-served communities, apparently fearing that giving free advice to poor people might discourage them from hiring private doctors they can’t afford to see anyway. 

The Council has always done all it can to promote profitable private practice, rather than whatever might most benefit patients. Generally, minor professionals who earn a good living from selling their advice, resent anyone who gives advice away for free, on Twitter or elsewhere.

Julsing-Strydom and her colleagues seem not to have demanded any deep evidence for the many fad diets that are so profitably promoted, some by dietitians. Has any fashionable diet, including illiterate “Detox” programmes, ever shocked her? Why is her horror so narrowly focused? If she’s devotedly evidence based, why didn’t she challenge Noakes scientifically, i.e. do research and prove him wrong? She said she complained because Noakes was giving unconventional advice. What is the scientific basis of these “conventions”?

Not a medical journal in any way

To discourage doctors and academics from giving free advice to the public is a restrictive practice. In fact, going back to Hippocrates, doctors are forbidden to keep secret remedies they discover, and must share them with others.

In her online CV, Julsing-Strydom asserts: “Claire has developed and implemented interactive nutrition education initiatives for various schools including the Oprah Winfrey Leadership Academy. Claire is an expert within the corporate wellness space … she consults to the food and pharmaceutical industries. She contributes regularly to magazine publications such as Longevity, Women’s Health and Woman & Home and has been hosted on a number of health-related television and radio shows. 

“ADSA has spoken fondly of how ‘our’ dietitians appear on radio and TV, and contribute to such academic journals as True Love Magazine (a well-known devotee of evidence-based advice, of course). She describes herself as having written for “medical journals” such as Medical Chronicle, which was a free tabloid designed to carry advertising, and not a medical journal in any way.

Read: Dietitians support 'Breast Fest'

What’s the difference, professionally and ethically, between giving advice to the Oprah Winfrey School or a corporate event, and advising the general public on social media? Does she find herself and her colleagues immune from all of the rules she lays down for others? 

How on earth are they not giving nutritional advice to people they have never met or assessed in person? It must take ages to get into the audience into her corporate events if she takes the time to assess every single person. Who does she consult, each time, to ensure she never says anything unconventional?

'One on one' advice

There’s a peculiar quote from ADSA saying that giving one-on-one nutrition advice on social media to a patient who has not been assessed was in contravention of the HPCSA’s ethical guidelines. There is absolutely no such guideline, and as the essence of such social media is that any of us can access and read them, how can one claim that he gave “one on one” advice?

Julsing-Strydom is herself on Twitter (@DietitianClaire). She has 1,936 followers last time I looked, and certainly is not shy about giving advice or recommending stuff through re-tweeting. I see she retweets an article on “detox”, although there’s a resounding lack of good evidence-based support for such advice. We also learn we can “boost athletic performance with beets”.  

Read: Nutrition basics in a nutshell

I tried to check her list of whom she follows on Twitter (unsurprisingly, masses of dietitians, almost all female – curious how many insist on telling us they’re married and have kids). Interestingly, I didn’t notice her following Prof Noakes, so one must wonder how she so rapidly discovered his minor tweet that drove her to emergency action. Was she simply browsing at precisely that time? Or did someone tip her off? Who actually instigated what looks like an anticipated swoop to find a pretext for attacking Noakes?

Sponsors and neutrality

ADSA says clearly both that they need sponsorship to cover their “administrative expenses” and that they “don’t allow sponsors to influence their advice”. Hmm! It is interesting that Ms Julsing-Strydom has apparently consulted for Kelloggs, which has its nutrition and public affairs manager and a nutrition assistant on the ADSA Executive Committee.

Other companies which have been sponsors of ADSA include Huletts the sugar people. It’s interesting to note that according to Noakes sugar is entirely unnecessary in the diet and can be effectively addictive – hardly a view Huletts would endorse. 

Read: Any added sugar is bad sugar

The ADSA website seems to have been tidied up recently and some companies recently listed as sponsors, including Kelloggs, have oddly disappeared, though Unilever remains. Other current or recent sponsors, according to other reports, but not now fully revealed on the website, include: Sea Harvest, EquiSweet, Pick n Pay, Woolworths, Parmalat, ProNutro, Health Connection etc. On the site, advice on child nutrition has included sports cereal bars and sports/energy drinks for kids. Hardly evidence-based! I have seen ADSA refer to their members as “medical professionals”, which they aren’t – they’re health professionals.

Poor quality of evidence against Noakes

Considering the unimpressive records in research and major contributions to public health of those sitting in judgement over him, Noakes is hardly facing a jury of his peers. Interestingly, not a single paediatrician in SA expressed outrage at Noakes’ tweet. Recently, the Canadian Paediatric Society, in a joint statement with Health Canada, Dietitians of Canada and the Breastfeeding Committee for Canada, issued the same advice as he did. So much for “unconventional”.

Read: Moms of food-allergic kids want more from dietitians

It’s become standard practice at the HPC, to accept peculiar and eccentric “evidence” on ethics. Strange how many aged former professors and doctors have turned to medical ethics as a sort of hobby, rather than growing roses, and claim expertise in their old age. Yet though they were actively in practice during the apartheid era, when there were appalling wrongs done within health care, none of these guys ever complained about any ethical problems then. Ethics evidence can be based on internationally accepted codes and practices, but self-appointed hobbyist “experts” should be viewed with great caution.

It is not merely Noakes’ absolute right, but his professional duty to explore what he believes to be true, and to challenge practices he believes may be damaging health. Dietitians, on the other hand, seem alarmingly devoted to seriously out-of-date “guidelines”, without realising that these are only guidelines, not laws.  

ADSA and its ethics

According to the ADSA Code of Ethics, a dietitian must recognise “legitimate differences of opinion”. On what basis did Strydom instantly assume that Dr Noakes’ views, apparently different from hers, cannot be legitimate? She registered her complaint against him as rapidly as practically possible, not pausing to check scientific data, or to consult anyone else. Yet her code requires her to “recognize and exercise professional  judgment  within  the  limits  of my  qualifications  and seek  counsel …  as appropriate”.  The code also several times warns not to “compromise standards of care to meet commercial targets”.   

The ADSA seems to have an anti-Noakes stance, not engaging with him in fair debate, but, for instance, after he had spoken to a group of Cape Dietitians, organising a meeting of speakers with fiercely opposing views, one referring to Noakes as "the North Korea of epistemology". How dreadful!

Other journalists have had great difficulty getting answers from ADSA’s PR company. Julsing-Strydom has not answered many interesting questions, and is quoted as having said that until the hearing is over, the HPCSA has “advised” her not to talk to the media as the inquiry is “sub judice”. If it did that, it was more than usually legally illiterate.

Read: Tim Noakes to defend Banting for babies

“Sub judice” objections don’t apply in this case, as anyone with even rudimentary knowledge of the legal process in SA knows. It only applies in a court of law. This natter isn’t currently before a judge. The HPCSA is a statutory body, not a court of law. Noakes doesn’t seem to have received the same “advice” from the HPCSA, and seems aware that it hasn’t the right to give instructions to parties to disputes like this. Julsing-Strydom is reported to have sent an urgent notice to ADSA members quoting this HPCSA “advice”.

There’s misinformation going round, too. Strydom’s successor as ADSA president said they’re not going after Noakes for what he says about weaning, but just because he said it on Twitter, which would be a ridiculous objection. Then she gave a statement to Health24, quaintly referring to Strydom’s complaint as a “query” done “with the intent to gain clarity and guidance on the use of social media by health professionals”.  This isn’t credible, not only ignoring Strydom’s actual words,  but also the fact that the Council has mechanisms to deal with complaints, not queries. 

Dodgy hearings 

The HPCSA Committee of Inquiry, chaired by wits Prof Ames Dhai, was highly irregular, as we’ve seen, and as Noakes’ advocate van der Nest easily demonstrated. There were serious concerns of bias and unfairness from the start, seriously breaching Prof Noakes’ basic constitutionally guaranteed rights. They didn’t even want to tell him what he was charged with.

Read: Telemedicine 'unethical', says HPCSA

HPCSA legal officer Nkagisang Madube said it was normal practice for professionals to be charged on the basis of reports kept secret from them, and saw nothing at all wrong with this. Yet this breaks the Council’s own rules, under the law that governs it. Asked to quote which law authorised him to do this, he was lost. A large file of documents was withheld from the defence team, and the Council’s lawyers were clearly agitated when told they had to give this to the defence.

The secret report was by an almost unknown nutritionist Prof Este Vorster, retired from Northwest University. It emerged that Vorster never practiced as a dietitian and never saw patients. Her original degree was in home economics, and she knew nothing about Twitter and social media. Major delays were caused because the HPCSA kept trying to force a dietitian onto the committee, breaking regulations and law.

One of its curious expert witnesses, kept secret and sprung on the committee at the last minutes, was a psychiatrist at the University of Stellenbosch, associate Prof Willie Pienaar, who has been a disastrous witness before, who, without basing arguments on basic widely accepted ethical principles, insisted that Noakes had a doctor/patient relationship with Leenstra, so it was unprofessional conduct to have advised on the infant’s diet. He kept saying Noakes had “made a mistake” and he feared for “my profession” if doctors could freely give advice on Twitter. “Patients will no longer trust us,” he insisted, and “lives would be at risk”.  I fear for my profession if evidence like this is ever taken seriously, not based on any coherent ethical principles but apparent personal animus.  

No actual harm

Noakes’ advocate demolished Pienaar on cross-examination, as he was forced to back-track, making multiple concessions. Leenstra never asked to be treated, didn’t consider Noakes her doctor (nor did he consider her his patient). If by some twisted logic Leenstra was considered a patient of Noakes, she was even more a patient of Strydom and her colleague Ellmer, who had both tweeted to Leenstra urging her to ignore Noakes and rather consult them. 

Both had butted in in an outrageous manner, which probably broke HPCSA rules against “supersession”, which is when you take a patient away from another practitioner without permission. If twittering is considered a formal professional relationship, why were they not both charged as well? She had tweeted her phone and email address, telling Leenstra to contact her for better advice.

To date, nobody has complained to the Council or anywhere else about any actual harm caused by any of the 29,000 tweets Noakes has sent out. 

Read: Researchers’ tweets move science forward

Julsing-Strydom herself was an emotional, flustered and unconvincing witness, and on cross-examination conceded that she had “probably over-reacted” and that Noakes was not in a doctor-patient relationship with Leenstra, and indeed that her “horrified” tweet to him constituted an attack on his professional reputation. 

A large and eloquent apology

When the matter resumes later this year, it may be nearly over. It’s clear that the entire matter against Prof Noakes was ridiculous, and highly suspect. This time it’s the Council and the complainant that will have to explain themselves.   

It’s also high time for the Health Minister to explain why he has not carried out the recommendations of his own investigating committee into this shambles at the Council, dismissed the incompetents and set things right. The Council must not be allowed to perpetrate another debacle like this, and action must be taken against those who showed such bias and spite and caused the waste of public and private funds. 

Somebody owes this man a large and eloquent apology!

Read more:

Professor Noakes' ridiculous Banting trial – Part I

Noakes' lawyer responds to ADSA

'Tim Noakes diet' put to the test

Professor MA Simpson is Health24's CyberShrink. A South African psychiatrist, he qualified in medicine and in psychiatry in Britain. He has been a senior academic, researcher, and Professor in several countries. Read more of his columns.

 

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